Management of Insomnia in Elderly Patients on Donepezil

Non-Pharmacological Approaches

The American Geriatrics Society recommends implementing stimulus control therapy to strengthen the association between sleep and the bedroom, including developing a sleep ritual, going to bed only when sleepy, leaving the bedroom if unable to fall asleep, and maintaining stable bedtimes and rising times 1
The American Geriatrics Society suggests addressing sleep hygiene factors that may impair sleep, such as avoiding daytime napping or limiting to 30 minutes before 2 pm, avoiding caffeine, nicotine, and alcohol, especially in the evening, and ensuring the bedroom is comfortable, quiet, and dark 1, 3
Relaxation techniques, including progressive muscle relaxation, guided imagery, diaphragmatic breathing, meditation, or biofeedback, may be considered to help improve sleep quality 1

For elderly patients on donepezil, the American Geriatrics Society recommends using melatonin receptor agonists as the first choice for short-term sleep aid, starting at the lowest available dose, due to their safer profile and minimal adverse effects 1
Short-acting non-benzodiazepines, such as zolpidem or eszopiclone, may be considered as a second choice, but their use should be cautious due to the risk of worsening dementia and increasing fall risk 5, 6
The American Geriatrics Society advises against the use of benzodiazepines in elderly patients due to increased risk of adverse effects, and antihistamines like diphenhydramine should also be avoided 5, 6

Regular monitoring for adverse effects, including excessive daytime somnolence, confusion, delirium, or worsening cognitive function, is crucial when using sleep medications in elderly patients on donepezil 4, 5, 6
Sleep medication should be used for the shortest duration possible and gradually tapered when discontinuing to avoid withdrawal symptoms 5

The use of benzodiazepines in patients with cognitive impairment can further decrease cognitive performance, and agents like zolpidem may not maintain sleep throughout the night and can cause daytime somnolence 4, 6
The combination of donepezil with certain sleep medications may increase the risk of bradycardia, and antipsychotics should not be used for sleep due to the increased mortality risk in patients with dementia 4, 6