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INSOMNIA IN THE ELDERLY: HYPNOTIC DRUGS SHOULD NOT BE "MAINSTAY"

Executive Summary

INSOMNIA IN THE ELDERLY: HYPNOTIC DRUGS SHOULD NOT BE "MAINSTAY" of treatment, an NIH panel concluded March 28 at a three-day meeting convened to develop a consensus statement on sleep disorders in older persons. Specifically, the group's recommendations include a statement that: "hypnotic medications should not be the mainstay of treatment of insomnia, are overused and have addictive potential." Hypnotic medications and sedative tricyclics are sometimes useful as short-term, intermittent treatment for "temporary problems such as bereavement, dislocation, and situational anxiety," the group indicated. However, "there are no studies which demonstrate their long term effectiveness," the statement added. During briefings on the statement, the panelists noted that their recommendations apply to both prescription and OTC drugs. The final language is more forceful than that contained in the first version of the consensus statement. Earlier in the day, the panel read its proposed statement and invited public comment. The draft stated only that "hypnotic drugs should not be the mainstay of treatment of insomnia." The emphases on "not" and additional language were chosen after audience members suggested that current data indicate that many clinicians rely upon such drugs, use of the products has increased, and the wording might not clearly signal a need to alter current treatment patterns. "Given the changes in drug metabolism associated with increasing age, all medication should be use with caution, especially those with long half-lives," the document advises. "Older people should avoid over-the-counter sleep medication due to their anticholinergic effects and questionable efficacy." There are no precise data on the prevalence of sleep disorders, but the panel cited estimates that sleep disturbances affect more than half of people over age 65 and about two-thirds of nursing home residents. One theme of the panel document is that while sleeping patterns change somewhat with age, serious problems with falling asleep and daytime sleepiness are not a given of old age, and that clinicians need to determine whether medical problems underlie sleep disorders. While insomnia has multiple causes, obstructive sleep apnea in particular can be a "potentially severe" cause of daytime hypersomia (sleepiness). Effective treatments exist for both insomnia and sleep apnea, the group says. Insomnia may be "of psychiatric (e.g., depression, anxiety), physiological (e.g., central apnea, limb movement), pharmacological (e.g., prescribed or unprescribed drugs or alcohol), or medical origin," the consensus document points out. Thus, treatment requires a thorough medical exam and will vary with the underlying problem.
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