BMJ  2005;331:1169 (19 November), doi:10.1136/bmj.38623.768588.47 (published 11 November 2005)

Paper

Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits

Jennifer Glass, PhD candidate1, Krista L Lanctôt, scientist, neuroscience research program3, Nathan Herrmann, head, division of geriatric psychiatry4, Beth A Sproule, research scientist, division of clinical research2, Usoa E Busto, head, clinical neuroscience section2

1 University of Toronto, Department of Pharmaceutical Sciences, Toronto, ON, Canada M5S 2S2, 2 Centre for Addiction and Mental Health, Toronto, ON, Canada M5S 2S1, 3 Department of Psychiatry, University of Toronto, Neuroscience Research Program, Sunnybrook and Women's College Health Sciences Centre, Toronto, ON, Canada M4N 3M5, 4 Division of Geriatric Medicine, University of Toronto, Department of Medicine, Sunnybrook and Women's College Health Sciences Centre

Correspondence to: U E Busto usoa_busto{at}camh.net

Objectives 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.

Data sources 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reviews and meta-analyses; manufacturers of newer sedative hypnotics (zaleplon, zolpidem, zopiclone) regarding unpublished studies.

Selection criteria 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.

Results 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.

Conclusions 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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