Elder Care Interprofessional Provider Sheets

Sleep in Older Adults - Pharmacotherapy

Jeannie Lee, PharmD, BCPS, CGP, College of Pharmacy, University of Arizona
Karen D'Huyvetter, ND, RN-MS, MS-HES, Center for Integrative Health and Healing, Seal Beach, CA

December 2019

TIPS FOR USING SLEEP PHARMACOTHERAPY IN OLDER ADULTS
  • Use medications only if non-drug therapy and preventive measures do not meet patients’ sleep needs.
  • Provide realistic expectations of sleep goals (e.g. 7+ hours of uninterrupted sleep is not natural in older patients)
  • Reverse underlying causes of sleep problems and use behavioral interventions as first-line treatment.
  • Discuss risks versus benefit of sleep agents with older patients and caregivers when choosing pharmacotherapy.
  • Use lowest effective dose of the chosen agent with regular follow up to assess effectiveness, adverse effects, and need for continued pharmacotherapy. Try discontinuing on a regular basis.
  • To improve sleep latency, use a shorter-acting agent such as short-acting melatonin or ramelteon.
  • To improve sleep maintenance, use a longer-acting agent (e.g., trazodone).

Older adults frequently report sleep-related complaints and have questions about appropriate sleep therapies. A previous edition of Elder Care,"Cognitive Behavioral Interventions for Insomnia in Older Adults," discusses the use of non-pharmacological, preventive, and behavioral strategies for treatment of sleep disorders in older adults. 

It is important to note that a two-stage or interrupted sleep can be normal.

The Role of Medication Therapy

Because many sleep agents are not appropriate for older adults as specified in the Beers Criteria, it is vital to remember that non-drug therapies, including preventive and behavioral  measures should be the first-line approach in this population. These include avoiding or adjusting medications and substances that might be contributing to sleep issues. (Table 1). It is also important to address related conditions such as external stressors, anxiety, bereavement, depression, breathing problems, reflux, urinary urgency, and pain. Medications for sleep should be reserved for instances when non-pharmacological and preventive measures do not meet the patient’s needs, and should be used in combination with these therapies and for a short period, only.

 

Table 1. Common Medications/Substances that Cause or Aggravate Sleep Disorders in Older Adults

Agents Effects and Advice
Alcohol
  • Sleep induction, subsequent disruption
  • Limit use
Antidepressants (e.g., SSRIs, SNRIs, bupropion)
  • Insomnia
  • Give stimulating agents in morning
ß-blockers, α-agonist (e.g., atenolol, clonidine)
  • Insomnia, may cause nightmares 
  • Use alternative agent if possible
Caffeine, Decongestants (e.g., pseudoephedrine)
  • Stimulating
  • Avoid evening use
Corticosteroids (e.g., prednisone)  
  • Stimulating, may cause agitation
  • Prescribe lowest dose possible
Diuretics (e.g., furosemide)
  • Awakening due to nocturia
  • Dose in morning or early afternoon
Levodopa
  • Insomnia, may cause nightmares
  • Avoid late dosing if possible
Nicotine
  • Stimulating
  • Smoking cessation
Phenytoin
  • Insomnia
  • Avoid late dosing if possible
Thyroid supplements
  • Insomnia
  • Check thyroid function test

Risk versus Benefit of Pharmacotherapy

Although there may be a modest benefit from a sleep agent, there are numerous potential adverse effects such as addiction, cognitive impairment, confusion, sleep walking, falls, and other accidents. Therefore, benefit-to-risk ratio should be carefully considered and discussed with older patients and caregivers before starting pharmacotherapy. Regular re-assessments with deprescribing should be performed.

Pharmacotherapy Recommendations

The choice of a sleep medication should be directed by several factors including: (a) insomnia pattern, (b) goals of therapy, (c) past treatment responses, (d) comorbidities, (e) contraindications, (f) side effects, (g) drug interactions, (h) cost,  and (i)  patient  preferences. The  lowest  effective dose  of  the  chosen  agent should  be  used  with  regular follow up to assess effectiveness, adverse effects, and need for continued use. Intermittent dosing (2-4 times/week) may be used. Again, short-term treatment (3-4 weeks) should be used unless chronic insomnia is present due to a chronic illness. After chronic use, many of the medications need to be tapered off to prevent rebound insomnia.

Table 2 describes sleep pharmacotherapy options, and Table 3 notes medications to avoid in older adults.

Table 2. Medications to Use
Melatonin Receptor Agonists - No abuse potential or morning-after effects 
  • Ramelteon (Rozerem®) 8 mg within 30 mins of bedtime (avoid high-fat meal)
  • Over-the-counter melatonin
Antidepressants - especially for patients with comorbid depression. These drugs have orthostatic side-effect. Tricyclic antidepressants should not be used. 
  • Trazodone (Desyrel®) 25-100 mg.
  • Mirtazapine (Remeron®) 7.5-15 mg - Has side effect of stimulating appetite, a potential benefit for some patients. Beers Criteria recommend use with caution because of potential to cause SIADH. 
  • Doxepin (Silenor®) 3-6 mg (Beers Criteria limit dose to <6mg/day; many potential drug interactions).
Gabapentin (Neurontin®) - For patients with neuropathic pain or restless legs syndrome, use gabapentin 100 mg to start, and then titrate as needed. Dose must be adjusted in renal insufficiency.
Table 3. Medications to Avoid
  • Antihistamines, including over-the-counter antihistamines (e.g., diphenhydramine), antipsychotics (all classes)
  • Benzodiazepines (short, intermediate, or long-acting)
  • Benzodiazepine receptor agonists: eszopiclone (Lunesta®), Zaleplon (Sonata®), Zolpidem (Ambien®), Zolpidem ER (Ambien CR®)
  • Barbiturates (e.g., phenobarbital)
  • Tricyclic Antidepressants (e.g., amitriptyline)

To improve sleep latency, use a shorter-acting agent (e.g., short acting melatonin or ramelteon). To improve sleep maintenance, consider trazodone or a sustained release melatonin. Do not try to medicate for 7+ hours of uninterrupted sleep! Most pharmacotherapies have potential drug/herbal/food interactions and adverse effects that need close monitoring. Patient education includes: (a) expectations and treatment goals, (b) safety concerns and potential adverse effects, (d) potential drug interactions, (e) dose escalation plan, (f) rebound insomnia, and (g) non-pharmacological therapies (e.g., cognitive behavioral and sleep hygiene).

Supplements for Sleep

The use of natural products and Complementary and Alternative Medicine (CAM) approaches among Americans are widespread according to the National Health Interview Survey (NHIS). In fact, data from 2012 suggest that at least 40% of adults in the US used at least one CAM approach with a cost in the billions of dollars.

Melatonin  Synthesized in the pineal glands during sleep, evidence suggests levels drop significantly in older adults when compared to younger adults. Melatonin supplementation may be beneficial for insomnia due to its effect on the circadian cycle, with onset of action within 40 minutes.  It is well tolerated. Vivid dreams, dysphoria in depressed patients or sleep apnea in predisposed patients are possible. Melatonin may have an additive effect with sedatives.  Melatonin can also potentiate anticoagulants, reduce insulin sensitivity, and possibly induce orthostatic hypotension. Effects from doses > 4mg may last 10 hours.

Valerian  Thought to have sedative-hypnotic, anxiolytic, antidepressant, anticonvulsant and antispasmodic effects, valerian modestly reduces sleep latency and improves subjective sleep quality.  It is generally well tolerated, but cases of headache, gastrointestinal upset, excitability, and cardiac problems have been reported. It may have hypotensive effects, and has an additive effect with sedatives.

Lemon Balm  Lemon Balm is “generally recognized as safe” by the FDA when taken by mouth. Clinical research has shown that taking a standardized extract of lemon balm twice daily for 15 days reduced insomnia by 42% in people with sleep disorders.  Lemon balm can have an additive effect with other sedating substances and thyroid therapy, and may modestly reduce blood glucose. Lemon Balm taken orally may increase appetite.

References and Resources