geropsych pearls

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 Let’s talk about sleep. Or lack thereof. Older adults tend to have progressively worse sleep cycles, with numerous arousals and poor REM sleep. So poor sleep is the norm.
There is no one-size-fits-all med for sleep. None. Nada. If you are looking for a magic bullet, you’re not going to find one. Here are some recommendations, tho.

1.  Avoid trazodone, as it tends to disrupt REM sleep. It can also be orthostatic, then they fall down and go boom. No one wants a hip fracture. Trazodone used to be the go-to for geriatrics, but it has fallen out of favor. 
2.  Melatonin or ramelteon is always worth a shot.

3.  Mirtazapine is also a consideration, as it tends to do a good job of protecting sleep architecture. I like very low dose mirtazapine 7.5mg qHS. Go as low as 3.75mg for the 90/90 club.
4.  Avoid OTC sleepers like the plague. No Unisom, Tylenol PM, Advil PM or any sleep aid containing diphenhydramine or any other antihistamine, as they are linked to confusion, urinary retention, and increased fall risk. Just.Don’t.Do.It.

Hands down, the BEST treatment for chronic insomnia is to get good and tired during the day. Lemme say it again; Get Good and Tired during the day. We are wired to sleep when we are tired. If your pt is laying in bed all day, they are not going to sleep at night. So… 
Do not let your patient sleep all day.
Do not let your patient sleep all day.
Do not let your patient sleep all day.
Do not let your patient sleep all day.
Do not let your patient sleep all day.
Do not let your patient sleep all day.
Do not let your patient sleep all day.
Do not let your patient sleep all day.

Seriously, get their butts out of bed at the same time every morning. Maximize sunlight; have breakfast in the sunniest room. Then go get some fresh air. Everyone gets a morning constitutional. Also helps them poop. If they can’t walk, have them rise to standing at bedside; feet on floor, eyes on the horizon. Stand there for 60 seconds. Write an order for the LTC staff to take the pts outside daily. Get good and tired during the day. No napping after 4PM. No TV or computer/LED screen for an hour before bedtime.

Try this:
1.  Minimize medications that disrupt sleep, such as SSRIs or SNRIs. If they are on 100mg of sertraline, they are going to have insomnia. Taper down the SSRI first.
2.  Sleep hygiene. Exercise. CBT. Sleep diary.
3.  Screen for OSA, RLS, PLMD. Sleep study, esp if they snore.
4.  A. For sleep onset insomnia, use a short-acting med such as melatonin, or ramelteon, low dose zolpidem or zaleplon
     B. For sleep maintenance insomnia, use a longer-acting med such as zolpidem ER, eszopiclone, LOW dose doxepin, or extended release melatonin. Temazepam if you must. Counsel pt about hangover sedation.

 - Zaleplon (Sonata): Half-life is 1 hr. Good for sleep onset, not so good for sleep maintenance. Avoid long term use
 - Zolpidem (Ambien): Half-life is 1.5 - 2.5 hrs. Good for sleep onset. Some morning hangover. Avoid long-term use.
 - Zolpidem CR: Half-life is 1.5 - 2.5 hrs, but released over longer duration to help with maintenance.
 - Eszopiclone (Lunesta): Half-life is 5-7 hrs, longer in elders. Higher risk of next-day impairment. 
 - This should be your last, last, last resort. Try low dose temazepam if you have to. Avoid estazolam, flurazepam, quazepam, or triazolam. 
Melatonin agonists
 - Melatonin: trick is to give it at least an hour prior to sleep, even as much as 5 hrs in some cases. Dim light melatonin onset (DLMO) is the evening increase in endogenous melatonin, and is delayed in pts with delayed sleep phase syndrome. Exogenous melatonin tx given FIVE hours before DLMO is effective for promoting sleep onset.
 - Ramelteon (Rozerem): Improves sleep latency, but not sleep maintenance. Not limited to short-term use.
 - Doxepin has an FDA indication for insomnia; keep dose at 3mg or less, and watch for cognitive impairment.
 - Amitriptyline: cognitive risk tends to outweigh potential benefit, try to avoid it.
 - Trazodone: orthostatic hypotension risk tends to outweigh potential benefit. Also disrupts REM. Has fallen out of favor in geriatrics.
 - Mirtazapine: protects sleep architecture. Good for short term, but benefit may be short-lived. Sedating effects often normalize. Keep the dose at 7.5mg or less.
 - Not recommended for tx of insomnia in pts without psychosis. Quetiapine should not be your first-line tx.
  - Not regulated. My momma always said unregulated OTC herbals were like a box of chocolates. You never know what you are gonna get. Run, Forest, run! 
 - Chamomile, Kava, wuling - no benefit over placebo, and risk of contaminants
 - Valerian - hepatoxicity risk, acts like a benzo, including a butt-ugly withdrawal that can cause psychosis. Avoid.
 - Melatonin - best for pts with circadian sleep/wake rhythm disorder or if low melatonin levels. See above.
Mood stabilizers:
 - Gabapentin. Useful, is also one of the only agents that enhances slow-wave delta sleep, which may be helpful for chronic pain syndromes.
What about the orexin receptor antagonists?
 - Suvorexant (Belsomra): keep dose low d/t next-day impairment. High potential for abuse. Plus, it’s expensive.