Karl Doghramji, MD: The question of which drug to use for which patient rests on a number of parameters, one of which is, what’s the nature of the sleep complaint? If the complaint is one of sleep initiation—not being able to fall asleep quickly enough—then there are certain agents that are appropriate for that. If it’s one of sleep maintenance, which is waking up a lot during the night, then there are other sets of agents. And if there’s a combination, then there are other agents as well. In general, if it’s a sleep initiation problem only, something like ramelteon, zolpidem, or zaleplon may be appropriate. If it’s a sleep maintenance problem, low-dose doxepin, 3 or 6 mg, may be appropriate. If it’s a problem involving both sleep initiation and maintenance, zolpidem extended release, S-zopiclone, as well as suvorexant may be appropriate.
A second consideration is whether the patient has some comorbidities and safety issues: respiratory compromise, sleep apnea, or COPD [chronic obstructive pulmonary disease], which are common in the elderly. If those are present, it favors the use of agents that have been tested in these disorders. Agents like suvorexant and ramelteon seem to be safe in mild and moderate sleep apnea, and mild and moderate COPD. Finally, if the patient has a history of drug addiction, we use agents that don’t have GABA [gamma-aminobutyric acid]-ergic potential that are not scheduled. For example, ramelteon and doxepin low-dose may be appropriate.
When do we switch hypnotic medications? Well, if they’re used for an appropriate length of time at the right dosage and they’re simply not working, their benefit is minimal compared to what we’d like to see, or if they have significant adverse effects, I think at that point stop the drug, go to something else. We don’t have any good data on whether we should stay with the same mechanism of drug or switch mechanisms. But many physicians recommend switching to another mechanism drug just on the basis of a theoretical potential advantage.
The American Geriatrics Society developed a new set of Beers Criteria for the inappropriate use of medications in the elderly. In terms of the recommendations that apply specifically to sleep drugs, they have recommended the short-, intermediate-, and long-acting benzodiazepines not be utilized in the elderly because of the possibility of developing neurocognitive difficulties, delirium, and falls and hip fractures, and so on.
Number 2, they’ve recommended that the “Z” drugs, the “Z” hypnotics such as zaleplon, zolpidem, and zopiclone, not be utilized, again because of similar concerns about falls and potential hip fractures. Third, they’ve recommended that the antihistamines not be utilized—things like diphenhydramine and doxylamine—for insomnia, because of the potential for anticholinergic adverse effects with these drugs, producing delirium potentially and also dry mouth, urinary retention, and gastrointestinal difficulties. And finally, fourth, they’ve cautioned us against using antipsychotics for elderly for insomnia specifically because of, again, some of the similar concerns.