Abstract
As aging comes, an increased prevalence of medical maladies and chronic pain independently or interactively disrupt sleep, which in turn can exacerbate either one. Furthermore, anxiety about pain can further negatively impact sleep. Fortunately, good quality sleep can improve pain management. Because benzodiazepine receptor agonists (including the “Z” drugs) can reduce anxiety and improve sleep, they seem a convenient choice. However, their use in this population, particularly for more than short-term (guidelines range from 2 to 6 weeks max), is not recommended because of increased likelihood of falls, further disruption of sleep, dependence, and problems with discontinuation (withdrawal). Besides, this population is often likely to take concomitant medication for pain or other central nervous system depressants leading to potentially serious and even life-threatening interactions involving synergistic amplification of respiratory depression (opioids being a particularly dangerous interaction). Therefore, insomnia in older adults should ideally be treated with a non-benzodiazepine receptor agonist; if indicated, they may be used, but should be closely monitored and tapered to avoid long-term adverse problems (direct or from withdrawal). Older adult patients with insomnia may be more optimally treated with sleep aids that do not interact with the GABAA receptor.
Highlights
IntroductionThe treatment of insomnia in the older chronic pain population remains problematic because many of these patients are on (usually necessary) polypharmacy, and the introduction of other medications increases the risk of potential pharmacokinetic drug-drug interactions
Older adult patients with insomnia may be more optimally treated with sleep aids that do not interact with the GABAA receptor
Most benzodiazepine prescriptions are written by non-psychiatrics; in the population of adults between 18 and 80, about 2/3rds of prescriptions are written by non-psychiatrists and in the subgroup of individuals between the ages 65 - 80, 90% of prescriptions for benzodiazepines are written by non-psychiatrists [5]
Summary
The treatment of insomnia in the older chronic pain population remains problematic because many of these patients are on (usually necessary) polypharmacy, and the introduction of other medications increases the risk of potential pharmacokinetic drug-drug interactions. A better agent for improving sleep in the geriatric chronic pain population would be an agent that would improve sleep latency (onset time), prolong the duration of sleep, prevent middle-of-the-night wakefulness, have few and tolerable adverse events, not be associated with increased somnolence or daytime drowsiness, and not have abuse potential or problems associated with discontinuation (withdrawal) [3]. Most benzodiazepine prescriptions are written by non-psychiatrics; in the population of adults between 18 and 80, about 2/3rds of prescriptions are written by non-psychiatrists and in the subgroup of individuals between the ages 65 - 80, 90% of prescriptions for benzodiazepines are written by non-psychiatrists [5]
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