Choosing Wisely:

Don’t routinely continue sedative hypnotics (Restoril, Ambien), diphenhydramine (Benadryl), benzodiazepines, or serotonin modulators (Trazadone) for long-term treatment of insomnia in geriatric populations. Consider the use of cognitive behavioral therapy as an alternative.

Rationale and Comments: Use of diphenhydramine (or other first generation antihistamines), benzodiazepines, or sedative hypnotics with anticholinergic side effects should be avoided, as the data suggests these drugs may cause confusion and delirium in the short term, and some have been associated with an increased risk of dementia with long-term use. These drugs are associated with a five-fold increase in adverse cognitive events, an increase in adverse psychomotor events, and are associated with an increased risk of falls. The 2019 updated Beers criteria for potentially inappropriate medications for use in older adults recognized these medications as problematic.
Sponsoring Organizations:
  • Society for Post-Acute and Long-Term Care Medicine
  • Sources:
  • Randomized controlled trials
  • Disciplines:
  • Psychiatric and Psychologic
  • Geriatric Medicine
  • References: • Choosing Wisely. Insomnia and anxiety in older people. https://www.choosingwisely.org/wp-content/uploads/2018/02/Treating-Insomnia-And-Anxiety-In-Older-People-AGS.pdf
    • Jacobs GD, et al. Cognitive behavior therapy and pharmacotherapy for insomnia: a randomized controlled trial and direct comparison. Arch Intern Med. 2004;164:1888-1896.
    • McMillan JM, et al. Management of insomnia and long-term use of sedative-hypnotic drugs in older patients. CMAJ. 2013;185(17):1499-1505.
    • Mysliwiec V, et al. The management of chronic insomnia disorder and obstructive sleep apnea: synopsis of the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guidelines. Ann Intern Med. 2020;172(5):325-336.
    • By the American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American Geriatrics Society 2015 updated Beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63(11):2227-2246.
    • Espinoza RT. Clarifying the relationship between benzodiazepines and dementia. J Am Med Dir Assoc. 2020;21(2):143-145.
    • Patel K. High-risk prescriptions for aging patients. In: Chun A. (eds) Geriatric Practice. Springer, Cham. 2020.
    • Ankuda CK, et al. Diagnosis and management of delirium. In: Chun A. (eds) Geriatric Practice. Springer, Cham. 2020.
    • Cummings K, et al. Driving. In: Chun A. (eds) Geriatric Practice. Springer, Cham. 2020.
    • GeriatricsCareOnline.org, American Geriatrics Society. American Geriatrics Society Updated Beers Criteria®. January 31, 2019. https://geriatricscareonline.org/toc/american-geriatrics-societyupdated-beers-criteria/CL001

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