BMJ, doi: 10.1136/bmj.38623.768588.47, (Published 11 November 2005)

PAPERS

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

Jennifer Glass ¹, Krista L Lanctôt ², Nathan Herrmann ³, Beth A Sproule ⁴, Usoa E Busto ^4*

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

^* Correspondence to: 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reviews and meta-analyses; manufacturers of newer sedative hypnotics (zaleplon, zolpidem, zopiclone) regarding unpublished studies.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.

---

(Accepted 16 September 2005)
CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    Technorati    What's this?

Relevant Articles

Uncertainty in heterogeneity estimates in meta-analyses

John P A Ioannidis, Nikolaos A Patsopoulos, and Evangelos Evangelou
BMJ 2007 335: 914-916. [Extract] [Full Text] [PDF]

Older people are wrongly excluded from drug trials

Christiane Rehwagen
BMJ 2005 331: 1360. [Extract] [Full Text]

Sedative use in older people with insomnia may not be advantageous
BMJ 2005 331: 0. [Full Text] [PDF]

This article has been cited by other articles:

• Cimolai, N. (2007). Zopiclone: Is it a pharmacologic agent for abuse?. cfp 53: 2124-2129 [Abstract] [Full text]  
• Ioannidis, J. P A, Patsopoulos, N. A, Evangelou, E. (2007). Uncertainty in heterogeneity estimates in meta-analyses. BMJ 335: 914-916 [Full text]  
• Hartikainen, S., Lonnroos, E., Louhivuori, K. (2007). Medication as a Risk Factor for Falls: Critical Systematic Review. J. Gerontol. A Biol. Sci. Med. Sci. 62: 1172-1181 [Abstract] [Full text]  
• Haw, C., Stubbs, J. (2007). Benzodiazepines a necessary evil? A survey of prescribing at a specialist UK psychiatric hospital. J Psychopharmacol 21: 645-649 [Abstract]  
• Wolkove, N., Elkholy, O., Baltzan, M., Palayew, M. (2007). Sleep and aging: 2. Management of sleep disorders in older people. CMAJ 176: 1449-1454 [Abstract] [Full text]  
• Greenblatt, D. J., Harmatz, J. S., Karim, A. (2007). Age and Gender Effects on the Pharmacokinetics and Pharmacodynamics of Ramelteon, a Hypnotic Agent Acting via Melatonin Receptors MT1 and MT2. J Clin Pharmacol 47: 485-496 [Abstract] [Full text]  
• SIVERTSEN, B., NORDHUS, I. H. (2007). Management of insomnia in older adults. Br. J. Psychiatry 190: 285-286 [Abstract] [Full text]  
• Clarfield, A M. (2006). Review: sedative hypnotics increase adverse effects more than they improve sleep quality in older persons with insomnia. Evid. Based Med. 11: 110-110 [Full text]  
• Sivertsen, B., Omvik, S., Pallesen, S., Bjorvatn, B., Havik, O. E., Kvale, G., Nielsen, G. H., Nordhus, I. H. (2006). Cognitive behavioral therapy vs zopiclone for treatment of chronic primary insomnia in older adults: a randomized controlled trial.. JAMA 295: 2851-2858 [Abstract] [Full text]  
• (2006). Risks and Benefits of Sedative Use in Older People. JWatch Psychiatry 2006: 9-9 [Full text]  
• (2006). Carphology by Rajendra. PN 6: 66-66 [Full text]  
• (2006). Risks and Benefits of Sedative Use in Older People. Journal Watch Cardiology 2006: 7-7 [Full text]  
• (2005). Risks and Benefits of Sedative Use in Older People. JWatch General 2005: 4-4 [Full text]  

Rapid Responses:

Read all Rapid Responses

Tautology in medicine

John F Corish
bmj.com, 21 Nov 2005 [Full text]

Let the patient decide

Peter A Haynes
bmj.com, 24 Nov 2005 [Full text]

Cancer Risk and Sedative Hypnotics

Justin Stebbing, et al.
bmj.com, 24 Nov 2005 [Full text]

Odds ratio for psychomotor adverse events, and sample characteristics

Debasish Basu
bmj.com, 24 Nov 2005 [Full text]

Sedative hypnotics in older people with insomnia; who benefits?

Charles N Antwi
bmj.com, 25 Nov 2005 [Full text]

Care needed to avoid creating hypnotic dependency in hospital inpatients.

Isabel E.R. Ellory
bmj.com, 5 Dec 2005 [Full text]

Neuropsychiatric reactions associated with zolpidem and zopiclone?

Geraldine M Moses, et al.
bmj.com, 6 Mar 2007 [Full text]