Management of Hot Flashes in Older Adults

Initial Assessment and Treatment

The American College of Physicians recommends evaluating the frequency and severity of hot flashes and their impact on sleep and daily function before initiating treatment, as this information is crucial for determining the best course of action 2, 3
A medication review should be conducted to rule out drug-induced vasomotor symptoms, and thyroid function should be evaluated to exclude hyperthyroidism as a cause of hot flashes 4

Gabapentin 900 mg/day taken at bedtime is a recommended first-line treatment, as it reduces hot flash severity by 46% compared to 15% with placebo, with no known drug interactions, making it a safer option for elderly patients on multiple medications 1
The American Society of Clinical Oncology recommends venlafaxine 37.5 mg daily, increasing to 75 mg after 1 week, as a second-line treatment, which reduces hot flash scores by 37-61% 5, 2, 1
Paroxetine 12.5-25 mg daily is a third-line treatment option, reducing hot flash frequency and severity by 62-65%, but should be avoided in patients taking tamoxifen due to CYP2D6 inhibition 5, 2

Weight loss of 10% or more of body weight may eliminate hot flash symptoms, and acupuncture shows equivalence or superiority to venlafaxine or gabapentin in some studies 1, 4
Paced respiration training and structured relaxation techniques, such as cognitive behavioral therapy, can also reduce the perceived burden of hot flashes 2, 1, 4

Estrogen therapy is contraindicated or strongly discouraged in older adults due to increased stroke risk, venous thromboembolism risk, and breast cancer risk 1, 4
Paroxetine and fluoxetine should be avoided in patients taking tamoxifen due to CYP2D6 inhibition, and vitamin E should not be used as monotherapy for severe symptoms due to limited efficacy and potential increased mortality risk 1, 2