A 76-year-old man comes to the office due to severe insomnia of several months' duration. He has trouble falling asleep and feels tired and irritable during the day. The patient's other medical problems include hypertension and a prior cerebrovascular accident with residual right leg weakness. He takes aspirin, rosuvastatin, and lisinopril regularly as prescribed. Temperature is 36.7 C (98.1 F), blood pressure is 118/76 mm Hg, pulse is 62/min, and respirations are 14/min. Examination shows clear lungs with normal S1 and S2. The abdomen is soft and nontender. In addition to nonpharmacologic interventions for insomnia, short-term pharmacologic therapy is being considered. Which of the following medications has the lowest risk of causing adverse effects in this patient?

Question

A 76-year-old man comes to the office due to severe insomnia of several months' duration.  He has trouble falling asleep and feels tired and irritable during the day.  The patient's other medical problems include hypertension and a prior cerebrovascular accident with residual right leg weakness.  He takes aspirin, rosuvastatin, and lisinopril regularly as prescribed.  Temperature is 36.7 C (98.1 F), blood pressure is 118/76 mm Hg, pulse is 62/min, and respirations are 14/min.  Examination shows clear lungs with normal S1 and S2.  The abdomen is soft and nontender.  In addition to nonpharmacologic interventions for insomnia, short-term pharmacologic therapy is being considered.  Which of the following medications has the lowest risk of causing adverse effects in this patient?

Quizplus · Accepted Answer

Insomnia is common in the elderly population and can significantly impair quality of life. Nonpharmacologic interventions such as sleep hygiene measures and cognitive-behavioral therapy are recommended for initial management. When nonpharmacologic interventions fail, pharmacotherapy may be indicated but must be used with extreme caution in elderly patients and should generally be limited to short-term management. Medication selection for elderly patients requires special attention to safety issues due to this population's increased sensitivity to adverse effects of medications in general and sedative-hypnotic agents in particular (eg, oversedation, dizziness, confusion, impaired psychomotor performance, ataxia). Of the currently available sedative-hypnotic agents, the melatonin agonist ramelteon has demonstrated the lowest side-effect burden in older adults. Ramelteon binds with high affinity to melatonin receptors in the suprachiasmatic nucleus. (Choices A, C, and D) Benzodiazepines should be avoided in elderly patients due to the increased risk of cognitive impairment, delirium, falls, fractures, and motor vehicle accidents when taking these medications. (Choices B and E) Amitriptyline, a tricyclic antidepressant, and diphenhydramine, an antihistamine, should be avoided in the elderly due to their strong anticholinergic effects and risks of sedation, delirium, and falls. (Choice F) Quetiapine is a second-generation antipsychotic that would not be appropriate as a first-line treatment for insomnia. Antipsychotics carry a risk of increased falls and cardiac mortality in older adults and should not be used without an appropriate indication (eg, psychosis, dangerous agitation). Educational objective: Benzodiazepines, antihistamines, and sedating antidepressants should be avoided in the treatment of insomnia in elderly patients due to their adverse effects. Ramelteon, a melatonin agonist, has a lower side-effect burden than other sedative-hypnotic agents and is effective in reducing time to sleep onset in the elderly. __________ References: Review of safety and efficacy of sleep medicines in older adults. (http://www.ncbi.nlm.nih.gov/pubmed/27751669) American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. (http://www.ncbi.nlm.nih.gov/pubmed/22376048)

A 76-Year-Old Man Comes to the Office Due to Severe