Drug therapy: The diagnosis and management of insomnia

Association of a History of Sleep Disorder With Risk of Mild Cognitive Impairment and Alzheimer's Disease Dementia

OBJECTIVE

We explored whether a history of sleep disorder affected a current diagnosis of cognitive impairment and clinical conversion in a non-demented elderly population.

METHODS

Comprehensive clinical data collected as part of the Alzheimer's Disease Neuroimaging Initiative (ADNI) was analyzed. A history of sleep disorder was recorded in the recent ADNI medical database. Standard clinical and neuropsychological tests were performed both at baseline and follow-up visit. Multiple logistic regression analysis was performed after adjusting for age, sex, education, apolipoprotein E ε4 status, vascular risk score, body mass index, Geriatric Depression Scale score, and use of sleeping pills.

RESULTS

A total of 391 cognitively normal individuals, 303 with early mild cognitive impairment (MCI) and 364 with late MCI were included. Sleep disorder history was significantly associated with an increased risk of MCI but not with clinical conversion. A history of insomnia or obstructive sleep apnea (OSA) significantly increased the risk of MCI, but only an OSA history predicted progression to Alzheimer's disease (AD) dementia.

CONCLUSION

Our findings suggest that a sleep disorder history usefully aids early detection of cognitive impairment and emphasize that such sleep disorder, particularly OSA, is important as potential target for AD prevention.

Novel hypnotics of Japanese traditional herbal medicines to caffeine-induced insomnia in Drosophila by using Newly-developed automated sleep and rhythm analysis system (AutoCircaS)

Sleep in Drosophila was defined in the year 2000 by using Drosophila Activity Monitor (DAM) system. But DAM is very small tube space and one fly per tube is very limited to analyze for fly social behavior. To overcome such demerits of DAM system, we developed a novel automated sleep and rhythm analysis system (AutoCircaS) which monitors and records any behaviors like social mating, sleep, and circadian rhythm in flies (Drosophila) and small fishes medaka (Oryzias latipes) in free space using the time-lapse (one frame per 10 sec) imaging. AutoCircaS can detect the caffeine-induced insomnia in flies in light-dark (LD) and constant dark (DD) conditions. Thus, using the AutoCircaS, we discovered that Japanese traditional herbal medicines, KyushinKannouGan-ki (KKG), NouKassei (NK) as well as, and Sansoninto, significantly improved caffeine-induced insomnia in flies. The data suggest that AutoCircaS is useful for sleep analysis of small animals and screening of new sedative-hypnotics from many origins.

Modulation of Sleep Architecture by Whole-Body Static Magnetic Exposure: A Study Based on EEG-Based Automatic Sleep Staging

A steady increase in sleep problems has been observed along with the development of society. Overnight exposure to a static magnetic field has been found to improve sleep quality; however, such studies were mainly based on subjective evaluation. Thus, the presented data cannot be used to infer sleep architecture in detail. In this study, the subjects slept on a magneto-static mattress for four nights, and self-reported scales and electroencephalogram (EEG) were used to determine the effect of static magnetic field exposure (SMFE) on sleep. Machine learning operators, i.e., decision tree and supporting vector machine, were trained and optimized with the open access sleep EEG dataset to automatically discriminate the individual sleep stages, determined experimentally. SMEF was found to decrease light sleep duration (N2%) by 3.51%, and sleep onset latency (SOL) by 15.83%, while it increased deep sleep duration (N3%) by 8.43%, compared with the sham SMFE group. Further, the overall sleep efficiency (SE) was also enhanced by SMFE. It is the first study, to the best of our knowledge, where the change in sleep architecture was explored by SMFE. Our findings will be useful in developing a non-invasive sleep-facilitating instrument.

Clinical evaluation of the pharmacological impact of ashwagandha root extract on sleep in healthy volunteers and insomnia patients: A double-blind, randomized, parallel-group, placebo-controlled study

ETHNOPHARMACOLOGICAL RELEVANCE

Ashwagandha (Withania somnifera (L.) Dunal.) is long known for its sleep-inducing effects. Ashwagandha can be proposed as an alternative to the recommended present treatments for insomnia. This study aimed to evaluate the pharmacological effect of Ashwagandha root extract on sleep in healthy subjects and also in the subjects having insomnia.

MATERIAL AND METHODS

We performed a randomized, parallel-group, stratified design, placebo-controlled study. A total of 80 eligible participants, 40 in Arm-A (healthy) and 40 in Arm-B (insomnia) were assigned to two groups, either Ashwagandha or placebo and studied for 8-weeks. The assessment was done based on the sleep parameters (Sleep Onset Latency, Total Sleep Time, Wake After Sleep Onset, Total time in bed, and Sleep Efficiency), Pittsburgh Sleep Quality Index and Hamilton Anxiety scale-A questionnaire, mental alertness on rising assessment, and sleep quality questionnaire. Safety and adverse events along with the concomitant medication were also assessed.

RESULTS

In both healthy and insomnia subjects, there was a significant improvement in the sleep parameters in the Ashwagandha root extract supplemented group. The improvement was found more significant in insomnia subjects than healthy subjects. Repeat measure Analysis of variance (ANOVA) confirmed the significant improvement in SOL (p 0.013), HAM-A outcomes (p < 0.05), mental alertness (p 0.01), and sleep quality (p < 0.05) of the insomnia patients. A two-way ANOVA was used to confirm the outcomes that denoted sleep onset latency (p < 0.0001) and sleep efficiency (p < 0.0001) as the most improved parameters, followed by TST (p < 0.002) and WASO(p < 0.040). All these parameters (SOL, TST, WASO, TIB, SE, PSQI, HAM-A, Mental Alertness, and Sleep quality) were also statistically assessed for the significant improvement within the group both for the treatment, and the placebo groups in the healthy and the insomnia datasets. Obtained results suggest statistically significant (p < 0.0001) changes between the baseline values and the end of the study results except for the HAM-A and the mental alertness scoresn the healthy subject group.

CONCLUSION

The present study confirms that Ashwagandha root extract can improve sleep quality and can help in managing insomnia. Ashwagandha root extract was well tolerated by all the participants irrespective of their health condition and age. Additional clinical trials are required to generalize the outcome.

Sleep, morning alertness and quality of life in subjects treated with zopiclone and in good sleepers. Study comparing 167 patients and 381 good sleepers

From 20,000 households regularly surveyed by a national survey institute (Sofres), two groups were selected and questioned (using a 23-item questionnaire) about sleep vigilance and quality of life. The first group was composed of insomniacs using zopiclone for the last 12 months and no other CNS treatments (167 subjects). The second group was composed of 381 “good sleepers” selected as having no or occasionally one sleep disturbance in the last 12 months. No difference was found between the two groups in average total sleep time. Sleep disturbances were statistically equal in the two groups except for difficulties in initiating sleep which is more present for zopiclone users (13% vs 3%). Vigilance was mostly comparable in both groups.Five aspects of quality of life explored by the questionnaires (the professional, relational and sentimental, domestic, leisure and safety aspects) appeared to be comparable in the two groups.

Photopotentiation of the GABAA receptor with caged diazepam

As the inhibitory γ-aminobutyric acid-ergic (GABAergic) transmission has a pivotal role in the central nervous system (CNS) and defective forms of its synapses are associated with serious neurological disorders, numerous versions of caged GABA and, more recently, photoswitchable ligands have been developed to investigate such transmission. While the complementary nature of these probes is evident, the mechanisms by which the GABA receptors can be photocontrolled have not been fully exploited. In fact, the ultimate need for specificity is critical for the proper synaptic exploration. No caged allosteric modulators of the GABA_A receptor have been reported so far; to introduce such an investigational approach, we exploited the structural motifs of the benzodiazepinic scaffold to develop a photocaged version of diazepam (CD) that was tested on basolateral amygdala (BLa) pyramidal cells in mouse brain slices. CD is devoid of any intrinsic activity toward the GABA_A receptor before irradiation. Importantly, CD is a photoreleasable GABA_A receptor-positive allosteric modulator that offers a different probing mechanism compared to caged GABA and photoswitchable ligands. CD potentiates the inhibitory signaling by prolonging the decay time of postsynaptic GABAergic currents upon photoactivation. Additionally, no effect on presynaptic GABA release was recorded. We developed a photochemical technology to individually study the GABA_A receptor, which specifically expands the toolbox available to study GABAergic synapses.

Cooccurrence and bidirectional prediction of sleep disturbances and depression in older adults: Meta-analysis and systematic review

The present study pooled the prevalence of sleep disturbances and depression in community-dwelling older adults (mean age≥60years) and quantified the strength of evidence of the relationship between these two problems. From 23 cross-sectional studies and five sets of baseline data, a high pooled prevalence of sleep disturbances (30.5%), depressive symptoms (18.1%) and coexisting disorders (10.6%) were found. In the 23 cohort studies, self-reported sleep disturbances increased the risk of the onset of depression (relative risk [RR]=1.92). Persistent sleep disturbances increased the risk of the development (RR=3.90), recurrence (RR=7.70), and worsening (RR=1.46) of depression in older adults. Little support was found for a predictive role for objective sleep characteristics in the development of depression. Older adults with depression had a higher risk of developing (RR=1.72) and worsening (RR=1.73) symptoms of sleep disturbances. This review emphasizes the importance of timely interventions in incipient sleep disturbances and depression among older adults, preventing the development of more serious comorbidities.

Sleep disturbances, TBI and PTSD: Implications for treatment and recovery

Post-Traumatic Stress Disorder (PTSD), traumatic brain injury (TBI), and sleep problems significantly affect recovery and functional status in military personnel and Veterans returning from combat. Despite recent attention, sleep is understudied in the Veteran population. Few treatments and rehabilitation protocols target sleep, although poor sleep remains at clinical levels and continues to adversely impact functioning even after the resolution of PTSD or mild TBI symptoms. Recent developments in non-pharmacologic sleep treatments have proven efficacious as stand-alone interventions and have potential to improve treatment outcomes by augmenting traditional behavioral and cognitive therapies. This review discusses the extensive scope of work in the area of sleep as it relates to TBI and PTSD, including pathophysiology and neurobiology of sleep; existing and emerging treatment options; as well as methodological issues in sleep measurements for TBI and PTSD. Understanding sleep problems and their role in the development and maintenance of PTSD and TBI symptoms may lead to improvement in overall treatment outcomes while offering a non-stigmatizing entry in mental health services and make current treatments more comprehensive by helping to address a broader spectrum of difficulties.

Assessing the effect of a guideline change on drug use prevalence by including the birth cohort dimension: the case of benzodiazepines

PURPOSE

The aim of this study was to investigate whether including the birth cohort dimension in time series analysis leads to a more accurate estimation of the (long-term) effect of a guideline change on the trend of benzodiazepine use.

METHODS

We calculated age-specific (20-84 years) and sex-specific prevalence of benzodiazepine use per 1000 population per quarter year (1998 to 2008) using a prescription database set in the Netherlands. We studied the prevalence over time by age group and within birth cohorts through interrupted time series analyses to estimate the effect of the guideline change in 2001.

RESULTS

From 1998 to 2008, the overall age-standardized prevalence of benzodiazepine use per 1000 population declined from ~54 for men and ~107 for women to ~45 for men and ~85 for women. The relative change increased significantly after 2001 for both sexes and for the majority of age groups. Within birth cohorts, the prevalence increased with age until the year 2001 and leveled thereafter. The age-period approach overall had worse model fit indicators than the within-cohort approach and predicted larger long-term effects than the within-cohort approach. The age-period projection estimated 36% decline in benzodiazepine use relative to 2008, whereas the birth-cohort projection estimated 8% decline.

CONCLUSION

Explicitly following birth cohort trajectories led to models with better fit; the conventional approach estimated a stronger long-term guideline effect. This has important implications for professional practice.

Promoting sleep for hospitalized patients with advanced cancer with relaxation therapy: experience of a randomized study

AIMS AND OBJECTIVES

Sleep disorders are frequent in patients with advanced cancer receiving palliative care. The objective of this study was to demonstrate whether relaxation therapy can improve their satisfaction with sleep.

BACKGROUND

Few studies have investigated the effectiveness of relaxation in patients hospitalized with an advanced chronic disease.

DESIGN

Prospective randomized study with an immediate intervention group (IIG; relaxation days 3-6) and a delayed intervention group (DIG; relaxation days 6-9).

METHODS

The main measure was the overall satisfaction of sleep measured on a Numerical Rating Scale of Satisfaction of Sleep (NRSSS) between 0 and 10.

RESULTS

Totally 18 (IIG: 9; DIG: 9) patients were included in this study (mean age 66 ± 10.7). The NRSSS improved in both the groups (almost statistically significant) between the day of inclusion and day 2. Because of the dropout of the patients during the last days of the study, we analyzed the improvement in sleep satisfaction only between day 2 and 5. The NRSSS D5 for the immediate and delayed groups were 4.0 ± 23 and 3.8 ± 2.3, respectively. There was no significant improvement in both the groups.

CONCLUSION

The results demonstrated the difficulty to include patients with advanced cancer in a randomized study with a DIG. We were not able to demonstrate the effectiveness of relaxation therapy on sleep satisfaction.

RELEVANCE TO CLINICAL PRACTICE

Techniques that can be easily used to improve sleep in patients with an advanced cancer should be developed and used already early in the disease.

An approach to long-term sedative-hypnotic use

Insomnia is a common, often chronic medical disorder with significant medical and socioeconomic repercussions. However, unlike other medical conditions, there is intense debate as to whether the long-term treatment of insomnia is clinically appropriate. The perceived deleterious side effect of sedative-hypnotic medications may result in patients remaining untreated or undertreated. This review proposes that a more subtle approach needs to be taken in the management of patients with chronic insomnia and that long-term use of the newer sedative-hypnotics may be a feasible and effective treatment option when used in conjunction with thorough medical assessment and regular patient follow-up. This review discusses these issues and discusses the pros and cons of long-term sedative-hypnotic use.

Organ Specific Tumor Markers: What's New?

Tumor markers are molecules produced in the body in response to cancer. An ideal tumor marker should have high sensitivity and specificity, should be cheap, and should be easily detected in body fluids. Identification of novel markers is important and it is expected that with the advent of newer technologies, more reliable markers will be discovered. This review discusses the currently available tumor markers for different malignancies.

Sleep and sleep disorders in older adults

A common but significant change associated with aging is a profound disruption to the daily sleep-wake cycle. It has been estimated that as many as 50% of older adults complain about difficulty initiating or maintaining sleep. Poor sleep results in increased risk of significant morbidity and mortality. Moreover, in younger adults, compromised sleep has been shown to have a consistent effect on cognitive function, which may suggest that sleep problems contribute to the cognitive changes that accompany older age. The multifactorial nature of variables affecting sleep in old age cannot be overstated. Changes in sleep have been thought to reflect normal developmental processes, which can be further compromised by sleep disturbances secondary to medical or psychiatric diseases (e.g., chronic pain, dementia, depression), a primary sleep disorder that can itself be age-related (e.g., Sleep Disordered Breathing and Periodic Limb Movements During Sleep), or some combination of any of these factors. Given that changes in sleep quality and quantity in later life have implications for quality of life and level of functioning, it is imperative to distinguish the normal age-related sleep changes from those originating from pathological processes.

Mental health implications of music: insight from neuroscientific and clinical studies

Neuroscientific and clinical studies of music over the past two decades have substantially increased our understanding of its use as a means of therapy. The authors briefly review current literature related to music's effect on people with different mental illnesses, and examine several neurobiological theories that may explain its effectiveness or lack thereof in treating psychiatric disorders. Neuroscientific studies have shown music to be an agent capable of influencing complex neurobiological processes in the brain and suggest that it can potentially play an important role in treatment. Clinical studies provide some evidence that music therapy can be used as an alternative therapy in treating depression, autism, schizophrenia, and dementia, as well as problems of agitation, anxiety, sleeplessness, and substance misuse, though whether it can actually replace other modes of treatment remains undetermined. Future research should include translational studies involving both neuroscience and clinical medicine that investigate the long-term effects of music intervention and that lead to the development of new strategies for music therapy.

Tackling sleeplessness: psychological treatment options for insomnia in older adults

This paper provides a broad review of the extant literature involving the treatment of sleeplessness in older adults with insomnia. First, background information (including information regarding key issues in late-life insomnia and epidemiology of late-life insomnia) pertinent to achieving a general understanding of insomnia in the elderly is presented. Next, theories of insomnia in older adults are examined and discussed in relation to treatment of insomnia in late-life. With a general knowledge base provided, empirical evidence for both pharmacological (briefly) and psychological treatment options for insomnia in late-life are summarized. Recent advances in the psychological treatment of insomnia are provided and future directions are suggested. This review is not meant to be all-inclusive; however, it is meant to provide professionals across multiple disciplines (physicians; psychologists; applied and basic researchers) with a mix of breadth and depth of knowledge related to insomnia in late-life. It is our hope that readers will see the evidence in support of psychological treatments for late-life insomnia, and the utility in continuing to investigate this treatment modality.

Auricular acupuncture for insomnia: a systematic review

OBJECTIVE

Auricular acupuncture (AA) is a therapeutic method by which specific points on the auricle are stimulated to treat various conditions. AA is often recommended as treatment for insomnia. The aim of this systematic review was to evaluate data from randomised, placebo-controlled clinical trials testing the effectiveness of AA for treating insomnia.

METHODS

We searched the literature using 18 databases from their inception to April 2008 without language restrictions. All prospective randomised clinical trials (RCTs) of AA for subjects with insomnia were considered. Methodological quality was assessed using the Jadad score.

RESULTS

We identified 433 possible relevant articles, in which include 10 acceptable RCTs. The methodological quality of the trials was generally poor. Magnetic pellets AA was compared with placebo AA in three of the studies. The results suggested beneficial effects on sleep efficiency compared with placebo AA. One RCT tested needle AA compared with placebo AA and failed to show the effectiveness of AA. Four RCTs compared Semen Vaccariae or magnetic pellet AA with conventional drugs (estazolam or diazepam). Favourable effects for AA were found. Two RCTs tested thumbtack needle AA vs. no treatment suggested beneficial effects of AA on a sleep score.

CONCLUSION

We conclude that, because of the paucity and of the poor quality of the data, the evidence for the effectiveness of AA for the symptomatic treatment of insomnia is limited. Further, rigorously designed trials are warranted to confirm these results.

INSÔNIA: PREVALÊNCIA E FATORES DE RISCO RELACIONADOS EM POPULAÇÃO DE IDOSOS ACOMPANHADOS EM AMBULATÓRIO

RESUMO Insônia é um problema comum em todos os estágios da vida, mas é particularmente comum após os 65 anos de idade. É definida como uma dificuldade para iniciar o sono ou para se manter dormindo. Os distúrbios do sono nos idosos são comuns e multifatoriais. Vários fatores, incluindo idade avançada, influências psicossociais, doenças clínicas e psiquiátricas e uso de medicações podem estar associados com insônia. Apesar disso, os fatores de risco envolvidos no desenvolvimento de insônia não têm sido completamente identificados. A privação do sono interfere de maneira negativa na qualidade de vida. O objetivo deste trabalho é verificar a prevalência de insônia e de fatores de risco relacionados a esta queixa nos idosos acolhidos no ambulatório de geriatria do NAI (Núcleo de Atenção ao Idoso) da UERJ, em 2005, com 60 anos ou mais, de ambos os sexos. A busca ativa de insônia e sua correta avaliação são passos fundamentais na avaliação geriátrica.

Management of chronic insomnia in elderly persons

BACKGROUND

Chronic insomnia is common among the elderly These elderly patients are often viewed as difficult to treat, yet they are among the groups with the greatest need of treatment.

OBJECTIVE

This article reviews the literature on the management of chronic insomnia in elderly persons.

METHODS

A search of MEDLINE was conducted for articles published in English between January 1966 and March 2006 using the terms insomnia, behavioral therapy, estsazolsam, fluvsazepsam, qusazepsam, teMsazepsam, tvisazolsam, eszopiclone, zaleplon, zolpidem, mirtazapine, nefazodone, trazodone, and ramelteon. Articles were selected if they were meta-analyses or evidence-based reviews of therapeutic modalities; randomized controlled trials of nonpharmacologic or pharmacologic treatment; or review articles covering the characteristics and management of insomnia. Preference was given to meta-analyses, evidence-based reviews, and articles that included relevant new information.

RESULTS

Available options for the treatment of insomnia include nonpharmacologic approaches, foremost among them cognitive behavioral therapy, and pharmacotherapies, including chloral hydrate, barbiturates, over-the-counter (OTC) and prescription antihistamines, OTC dietary supplements (including melatonin), sedating antidepressants, benzodiazepine and nonbenzodiazepine sedative-hypnotics, and melatonin agonists. There is considerable evidence to support the effectiveness and durability of nonpharmacologic interventions for insomnia in adults of all ages, yet these interventions are underutilized. With some recent exceptions, the majority of identified studies of pharmacotherapy were of short duration (< or =6 weeks) and did not exclusively enroll older adults. Compared with the benzodiazepines, the nonbenzodiazepine sedative-hypnotics appeared to offer few, if any, significant clinical advantages in efficacy or tolerability in elderly persons. Newer agents with novel mechanisms of action and improved safety profiles, such as the melatonin agonists, hold promise for the management of chronic insomnia in elderly people.

CONCLUSIONS

Long-term use of sedative-hypnotics for insomnia lacks an evidence base and has traditionally been discouraged for reasons that include concerns about such potential adverse drug effects as cognitive impairment (anterograde amnesia), daytime sedation, motor incoordination, and increased risk of motor vehicle accidents and falls. In addition, the effectiveness and safety of long-term use of these agents remain to be determined. More research is needed to evaluate the long-term effects of treatment and the most appropriate management strategy for elderly persons with chronic insomnia.

Sleep Disorders in the Older Patient

Sleep changes dramatically with old age. Subjective and objective measures demonstrate an increase in sleep and wake disturbances with advancing age. The older person has a more fragmented sleep, sleeps less deeply, and tends to experience early morning awakenings. When older patients have sleep disorders, they often present with excessive daytime sleepiness, insomnia, or abnormal motor activity. In making the appropriate diagnosis, the role of the provider is to review the patient's medical history,psychiatric history, medications, underlying medical illnesses, and sleep-wake pattern. The aging process itself does not cause sleep problems and sleep requirements do not decrease with advanced age. The prevalence of insomnia, sleep-related breathing disorder, PLMS, and RLS increases with age and may lead to poor sleep quality. Because many sleep disorders are potentially reversible, it is the responsibility of the primary care provider to screen for these problems. A carefully planned clinical decision-making process when encountering a sleep disturbance in the older patient can greatly enhance quality of life and daytime function.

Les symptômes psychologiques et comportementaux de la démence : description et prise en charge

Behavioral and Psychological Symptoms in Dementia (BPSD) are, beside cognitive disorders, major features of Alzheimer's disease and related disorders. Diagnosis is important to enhance our knowledge of the pathophysiology of dementia and of their functional consequences for patients and caregivers. Pharmacological and non-pharmacological management of dementia depends to a large extent on the presence of BPSD. A committee of geriatricians, neurologists and psychiatrists specialized in dementia (THEMA 2) has promoted an epidemiological, diagnostic and therapeutic update in this field. This work was based on the BPSD Consensus Conference Report edited in 2000 by the International Psychogeriatric Association. This report was updated with the most recent literature reports, and was adapted to the French environment. This paper is a synthesis of this meeting, validated and corrected by the entire Thema 2 group.

Music improves sleep quality in older adults

AIM

The aim of this paper is to report an investigation of the effects of soft music on sleep quality in older community-dwelling men and women in Taiwan.

BACKGROUND

Sleep is a complex rhythmic state that may be affected by the ageing process. Few studies have focused on the effects of music, a non-pharmacological method of improving the quality of sleep in older adults.

METHOD

A randomized controlled trial was used with a two-group repeated measures design. Sixty people aged 60-83 years with difficulty in sleeping were recruited through community leaders and screened using the Pittsburgh Sleep Quality Index (PSQI) and Epworth Sleepiness Scale. Those reporting depression, cognitive impairment, medical or environmental problems that might interfere with sleep; and those who used sleeping medications, meditation, or caffeine at bedtime were excluded. Participants listened to their choice among six 45-minute sedative music tapes at bedtime for 3 weeks. There were five types of Western and one of Chinese music. Sleep quality was measured with the PSQI before the study and at three weekly post-tests. Groups were comparable on demographic variables, anxiety, depressive symptoms, physical activity, bedtime routine, herbal tea use, napping, pain, and pretest overall sleep quality.

RESULTS

Music resulted in significantly better sleep quality in the experimental group, as well as significantly better components of sleep quality: better perceived sleep quality, longer sleep duration, greater sleep efficiency, shorter sleep latency, less sleep disturbance and less daytime dysfunction (P = 0.04-0.001). Sleep improved weekly, indicating a cumulative dose effect.

CONCLUSION

The findings provide evidence for the use of soothing music as an empirically-based intervention for sleep in older people.

Valerian does not appear to reduce symptoms for patients with chronic insomnia in general practice using a series of randomised n-of-1 trials

OBJECTIVE

To investigate the effectiveness of valerian for the management of chronic insomnia in general practice.

DESIGN

Valerian versus placebo in a series of n-of-1 trials, in Queensland, Australia.

RESULTS

Of 42 enrolled patients, 24 (57%) had sufficient data for inclusion into the n-of-1 analysis. Response to valerian was fair for 23 (96%) participants evaluating their "energy level in the previous day" but poor or modest for all 24 (100%) participants' response to "total sleep time" and for 23 (96%) participants' response to "number of night awakenings" and "morning refreshment". As a group, the proportion of treatment successes ranged from 0.35 (95% CI 0.23, 0.47) to 0.55 (95% CI 0.43, 0.67) for the six elicited outcome sleep variables. There was no significant difference in the number (P=0.06), distribution (P=1.00) or severity (P=0.46) of side effects between valerian and placebo treatments.

CONCLUSIONS

Valerian was not shown to be appreciably better than placebo in promoting sleep or sleep-related factors for any individual patient or for all patients as a group.

Congruence of self-reported medications with pharmacy prescription records in low-income older adults

PURPOSE

This study examined the congruence of self-reported medications with computerized pharmacy records.

DESIGN AND METHODS

Pharmacy records and self-reported medications were obtained for 294 members of a state pharmaceutical assistance program who also participated in ACTIVE, a clinical trial on cognitive training in nondemented elderly persons. The average age of the sample participants was 74.5 years (range = 65-91); 87.8% were females.

RESULTS

Congruence between self-report and pharmacy data was generally high. Self-reports omitted drug classes in the pharmacy records less often than the pharmacy records did not include self-reported drug classes. The percentage of individuals with perfect agreement between self-reports and pharmacy records varied from 49% for major drug classes to 81% for specific cardiovascular and central nervous system drugs. Within a drug class, agreement tended to be higher for individuals without a prescription in that class. Poorer health was consistently related to poorer self-report of medications.

IMPLICATIONS

Self-reported medications are most likely to be congruent with pharmacy records for drugs prescribed for more serious conditions, for more specific classes of drugs, and for healthier individuals.

Zolpidem prescribing and adverse drug reactions in hospitalized general medicine patients at a veterans affairs hospital

BACKGROUND

Zolpidem is prescribed for sleep disruption in hospitalized patients, but data on the incidence of adverse drug reactions (ADRs) are based largely on outpatient studies. Thus, the incidence of ADRs in hospitalized patients may be much higher.

OBJECTIVE

The goal of this study was to describe prescribing patterns of zolpidem for hospitalized medical patients aged 50 years, the incidence of ADRs possibly and probably associated with its use, and the factors associated with central nervous system (CNS) ADRs.

METHODS

This case series was conducted in 4 general medicine wards at a Veterans Affairs hospital and was a consecutive sample of patients aged 50 years who were hospitalized between 1993 and 1997 and received zolpidem as a hypnotic during hospitalization, but had not received it in the previous 3 months. Chart review was conducted by 2 evaluators. Data extracted from the medical records included admission demographic characteristics, medications, comorbidities, and levels of function in performing basic and instrumental activities of daily living. The main outcome measure was ADRs possibly or probably related to zolpidem use. The association between zolpidem and the occurrence of CNS ADRs (eg, confusion, dizziness, daytime somnolence) was analyzed separately.

RESULTS

The review included 119 medical patients aged > or =50 years who had newly received zolpidem for sleep disruption during hospitalization. The median age of the population was 70 years; 86 (72.3%) patients were aged 65 years. The initial zolpidem dose was 5 mg in 42 patients (35.3%) and 10 mg in 77 patients (64.7%). Twenty-three patients had a respective 16 and 10 ADRs possibly and probably related to zolpidem use (19.3% incidence). Of a total of 26 ADRs, 21 (80.8%) were CNS ADRs, occurring with both zolpidem 5 mg (10.8% of users) and 10 mg (18.3% of users). On univariate analyses, the only factor significantly associated with a CNS ADR was functional impairment at baseline (P = 0.003). Zolpidem was discontinued in 38.8% of patients experiencing a CNS ADR CONCLUSIONS: In this case series in medical inpatients, there was a high frequency of ADRs, particularly CNS ADRs, associated with zolpidem use. Zolpidem should be used cautiously in the hospital setting.

Problems with sleep: what should the doctor do?

Complaints of poor sleep are frequent. The physician's assessment should seek to diagnose the social, medical, and psychiatric etiologies of insomnia and to treat the identified causative conditions. Management must match the specific pathology and type of sleep problem.

From nursing home to hospital and back again: an educational program to improve care for hospitalized nursing home patients

Hospital nurses have little knowledge of the geriatric syndromes and the processes of caregiving in nursing homes. This lack of knowledge is a barrier to continuity of care for patients admitted to hospitals from nursing homes. An educational program, including both classroom and clinical components, was designed to help bridge this gap. A plan for dissemination to other hospital staff was developed by the 15 nurses who participated.

The impact of attitudes and beliefs on length of benzodiazepine use: a study among inexperienced and experienced benzodiazepine users

Prolonged benzodiazepine use is a widespread phenomenon in medical practice. In the present article, we argue that psychological models may contribute to our understanding of benzodiazepine use. This study examined variables derived from the theory of planned behaviour and the health belief model in relation to the length of benzodiazepine use. Data were collected from a sample of all benzodiazepine users with a request for this medicine in the only pharmacy in a Dutch community (N=467). Determinants of the length of benzodiazepine use were analysed separately for inexperienced and experienced users using structural equation modelling (SEM) analyses. For both groups, results showed that the intention to use benzodiazepines was a predictor of length of use. Attitudes towards benzodiazepine use had an indirect influence on length of use, through intentions. Furthermore, a positive attitude toward using benzodiazepines was related to the perceived norm of the prescriber. Experienced users were more inclined to consume benzodiazepines when they had less control over drug taking. In this group, the belief that benzodiazepine use leads to dependence was associated with less control over drug taking and a high intention to use the drug. In addition, older experienced users reported a higher intention to use the drug. For inexperienced users, the perceived attitude of the prescriber towards use of the medicine was a strong determinant. Finally, results of SEM-analyses showed that the model accounted for far more variance in behaviour for experienced users (67%), than for inexperienced users (18%).

Consensus on Drug Treatment, Definition and Diagnosis for Insomnia

Thirty-four experts and a literature supervisor got together in order to reach a 'consensus' regarding the definition, diagnosis and pharmacological treatment of insomnia. Insomnia is a subjective perception of dissatisfaction with the amount and/or quality of sleep. It includes difficulty in initiating or maintaining sleep or early awakening with inability to fall asleep again. It is associated with complaints of non-restorative sleep and dysfunction of diurnal alertness, energy, cognitive function, behaviour or emotional state, with a decrease in quality of life. The diagnosis is based on clinical and sleep history, physical examination and additional tests, although polysomnography is not routinely indicated. Therapy should include treatment of the underlying causes, cognitive and behavioural measures and drug treatment. Hypnotic therapy can be prescribed from the onset of insomnia and non-benzodiazepine selective agonists of the GABA-A receptor complex are the drugs of first choice. It is recommended that hypnotic treatment be maintained in cases where withdrawal impairs the patient's quality of life and when all other therapeutic measures have failed. Experience suggests that intermittent treatment is better than continuous therapy. The available data do not confirm safety of hypnotics in pregnancy, lactation and childhood insomnia. Benzodiazepines are not indicated in decompensated chronic pulmonary disease but no significant adverse effects on respiratory function have been reported with zolpidem and zopiclone in stable mild to moderate chronic obstructive pulmonary disease and in treated obstructive sleep apnoea syndrome. Data for zaleplon are inconclusive. If the patient recovers subjective control over the sleep process, gradual discontinuation of hypnotic treatment can be considered.

Is there a rationale for prescription of benzodiazepines in the elderly? Review of the literature

Benzodiazepines (BZDs) constitute the most widely used symptomatic treatment of insomnia and anxiety. Many of these drugs are associated with adverse effects, such as daytime sedation and dependence with continued use. There is a concern about the rationale for and extent of benzodiazepine (BZD) use in the elderly. The sedation due to BZD use is a main risk factor for falls and other accidents. Impaired cognitive function with continuous use appears to be a major side effect. There is a general awareness that BZD use is inappropriate in many patients, and therefore discontinuation should be recommended whenever possible. Moreover, long-term use of these drugs should be actively discouraged. Although no unanimous recommendations concerning the optimal duration of the withdrawal process exist, BZDs may easily be withdrawn during a short period in most patients who are habituated to a low dose, if an initial phase with dose reduction and psychological support are provided. Alternative approaches involve sleep hygiene guidelines, behavioural treatment and psychotherapy tailored to the needs of the individual patient.

Comparing patterns of long-term benzodiazepine use between a Dutch and a Swedish community

BACKGROUND

There is much concern about the widespread long-term use of benzodiazepines. Utilisation data can give a foundation for interventions for appropriate use.

OBJECTIVE

To compare long-term usage patterns of benzodiazepines in a Dutch and a Swedish community in different periods.

METHODS

Eight-year follow-up patterns of use were investigated with respect to the characteristics of those who continued use over the whole follow-up period. In the Dutch community of 13,500, the data of a cohort of 1358 benzodiazepine users were analysed during the years 1984-1991; in the Swedish community of 20,000 people, a cohort of 2038 benzodiazepine users was followed from 1976.

RESULTS

At the end of the follow-up period, 32.9% of the Dutch cohort and 33% of the Swedish cohort had continued use of benzodiazepines. The two overall survival curves showed similar patterns. Stratification for age, gender, previous versus initial use and heavy versus non-heavy use showed comparable proportions of patients continuing benzodiazepine use over time.

CONCLUSION

The parallels in the results of two cohorts in different countries and different periods are striking and give support to the idea to stimulate interventions to reduce long-term benzodiazepine use.

Senescence, sleep, and circadian rhythms

The goal of this review article is to summarize our knowledge and understanding of the overlapping (interdisciplinary) areas of senescence, sleep, and circadian rhythms. Our overview comprehensively (and visually wherever possible), emphasizes the organizational, dynamic, and plastic nature of both sleep and circadian timing system (CTS) during senescent processes in animals and in humans. In this review, we focus on the studies that deal with sleep and circadian rhythms in aged animals and how these studies have closely correlated to and advanced our understanding of similar processes in ageing humans. Our comprehensive summary of various aspects of the existing research on animal and human ageing, both normal and pathological, presented in this review underscores the invaluable advantage of close collaboration between clinicians and basic research scientists and the future challenges inherent in this collaboration. First, our review addresses the common age-related changes that occur in sleep and temporal organization of both animals and humans. Second, we examine the specific modifications that often accompany sleep and CTS during aging. Third, we discuss the clinical epidemiology of sleep dysfunctions during ageing and their current clinical management, both pharmacological and non-pharmacological. Finally, we predict the possible future promises for complementary and alternative medicine (CAM) that pave the way to the emergence of a "Holistic Sleep Medicine" approach to the treatment of sleep disorders in the ageing population. Further studies will provide additional valuable insights into the understanding of both sleep and circadian rhythms during senescence.

Insomnia: conceptual issues in the development, persistence, and treatment of sleep disorder in adults

This paper critically reviews the evidence base for previously reported conceptual models of the development and persistence of insomnia. Although a number of perspectives have some empirical support, no one approach emerges as preeminent. Importantly, the efficacy of any particular psychological intervention cannot be taken as confirmation of presumed, underlying mechanisms. An integrated psychobiological inhibition model of insomnia is developed that accounts for the research data. The model views insomnia as arising from inhibition of de-arousal processes associated with normal sleep. It is proposed that sleep homeostatic and circadian factors are compromised by impairment of the automaticity and plasticity associated with good sleep, and that cognitive/affective processes activate the clinical complaint of insomnia. Common pathways for the action of cognitive-behavioral interventions are identified, and a research agenda is set for further conceptual and clinical study.

Sleep changes and disorders in the elderly patient

Sleep disorders are very common among older patients. Our population as a whole is experiencing substantial growth in the geriatric population. Thus, it is all the more prudent that healthcare professionals become familiar with the major sleep disorders that affect the older patient, as well as the diagnosis and treatment of these disorders. This paper deals with the various sleep changes that take place in the course of the aging process and with the assessment of sleep disorders in the older patient. Special attention is paid to sleep-disordered breathing, periodic limb-movement disorder of sleep, insomnia, and circadian rhythm anthology, as well as parasomnias that are unique to the older patient. The final section of the paper deals with specific neurologic disorders and their impact on sleep patterns.

Pharmacodynamic profile of Zaleplon, a new non-benzodiazepine hypnotic agent

The challenge in developing hypnotic agents for the treatment of insomnia is to balance the sedative effect needed at bedtime with the residual sedation on awakening. Zaleplon is a novel pyrazolopyrimidine hypnotic agent that acts as a selective agonist to the brain omega(1) receptor situated on the alpha(1) subunit of the GABA(A) receptor complex. Zaleplon was proven to be an effective hypnotic drug as it consistently and significantly reduced latency to persistent sleep in insomniac patients for doses of 10 mg and above in polysomnography studies. The pharmacodynamic profile of zaleplon on psychomotor performance, actual driving and cognitive function, including memory, was assessed in several randomized, double-blind, placebo-controlled studies in healthy young subjects as well as insomniac patients by using various positive controls (zolpidem, zopiclone, triazolam and flurazepam). The recommended hypnotic dose of zaleplon in young adults (10 mg) produced minimal or no impairment of psychomotor and memory performance even when administered during the night as little as 1 h before waking. No impairment of actual driving was observed when zaleplon 10 mg was administered either at bedtime or in the middle of the night as little as 4 h before waking. Zaleplon 20 mg, twice the recommended dose, generally produced significant impairment of performance and cognitive functions when these functions were measured at the time of peak plasma concentration, i.e. 1 h after dose administration, and no impairment of driving abilities was observed 4 h after a middle-of-the-night administration. In contrast, consistent detrimental residual effects on various aspects of psychomotor and cognitive functions were observed with the therapeutic doses of the various commonly prescribed hypnotic agents used as comparators, e.g. zolpidem 10 mg up to 5 h after dose administration, zopiclone 7.5 mg up to 10 h after, flurazepam 30 mg up to 14 h after and triazolam 0.25 mg up to 6 h after. Also, zolpidem 10 mg and zopiclone 7.5 mg were also shown to significantly impair driving ability the next morning when this was measured 4 h and up to 10 h after dose administration, respectively. The present review shows that zaleplon 10 mg has little or no residual effect when administered in the middle of the night, as late as 1 h before waking, and is devoid of impairment of driving abilities as assessed by actual driving 4 h after dose administration. The lack of clinically significant or minimally statistically significant residual effects of zaleplon even at its peak concentration may be explained by its unique pharmacokinetic (rapid elimination half-life) and pharmacodynamic (low affinity, and specific binding profile to various subunits of the GABA(A)receptor) profiles. These properties allow zaleplon to be used for treatment of symptoms only when they occur, either at bedtime or later in the night, without incurring significant risk of developing next-day impairment of psychomotor and cognitive functioning. Copyright 2001 John Wiley & Sons, Ltd.

COMPUTER Addiction: When Monitor Becomes Control Center

Computer addiction is a newly recognized problem. While controversy exists about whether computer addiction should be considered a primary psychiatric disorder, clinicians are treating increasing numbers of clients experiencing problems caused by excessive computer use. Case studies are provided that include typical histories and symptoms. Behavioral cognitive therapy is discussed as a treatment approach. The stages of change theory is recommended as a strategy to help clients plan and implement change.

Determinants for the use of psychotropics among nursing home residents

PURPOSE

To characterise the prescription pattern of psychotropics in Danish nursing homes and to identify diagnostic, behavioural, cognitive and performance characteristics associated with prevalent psychotropic drug use.

METHODS

Prescribed daily medication was recorded from nurses' files. Based on the Anatomical Therapeutical Chemical (ATC) classification index, psychotropics were categorised into neuroleptics, benzodiazepines and antidepressants. Two hundred and eighty-eight residents were diagnosed using the GMS-AGECAT. One hundred and eighteen staff members were interviewed about the residents's Activities of Daily Living (ADL), behavioural problems (Nursing Home Behavior Problem Scale), orientation, communication skills and if the resident had any psychiatric disorder. Multiple logistic regression was used to select the items that determined the use of psychotropics.

RESULTS

Fifty-six percent of the residents received a psychotropic, 21% received neuroleptics, 38% received benzodiazepines and 24% received antidepressants. In the multivariate analysis, staff assessment of the resident's mental health was a determinant for the use of all types of specific psychotropics, whereas a GMS-AGECAT diagnosis only determined the use of neuroleptics. Behavioural problems were a determinant for the use of neuroleptics and the use of benzodiazepines irrespective of the psychiatric diagnosis of the resident. Use of antidepressants was associated with male gender and increasing age.

CONCLUSIONS

Staff perceptions of psychiatric morbidity and norms have a greater impact on the prescription of psychotropics than standardised clinical criteria.

Predicting clinically significant response to cognitive behavior therapy for chronic insomnia in general medical practice: analysis of outcome data at 12 months posttreatment

The clinical efficacy of cognitive behavior therapy (CBT) for chronic insomnia has been established, yet clinical effectiveness is less clear. This study presents data on 109 patients from general practice during a formal evaluation of clinical effectiveness. Two thirds achieved normative values of < or =30 min for sleep latency and wakefulness during the night after CBT. Furthermore, almost half of the sample reduced sleeplessness by > or =50%. Logistic regression revealed that initial severity did not contraindicate good outcome. Rather, greater sleep disturbance was positively associated with large symptom reduction, although lower endpoint scores were less likely. Similarly, symptoms of anxiety, depression, and thinking errors positively predicted good outcome. Hypnotic using patients responded equally well to CBT, and demographic factors were of no significant predictive value. It is concluded that CBT is clinically and durably effective for persistent insomnia in routine practice.

Zaleplon: a pyrazolopyrimidine sedative-hypnotic agent for the treatment of insomnia

BACKGROUND

Insomnia is the subjective complaint of poor sleep or an inadequate amount of sleep that adversely affects daily functioning. For the past 4 decades, treatment of insomnia has shifted away from the use of barbiturates toward the use of hypnotic agents of the benzodiazepine class. However, problems associated with the latter (eg, next-day sedation, rebound insomnia, dependence, and tolerance) have prompted development of other agents.

OBJECTIVE

This review describes the recently approved nonbenzodiazepine agent, zaleplon.

METHODS

Studies of zaleplon were identified through a search of English-language articles listed in MEDLINE and International Pharmaceutical Abstracts, with no limitation on year. These were supplemented by educational materials from conferences.

RESULTS

The efficacy and tolerability of zaleplon have been documented in the literature. Zaleplon has been shown to improve sleep variables in comparison with placebo. Like most hypnotic agents, zaleplon can be used for problems of sleep initiation at the beginning of the night, but its short duration of clinical effect may also allow patients to take it later in the night without residual effects the next morning. Zaleplon can be taken < or = 2 hours before awakening without "hangover" effects. It is generally well tolerated, with headache being the most commonly reported adverse event in clinical trials (15%-18%). Compared with flurazepam, a long-acting benzodiazepine sedative-hypnotic agent, zaleplon causes significantly less psychomotor and cognitive impairment (P < 0.001). Zaleplon has not been studied in pregnant women or children. The dose of zaleplon should be individualized; the recommended daily dose for most adults is 10 mg.

CONCLUSIONS

Insomnia has a substantial impact on daily functioning. If pharmacologic treatment is indicated for insomnia, the choice of an agent should be guided by individual patient characteristics.

Psychophysiological insomnia: combined effects of pharmacotherapy and relaxation-based treatments

Objective: To compare treatment outcomes associated with combined pharmacologic and non-pharmacologic treatments for psychophysiological insomnia.Background: Treatments for insomnia have included a variety of pharmacotherapy and cognitive-behavioral interventions, although few studies have investigated the combined efficacy of drug and non-drug therapy.Methods: Forty-one patients with primary insomnia were randomly assigned to one of three treatment groups: (i) estazolam + muscle relaxation, (ii) estazolam + guided imagery, and (iii) estazolam + sleep education. After 4 weeks of active treatment, subjects were withdrawn from medication and followed for an additional 6 months.Results: Significant improvements were observed in self-report measures of total sleep time, sleep efficiency, and wakefulness after sleep onset in the combined drug and relaxation groups, compared to a significant improvement in total sleep time only in the educational control group. At follow-up, all three groups showed significant improvements across the major sleep measures. Positive changes were also observed in quality of life measures, including mood state and self- ratings of daytime arousal.Conclusions: These findings provide support for the value of combined pharmacotherapy and relaxation training in the treatment of psychophysiological insomnia.