One-Year Evolution of Sleep Quality in Older Users of Benzodiazepines: A Longitudinal Cohort Study in Belgian Nursing Home Residents

Improving Sleep Using Mentored Behavioral and Environmental Restructuring (SLUMBER)

OBJECTIVES

To evaluate the impact of a mentoring program to encourage staff-delivered sleep-promoting strategies on sleep, function, depression, and anxiety among skilled nursing facility (SNF) residents.

DESIGN

Modified stepped-wedge unit-level intervention.

SETTING AND PARTICIPANTS

Seventy-two residents (mean age 75 ± 15 years; 61.5% female, 41% non-Hispanic white, 35% Black, 20% Hispanic, 3% Asian) of 2 New York City urban SNFs.

METHODS

Expert mentors provided SNF staff webinars, in-person workshops, and weekly sleep pearls via text messaging. Resident data were collected at baseline, post-intervention (V1), and 3-month follow-up (V2), including wrist actigraphy, resident behavioral observations, Pittsburgh Sleep Quality Index (PSQI), Patient Health Questionnaire-9 (PHQ-9) depression scale, Brief Anxiety and Depression Scale (BADS), Brief Cognitive Assessment Tool (BCAT), and select Minimum Data Set 3.0 (MDS 3.0) measures. Linear mixed models were fit for continuous outcomes and mixed-effects logistic models for binary outcomes. Outcomes were modeled as a function of time. Planned contrasts compared baseline to V1 and V2.

RESULTS

There was significant improvement in PSQI scores from baseline to V1 (P = .009), and from baseline to V2 (P = .008). Other significant changes between baseline and V1 included decreased depression (PHQ-9) (P = .028), increased daytime observed out of bed (P ≤ .001), and increased daytime observed being awake (P < .001). At V2 (vs baseline) being observed out of bed decreased (P < .001). Daytime sleeping by actigraphy increased from baseline to V1 (P = .004), but not V2. MDS 3.0 activities of daily living and pain showed improvements by the second quarter following implementation of SLUMBER (P's ≤ .034). There were no significant changes in BADS or BCAT between baseline and V1 or V2.

CONCLUSIONS AND IMPLICATIONS

SNF residents had improvements in sleep quality and depression with intervention, but improvements were not sustained at 3-month follow-up. The COVID-19 pandemic led to premature study termination, so full impacts remain unknown.

Guidance for appropriate use of psychotropic drugs in older people

Psychotropic drugs are widely prescribed in older people although their use is associated with important risks. In this position paper, we discuss the appropriateness of using these medications in older people in terms of different aspects such as indications, contraindications, dosing, adverse drug reactions, interactions and duration of therapy. Consequently, we discuss different strategies to increase the appropriateness of therapy while formulating some practical recommendations to keep in mind when (de)prescribing psychotropic drugs in older people.

The association between benzodiazepine use and falls, and the impact of sleep quality on this association: data from the TILDA study

BACKGROUND

Benzodiazepines (BZD) are associated with adverse effects, particularly in older adults.

AIM

This study assesses the association between BZD use and falls, and the impact of sleep quality on this association, in community dwelling adults aged over 50.

DESIGN

Cross-sectional analysis of data from wave 1 of The Irish Longitudinal Study on Ageing.

METHODS

Participants were classed as BZD users or non-users and asked if they had fallen in the last year, and whether any falls were unexplained. Sleep quality was assessed via self-reported trouble falling asleep, daytime somnolence and early-rising. Logistic regression assessed for an association between BZD use and falls, and the impact of sleep quality on this association was assessed by categorizing based on BZD use and sleep quality variables.

RESULTS

Of 8175 individuals, 302 (3.69%) reported taking BZDs. BZD use was associated with falls, controlling for confounders [Odds Ratio (OR) 1.40; 1.08, 1.82; P-value 0.012]. There was no significant association between BZDs and unexplained falls, controlling for confounders [OR 1.41; 95% Confidence Interval (CI) 0.95, 2.10; P-value 0.09]. Participants who use BZDs and report daytime somnolence (OR 1.93; 95% CI 1.12, 3.31; P-value 0.017), early-rising (OR 1.93; 95% CI 1.20, 3.11; P-value 0.007) or trouble falling asleep (OR 1.83; 95% CI 1.12, 2.97; P-value 0.015), have an increased odds of unexplained falls.

CONCLUSION

BZD use is associated with falls, with larger effect size in those reporting poor sleep quality in community dwelling older adults. Appropriate prescription of medications such as BZDs is an important public health issue.

The relationship between sleep quality, inappropriate medication use and frailty among older adults in aged care homes in Malaysia

Poor sleep quality is prevalent among older adults and is compounded by frailty and polypharmacy. This descriptive, cross-sectional study examines the associations between sleep quality, inappropriate medication use and frailty. The study was conducted among 151 residents of 11 aged care homes in three states in Malaysia; convenience sampling was used. Subjective sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI), and Groningen Frailty Indicator (GFI) was used to assess frailty. Medication appropriateness was assessed using Drug burden Index (DBI), Potentially Inappropriate Medications (PIMs) and Potentially Inappropriate Prescriptions (PIPs). Most of the subjects (approximately 95%) reported poor sleep quality, as measured by a cut-off of global PSQI score of ≥ 5. With a second cut-off at 10, just over half (56%) reported moderately poor sleep quality followed by 39% who had very poor sleep quality. Most (90%) denied taking medication to improve their sleep during the previous month. There was no statistically significant association between medication inappropriateness (PIMs, PIPs, DBI) and global PSQI score. However, the average number of PIM was associated significantly with sleep efficiency (a measure of the actual 'sleep to total time spent in bed) (p = 0.037). The average number of PIP was associated with subjective sleep quality (p = 0.045) and the use of sleep medications (p = 0.001), and inversely associated with sleep disturbance (0.049). Furthermore, frailty correlated significantly with poor overall sleep quality (p = 0.032). Findings support the need for medication review to identify and reduce PIMs and optimise prescriptions to improve sleep quality and hence, related health outcomes among residents of aged care homes.

Characteristics of New-Onset and Chronic Sleep Medication Users Among Older Adults: A Retrospective Study of a US Medigap Plan Population using Propensity Score Matching

Background

Prescription sleep medications are often utilized to manage sleep problems among older adults even though these drugs are associated with multiple risks.

Objective

The aim was to determine the prevalence and characteristics of new-onset compared to chronic sleep medication users and to examine factors associated with the conversion from new to chronic use. A secondary objective was to investigate the impact of sleep medications on health outcomes of injurious falls and patterns of healthcare utilization and expenditures.

Methods

A 25% random sample of adults ≥ 65 years with 3-year continuous AARP^® Medicare Supplement medical and AARP^® MedicareRx drug plan enrollment was utilized to identify new-onset and chronic sleep medication users. Prescription sleep medication drugs were defined using National Drug Codes (NDCs); falls or hip fractures were identified from diagnosis codes. New users had no sleep medication use in 2014, but initiated medication use in 2015; chronic users had at least one sleep medication prescription in 2014 and in 2015; both groups had follow-up through 2016. Characteristics associated with new users, new users who converted to chronic use, and chronic users were determined using multivariate logistic regression. Prevalence of falls, healthcare utilization and expenditures were regression adjusted.

Results

Among eligible insureds, 3 and 9% were identified as new-onset and chronic sleep medication users, respectively. New-onset sleep medication prescriptions were often associated with an inpatient hospitalization. The strongest characteristics associated with new users, those who converted to chronic use, and chronic users were sleep disorders, depression and opioid use. About 50% of new users had > 30 days’ supply; 25% converted to chronic use with ≥ 90 days’ supply. The prevalence of falls for new-onset users increased by 70% compared to a 22% increase among chronic users.

Conclusion

New-onset and chronic sleep medication users were characterized by sleep disorders, depression and pain. Addressing the underlying problems associated with sleep problems among older adults may decrease the need for sleep medications and thus reduce the risk of sleep medication-related adverse events.

Stilbene Glucoside, a Putative Sleep Promoting Constituent from Polygonum multiflorum Affects Sleep Homeostasis by Affecting the Activities of Lactate Dehydrogenase and Salivary Alpha Amylase

Chinese herbal medicine (CHM) has been used for treating insomnia for centuries. The most used CHM for insomnia was Polygonum multiflorum. However, the molecular mechanism for CHM preventing insomnia is unknown. Stilbene glucoside (THSG), an important active component of P. multiflorum, may play an important role for treating insomnia. To test the hypothesis, Kunming mice were treated with different dosages of THSG. To examine the sleep duration, a computer-controlled sleep-wake detection system was implemented. Electroencephalogram (EEG) and electromyogram (EMG) electrodes were implanted to determine sleep-wake state. RT-PCR and Western blot was used to measure the levels of lactate dehydrogenase (LDH) and saliva alpha amylase. Spearman's rank correlation coefficient was used to identify the strength of correlation between the variables. The results showed that THSG significantly prolonged the sleep time of the mice (p<0.01). THSG changed sleep profile by reducing wake and rapid eye movement (REM) period, and increasing non-REM period. RT-PCR and Western blot analysis showed that THSG could down-regulate the levels of LDH and saliva alpha amylase (p<0.05). The level of lactate and glucose was positively related with the activity of LDH and saliva alpha amylase (p<0.05), respectively. On the other hand, the activities of LDH and amylase were negatively associated with sleep duration (p<0.05). The levels of lactate and glucose affect sleep homeostasis. Thus, THSG may prevent insomnia by regulating sleep duration via LDH and salivary alpha amylase.

A Four-Session Sleep Intervention Program Improves Sleep for Older Adult Day Health Care Participants: Results of a Randomized Controlled Trial

Study Objective

To test the effectiveness of a 4-week behavioral Sleep Intervention Program (SIP: sleep compression, modified stimulus control, and sleep hygiene) compared to a 4-week information-only control (IC) among older adults attending a VA Adult Day Health Care (ADHC) program in a double-blind, randomized, clinical trial.

Methods

Forty-two individuals (mean age: 77 years, 93% male) enrolled in a VA ADHC program were randomized to receive SIP or IC. All completed in-person sleep and health assessments at baseline, post-treatment and 4-months follow-up that included 3 days/nights of wrist actigraphy, the Pittsburgh Sleep Quality Index (PSQI), and the Insomnia Severity Index (ISI). Mixed repeated measures analysis was used to compare sleep outcomes at post-treatment and 4-months follow-up, with baseline values as covariates.

Results

SIP participants (n = 21) showed significant improvement on actigraphy sleep efficiency (p = .007), number of nighttime awakenings (p = .016), and minutes awake at night (p = .001) at post-treatment, compared to IC participants (n = 21). Benefits were slightly attenuated but remained significant at 4-month follow-up (all p's < .05). There were no differences in total sleep time between groups. There was significant improvement on PSQI factor 3 (daily disturbances) at 4-month follow-up (p = .016), but no differences were observed between SIP and IC on other PSQI components or ISI scores at post-treatment or 4-month follow-up.

Conclusions

A short behavioral sleep intervention may have important benefits in improving objectively measured sleep in older adults participating in ADHC. Future studies are needed to study implementation of this intervention into routine clinical care within ADHC.

[Discontinuation of benzodiazepines in old age : When and if so, how?]

Although viewed critically in geriatrics, benzodiazepine use is still common among old people. Before reducing the dosage the following questions must be considered: 1. Are there indications for benzodiazepine treatment and will discontinuation cause relevant rebound symptoms of the initial disorder treated? 2. To what extent do the patient and other key persons consider discontinuation to be reasonable and will they support discontinuation? 3. Is the target complete withdrawal, a dose reduction or shift to another benzodiazepine drug which is more suitable in old age for pharmacokinetic reasons? This article provides assistance in answering these questions and some guidelines for the practical management of discontinuation. It is mandatory 1) to periodically address the problem of long-term benzodiazepine use when counseling the patient and key persons and 2) to be aware that several intermediate steps exist between continuation and complete discontinuation, which may be considered successful treatment.