What are the side effects of trazodone for older adults?

Trazodone is a type of antidepressant known as a serotonin antagonist and reuptake inhibitor (SARI). Also known by the brand name Desyrel, trazodone is FDA-approved to treat symptoms of major depressive disorders. It’s also frequently prescribed off-label to alleviate symptoms of anxiety, insomnia, obstructive sleep apnea, and fibromyalgia. Like many other mental health medications, trazodone works by balancing the levels of serotonin in your brain.

While trazodone is generally safe, it has several possible short- and long-term side effects. It’s important to know what to look for before you start taking this prescription.

Common side effects of trazodone for older adults

According to clinical trials, the most common side effect is drowsiness or sedation, followed by lightheadedness, nausea, and dry mouth. Older adults may also experience dizziness, confusion, constipation, blurred vision, and headache, says Arpit Aggarwal, MD, a psychiatrist with University of Missouri Health Care.

Serious side effects of trazodone for older adults

Some of the serious side effects of trazodone are particularly dangerous for older adults, while others are potentially dangerous for anyone taking this medication. In general, serious side effects of trazodone include:

• Priapism, or prolonged erection in males, lasting more than six hours. This is a medical emergency requiring immediate attention to prevent permanent damage, says Dr. Aggarwal.
• Orthostatic hypotension, or low blood pressure when moving into a standing position, which can result in fainting.
• Increased risk of suicidal thoughts, especially in children and young adults.
• Increased risk of serotonin syndrome, a drug reaction that results in too much serotonin being produced by the brain.
• Abnormal heart rhythm or cardiac arrhythmias, specifically something called QT prolongation, an issue with the electrical activity regulating your heartbeat.
• Weight gain or weight loss. In clinical trials of outpatients taking trazodone, 5% of participants reported weight gain, and 7% reported weight loss.

For the elderly population specifically, certain side effects of trazodone can become serious or cause further complications, notes Dr. Aggarwal, such as:

• Dizziness, which can be exacerbated by other medications and increases the risk of falls and injuries.
• Blurred vision, which also presents a fall risk and interferes with safe driving.
• Cognitive impairment and confusion symptoms can be made worse if you already have an existing cognitive disorder like dementia or Alzheimer’s disease.
• Hyponatremia, or low sodium levels, which may be exacerbated by drugs such as diuretics.

How soon do trazodone side effects start for older adults?

It depends on the individual side effect, says Dr. Aggarwal. You might experience side effects as soon as your first dose, or it may take several weeks. Typically, milder symptoms such as sleepiness, headache, and dry mouth are more likely to occur right away, or within the first few hours after taking the drug. Side effects like weight loss, weight gain, and cardiac arrhythmia are more likely after prolonged use of trazodone. These side effects are dose-dependent, with higher doses causing increased side effects.

How long do trazodone side effects last for older adults?

The most common side effects of trazodone, like dizziness, dry mouth, and headache, often go away after one to two weeks. Some of the more serious side effects, like cognitive impairment, may last longer. Your provider may start you on a lower daily dose initially and gradually increase to a higher dose as these early, mild symptoms resolve.

However, some people never fully tolerate the side effects, says Upinder Singh, MD, internist, geriatric specialist, and chief medical officer of Valley Oaks Medical Center. Talk to your provider if you are still having side effects after two to three weeks of taking the medication.

What are the long-term side effects of trazodone for older adults?

Unfortunately, there are no systematic studies on the side effects of long-term trazodone use. There is no data on how many people are affected or what other risk factors—like co-existing medical conditions or interactions with other medications that increase the chances of side effects, says Dr. Singh. Furthermore,  it can be difficult to determine whether long-term side effects are actually caused by trazodone since many older adults are taking other medications that may interact with trazodone and also lead to serious issues.

However, heart palpitations, diarrhea, and blurred vision are the side effects most commonly associated with long-term use of the drug, Dr. Singh notes. These risks are increased with higher doses of trazodone. According to a 2015 case report, prolonged use of 150 to 200 milligrams of trazodone per day is more likely to cause side effects than low doses or short-term doses. In some cases, sexual side effects such as lower libido may also occur.

Trazodone warnings for older adults

Trazodone is an antidepressant that may increase suicidal thoughts, so it has been issued a black box warning by the FDA. It should be used with caution in patients with mental health conditions and other health conditions. For example, Dr. Aggarwal says people with compromised liver or renal function should be careful taking trazodone.

There is a long list of medications that could potentially interact with trazodone. Some of the more common drugs include triptans for migraine, other antidepressants, NSAIDs (such as Advil), and warfarin, which is used as a blood thinning agent.

While many people can safely take trazodone when they have other medical conditions or are taking other prescription drugs, some people should not take trazodone at all. This typically includes people with angle-closure glaucoma (increased pressure in the eye), cardiac arrhythmias (especially QT prolongation), or a history of priapism, says Dr. Singh. The manufacturer of trazodone also advises that people taking monoamine oxidase inhibitors (MAOIs) not use the drug.

All that said, trazodone is still considered a fairly safe drug. In fact, it’s safer than many other sleep medications, including Ambien, diphenhydramine, and benzodiazepines such as Ativan and Xanax, says Alex Dimitriu, MD, psychiatrist, sleep medicine specialist, and founder of Menlo Park Psychiatry & Sleep Medicine.

Trazodone is generally not habit-forming, though it’s better to taper off the dose slowly rather than stop abruptly, says Dr. Singh. If trazodone is suddenly stopped when you’re on higher doses, it may cause irritability, sleep problems, and excessive sweating. These are considered mild withdrawal symptoms, but they can be easily avoided with guidance from a healthcare provider. While it’s possible to overdose on trazodone, it’s not common with appropriate use.

Managing trazodone side effects in the elderly

Although trazodone can cause several short- and long-term side effects, some of these effects can be managed with easy-to-implement strategies. Dr. Dimitriu shares the following advice for managing trazodone side effects in elderly patients:

1. Take it at night. Even if you’re not using it for insomnia, trazodone can be sedating. Remember to be cautious when getting up at night to use the bathroom. Sit up in bed and then stand slowly, using supports if needed, to avoid falls.
2. Start with a low dose. Ask your provider about starting on a low dose at first and then increasing the amount slowly until you find the lowest effective dose for you.
3. Practice good sleep hygiene. Though it’s an antidepressant, trazodone is commonly used for insomnia. A good sleep hygiene routine can also help manage insomnia symptoms. Exercise daily; set regular bedtimes and wake times; limit technology use after 10 p.m.; and create a cool, comfortable sleep environment.
4. Take on an empty stomach. Though taking trazodone with food can mitigate any nausea the drug causes, taking it on an empty stomach—if you can tolerate it—will help it work more effectively.
5. Prioritize rest. Adults naturally sleep a little less as they age, but getting enough sleep is important for overall health and can improve memory, focus, attention, and emotional regulation. If you’re not sleeping well at night, talk to your healthcare provider.

Though trazodone is generally a safe and effective treatment for health conditions such as depression and insomnia, it’s not without risks and drug interactions. It’s important always to inform your prescribing healthcare provider of existing health conditions and all the medications you take—including supplements and over-the-counter treatments.

If you are taking trazodone and experience any of the following, contact your healthcare provider immediately or seek urgent medical care:

• Confusion
• Loss of balance
• Muscle weakness
• Irregular heart rate or breathing
• Erection lasting longer than four hours
• Excessive drowsiness
• Vomiting
• Seizures
• New or worsening symptoms of depression
• Suicidal thoughts

These can be signs of a serious adverse reaction and require immediate medical attention.