Hypnotic Users Research Articles

Abstract P1-10-29: Randomized trial of aromatherapy vs. conventional care for breast cancer patients during perioperative periods

Abstract PURPOSE: The aromatherapy has been performed as palliative care of the breast cancer patients but no studies have been reported regarding whether the therapy improved QOL of the patients during perioperative periods or not. Therefore, in this study, we compared the effects on QOL between aromatherapy and conventional therapy during perioperative periods of the patients. METHODS: We examined Japanese breast cancer patients operated at Nahanishi Clinic , Okinawa, JAPAN.The patients were randomly assigned to a 2:1 ratio to aromatherapy or usual care following the informed consents were obtained. The aromatherapy group had aroma-oil (lavender, orange or ylang-ylang) placed at the bedside from 9 pm until 6 am. QOL of the patients was the primary endpoints and the changes of vital signs and the rate of hypnotic usage as secondary endpoints. QOL was assessed using the EORTC QLQ-C30,in which the Patients completed a baseline QOL assessment at the time of admission , of surgery day (AM7:00) and at the morning of post-operative day 1. Vital signs and hypnotic usage were also recorded at the same time. RESULTS: Among 249 women screened, we randomized 153 women, with 102 to aromatherapy and 51 to conventional care. QOL tended to be improved among aromatherapy groups in physical functioning and role functioning at the morning of post-operative day 1, but the differences did not reach statistical significance (P = 0.08 and 0.09, respectively). There were no statistically significant differences between two groups in the other points of QOL assessment. Aromatherapy did by no means improve vital signs and the rate of hypnotic usage of the patients. Global health status, functional scales and symptomatic scales of aromatherapy and usual care assessed by the EORTC QLQ-C30 questionnaire Aromatherapy Usual care (%)Good (≥66.7)Average (33.3-66.6)Poor (<33.3)Good (≥66.7)Average (33.3-66.6)Poor (<33.3)PAfter operation Global health status QOL47.143.19.833.352.913.7.26Functional scales Physical functioning76.518.64.958.831.49.8.08Role functioning81.48.89.870.621.67.8.09Emotional functioning81.416.71.976.519.63.9.68Congnitive functionin85.313.71.090.27.82.0.51Social functioning82.412.74.968.619.611.8.13Symptom scales/items Fatigue10.856.932.415.758.825.5.56Nausea and vomiting2.922.574.52.013.784.3.39Pain11.853.934.319.649.031.4.43Dyspnoea3.927.568.65.933.360.8.61Insomnia22.548.029.435.339.225.5.24Appetite loss8.839.252.07.839.252.9.98Constipation8.834.356.99.837.352.9.90Diarrhoea1.08.890.23.93.992.2.27Financial functioning16.742.241.225.535.339.2.41 Conclusion: Aromatherapy did not improve the QOL including vital signs and the rate of hypnotic usage during perioperative periods but no adverse effects also detected. Therefore, aromatherapy may not be prohibited during perioperative periods of the patients when they asked to the physicians. Citation Format: Tamaki K, Komatsu-Fukuyama A, Terukina S, Kamada Y, Uehara K, Yamashiro K, Arakaki M, Miyashita M, Ishida T, Ohuchi N, Sasano H, Tamaki N. Randomized trial of aromatherapy vs. conventional care for breast cancer patients during perioperative periods. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P1-10-29.

Qualitative Study of Long-Term Sedative-Hypnotic use Patterns

Hypnotics are the most common choice of treatment for insomnia. Clinically, high proportion of hypnotic users is long-term user. However, studies showed disagreements over the effectiveness and safety of long-term use of hypnotics. Adopting the methods of the grounded theory, this research has conducted a series of in-depth interviews in order to understand the psychological experience and to construct a behavioral theory of the long-term hypnotics users. Twenty-two long-term users of hypnotics have been interviewed with well-trained interviewer. This research has found that long-term hypnotic users could be divided into three pattern groups: “transitional modality”, “contradictory control”, and “inertia balance”. It is anticipated that this research will shed lights on the treatment of long-term hypnotics medication for the clinical practitioners and provide a foundation for the future studies on the relationship between the relevant variables of the medication patterns and the prognosis.

Acupuncture for Ischemic Stroke, Music for Anxiety in Mechanical Ventilation, Essential Fatty Acids for Depression, Mindfulness Meditation for Sleep in Older Adults, Tripterygium wilfordii for Rheumatoid Arthritis

The interest in non-pharmacological interventions for insomnia disorder has increased. The aim was to assess the immediate treatment effects of auricular acupuncture (AA) and cognitive behavioural therapy for insomnia (CBT-i) regarding discontinuation of hypnotic usage and symptoms of anxiety, depression and insomnia.Prospective randomised controlled study. Fifty-seven participants (mean age 61 years (SD 8.6)) with insomnia disorder and long-term use of non-benzodiazepine hypnotics received group-treatment with AA or CBT-i.Pre- and post-treatment measures included symptoms of anxiety, depression and insomnia via self-report questionnaires: Hospital Anxiety and Depression scale (HAD-A, HAD-D) and Insomnia Severity Index (ISI). Other sleep parameters and hypnotic consumption were measured with a sleep diary. Linear mixed models were performed to examine treatment effect over time within and between the groups.Seventy-one percent of the AA participants and 84% of the CBT-i participants managed to discontinue their hypnotic drug consumption post-treatment. Symptoms of anxiety and depression decreased within the AA group (HAD-A (p < 0.05), HAD-D (p < 0.05)) and insomnia symptoms decreased within the CBT-i group (ISI (p < 0.001)). The only between-group difference occurred in ISI (p < 0.001), in favour of CBT-i. According to the within-group sleep diary results, the CBT-i group went to bed later (p < 0.001), fell asleep quicker (p < 0.05), increased their sleep efficiency (p < 0.001) and self-rated sleep quality (p < 0.05) post-treatment.Both groups ended/maintained low hypnotic drug consumption post-treatment. Short-term reductions occurred in the AA group in anxiety and depression symptoms and in the CBT-i group regarding insomnia symptoms.

Hypnotics use but not insomnia increased the risk of dementia in traumatic brain injury patients

This study was intended to determine whether the use of hypnotics is associated with dementia in traumatic-brain-injury (TBI) patients. Data retrieved from the Longitudinal Health Insurance Database 2000. TBI patients who received a diagnosis of insomnia at 2 or more independent examinations after the index date of TBI were included. The comparison cohort consisted of randomly selected TBI patients who were matched to insomnia cohort patients based on sex and age. The 2 cohorts of TBI patients were subsequently divided into the following 4 study groups: hypnotics users with insomnia (TBI-IH, N=599), insomniacs who did not use hypnotics (TBI-I, N=931), hypnotics users without insomnia (TBI-H, N=199), and people without insomnia who did not use hypnotics (TBI-C, N=4271). Cox proportional-hazards regression models were used to determine the difference in dementia-free survival among the 4 study groups, after adjusting for the propensity score. The adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) of the TBI-IH and TBI-H groups showed that they had a higher risk of dementia (aHRs: 1.86 and 3.98; 95% CIs: 1.15–3.00 and 2.44–6.47, respectively), compared with that of the TBI-C group. However, the risk of dementia in the TBI-I group was not significantly different from that of the TBI-C group (aHR: 1.36; 95% CI: 0.85–2.19). This study suggests that the use of hypnotics is associated with an increased risk of dementia in TBI patients with or without insomnia, whereas insomnia alone is not.

Is suvorexant a better choice than alternative hypnotics?

Suvorexant is a novel dual orexin receptor antagonist (DORA) newly introduced in the U.S. as a hypnotic, but no claim of superiority over other hypnotics has been offered. The manufacturer argued that the 5 and 10 mg starting doses recommended by the FDA might be ineffective. The manufacturer's main Phase III trials had not even included the 10 mg dosage, and the 5 mg dosage had not been tested at all in registered clinical trials at the time of approval. Popular alternative hypnotics may be similarly ineffective, since the FDA has also reduced the recommended doses for zolpidem and eszopiclone. The "not to exceed" suvorexant dosage of 20 mg does slightly increase sleep. Because of slow absorption, suvorexant has little effect on latency to sleep onset but some small effect in suppressing wakening after sleep onset and in improving sleep efficiency. The FDA would not approve the manufacturer's preferred 40 mg suvorexant dosage, because of concern with daytime somnolence, driving impairment, and possible narcolepsy-like symptoms. In its immediate benefits-to-risks ratio, suvorexant is unlikely to prove superior to currently available hypnotics—possibly worse—so there is little reason to prefer over the alternatives this likely more expensive hypnotic less-tested in practice. Associations are being increasingly documented relating hypnotic usage with incident cancer, with dementia risks, and with premature death. There is some basis to speculate that suvorexant might be safer than alternative hypnotics in terms of cancer, dementia, infections, and mortality. These safety considerations will remain unproven speculations unless adequate long-term trials can be done that demonstrate suvorexant advantages.

Is suvorexant a better choice than alternative hypnotics?

Suvorexant is a novel dual orexin receptor antagonist (DORA) newly introduced in the U.S. as a hypnotic, but no claim of superiority over other hypnotics has been offered. The manufacturer argued that the 5 and 10 mg starting doses recommended by the FDA might be ineffective. The manufacturer's main Phase III trials had not even included the 10 mg dosage, and the 5 mg dosage had not been tested at all in registered clinical trials at the time of approval. Popular alternative hypnotics may be similarly ineffective, since the FDA has also reduced the recommended doses for zolpidem and eszopiclone. The "not to exceed" suvorexant dosage of 20 mg does slightly increase sleep. Because of slow absorption, suvorexant has little effect on latency to sleep onset but some small effect in suppressing wakening after sleep onset and in improving sleep efficiency. The FDA would not approve the manufacturer's preferred 40 mg suvorexant dosage, because of concern with daytime somnolence, driving impairment, and possible narcolepsy-like symptoms. In its immediate benefits-to-risks ratio, suvorexant is unlikely to prove superior to currently available hypnotics-possibly worse-so there is little reason to prefer over the alternatives this likely more expensive hypnotic less-tested in practice. Associations are being increasingly documented relating hypnotic usage with incident cancer, with dementia risks, and with premature death. There is some basis to speculate that suvorexant might be safer than alternative hypnotics in terms of cancer, dementia, infections, and mortality. These safety considerations will remain unproven speculations unless adequate long-term trials can be done that demonstrate suvorexant advantages.

Self-efficacy enhancement can facilitate hypnotic tapering in patients with primary insomnia

Self-efficacy plays an important role in motivating behavior change. The present study implemented a self-efficacy enhancement procedure to examine its influence on hypnotic tapering. Twenty-four long-term hypnotic users underwent a self-efficacy enhancement procedure prior to undergoing a systematic gradual tapering program, and another 24 hypnotic users underwent the systematic tapering program only to serve as a control group. Self-efficacy in tapering off hypnotics was significantly increased following the self-efficacy enhancement procedure. The increase could predict the percentage of dosage reduction after controlling for baseline self-efficacy level. Further, patients in the self-efficacy enhancement group showed a greater percentage of dosage reduction than those in the control group. In terms of sleep parameters, the program resulted in shorter waking time after sleep onset than the control program, but did not show significant effects on the other sleep parameters. The findings support the facilitating effect of self-efficacy enhancement on hypnotic tapering.

Impact of hypnotics use on daytime function and factors associated with usage by female shift work nurses

ObjectiveWe investigated quality of life (QOL) and work performance of hypnotics users, and explored the factors associated with multiple hypnotics usage in shift work nurses. MethodsWe conducted a questionnaire-based, cross-sectional survey on nurses in university hospitals. We analyzed responses from 1202 nurses; 997 were female shift work nurses (82.9%), including 696 and 281 two- and three-shift workers, respectively. ResultsThe rate of hypnotics use was 10% (6.9% were single hypnotic users and 3.1% were multiple hypnotics users). The rate of insomnia did not differ between the single and multiple hypnotics users. However, multiple hypnotics users showed lower QOL, more severe depressive symptoms, and greater frequencies of work-related errors than those using a single hypnotic. A multiple logistic regression analysis revealed that age ≥27 years, presence of depression, eveningness chronotype, and presence of insomnia symptoms were significantly associated with hypnotics use. On the other hand, only the existence of shift work disorder (SWD) was significantly associated with usage of multiple hypnotics. ConclusionsThe present study suggested that usage of multiple hypnotics is not beneficial for relieving insomnia or for keeping better QOL in shift work nurses. It would be desirable to explore the causal relationship between SWD and multiple hypnotics use in a future longitudinal study.

Sleep-wake time perception varies by direct or indirect query.

The diagnosis of insomnia rests on self-report of difficulty initiating or maintaining sleep. However, subjective reports may be unreliable, and possibly may vary by the method of inquiry. We investigated this possibility by comparing within-individual response to direct versus indirect time queries after overnight polysomnography. We obtained self-reported sleep-wake times via morning questionnaires in 879 consecutive adult diagnostic polysomnograms. Responses were compared within subjects (direct versus indirect query) and across groups defined by apnea-hypopnea index and by self-reported insomnia symptoms in pre-sleep questionnaires. Direct queries required a time duration response, while indirect queries required clock times from which we calculated time durations. Direct and indirect queries of sleep latency were the same in only 41% of cases, and total sleep time queries matched in only 5.4%. For both latency and total sleep, the most common discrepancy involved the indirect value being larger than the direct response. The discrepancy between direct and indirect queries was not related to objective sleep metrics. The degree of discrepancy was not related to the presence of insomnia symptoms, although patients reporting insomnia symptoms showed underestimation of total sleep duration by direct response. Self-reported sleep latency and total sleep time are often internally inconsistent when comparing direct and indirect survey queries of each measure. These discrepancies represent substantive challenges to effective clinical practice, particularly when diagnosis and management depends on self-reported sleep patterns, as with insomnia. Although self-reported sleep-wake times remains fundamental to clinical practice, objective measures provide clinically relevant adjunctive information.

Analysis of potential cost reductions related to falls in hospitalized elderly patients by correcting high-dose prescriptions of sedative

Background: Risk factors for falls include older age, diseases, and certain medications. High-dose sedative hypnotics have been shown to increase the risk of falls, necessitating caution when these medications are used. High-dose sedative hypnotics have an increased half-life in elderly patients with reduced hepatic and renal function, which may increase fall risk. Methods: This retrospective survey evaluated the potential cost reductions associated with fall prevention by changing high-dose prescriptions. For this purpose, the association between falls and high-dose usage of sedative hypnotics was analyzed in hospitalized elderly patients. Study participants were 267 ambulatory patients aged ≥65 years who were taking sedative hypnotics and were hospitalized for ≥3 days from May 2012 to April 2013 at the Gifu Municipal Hospital, Japan. Patients’ age, sex and usage of sedative hypnotics (high-dose vs. non-highdose) were analyzed, as well as the costs incurred by tests, drugs, and wages for medical personnel for patients on high-dose sedative hypnotics who experienced falls. Results: Analysis revealed a significantly higher rate of falls in the group using high-dose sedative hypnotics (21.4%; 14/224) compared to the non-high-dose group (6.3%; 9/42, p=0.004). Assessment of cost demonstrated potential savings of ¥589 per case if falls could be prevented by correcting high-dose prescriptions. Conclusions: This study indicates that high-dose prescriptions of sedative hypnotics may be associated with fall risk in the elderly. Correcting high-dose prescriptions for these drugs would be beneficial not only for medical safety, but also the medical economy.

Insomnia, hypnotic use, and health-related quality of life in a nationally representative sample.

To assess health-related quality of life (HRQoL) associated with insomnia and prescription hypnotic use. Primary outcomes were mental component summary (MCS) and physical component summary (PCS) scores from the 12-item Short-Form Health Survey. Using multiple regression, subjects in the 2005 through 2009 Medical Expenditure Panel Survey with diagnosed insomnia were compared against those without that diagnosis. Among subjects with diagnosed insomnia, users of prescription hypnotics were compared against nonusers. Of 104,274 adults, 1.3 % (n = 1,401) had an insomnia diagnosis. Of those, 45.6 % (n = 639) used prescription hypnotics. For subjects with insomnia, mean PCS and MCS scores were 9.2 and 7.0 points lower (p < 0.001), respectively. After controlling for demographic and clinical covariates, differences remained significant (PCS:5.1; 6.2; p < 0.001). Among subjects with insomnia, HRQoL scores were not different between prescription hypnotic users (n = 639) and nonusers (n = 762). Analysis by drug class revealed lower PCS scores (difference: 7.5, p < 0.001) with benzodiazepine use (n = 129) versus benzodiazepine receptor agonist use (n = 493), but the adjusted difference was not significant (difference: 3.8, p = .018). Diagnosed insomnia was associated with consistent decreases in both physical and mental HRQoL scores, regardless of whether prescription hypnotics were used. Benzodiazepine use may be associated with a further decrease in physical HRQoL scores. Although limited by its retrospective design, this study provides a first look at real-world hypnotic use outcomes at a national level. Important next steps include studies with patients serving as their own controls, and further evaluation of the sensitivity of HRQoL instruments to the effects of insomnia treatments.

Quality of Psychopharmacological Medication Prescribing and Mortality in Medicare Beneficiaries in Nursing Homes

To examine the influence of quality measures of psychopharmacological medication (PPM) prescribing on all-cause mortality in a Medicare long-stay nursing home (NH) population. Longitudinal. 2007-09 Medicare data linked to Minimum Data Set 2.0 files. Four new-user cohorts of residents initiating antipsychotic (n=13,105), antidepressant (n=14,251), anxiolytic and sedative-hypnotic (n=10,789), and any PPM (n=14,568) medication. Three measures of PPM prescribing quality were assessed monthly with a 6-month look-back: evidence of appropriate indication, dose (modified standardized daily dose (mSDD); below (<1), at (1), and above (>1) recommended geriatric dose), and duration of therapy (DOT; ≤30, 31-60, 61-90, 91-180 days from medication initiation). Complementary log-log models with quality measures as time-dependent variables were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for mortality. Appropriate use of antidepressants, anxiolytics and sedative-hypnotics, and any PPMs, as evidenced by appropriate indications, was significantly associated with lower mortality risk (HRantidepressants=0.81, 95% CI=0.76-0.86; HRanxiolytics and sedative-hypnotics=0.81, 0.75-0.88; HRPPM=0.89, 0.83-0.95). Antipsychotic and anxiolytic and sedative-hypnotic users with a mSDD of less than 1 had lower mortality risk than those with a mSDD greater than 1, whereas a protective effect was observed in antidepressant users with a mSDD greater than 1. In all four cohorts, those with a DOT of 91 to 180 days had lower mortality than those with a DOT of 1 month or less; the lower risk of mortality was detected after antipsychotic use for 31 days or longer. Optimal PPM prescribing quality, as measured by indication and duration, is associated with low mortality. The benefit related to drug dosage varied by therapeutic class. When prescribing PPMs to NH residents, providers should consider not only drug choice, but also dose and duration of prescribed regimens.

On-the-road driving performance and driving-related skills in older untreated insomnia patients and chronic users of hypnotics

RationaleMany older adults report sleep problems and use of hypnotics. Several studies have shown that hypnotics can have acute adverse effects on driving the next morning. It is unclear however whether driving of chronic hypnotic users is impaired. Therapeutic effects on insomnia and development of tolerance may reduce the residual effects on driving.ObjectivesThe present study aimed to compare actual driving performance and driving-related skills of chronic hypnotic users to good sleepers. To determine whether insomnia itself affects driving performance, driving and driving-related skills were compared between insomnia patients who do not or infrequently use hypnotics and good sleepers.MethodsTwenty-two frequent users of hypnotics (using hypnotics ≥4 nights per week for more than 3 months), 20 infrequent users (using hypnotics ≤3 nights per week), and 21 healthy, age-matched controls participated in this study. On the night before testing, all subjects were hospitalized for an 8-h sleep recorded by polysomnography. Frequent hypnotic users used their regular medication at bedtime (2330 hours), while infrequent users and controls received no medication. Cognitive performance (word learning, digit span, tracking, divided attention, vigilance, and inhibitory control) was assessed 8.5 h and driving performance between 10 and 11 h after bedtime and dosing.ResultsPolysomnographic recordings did not significantly differ between the groups, but the insomnia patients, treated or untreated, still reported subjective sleep complaints. Results show no differences in driving performance and driving-related skills between both groups of insomnia patients and controls.ConclusionsDriving performance in chronic users of hypnotics and untreated insomnia patients is not impaired. For chronic users, this may be due to prescription of relatively safe drugs and low doses. For untreated insomniacs, this corroborates previous findings showing an absence of neuropsychological deficits in this group of patients.

Sleep-related eating disorder: a descriptive study in Chilean patients

ObjectivesWe aimed to describe a group of adults diagnosed with sleep-related eating disorder (SRED) at the Sleep Medicine Center of the Pontificia Universidad Catolica de Chile. MethodsWe performed a descriptive study of 34 consecutive patients who met the criteria of the International Classification of Sleep Disorders for SRED evaluated during a 3-year period who did not have an eating disorder according to the criteria of the Diagnostic and Statistical Manual of Mental Disorders, fourth edition. All patients had a structured clinical interview performed by a sleep specialist and completed the Beck Depression Inventory (BDI). Polysomnography (PSG) was performed when clinically indicated for ruling out other sleep-related disorders (18 patients; 52.9%). Patients’ demographic and clinical data, comorbidities, and treatment response also were analyzed. ResultsMost patients were women (n=23; 67.6%). The average age at the time of diagnosis was 39±13.8 (17–67years) and the latency since symptom onset was 8.3±8.8years. Most patients had several episodes per night (average, 2.6±1.6; 1–8) and all except one patient had partial or total amnesia of these events (n=33; 97%). Comorbidities were frequent and included insomnia (n=20; 58.8%), restless legs syndrome (RLS) (n=16; 47%), sleep-disordered breathing (SDB) (n=9; 26%), psychiatric disorders (n=13; 38.2%), and overweight or obesity (n=14; 41.1%). Most patients were hypnotic users (n=21; 61.7%) and reported weight-centered anxiety (n=23; 67.6%). Twenty patients (58.8%) were treated with topiramate, 17 of whom had adequate symptomatic responses. ConclusionOur SRED patients showed female preponderance, amnesia during the episodes, association with other sleep disorders, use of hypnotics, weight-centered anxiety, and positive response to topiramate. The presence of anxiety focused on weight in most patients may be an important element in the emergence of this behavior during sleep.

The impact of hypnotics usage on daytime function and associated factor for the usage in shiftwork nurses

Introduction It has been known that a certain number of shiftwork nurses have shift work disorder (SWD) and regularly take hypnotics. @However, impact of hypnotics usage on health-related quality of life (QOL) and daytime function in shiftwork nurses remain unclear. Especially, condition of usage of high dose or multiple kinds of hypnotics, which is likely to cause dependency of hypnotics, has not been investigated in this population. To clarify this issue, we investigated QOL and work performance status of hypnotic user and explored the factors associated with multiple hypnotics usage in shiftwork nurses. Materials and methods We conducted a questionnaire-based, cross-sectional survey on nurses working in university hospitals. The questionnaires included items relevant to age, gender, family member structure, work environment, history of work-related accidents/errors, social functioning 8 (SF8), chronotype, sleep problems, status of hypnotics usage, the Center for Epidemiological Studies Depression Scale (CESD) and presence/absence of SWD. Responses were obtained from 1202 nurses. Among them, 997 female shift work nurses including 696 two-shift workers and 281 three-shift workers were subjected for the analyses. Results The prevalence of hypnotics usage in the sampled shiftwork nurses was 10.0% (6.9% were single hypnotics users and 3.1% were multiple hypnotics users). The diazepam equivalent dose of benzoziazepine or benzoziazepine agonist hypnotics were significantly higher in the multiple hypnotics users than in the single hypnotics users. The number of nurses having insomnia were not different between the single hypnotics users and the multiple hypnotics users. The sampled sfiftwork nurses with usage of multiple hypnotics showed lower QOL, more severe depressive symptoms and greater frequencies of work-related accidents / errors than those with usage of single hypnotics. A multiple logistic regression analyses revealed that age (over 27 years old), insomnia, existence of SWD, longer working hours and having an eveningness-oriented chronotype were significantly associated with usage of hypnotics. However, as for multiple hypnotics, only existence of SWD was significantly associated with the usage. Conclusion The present study indicated that usage of multiple hypnotics does not necessarily bring about improvement of insomnia or QOL in shiftwork nurses. It was also suggested that prevention of SWD is needed to avoid multiple hypnotics usage in this population. Acknowledgements We thank members of the Department of Somnology of Tokyo Medical University for technical support.

Psychotropic drug use among people with dementia – a six-month follow-up study

BackgroundPsychotropic drugs are widely used among old people with dementia but few studies have described long-term treatment in this group of patients. The purpose of this study was to explore the long-term use of psychotropic drugs in old people with dementia.MethodsData on psychotropic drug use, functioning in the activities of daily living (ADL), cognitive function and behavioral and psychological symptoms were collected at baseline and six months later, using the Multi-Dimensional Dementia Assessment Scale (MDDAS). The data were collected in 2005–2006. Detailed data about the prescribing of psychotropic drugs were collected from prescription records. This study was conducted in 40 specialized care units in northern Sweden, with a study population of 278 people with dementia.ResultsAt the start of the study, 229 of the participants (82%) were prescribed at least one psychotropic drug; 150 (54%) used antidepressants, 43 (16%) used anxiolytics, 107 (38%) used hypnotics and sedatives, and 111 (40%) used antipsychotics. Among the baseline users of antidepressants, anxiolytics, hypnotics and sedatives and antipsychotics, 67%, 44%, 57% and 57% respectively, still used the same dose of the same psychotropic drug after six months. Associations were found between behavioral and psychological symptoms and different psychotropic drugs.ConclusionPsychotropic drug use was high among people with dementia living in specialized care units and in many cases the drugs were used for extended periods. It is very important to monitor the effects and adverse effects of the prescribed drug in this frail group of people.

Nonbenzodiazepine Hypnotics are Associated with an Increased Risk of Hip Fracture in Residential Aged Care Facilities

Evaluation of: Berry SD, Lee Y, Cai S, Dore DD. Nonbenzodiazepine sleep medication use and hip fractures in nursing home residents. JAMA Intern. Med. 173(9), 754–761 (2013). Sleep disturbances and complaints about poor sleep are common among residents of aged care facilities. Nonbenzodiazepine (non-BZD) hypnotics are often prescribed to older individuals in preference to benzodiazepines. To establish whether the use of non-BZD hypnotics is associated with an increased risk of hip fracture, Berry et al. conducted a case-crossover study among 15,528 long-stay US nursing home residents with a hip fracture. Medicare hospitalization and pharmacy claims data were used for determining hip fractures and medication use, and the minimum data set was used to ascertain resident characteristics. Odds ratios (ORs) for hip fracture were estimated by comparing the use of non-BZD hypnotics 0–29 days before hip fracture (hazard period) with use of non-BZD hypnotics 60–89 days and 120–149 days before hip fracture (control periods). During the 18-month study period, non-BZD hypnotics were dispensed to 11% (n = 1715) of the residents with hip fracture. There was an increased risk of hip fracture within 30 days of using a non-BZD hypnotic (OR: 1.66; 95% CI: 1.45–1.90). The risk of hip fracture was higher among new users of non-BZD hypnotics (OR: 2.20; 95% CI: 1.76– 2.74) and in those requiring supervision or limited assistance to transfer, compared with those requiring full assistance to transfer (OR: 2.02 vs 1.43; p = 0.02). The present study did not directly compare the risk of hip fracture associated with non-BZD hypnotics and benzodiazepines. However, the results suggest that clinicians should continue to exercise caution when prescribing non-BZD hypnotics to residents of aged care facilities.

Use of benzodiazepines or benzodiazepine related drugs and the risk of cancer: a population‐based case‐control study

Studies of the carcinogenic potential of benzodiazepines and related drugs (BZRD) have been equivocal. A recent study reported a 35% excess cancer risk among users of hypnotics, including benzodiazepines. Using Danish nationwide registers, we conducted a matched case-control study of the association between BZRD and cancer risk. During 1 January 2002 and 31 December 2009, we identified 152 510 cases with a first time cancer who were matched (1:8) by age and gender to 1,220,317 cancer-free controls. A new-user design was applied by excluding all subjects who had used anxiolytics, hypnotics or sedatives during the first 2 years of available prescription data (1995-6). Odds ratios (ORs) with 95% confidence intervals (CI) were estimated using conditional logistic regression, adjusting for potential confounders. In the primary analysis, long term use of BZRD was defined by a cumulative amount of ≥500 defined daily doses of BZRD within a period of 1 to 5 years prior to the index date. The adjusted OR for cancer associated with BZRD use was 1.09 (95% CI 1.04, 1.14). ORs were close to unity for most cancer sites, except stomach 1.40 (95% CI 1.05, 1.88), oesophagus 1.43 (95% CI 1.01, 2.02), liver 1.81 (95% CI 1.18, 2.80), lung 1.38 (95% CI 1.23, 1.54), pancreas 1.35 (95% CI 1.02, 1.79) and kidney 1.39 (95% CI 1.01, 1.91). For tobacco-related cancers, the OR was 1.15 (95% CI 1.09, 1.22) and for the remaining cancer sites 1.01 (95% CI 0.94, 1.08). Sub-group analyses revealed only small differences between different levels of exposure or different patient subgroups. BZRD use was not associated with an overall increase in cancer risk, except for what is likely explained by minor lifestyle confounding, e.g. smoking.

Ten-year trend in prescriptions of z-hypnotics among the elderly: A nationwide, cross-sectional study in Taiwan

Background/PurposeThe objective of this study was to characterize the 10-year trend in prescriptions of z-hypnotics among the elderly in Taiwan, focusing on duration and dosages of the z-hypnotics prescribed. Data from the 2001–2010 Taiwan National Health Insurance Research Database (NHIRD) were used for this study. MethodsIncident users of hypnotics[z-hypnotics and benzodiazepine (BZD)], aged ≥65 years, for each fiscal year from 2001 to 2010 were identified from the Longitudinal Health Insurance Database 2000 and 2005 of NHIRD. The annual prevalence of z-hypnotic and BZD prescriptions was reported for each fiscal year during 2001–2010. Demographics of patients who received z-hypnotics and characteristics of their providers were described. Several measures, including prescription duration, daily pills, and daily dosage, were used to quantify the use of z-hypnotics in the elderly. ResultsDuring 2001–2010, the annual use of z-hypnotics per elderly patient was doubled: from 3.1 prescriptions in 2001 to 5.8 prescriptions of z-hypnotics annually in 2010. A similar pattern was observed in the annual use of BZD per elderly patient (3.2 prescriptions in 2001 to 5.5 prescriptions of BZD in 2010). The frequency of z-hypnotic prescriptions from medical centers decreased from 33.6% in the fiscal year 2001 to 19.7% in the fiscal year 2010. In recent years, most z-hypnotics were prescribed by clinics (38.6% in 2010) and by physicians not specializing in psychiatry. The frequency of zolpidem prescriptions was 66.6% in 2001, which increased to 86.7% in 2010. The most frequent prescription duration of z-hypnotics was 8–30 days, followed by 4–7 days and ≤3 days. Over 70–80% of the z-hypnotic prescriptions contained more than 1 weeks' supply of z-hypnotics. ConclusionOur empirical findings revealed a significant nationwide outpatient consumption of z-hypnotics in Taiwan. To our knowledge, our study was the first one to conduct an in-depth examination of patients' and providers' characteristics associated with z-hypnotics use among the elderly.

Concurrent Use of Hypnotic Drugs and Chinese Herbal Medicine Therapies among Taiwanese Adults with Insomnia Symptoms: A Population-Based Study.

Background. The increased practice of traditional Chinese medicine (TCM) worldwide has raised concerns regarding herb-drug interactions. The purpose of our study is to analyze the concurrent use of Chinese herbal products (CHPs) among Taiwanese insomnia patients taking hypnotic drugs. Methods. The usage, frequency of services, and CHP prescribed among 53,949 insomnia sufferers were evaluated from a random sample of 1 million beneficiaries in the National Health Insurance Research Database. A logistic regression method was used to identify the factors that were associated with the coprescription of a CHP and a hypnotic drug. Cox proportional hazards regressions were performed to calculate the hazard ratios (HRs) of hip fracture between the two groups. Results. More than 1 of every 3 hypnotic users also used a CHP concurrently. Jia-Wei-Xiao-Yao-San (Augmented Rambling Powder) and Suan-Zao-Ren-Tang (Zizyphus Combination) were the 2 most commonly used CHPs that were coadministered with hypnotic drugs. The HR of hip fracture for hypnotic-drug users who used a CHP concurrently was 0.57-fold (95% CI = 0.47–0.69) that of hypnotic-drug users who did not use a CHP. Conclusion. Exploring potential CHP-drug interactions and integrating both healthcare approaches might be beneficial for the overall health and quality of life of insomnia sufferers.