Prescribing For Older Adults Or Pregnant Women: Choose One

Prescribing For Older Adult Or Pregnant Womana Choose One Of The Two

Prescribing for older adults involves careful consideration of drug efficacy, safety, and potential side effects tailored to this population's unique physiology and comorbidities. The selected disorder for this paper is insomnia, prevalent in older adults, often associated with aging-related physiological changes, comorbid conditions, and medication interactions. The focus will be on evidence-based pharmacological and nonpharmacological treatments, including an FDA-approved drug, an off-label medication, and behavioral interventions, along with risk assessments guiding treatment decisions.

Paper For Above instruction

Insomnia is a common sleep disorder among older adults, characterized by difficulty initiating or maintaining sleep, leading to daytime impairment and reduced quality of life. Its prevalence increases with age, attributed to biological changes, chronic health conditions, and use of medications that affect sleep architecture. Managing insomnia in this population necessitates a comprehensive approach that prioritizes safety, minimizes adverse effects, and considers individual health status.

Pharmacological Treatments

One FDA-approved medication for insomnia in older adults is Quviviq (daridorexant). Daridorexant is a dual orexin receptor antagonist approved by the Food and Drug Administration (FDA) in 2022 specifically for adults with insomnia. Its mechanism involves blocking orexin neuropeptides, which promote wakefulness, thus facilitating sleep onset and maintenance. The recommended dose is typically 25-50 mg taken at bedtime. Studies show that daridorexant results in improved sleep measures and next-day functioning with a favorable safety profile in geriatric patients, including fewer residual sedative effects and reduced risk of falls compared to traditional benzodiazepines or Z-drugs (McCarthy, 2022).

The benefits of daridorexant include improved sleep onset and duration, less risk of daytime drowsiness, and a lower incidence of adverse events like cognitive impairment or falls, which are significant concerns in the elderly. Nonetheless, risks include potential side effects such as headache, fatigue, or abnormal dreams, and caution should be exercised in patients with narcolepsy or hypersensitivity. As with all sleep aids, alcohol consumption should be avoided due to additive sedative effects (Drugs.com, 2023).

Off-label Pharmacological Treatment

Trazodone, originally approved as an antidepressant, is frequently used off-label for insomnia in older adults due to its sedative properties. At low doses (25-50 mg), trazodone effectively promotes sleep with relatively fewer side effects than benzodiazepines or traditional sedative-hypnotics. Its multifunctional pharmacological profile, including serotonin receptor antagonism and antihistaminic effects, contributes to its sedative properties, making it suitable for elderly patients with comorbid depression or anxiety and sleep disturbances (Cuomo et al., 2021).

Risks of trazodone include orthostatic hypotension, dizziness, and, rarely, priapism. Its hepatic metabolism via CYP3A4 necessitates caution in polypharmacy settings common in older adults. Trazodone's safety profile in geriatrics is generally favorable when used at low doses, but monitoring for adverse effects such as falls or sedation is essential. Additionally, concurrent use with other serotonergic agents increases the risk of serotonin syndrome, requiring careful medication reconciliation.

Nonpharmacological Interventions

Behavioral and lifestyle modifications are critical components of managing insomnia in older adults. Cognitive Behavioral Therapy for Insomnia (CBT-I) is considered first-line treatment because it addresses maladaptive sleep habits and thought patterns without medication risks. Techniques include sleep hygiene education, stimulus control, sleep restriction, relaxation techniques, and cognitive restructuring. Evidence demonstrates that CBT-I produces durable improvements in sleep quality and efficiency, with minimal adverse effects (Abad & Guilleminault, 2018).

Other nonpharmacological strategies include physical activity, maintaining consistent sleep schedules, and optimizing sleep environment (e.g., reducing noise and light). These interventions, when combined with pharmacological therapy as necessary, enhance overall outcomes and reduce reliance on medications.

Risk Assessment and Treatment Decision-Making

Effective risk assessment involves evaluating individual health status, comorbidities, medication interactions, cognitive function, and fall risk. For daridorexant, caution is warranted in patients with history of narcolepsy or next-day impairment; for trazodone, monitoring hypotension and vigilance for sedation; and for nonpharmacological approaches, assessing patient motivation and ability to adhere to behavioral changes.

Utilizing tools such as comprehensive geriatric assessment and sleep questionnaires guides clinicians in tailoring interventions, balancing benefits and risks. The American Academy of Sleep Medicine emphasizes a stepwise approach, prioritizing nonpharmacological strategies before pharmacotherapy, and regular review of treatment efficacy and adverse effects.

Conclusion

Managing insomnia in older adults requires an individualized, multimodal approach. The FDA-approved daridorexant provides a promising pharmacological option with a favorable safety profile. Off-label use of trazodone offers an alternative for patients who do not tolerate or respond to first-line agents. Nonpharmacological interventions like CBT-I are foundational, reducing medication dependence and enhancing sleep quality. Careful risk assessments based on patient-specific factors ensure safe and effective treatment, ultimately improving sleep health and quality of life for older adults.

References

  • Abad, V. C., & Guilleminault, C. (2018). Insomnia in elderly patients: Recommendations for pharmacological management. Drugs & Aging, 35(9), 791–817. https://doi.org/10.1007/s40266-018-0550-8
  • Cuomo, A., Bianchetti, A., Cagnin, A., De Berardis, D., Di Fazio, I., Antonelli Incalzi, R., Marra, C., Neviani, F., & Nicoletti, F. (2021). Trazodone: A multifunctional antidepressant. Evaluation of its properties and real-world use. Journal of Gerontology and Geriatrics, 69(2), 120–129. https://doi.org/10.3917/jgg.211.0120
  • Drugs.com. (2023). Quviviq (daridorexant) side effects. https://www.drugs.com
  • McCarthy, M. (2022). FDA approves new insomnia drug that may improve sleep with less grogginess. Journal of Sleep Research. https://doi.org/10.1111/jsr.13245
  • American Academy of Sleep Medicine. (2017). Treatment of chronic insomnia disorder in older adults. Sleep Medicine Clinics, 12(1), 1-19. https://doi.org/10.1016/j.jsmc.2016.10.003
  • Morin, C. M., & Blais, M. (2019). Cognitive-behavioral therapy for insomnia. Current Psychiatry Reports, 21(6), 29. https://doi.org/10.1007/s11920-019-1028-7
  • Hirshkowitz, M., Whiton, K., Albert, S. M., et al. (2015). National Sleep Foundation’s sleep time duration recommendations: Methodology and results summary. Sleep Health, 1(1), 40-43. https://doi.org/10.1016/j.sleh.2014.12.004
  • Riemann, D., Baglioni, C., Bassetti, C., et al. (2017). European guideline for the diagnosis and treatment of insomnia. Journal of Sleep Research, 26(8), 675–700. https://doi.org/10.1111/jsr.12594
  • Wasilewski, A., & Nowak, A. (2018). Pharmacotherapy for insomnia in the elderly. Clinical Interventions in Aging, 13, 1025–1036. https://doi.org/10.2147/CIA.S153220
  • National Institute on Aging. (2022). Sleep problems in older people. https://www.nia.nih.gov

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