DENVER — The conventional wisdom holding that prescribing hypnotic agents for nursing home patients increases their risk of falling and hip fracture may not be correct.
A recent study involving more than 34,000 Michigan nursing home residents suggests an alternative explanation: The increased risk of falls may be attributable to the insomnia for which hypnotic agents are so often prescribed, rather than to the drugs themselves, W. Vaughn McCall, M.D., said at a satellite symposium held in conjunction with the annual meeting of the Associated Professional Sleep Societies.
He cited an analysis of a Michigan Medicare database by Alon Y. Avidan, M.D., and coinvestigators at the University of Michigan and the Veterans Affairs Medical Center in Ann Arbor. They examined the risk of falls and hip fracture over roughly 6 months of follow-up in 34,163 elderly residents in 437 Michigan nursing homes.
During follow-up, 42.9% of patients fell and 2.5% sustained a hip fracture. After adjusting for numerous potential confounders in a multiple logistic regression analysis, including age, gender, functional status, illness burden, number of medications being taken, cognitive status, and intensity of resource utilization, the investigators concluded that insomnia—but not hypnotic use per se—was predictive of future falls, noted Dr. McCall, professor and chairman of the department of psychiatry and behavioral medicine at Wake Forest University, Winston-Salem, N.C.
Dr. Avidan and colleagues went on to speculate that the use of hypnotics to treat insomnia in the frail elderly might actually protect against falls. Dr. McCall called that “a very provocative statement.” And while he is intrigued by the Michigan findings, it will take more than a single observational study, however large, to convince him.
“I'm not ready to state this as the final word on the subject. I'm personally not prepared to go that far, even though this is a large study of debilitated nursing home patients. But I do think the study opens the door to looking at this issue more carefully,” he said at the symposium, sponsored by Sepracor.
In the Michigan study, supported by the National Institute on Aging, the 259 insomniac nursing home residents on a hypnotic agent had an adjusted 32% greater risk of falls than did the 31,391 who did not have insomnia and were not on a hypnotic. Particularly noteworthy was the finding that the 1,890 individuals with insomnia who were not taking a hypnotic agent had a 55% greater risk of falls. Among the nursing home population who did not have insomnia, the 632 on a hypnotic agent did not have a significantly greater risk of falling than did those who were not on this class of medication (J. Am. Geriatr. Soc. 2005;53:955–62).
There is no doubt that sleep problems are more common in the elderly than in any other age group, and that those sleep difficulties produce next-day impairments in cognitive ability that can be confused with dementia. This underscores the importance of appropriately assessing and treating elderly patients with sleep problems using the behavioral therapies and/or medications, particularly the newer short-acting nonbenzodiazepines—zolpidem (Ambien), zaleplon (Sonata), and eszopiclone (Lunesta)—with demonstrated efficacy in this setting, he said.
Of interest is a recent multicenter double-blind randomized trial in which Dr. McCall was a coinvestigator. It involved 231 patients aged 65–85 years with primary insomnia randomized to nightly 1- or 2-mg eszopiclone or placebo for 2 weeks.
While the lower dose induced sleep compared with placebo, the higher dose induced and maintained sleep. The 2-mg dose was accompanied by significantly higher patient-reported ratings of daytime alertness, sense of physical well-being, and quality of life (Sleep 2005;28:720–7).
The trial also was sponsored by Sepracor. Dr. McCall serves as a consultant to the company.