Karl Doghramji, MD: Managing Elderly Insomnia Prescription


Benzodiazepines are a common yet not very well understood drug class for elderly patients with insomnia.

The market for insomnia pharmacologic therapies is fairly full. The real hurdle physicians must handle when prescribing a patient is the intricacies of their condition, and what their treatment goals are.

In an interview with MD Magazine®, Karl Doghramji, MD, a professor at Thomas Jefferson University, detailed his criteria for insomnia prescribing, as well as his points of advice for physicians prescribing benzodiazepines.

MD Mag: What is your criteria for determining insomnia treatment options in the elderly?

Doghramji: The question of which drug to use for which patients rests on a number of parameters, the first 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's 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’s other sets of agents.

And after the combination, then there are other agents as well. In general, if it's a sleep initiation problem, only something like ramelteon, zolpidem, zaleplon may be appropriate.

If it's a sleep maintenance problem, low-dose doxepin, 3 or 6 milligrams, may be appropriate. If it's a problem involving both sleep initiation and maintenance, zolpidem extended-release, eszopiclone, as well as suvorexant may be appropriate.

A second consideration is whether the patient has some comorbidities and safety issues. So, respiratory compromise, sleep apnea, COPD—which are common in the elderly. If those are present, that favors the use of agents which have been tested in these disorders. Agents like suvorexant and ramelteon seem to be a safe in the use of mild and moderate sleep apnea and mild and moderate COPD.

Finally, if the patient has a history of drug addiction, if that's the case, the agents that don't have GABAergic potential that are not scheduled—for example, ramelteon and doxepin low-dose—may be appropriate.

MD Mag: What is the importance of patient education when prescribing benzodiazepines?

Doghramji: So I think it's important to educate patients on the use of benzos. One of the most important lesson is that they should take them right at bedtime and go to sleep, as opposed to taking them a little bit before bedtime and be and walking around. Many elderly begin to have motor imbalance, without being aware of the cognitive effects that the drug may be having on them and the motor effects.

So, take the drug at bedtime, go right to bed, don't mix with alcohol—which seems to reinforce amnestic behavior and respiratory compromise. And, not to mix with other sedating compounds as much as possible.

Third: warn older individuals and anybody takes these medications that if they do develop parasomnia behavior—getting out of bed, walking out of bed—to discontinue drug right away and call the physician.

Fourth: tell the physician at all times if they develop new medical conditions which may impact the patient negatively if mixed with the drug. And of course, tell the doctor anytime they have a new prescription for another medication.

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