A physician-validated, board-style question from the Active Transport QBank. Try it, then check the reasoning for every option.
A 62-year-old man presents to his geriatrician due to waking several times during the night and also rising too early in the morning. He says this has worsened over the past 7 months. In the morning, he feels unrefreshed and tired. His medical history is positive for hypertension and benign prostatic hyperplasia. He has never been a smoker. He denies drinking alcohol or caffeine prior to bedtime. Vital signs reveal a temperature of 36.6°C (97.8°F), blood pressure of 130/80 mm Hg, and heart rate of 77/min. Physical examination is unremarkable. After discussing good sleep hygiene with the patient, which of the following is the best next step in the management of this patient’s condition?
-
A
ZolpidemCorrect. Zolpidem (non-benzodiazepine hypnotic) is appropriate pharmacotherapy for chronic insomnia after sleep hygiene fails; preferred over benzos in geriatric patients due to less side effect burden.
-
B
TriazolamIncorrect. Triazolam is a benzodiazepine hypnotic with more side effects (amnesia, dependence) than zolpidem; particularly risky in older adults.
-
C
PolysomnographyIncorrect. Polysomnography is reserved for suspected sleep apnea, parasomnias, or other sleep disorders; not warranted here without features of OSA.
-
D
Light therapyIncorrect. Light therapy treats circadian rhythm disorders and seasonal depression, not primary insomnia.
-
E
Melatonin at bedtimeIncorrect. Melatonin is most effective for circadian rhythm disorders and jet lag with modest benefit for sleep-onset insomnia; in chronic insomnia after sleep hygiene failure, zolpidem has stronger evidence for efficacy.
↑ Tap an answer to reveal the reasoning
Answer: A. This 62-year-old man has chronic insomnia: difficulty maintaining sleep (multiple nighttime awakenings) and early morning awakening, with daytime fatigue and unrefreshing sleep. He has already been counseled on sleep hygiene without improvement. The next step in managing chronic insomnia in adults is pharmacotherapy — and zolpidem is the standard answer for primary insomnia after sleep hygiene fails.
Zolpidem is a NON-benzodiazepine hypnotic ('Z-drug') that binds selectively to the α1 subunit of the GABA-A receptor. Compared to benzodiazepines, it has less daytime sedation, less tolerance, less rebound insomnia, less abuse potential, and shorter half-life. It primarily induces sleep onset. Zolpidem ER is available for sleep maintenance issues. Other options include eszopiclone, zaleplon, ramelteon (melatonin receptor agonist), and low-dose doxepin. Cognitive behavioral therapy for insomnia (CBT-I) is the gold standard non-pharmacologic treatment but isn't an answer choice.
Triazolam is a short-acting benzodiazepine — older, more side effects (anterograde amnesia, dependence) than zolpidem; not preferred in geriatric patients due to fall risk. Polysomnography is reserved for suspected sleep apnea, parasomnias, narcolepsy, or restless legs — none of which are described (no snoring, no apneic episodes, no daytime sleepiness severe enough to suggest sleep apnea). Light therapy is for circadian rhythm disorders (delayed sleep phase, seasonal affective disorder) — not standard insomnia.
**Why each option:**
**A.** Correct. Zolpidem (non-benzodiazepine hypnotic) is appropriate pharmacotherapy for chronic insomnia after sleep hygiene fails; preferred over benzos in geriatric patients due to less side effect burden.
**B.** Triazolam is a benzodiazepine hypnotic with more side effects (amnesia, dependence) than zolpidem; particularly risky in older adults.
**C.** Polysomnography is reserved for suspected sleep apnea, parasomnias, or other sleep disorders; not warranted here without features of OSA.
**D.** Light therapy treats circadian rhythm disorders and seasonal depression, not primary insomnia.