question and answer
Sleeping pills in the elderly
October 2011
What are the best type of sleeping pills to use in the elderly? Roshan Dheda, MD, Bradford, ON

Sleeping pills unfortunately are widely prescribed in the elderly and are often initiated during a period of acute hospitalization. In acute care medicine units, well over 50% of the elderly are prescribed hypnotics, and on surgical wards, it’s close to 100%. This despite the well-documented relationship between hypnotics and falls, impaired cognition and other adverse effects.

Generally, I would try to spend time reviewing reasonable expectations for sleep in an older person. Although the elderly probably sleep a similar number of hours over a 24-hour period as do the young, older adults take longer to fall asleep, have lower sleep efficiency, have more nighttime awakenings and wake up earlier in the morning. They also tend to underestimate the length of time they actually sleep during the night.

Principles of sleep hygiene should be emphasized including a comfortable bedroom without a television, avoidance of alcohol in the evening, use of warm milk/herbal tea at bedtime.

Drugs to avoid, especially for long-term use, include the benzodiazepines (particularly the long-acting benzos, e.g. diazepam, flurazepam) and any barbiturates. Use of acetaminophen at bedtime to alleviate various aches and pains can be beneficial.

If you have to prescribe a soporific medication, try to avoid long-term use. Options include trazodone starting at 25 mg or perhaps an antidepressant, e.g. Mirtazapine, since these tend not to be addictive.

Despite the widespread use of zopiclone (Imovane), there’s really no evidence that this and the other “z-drugs” (zolpidem, zaleplon) are any safer than a benzodiazepine, especially for longer-term use. Health Canada has linked zopiclone to rare instances of sleepwalking and even sleepdriving. Also, it isn’t covered by many of the provincial drug benefit plans for seniors

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