Treatment of Insomnia in Elderly Patients

Non-Pharmacological Interventions

The American Academy of Sleep Medicine recommends sleep hygiene education, including maintaining a regular sleep-wake schedule, avoiding daytime napping, limiting caffeine and alcohol, and creating a comfortable sleep environment, for the treatment of insomnia in elderly patients 1, 2
The American Geriatrics Society suggests stimulus control therapy to strengthen the association between the bedroom and sleep, as well as relaxation techniques such as progressive muscle relaxation, guided imagery, or diaphragmatic breathing, for the treatment of insomnia in elderly patients 3
Cognitive behavioral therapy for insomnia (CBT-I) is recommended by the American Geriatrics Society, which combines behavioral treatments with cognitive restructuring, for the treatment of insomnia in elderly patients 4

The American Academy of Sleep Medicine recommends ramelteon 8 mg at bedtime as a first-line medication for sleep onset insomnia in elderly patients, with no evidence of abuse potential or significant cognitive/motor impairment 4, 1
Low-dose doxepin (3-6 mg) is recommended by the American Academy of Sleep Medicine for sleep maintenance insomnia, with a different mechanism than previously discontinued medications 5, 1
The American Academy of Sleep Medicine suggests short-acting benzodiazepine receptor agonists, such as zaleplon 5 mg or zolpidem 5 mg, for sleep onset and maintenance insomnia in elderly patients, with caution due to increased risk of falls and cognitive impairment 1, 5

Mirtazapine is associated with weight gain and may have similar sedating effects to previously discontinued medications, according to the American Academy of Sleep Medicine 1
Trazodone is not recommended for sleep onset or maintenance insomnia based on clinical guidelines from the American Academy of Sleep Medicine 5
Diphenhydramine and other antihistamines are not recommended for insomnia in older adults due to strong anticholinergic effects, according to the American Academy of Sleep Medicine 5

The American Geriatrics Society recommends starting with the lowest effective dose of any medication and being vigilant for adverse effects, including falls, cognitive impairment, and delirium, in elderly patients 4
Older adults often have altered pharmacokinetics and increased sensitivity to CNS medications, according to the American Geriatrics Society, and medical comorbidities should be considered when treating insomnia 4