Non-benzodiazepine hypnotic sleep agents pose high risk for older adults

Earlier this year, the American Geriatrics Society updated the Beers Criteria for potentially inappropriate medication use in older adults. Non-benzodiazepine hypnotic sleep agents – such as those marketed under the brand names Lunesta® (eszopiclone), Ambien® (zolpidem) and Sonata® (zaleplon) – are not recommended for chronic use (considered longer than 90 days), and have been shown to have minimal improvements in sleep latency and duration. (1) This drug class has shown to improve sleep latency only up to 16 minutes and improve wake after sleep onset up to 25 minutes compared to placebo.(2,3)

With minimal evidence for efficacy, these agents are inappropriately used chronically – something that carries safety risks in older patients. These drugs may alter postural stability and equilibrium, leading to greater risk of falls and hip fractures. One study found the falling prevalence to be as high as 16.9 percent. (4) These high-risk injuries imply a significant number of fractures and consequential costs. (5) Trazodone and melatonin could be considered as safer alternatives for patients who have tried and failed to achieve success with non-pharmacological treatment recommendations.

Non-pharmacological sleep hygiene: first-line recommendations

  • Sleep only as much as needed to feel rested
  • Avoid caffeinated beverages after lunch
  • Avoid alcohol near bedtime; no nightcap
  • Keep a regular sleep schedule
  • Do not go to bed hungry
  • Avoid forcing sleep
  • Avoid smoking, especially in the evening
  • Adjust bedtime environment
  • Exercise regularly for at least 20 minutes daily
  • Deal with worries prior to bedtime

References:

  1. The American Geriatrics Society 2012 Beers Criteria Update Expert Panel. AGS Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc 2012.
  2. Erman MK, Zammit G, Rubens R, et al. A polysomnographic placebo-controlled evaluation of the efficacy and safety of Eszopiclone Relative to Placebo and Zolpidem in the Treatment of Primary Insomnia. J Clin Sleep Med.2008;4(3):229-234.
  3. Walsh J, Soubrane C, Roth T. Efficacy and Safety of Zolpidem Extended Release in Elderly Primary Insomnia Patients. Am J Geriatr Psychiatry. 2008 Jan; 16 (1):44-57
  4. Allain H, Bentue-Ferrer D, Polard E, et al. Postural Instability and Consequent Falls and Hip Fractures Associated with use of Hypnotics in the Elderly: a comparative review. Drugs Aging.2005; 22 (9):749-765
  5. Finkle WD, Der JS, Greenland S, et al. Risk of Fractures Requiring Hospitalization After an Initial Prescription of Zolpidem, Alprazolam, Lorazepam or Diazepam in Older Adults. J Am Geriatr Soc 2011; 59 (10): 1883-1890