AASM Pharmacologic Treatment of Chronic Insomnia Guidelines and Geriatric Drug Information Resources

Treatment of chronic insomnia in older adults is a common clinical question. There is strong evidence for multicomponent cognitive behavioral therapy and Cognitive Behavioral Therapy for Insomnia (CBT-I) for the treatment of chronic insomnia disorder in adults. However, in selected scenarios, medications may be offered after discussion of risk and benefits. While there are no available guidelines specific to older adults, the Clinical Practice Guideline for the Pharmacologic Treatment of Chronic Insomnia in Adults by The American Academy of Sleep Medicine (AASM) provides recommendations regarding available medications for sleep onset and maintenance insomnia and evidence to date suggest comparable efficacy across the adult age range.¹ The limited evidence regarding adverse effects in older adults, however, does not allow for meaningful conclusions about the frequency of such events in older patients compared to a younger population.

Please find below links to GeriMedRisk drug summaries and infographics for considerations for prescribing in older adults.² To access the drug summaries and infographics, click on the drug names highlighted in purple. Summaries for other drugs are either unavailable or currently under development.

Note that American Geriatric Society Beers criteria recommend that benzodiazepines be avoided for treatment of insomnia in older patients, due to risk of cognitive impairment, falls, and motor vehicle accidents.³ We have included considerations for the use of these medications in older adults and the Beers criteria statements below.

Recommendations by the AASM Clinical Practice Guidelines

Under the GRADE classification system, a STRONG recommendation is one that clinicians should, under most circumstances, follow. A WEAK recommendation reflects a lower degree of certainty in the outcome and appropriateness of the patient-care strategy for all patients but should not be construed as an indication of ineffectiveness. GRADE recommendation strengths do not refer to the magnitude of treatment effects in a particular patient, but rather, to the strength of evidence in published data.

WEAK Recommendation for Treating Sleep Onset and Maintenance Insomnia (versus no treatment)

Medication	Considerations in Older Adults
Zopiclone Benzodiazepine Receptor Agonist, “Z drugs”	Nonbenzodiazepine benzodiazepine receptor agonist hypnotics (“Z-drugs”) have adverse events similar to those of benzodiazepines in older adults (e.g., cognitive impairment, delirium, falls, fractures, increased emergency room visits/hospitalizations, motor vehicle crashes); minimal improvement in sleep latency and duration.³
Zolpidem Non- Benzodiazepine Receptor Agonist, “Z drugs”
Temazepam Benzodiazepine	The use of benzodiazepines exposes users to risks of abuse, misuse, and addiction. Concomitant use with opioids may result in profound sedation, respiratory depression, coma, and death. Older adults have increased sensitivity to benzodiazepines and decreased metabolism of long-acting agents; the continued use of benzodiazepines may lead to clinically significant physical dependence. In general, all benzodiazepines increase risk of cognitive impairment, delirium, falls, fractures, and motor vehicle crashes in older adults.³

WEAK Recommendation for Treating Sleep Maintenance Insomnia (versus no treatment)

Medication	Considerations in Older Adults
Doxepin Tricyclic Antidepressant	Generally considered highly anticholinergic at higher doses, sedating, and cause orthostatic hypotension; however, safety profile of low-dose doxepin (≤6 mg/day) is comparable to that of placebo. Contra-indicated with concomitant MAOI use due to increased risk of Serotonin Syndrome.

Medication

Considerations in Older Adults

Doxepin
Tricyclic Antidepressant

Generally considered highly anticholinergic at higher doses, sedating, and cause orthostatic hypotension; however, safety profile of low-dose doxepin (≤6 mg/day) is comparable to that of placebo.

Contra-indicated with concomitant MAOI use due to increased risk of Serotonin Syndrome.

WEAK Evidence Against Treating Sleep Onset or Maintenance Insomnia

Medication	Rationale
Trazodone Serotonin Antagonist and Reuptake Inhibitor (SARI)	Not recommended for sleep onset or maintenance (harms outweigh benefits).
Diphenhydramine Antihistamine	Not recommended for sleep onset or maintenance (benefits approximately equal to harms in the general adult population though harms may be higher in older adults).
Melatonin Pineal hormone	Not recommended for use for sleep onset or maintenance (benefits approximately equal to harms).
L-tryptophan Essential Amino Acid	Not recommended for use for sleep onset or maintenance (harms outweigh benefits).
Valerian Phytochemical	Not recommended for use for sleep onset or maintenance (benefits approximately equal to harms).

Other Health Canada Approved Agents for Insomnia Not Included in the AASM Guidelines

Daridorexant – Orexin Receptor Antagonist – Approved by Health Canada in 2023 for the treatment of insomnia.
Lemborexant – Orexin Receptor Antagonist – Approved by Health Canada in 2021 for the treatment of insomnia.

References

Sateia MJ, Buysse DJ, Krystal AD, Neubauer DN, Heald JL. Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: an American Academy of Sleep Medicine clinical practice guideline. Journal of clinical sleep medicine. 2017 Feb 15;13(2):307-49.
Tung J, Bodkin RJ, Laughton T, Neat C, Benjamin S, An H, Antoniou T, Ho JM. Efficiency and effectiveness of geriatric drug infographics: A randomized, controlled trial. Journal of the American Geriatrics Society. 2021 Aug 1;69(8).
2023 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society. 2023 Jul;71(7):2052-81.