DENVER – Older adults who have longstanding hypnotic-dependent insomnia and wish to discontinue their sleep medication are largely able to do so successfully–with resultant improvement in sleep–by participating in a program focusing on gradual weaning preceded by behavioral therapy, Kenneth L. Lichstein, Ph.D., said at the annual meeting of the Associated Professional Sleep Societies.
With gradual weaning alone, minus the behavioral therapy, hypnotic use is greatly reduced but sleep is unchanged. This indicates that in elderly patients with a history of chronic hypnotic use, the drugs are therapeutically inert, said Dr. Lichstein of the University of Alabama, Tuscaloosa.
He presented a randomized, multicenter trial in which 64 older patients with hypnotic-dependent insomnia were assigned to one of three treatment strategies: gradual weaning from their hypnotic drugs, placebo biofeedback followed by gradual weaning from hypnotics, or eight sessions of behavioral therapy followed by weaning from hypnotics.
The study participants averaged 63 years of age. Their mean insomnia duration was 9.1 years, with a 4.3-year duration of hypnotic use. They had primary insomnia; that is, the participants were free of sleep apnea and other medical and psychiatric conditions that often contribute to insomnia.
At baseline they used hypnotic agents 7 nights per week at an average of three times the minimum recommended dose. Roughly half were on benzodiazepines, one-third on nonbenzodiazepine receptor antagonists, and the remainder on sedating antidepressants. One-quarter were steady users of two hypnotics.
Most subjects had tried at least once before to stop their taking of hypnotics, without success.
A program of gradual weaning was chosen as the comparator arm because it's the standard therapy available today to patients who present to their physicians asking for help in getting off hypnotic drugs. The adjunctive behavioral therapy emphasized stimulus control, relaxation techniques, and education regarding sleep hygiene.
One year following therapy, subjects maintained an 86% reduction in hypnotic use compared with baseline, with no significant difference in this rate among the three study arms. Where the treatment groups did differ was in sleep effects. Sleep diary data showed that only the patients randomized to behavioral therapy plus gradual medication weaning showed significantly improved self-reported sleep efficiency, onset, and latency; the other two groups displayed nonsignificant trends in the same desirable direction.
“What I want to emphasize, given the fact that these people were withdrawing from their hypnotics, is that on no self-reported sleep measure did we get a significant deterioration in sleep over the course of drug withdrawal,” he said. “We either saw sleep improvement or no sleep change.”
He added that prescription hypnotic dependence may have more serious effects in older patients because they are more sensitive to the cognitive side effects associated with many of these medications. They are also often on multiple other drugs for comorbid conditions, raising the risk of drug interactions. And their drug elimination time is longer than in younger individuals.
The major caveat regarding this study, Dr. Lichstein said, is that the results apply only to those older patients with hypnotic-dependent insomnia who are motivated to quit taking the drugs. In his experience, there are two additional subgroups of elderly patients with hypnotic-dependent insomnia: those who've been on the drugs for many years, continue to receive therapeutic benefit, and have absolutely no interest in getting off the medications; and others who can't tolerate hypnotic withdrawal because they experience a sustained, magnified rebound insomnia no matter how slow the weaning schedule.
“The frustrating thing to me is there's very little long-term drug usage information out there, so we have no idea how these several groups are distributed in the population of chronic hypnotic users,” Dr. Lichstein noted.
The study was supported by the National Institute on Aging.