Glass J, Lanctot KL, Herrmann N, Sproule BA, Busto UE. Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits. BMJ 331: 1169

Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
BMJ (online) (Impact Factor: 17.45). 11/2005; 331(7526):1169. DOI: 10.1136/bmj.38623.768588.47
Source: PubMed


To quantify and compare potential benefits (subjective reports of sleep variables) and risks (adverse events and morning-after psychomotor impairment) of short term treatment with sedative hypnotics in older people with insomnia.
Medline, Embase, the Cochrane clinical trials database, PubMed, and PsychLit, 1966 to 2003; bibliographies of published reviews and meta-analyses; manufacturers of newer sedative hypnotics (zaleplon, zolpidem, zopiclone) regarding unpublished studies.
Randomised controlled trials of any pharmacological treatment for insomnia for at least five consecutive nights in people aged 60 or over with insomnia and otherwise free of psychiatric or psychological disorders.
24 studies (involving 2417 participants) with extractable data met inclusion and exclusion criteria. Sleep quality improved (effect size 0.14, P < 0.05), total sleep time increased (mean 25.2 minutes, P < 0.001), and the number of night time awakenings decreased (0.63, P < 0.001) with sedative use compared with placebo. Adverse events were more common with sedatives than with placebo: adverse cognitive events were 4.78 times more common (95% confidence interval 1.47 to 15.47, P < 0.01); adverse psychomotor events were 2.61 times more common (1.12 to 6.09, P > 0.05), and reports of daytime fatigue were 3.82 times more common (1.88 to 7.80, P < 0.001) in people using any sedative compared with placebo.
Improvements in sleep with sedative use are statistically significant, but the magnitude of effect is small. The increased risk of adverse events is statistically significant and potentially clinically relevant in older people at risk of falls and cognitive impairment. In people over 60, the benefits of these drugs may not justify the increased risk, particularly if the patient has additional risk factors for cognitive or psychomotor adverse events.

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    • "Epidemiology, pathophysiology and treatment of sleep disorders in CRF and dialysis patients are still unclear and requires further research (Haba-Rubio et al., 2011). Our patients were relatively young as compared to other studies which stated that the sleep the general population as reported by Makhlouf et al. (2007); Colbay et al. (2007); Mavanur et al. (2010); Glass et al. (2005); Guney et al. (2010); Elias et al. (2009); Roumeliote et al. (2011); Sabbattini et al. (2003); Sakkas et al. (2008). This was not observed in HD population, on the contrary younger age ranges were reported by Koch et al. (2008) and Musci et al. (2004). "

    Full-text · Article · Jan 2015
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    • "Despite these limitations, our results illustrate benzodiazepine use is associated with greater long-term risk for limited life-space mobility differentially by residency status, greater difficulty with basic ADL, and more frequent pain. Clinicians should exercise caution when prescribing benzodiazepines to older adults as they may confer risks described in this study as well as in other domains such as falls, fractures and other injuries documented heavily in the extant literature (Glass et al., 2005). If benzodiazepines are prescribed, patients should take them as indicated by their provider and generally should refrain from taking them longer than two to four weeks to reduce risk of physical dependence and other long-term risks indicated from the present results. "
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    ABSTRACT: The aim of the study was to determine the prospective association between baseline BZD use and mobility, functioning, and pain among urban and rural African-American and non-Hispanic white community-dwelling older adults. From 1999 to 2001, a cohort of 1000 community-dwelling adults, aged ≥65 years, representing a random sample of Medicare beneficiaries, stratified by ethnicity, sex, and urban/rural residence were recruited. BZD use was assessed at an in-home visit. Every six months thereafter, study outcomes were assessed via telephone for 8.5-years. Mobility was assessed with the Life-Space Assessment (LSA). Functioning was quantified with level of difficulty in five basic activities of daily living (ADL: bathing, dressing, transferring, toileting, eating), and six instrumental activities of daily living (IADL: shopping, managing money, preparing meals, light and heavy housework, telephone use). Pain was measured by frequency per week and the magnitude of interference with daily tasks. All analytic models were adjusted for relevant covariates and mental health symptoms. After multivariable adjustment, baseline BZD use was significantly associated with greater difficulty with basic ADL (Estimate=0.39, 95% confidence interval (CI): 0.04-0.74), and more frequent pain (Estimate=0.41, 95%CI: 0.09-0.74) in the total sample and declines in mobility among rural residents (Estimate=-0.67, t(5,902)=-1.98, p=0.048), over 8.5 years. BZD use was prospectively associated with greater risk for basic ADL difficulties and frequent pain among African-American and non-Hispanic white community-dwelling older adults, and life-space mobility declines among rural-dwellers, independently of relevant covariates. These findings highlight the potential long-term negative impact of BZD use among community-dwelling older adults.
    Full-text · Article · Sep 2014 · Archives of Gerontology and Geriatrics
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    • "Nevertheless, observational studies suggest that z-hypnotics are not safer regarding falls [12] or hip fractures [13, 14], probably by inducing or worsening impairment of balance and cognition. Further, the effectiveness of z-hypnotics is limited among people aged 60 years or older, which has led to a great controversy on the use of these drugs among older people [24]. Cognitive behavioural therapy (including, e.g. "
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    ABSTRACT: Purpose Anxiolytics and hypnotics are widely used and may cause injurious falls. We aimed to examine associations between exposure to anxiolytics and hypnotics and the risk of hip fracture among all older people in Norway. Further, we wanted to examine associations between exposure to hypnotics and time of fracture. Methods A nationwide prospective cohort study of people in Norway born before 1945 (n = 906,422) was conducted. We obtained information on all prescriptions of anxiolytics and hypnotics dispensed in 2004–2010 (the Norwegian Prescription Database) and all primary hip fractures in 2005–2010 (the Norwegian Hip Fracture Registry). We compared the incidence rates of hip fracture during drug exposure and non-exposure by calculating the standardized incidence ratio (SIR). Results Altogether, 39,938 people (4.4 %) experienced a primary hip fracture. The risk of hip fracture was increased for people exposed to anxiolytics (SIR 1.4, 95 % confidence interval (CI) 1.4–1.5) and hypnotics (SIR 1.2, 95 % CI 1.1–1.2); the excess risk was highest regarding short-acting benzodiazepine anxiolytics (SIR 1.5, 95 % CI 1.4–1.6). Benzodiazepine-like hypnotics (z-hypnotics) were associated with higher excess risk of hip fracture at night (SIR 1.3, 95 % CI 1.2–1.4) than during the day (SIR 1.1, 95 % CI 1.1–1.2). Conclusions Older people had an increased risk of hip fracture during anxiolytic or hypnotic drug use, including short-acting benzodiazepine anxiolytics and z-hypnotics that were previously considered less harmful; cautious prescribing is therefore needed. People using z-hypnotics were at greatest excess risk at night; this association deserves further investigation.
    Full-text · Article · Jul 2014 · European Journal of Clinical Pharmacology
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