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Archived Questions
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Managing Insomnia in Depressed Elderly Patients
I have an elderly patient who is on 30 mg. of Paxil® for depression and insomnia. The medication is being tolerated and her mood is improved, but her sleep remains a problem. Would you increase the dose of SSRI or add an additional medication for sleep, or what else would you choose to do?
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It's difficult to say exactly what I would do without having all of the clinical details. However, I would consider the following to be a rational approach:
Be sure that depression is optimally treated before adding any medications specifically for the purpose of helping sleep induction or sleep quality.
In this case you say that your patient is tolerating Paxil® at 30 mg. daily and her mood has improved, but sleep is still problematic. This leaves the impression that, despite overall improvement, she is not quite in full remission from the depressive picture. If so, I would not hesitate to increase Paxil® to 40 mg. daily, which for some-even for frail, elderly patients-would be a more optimal dose. Since she seems to respond to and tolerate SSRI antidepressants, another option would be to switch to a more potent SSRI, namely Lexapro®(Escitalopram), starting at 10 mg. daily and moving up to 20 mg. if needed. This could be done in one step without any tapering of the Paxil®. Whether you increase the Paxil® dose or switch to Lexapro®, the presumption here is that your patient's ongoing sleep difficulties reflect residual depression.
If you are satisfied that the patient is in complete remission from depression and still complains of poor sleep, I would make sure that her 'sleep hygiene' is reasonable.
By the term 'sleep hygiene' I refer to a few very basic and obvious measures. For example, I would ask your patient to do the following: 1) get plenty of exercise during the day, (usually this means walking), preferably in direct sunlight, but do not exercise in the evening; 2) avoid fluids during the last several waking hours and void before going to bed; 3) avoid alcohol or caffeine during evening hours; 4) read or do whatever seems to help with relaxation and sleep induction before turning the lights out; 5) leave window shades up so that morning sunlight can enter the bedroom; 6) get up at approximately the same hour each a.m. even if nighttime sleep had been poor, and do not nap during the day; 7) get a comfortable mattress and sleep in an uncluttered bedroom.
Having followed the first and second recommendations above, but find that your patient still complains of poor sleep, you are ready to consider pharmacological approaches.
The agent most widely used is Desyrel® (Trazodone), a sedating antidepressant that is used for this purpose in "sub-antidepressant" doses, usually 50 to 150 mg. QHS (versus the 400 mg. daily or more for monotherapy of depression, a dose which most elderly cannot tolerate). Trazodone was the first-line choice of geriatric psychiatrists and geriatricians for residual insomnia in a recent expert consensus study on the diagnosis and management of late-life depression (1). It is safe and usually well tolerated at the dose range recommended above. An added advantage to the use of Trazodone is that, even at low doses, it may provide an augmenting effect to the principal antidepressant, in this case Paxil® or Lexapro®.
Virtually all other approaches to pharmacological augmentation involve considerable risk of side effects or other difficulties, but I will mention them in order to be complete.
First, you may augment with, or switch to, an antidepressant with a more distinctly sedating side-effect profile. For the elderly this usually means Remeron® (Mirtazapine), since tricyclics, which are also sedating, are associated with falls, orthostatic hypotension and other anti-adrenergic side effects, and possibly with anticholinergic toxicity as well. You might add Remeron® 7.5 mg. QHS and perhaps slightly reduce the Paxil® or Lexapro® dose, or you might gradually cross-taper onto Remeron® alone if it is helpful.
Other anticholinergics, such as Benadryl® (Diphenhydramine), in doses of 25 to 100 mg. QHS, might be helpful but in vulnerable elderly individuals can cause confusional episodes and sometimes frank delirium. Commercial over-the-counter products such as Tylenol®PM or Unisom® also contain Diphenhydramine as their sedating agent. Patients with glaucoma, BPH or COPD should probably avoid them.
Geriatricians are usually reluctant to prescribe benzodiazepines because of their potential to cause dependence, their tendency to produce tolerance to sedating effects and their association with confusion, ataxia and falls. The worst are hypnotics, including the older ones such as Dalmane® (Flurazepam), or the hypnotics which came out in the 1980s, such as Halcion®(Triazolam) or Restoril®(Temazepam). Short-acting benzodiazepines, such as Ativan®(Lorazepam) or Xanax®(Alprazolam), are considered safer for the elderly but better adapted for acute anxiety symptoms than for relief of insomnia, since their brief duration of action is likely to produce a rebound wakefulness, and sometimes agitation, in 3 or 4 hours. Alcohol often produces the same effect-initial sedation with abrupt awakening a few hours later, sometimes with anxiety and palpitations.
If nothing helps, the expert consensus panel rather grudgingly recommended, as a second line, the use of nonbenzodiazepine hypnotics, such as Ambien® (Zolpidem) or
Sonata® (Zaleplon), but only on a temporary basis and at the lowest possible doses. In my own experience Ambien® and Sonata® are both effective, but highly addicting and associated with many of the same problemsfor elderly patients as the hypnotic benzodiazepines.
Finally, some psychiatrists have provided anecdotal support for the use of mood stabilizers, which in some individuals can be particularly sedating, e.g., Neurontin® (Gabapentin), Topamax® (Topiramate), or Trileptal® (Oxcarbazepine).
The expert consensus panel did not recommend the use of homeopathic or herbal preparations, such as Valerian or Melatonin.
Reference
Alexopoulos GS, Katz IR, Reynolds CF, Carpenter D, Docherty JP. Expert Consensus Guideline Series: Pharmacotherapy of Depressive Disorders in Older Adults. A Post-Graduate Medicine Special Report. October 2001; The McGraw-Hill Companies, Inc.
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