This new class of medications holds the promise of greater efficacy, as the target mechanism may more directly address the issue of the failure to inhibit wakefulness, and the potential for reduced adverse effects, especially in the domain of cognition, memory, and psychomotor behavior. More recently, a new class of pharmacologic agents, dual orexin receptor antagonists, has been developed, evaluated, approved, and introduced into prescriptive formularies. These include on-label approaches (eg, melatonin agonists, such as ramelteon) and off-label approaches (eg, sedating antidepressants, such as trazodone). 2 This being the case, other medications tend to be prescribed for older adults.

Of the pharmacologic agents indicated for the treatment of insomnia disorder, nearly all of which are γ-aminobutyric acid agonists, most are associated with significant risks for use in older adults. This is true for a variety of reasons, including the unavailability of clinicians who can provide cognitive behavioral therapy for insomnia, the universal availability of pharmacotherapy, and the reduced time commitment and behavioral work required by pharmacotherapy. While the recommended first-line treatment for insomnia is cognitive behavioral therapy for insomnia, 1 most patients will be offered or opt for medical management of their insomnia.

Accordingly, treating insomnia should be a priority, especially among older adults, as this group is at increased risk for sleep continuity disturbance (ie, problems with sleep initiation, maintenance, and duration). Insomnia, even when variably defined, is a well-established risk factor for impaired daytime functioning, unhealthy substance use, depression, other psychiatric disorders, chronic pain, and a variety of other medical conditions, including obesity, high blood pressure, cardiovascular disease, and dementia.

Insomniax alternative