Sleep quality of benzodiazepine users in nursing homes: a comparative study with nonusers

Nurses' attitudes, beliefs and knowledge of sleep health in residential aged care: An integrative literature review

AIM

To identify, synthesize and evaluate primary research on registered nurses' (RN) knowledge, attitudes and beliefs about sleep health and sleep health management of older adults living in residential aged care.

DESIGN

Integrative review.

DATA SOURCES

Medline, Embase and CINAHL databases from inception to September 2023.

REVIEW METHODS

Databases were searched using a combination of key words, subject heading terms. All abstracts and full-text articles were screened by two researchers. Qualitative synthesis of the included articles was conducted. Inductive content analysis was used to identify themes and analyse data.

RESULTS

A total of 923 abstracts were screened resulting in a final yield of 13 articles. Three themes were identified: (i) RN experience with sleep-disturbed residents, (ii) the emotional burden of sleep disturbances on RN and, (iii) organizational barriers to promoting resident's healthy sleep. Inappropriate administration of benzodiazepines and psychotropic drugs to manage residents' sleep disturbances was a major issue and lack of resources in residential aged care to facilitate sleep. There were concerns on nursing activity that disturbed residents' sleep and striking a balance between facilitating sleep and meeting managerial expectations was challenging.

CONCLUSION

This review identified that nurses' decision-making has an integral role in the management of sleep health in residents in aged care. Whilst evidence-based guidelines for managing sleep in residential aged care are available, there is a lack of translation to practice. Understanding RN perspectives is critical to improving sleep health models of care in residential aged care.

IMPACT

This review found that RN are attuned to the implications of sleep disturbance in residential aged care but are constrained by current sleep health models of care.

PATIENT OR PUBLIC CONTRIBUTION

Not applicable.

Prescribing and deprescribing guidance for benzodiazepine and benzodiazepine receptor agonist use in adults with depression, anxiety, and insomnia: an international scoping review

Background

Clinical practice guidelines and guidance documents routinely offer prescribing clinicians' recommendations and instruction on the use of psychotropic drugs for mental illness. We sought to characterise parameters relevant to prescribing and deprescribing of benzodiazepine (BZD) and benzodiazepine receptor agonist (BZRA), in clinical practice guidelines and guidance documents internationally, for adult patients with unipolar depression, anxiety disorders and insomnia to understand similarities and discrepancies between evidence-based expert opinion.

Methods

A Scoping Review was conducted to characterize documents that offered evidence-based and/or consensus pharmacologic guidance on the management of unipolar depression, anxiety disorders, obsessive-compulsive disorders, post-traumatic stress disorders and insomnia. A systematic search was conducted of PubMed, SCOPUS, PsycINFO and CINAHL from inception to October 13, 2023 and supplemented by a gray literature search. Documents were screened in Covidence for eligibility. Subsequent data-charting on eligible documents collected information on aspects of both prescribing and deprescribing.

Findings

113 documents offering guidance on BZD/BZRA use were data-charted. Overall, documents gathered were from Asia (n = 11), Europe (n = 34), North America (n = 37), Oceania (n = 7), and South America (n = 4) with the remainder being "International" (n = 20) and not representative to any particular region or country. By condition the documents reviewed covered unipolar depressive disorders (n = 28), anxiety disorders, obsessive-compulsive disorder and post-traumatic stress disorder (n = 42) and Insomnia (n = 25). Few documents (n = 18) were sufficiently specific and complete to consider as de-prescribing focused documents.

Interpretation

Documents were in concordance in terms of BZD and BZRA not being used routinely as first-line pharmacologic agents. When used, it is advisable to restrict their duration to "short-term" use with the most commonly recommended duration being less than four weeks. Documents were less consistent in terms of prescriptive recommendations for specific drug, dosing and administration pattern (i.e regular or 'as needed') selection for each condition. Deprescribing documents were unanimously in favor of gradual dose reduction and patient shared decision-making. However, approaches towards dose-tapering differed substantially. Finally, there were inconsistencies and/or insufficiency of detail, among deprescribing documents, in terms of switching to a long-acting BZD, use of adjunctive pharmacotherapies and micro-tapering.

Funding

The authors received no funding for this work.

The devil is in the detail: a critique of nine editorials published by the International Task Force on Benzodiazepines

Since 2018, the International Task Force on Benzodiazepines (ITFB), a group of academic psychiatrists and academic psychologists, has advocated that clinical guidelines should change to promote benzodiazepines from second- to first-line treatment for anxiety disorders, accept their use as maintenance treatment for anxiety conditions (in particular, panic disorder) and increase their use in gastrointestinal disorders. There is merit in much of what the ITFB argues, but in this article I analyse four major claims it has made in opinion editorials that I believe are not fully supported by the available evidence.

Nocturia severely impairs the sleep quality of nursing home residents: results from a multi-center study

OBJECTIVES

To assess the association between self-reported sleep quality and nocturia in nursing home residents.

METHODS

The association between self-reported poor sleep quality and nocturia was examined in eighty nursing home residents from two nursing facilities using logistic regression analysis.

RESULTS

Poor sleep quality was reported by 29% of the eighty participants (median age 89±7 years, 77% of women). Nocturia was more frequent in patients with versus without self-reported poor sleep quality (78% vs 47%, p=0.01). Nocturia was independently associated with self-reported poor sleep quality after controlling for age, gender, self-rated health status, cognitive frailty score, antidepressant and hypnosedative use (OR[95%CI] of 6.1[1.8-25.4]).

CONCLUSION

Nocturia severely impaired sleep quality in nursing home residents. Nocturia should be investigated in nursing home residents to optimize sleep quality.

Improvements in sleep quality and fatigue are associated with improvements in functional recovery following hospitalization in older adults

Study objectives

Poor sleep quality, a frequent problem in older adults, has been shown to be associated with reduced physical function and wellbeing. However, little is known about the relationship between sleep quality and the recovery of physical function following hospitalization. Thus, we conducted this study to examine the association between sleep quality and functional recovery after an acute hospitalization in community dwelling older adults.

Methods

Older adult patients (N = 23, mean age = 74 ± 9 years) were recruited during an acute hospitalization (average length of stay 3.9 days) with a cardiovascular (56%), pulmonary (22%), or metabolic (13%) admission diagnosis. Objective physical function was measured using the Short Physical Performance Battery (SPPB) and self-reported function was assessed with Katz Index of Independence in Activities of Daily Living (ADL) and Lawton Instrumental Activities of Daily Living Scale (IADL). Sleep quality was measured using Pittsburgh Sleep Quality Index (PSQI) global score and Iowa Fatigue Score (IFS). Testing was performed prior to discharge (baseline) and 4-weeks post-discharge (follow-up).

Results

Regression models showed PSQI Subjective Sleep Quality change scores from baseline to 4-week follow-up predicted a change in ADL (β = -0.22); PSQI Use of Sleep Medications change scores predicted a change in SPPB Total (β = 1.62) and SPPB Chair Stand (β = 0.63); IFS change scores predicted SPPB Total (β = -0.16) and SPPB Chair Stand performance (β = -0.07) change scores.

Conclusions

For older adults, changes in sleep medication use, daytime dysfunction, and fatigue were associated with improvements in functional recovery (including physical performance and independence) from acute hospitalization to 4-week follow-up. These results suggest that interventions focused on improving sleep quality, daytime consequences, and fatigue might help enhance physical functioning following hospitalization.

Clinical trial registration

ClinicalTrials.gov, identifier: NCT02203656.

Sleep and other Non-motor Symptoms in Patients with Idiopathic Oromandibular Dystonia and Meige Syndrome: A Questionnaire-based Study

Introduction:

Non-motor symptoms are an essential cause of comorbidity in generalized and focal dystonia. However, there are few studies on dystonia involving the craniofacial regions.

Methods:

We studied non-motor symptoms in patients with oromandibular dystonia (OMD) and Meige syndrome using a questionnaire, and validated instruments for depression, anxiety, REM behaviour disorder, restless leg syndrome, sleep quality, excessive daytime sleepiness, and self-esteem. The severity of dystonia and blepharospasm was also studied.

Results:

Nineteen patients with OMD were recruited into the study. Among patients with OMD, depression was seen in 63.6% (n = 7), sleep impairment in 27.3% (n = 3), excessive daytime sleepiness in 27.3% (n = 3), and poor self- esteem in 18.2% (n = 2) of the patients. Among patients with Meige syndrome, depression was seen in 37.5% (n = 3), sleep impairment in 12.5% (n = 1), excessive daytime sleepiness in 25% (n = 2), low self-esteem in 25% (n = 2) of the patients.

Conclusion:

This study highlights the significant frequency of depression and sleep disturbances in patients with idiopathic OMD and Meige syndrome.

A study on depression of the elderly with different sleep quality in pension institutions in Northeastern China

Background

China owns he largest aged population in the world, and the elderly adults who live in pension institutions are more likely to suffer from mental disorders than other elderly adults. The purpose of this study is to discover the risky factors of depression among nursing home residents with various sleeping quality.

Methods

We conducted a cross-sectional study in Northeastern China from May to September in 2017 using multistage sampling method and 507 elderly people without cognitive impairment in six pension institutions were interviewed. The Pittsburgh Sleep Quality Index (PSQI) and Geriatric Depression Scale (GDS) were adopted to collect the information of sleep quality and depression. We used logistic regression to analyze the factors influencing depression among the elderly adults with poor or good sleep quality.

Results

The overall depression rate among elderly adults was 21.7%. The logistic regression analysis revealed that marital status, chronic disease, regular exercise, physical ache, filial piety and chewing ability had significant effects on the depression of the elderly with good sleep quality. Loneliness, self-caring ability, chewing ability and chronic diseases had significant effects on depression of the elderly with poor sleep quality.

Conclusion

The prevalence of depressive symptoms in the elderly is not high. However, sleeping quality distinguishes root causes on elderly adults depression. Therefore, the risk factors of depression among elderly adults should be analyzed separately.

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.

Changes in Australian Early-Career General Practitioners' Benzodiazepine Prescribing: a Longitudinal Analysis

BACKGROUND

Australian and international guidelines recommend benzodiazepines and related drugs (hereafter "benzodiazepines") as second-line, short-term medications only. Most benzodiazepines are prescribed by general practitioners (GPs; family physicians). Australian GP registrars ("trainees" or "residents" participating in a post-hospital training, apprenticeship-like, practice-based vocational training program), like senior GPs, prescribe benzodiazepines at high rates. Education within a training program, and experience in general practice, would be expected to reduce benzodiazepine prescribing.

OBJECTIVE

To establish if registrars' prescribing of benzodiazepines decreases with time within a GP training program DESIGN: Longitudinal analysis from the Registrar Clinical Encounters in Training multi-site cohort study PARTICIPANTS: Registrars of five of Australia's 17 Regional Training Providers. Analyses were restricted to patients ≥ 16 years.

MAIN MEASURES

The main outcome factor was prescription of a benzodiazepine. Conditional logistic regression was used, with registrar included as a fixed effect, to assess within-registrar changes in benzodiazepine-prescribing rates. The "time" predictor variable was "training term" (6-month duration Terms 1-4). To contextualize these "within-registrar" changes, a mixed effects logistic regression model was used, including a random effect for registrar, to assess within-program changes in benzodiazepine-prescribing rates over time. The "time" predictor variable was "year" (2010-2015).

KEY RESULTS

Over 12 terms of data collection, 2010-2015, 1161 registrars (response rate 96%) provided data on 136,809 face-to-face office-based consultations. Two thousand six hundred thirty-two benzodiazepines were prescribed (for 1.2% of all problems managed). In the multivariable model, there was a significant reduction in within-program benzodiazepine prescribing over time (year) (p = < 0.001, OR = 0.94, CI = 0.90, 0.97). However, there was no significant change in 'within-registrar' prescribing over time (registrar Term) (p = 0.92, OR = 1.00 [95% CI = 0.94-1.06]).

CONCLUSIONS

Despite a welcome temporal trend for reductions in overall benzodiazepine prescribing from 2010 to 2015, there is still room for improvement and our findings suggest a lack of effect of specific GP vocational training program education and, thus, an opportunity for targeted education.

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.

Long-term persistence of withdrawal of temazepam, zopiclone, and zolpidem in older adults: a 3-year follow-up study

BACKGROUND

Studies on persistence of benzodiazepine agonist (BZDA) withdrawal in older outpatients are few, and few studies on long-term persistence over years have yet been published. To describe the persistence of temazepam, zolpidem, and zopiclone (BZDA) withdrawal among older outpatients at 3 years from the beginning of withdrawal, as well as any changes in use of other medications.

METHODS

92 outpatients (≥55 years) with primary insomnia, long-term BZDA use as hypnotics (mean duration of BZDA use 9.9 ± 6.2 years), and willingness to withdraw from BZDAs each received either melatonin or a placebo nightly for one month. During this period, BZDAs were meant to be gradually withdrawn. Sleep hygiene counselling and psychosocial support were provided. Three years later, use of BZDAs and other medications was determined by interview and confirmed from medical records.

RESULTS

Of the original 92 outpatients, 83 (90%) participated in the 3-year survey (mean follow-up 3.3 ± 0.2 years). The number of BZDA-free participants decreased from 34 (37%) at 6 months to 26 (28%; intention-to-treat) at 3 years, that of irregular BZDA users decreased from 44 (48%) at 6 months to 27 (29%) at 3 years, while that of regular users increased from 11 (12%) at 6 months to 30 (33%) at 3 years (P = 0.001). Those who were regular BZDA users at 3 years had at baseline (before withdrawal) higher BMI (P = 0.001) than did other participants. At 3 years, the total number of medications remained unchanged for non-users (P = 0.432), but increased for the irregular (P = 0.011) and regular users (P = 0.026) compared to baseline. At 3 years, compared to baseline, use of antidepressants, dopamine agonists, melatonin, and NSAIDs/paracetamol was significantly more common in the whole cohort, but their use did not differ between the BZDA-user subgroups. Randomization to melatonin or placebo during BZDA withdrawal was unrelated to BZDA-withdrawal result.

CONCLUSIONS

At 3 years after withdrawal, the number of BZDA-free participants had decreased, but still one-third of the subjects remained BZDA-free, and one-third had reduced their use. Successful BZDA withdrawal did not lead to any increase in total number of medications; use of symptomatic medications in the whole cohort, however, did increase.

Prescription Benzodiazepine Use Among Older Adults: A Critical Review

OBJECTIVES

Despite evidence for many potential risks, use of benzodiazepines (BZDs) among older adults is common. The authors evaluated the available evidence for BZD effectiveness and tolerability for use in older adults in three psychiatric conditions for which BZDs are commonly prescribed: insomnia, anxiety disorders, and behavioral and psychological symptoms of dementia.

DESIGN

Electronic databases, including PubMed/MEDLINE, were searched to identify articles that (1) included patients ≥50 years of age, (2) focused on patients diagnosed with insomnia, anxiety disorders, or behavioral and psychological symptoms of dementia, and (3) were either a randomized, placebo-controlled trial or a randomized trial comparing a BZD with either another psychotropic medication or psychotherapy.

RESULTS

Thirty-one studies met the inclusion criteria. Of the three clinical indications evaluated, treatment of insomnia had the greatest available evidence for use of BZDs among older adults, with 21 of 25 trials demonstrating improved sleep outcomes with use of BZDs. Only one trial was found to meet eligibility criteria for BZD use in anxiety disorders, demonstrating benefit over placebo. Five studies for use in behavioral disturbances in dementia were included, of which only one demonstrated improvement over placebo.

CONCLUSION

This systematic review suggests that BZD prescribing to older adults is significantly in excess of what the available evidence suggests is appropriate. Future trials should focus on efforts to reduce both acute and chronic BZD use among older adults while improving access to effective non-pharmacologic treatment alternatives.

Sleep and Long-Term Care

Long-term care (LTC) involves a range of support and services for people with chronic illness and disabilities who can not perform activities of daily living independently. Poor sleep increases the risk of LTC placement, and sleep disturbance is extremely common among LTC residents. The identification and management of sleep disturbance in LTC residents is a vital, but perhaps underappreciated, aspect of offering high-quality care for this already compromised population. This review describes the nature and consequences of sleep disturbances in LTC, clinical assessment and management of sleep disturbances in LTC, and implications for future research and clinical practice.

The use of an electronic clinical rule to discontinue chronically used benzodiazepines and related Z drugs

PURPOSE

The chronic use of benzodiazepines and benzodiazepine-related drugs (BZ/Z) in older people is common and not without risks. The objective of this study was to evaluate whether the implementation of a clinical rule promotes the discontinuation of chronically used BZ/Z for insomnia.

METHODS

A clinical rule, generating an alert in case of chronic BZ/Z use, was created and applied to the nursing home (NH) setting. The clinical rule was a one-off intervention, and alerts did not occur over time. Reports of the generated alerts were digitally sent to NH physicians with the advice to phase out and eventually stop the BZ/Z. In cases where the advice was adopted, a follow-up period of 4 months on the use of BZ/Z was taken into account in order to determine whether the clinical rule alert led to a successful discontinuation of BZ/Z.

RESULTS

In all, 808 NH patients were screened. In 161 (19.1%) of the patients, BZ/Z use resulted in a clinical rule alert. From these, the advice to phase out and stop the BZ/Z was adopted for 27 patients (16.8%). Reasons for not following the advice consisted of an unsuccessful attempt in the past (38 patients), patients family and/or patient resistance (37 patients), the non-continuous use of BZ/Z (32 patients) and indication still present (27 patients). Of the 12 NH physicians, seven adopted the advice.

CONCLUSIONS

The success rate of a clinical rule for discontinuation of chronically used BZ/Z for insomnia was low, as reported in the present study. Actions should be taken to help caregivers, patients and family members understand the importance of limiting BZ/Z use to achieve higher discontinuation rates.

The association between benzodiazepine use and sleep quality in residential aged care facilities: a cross-sectional study

BACKGROUND

Benzodiazepines are commonly prescribed in residential aged care facilities (RACFs) for their sedative and anxiolytic effects. The objective of this study was to investigate the association between benzodiazepine use and sleep quality in residents of RACFs.

METHODS

A cross-sectional study involving 383 participants was conducted in six Australian RACFs. Night-time sleep quality, day-time drowsiness and day-time napping behavior were assessed using a validated questionnaire. Logistic regression was used to compute adjusted odds ratios (AORs) and 95% confidence intervals (CIs) for the association between benzodiazepine use and sleep quality. Covariates included pain, dementia severity, depression, insomnia and other sedative use.

RESULTS

Of the 383 residents (mean age 87.5 years, 77.5% female), 96(25.1%) used a benzodiazepine on a regular basis. Residents who used long-acting benzodiazepines on a regular basis had higher night-time sleep quality than non-users (AOR = 4.00, 95%CI 1.06 - 15.15). Residents who used short-acting benzodiazepines on a PRN only basis had longer daytime napping times than non-users (AOR = 1.77, 95%CI 1.01 - 3.08). No benzodiazepine category was associated with day-time drowsiness.

CONCLUSIONS

The association between benzodiazepine use and sleep quality is dependent on the half-life and prescribing pattern of the benzodiazepine. Short-acting PRN benzodiazepines were associated with lower night time sleep quality and longer day-time napping compared to long-acting regular benzodiazepines. Longitudinal studies are needed to determine whether these findings reflect channeling of short-acting agents to residents at higher risk of sleep disorders.

The Effects of Ramelteon on Glucose Metabolism and Sleep Quality in Type 2 Diabetic Patients With Insomnia: A Pilot Prospective Randomized Controlled Trial

Background

Insomnia is associated with the onset and development of diabetes. Melatonin affects sleep quality and glucose metabolism in diabetic patients with insomnia. We administered ramelteon, an agonist of melatonin, to type 2 diabetic patients and investigated its effects on glucose metabolism and insomnia.

Methods

This multicenter, prospective, randomized, and observational pilot study was performed between April 2014 and April 2015 at three institutes in Japan. Patients were prescribed ramelteon 8 mg/day for 3 months (first period). And patients were divided at random into the continuation group that continued taking ramelteon and the discontinuation group that discontinued taking ramelteon for 3 additional months (second period). The primary endpoint was change in glycated hemoglobin (HbA1c) level. Secondary endpoints were changes in global Pittsburgh sleep questionnaire index (PSQI) score and other glucose metabolism makers.

Results

We enrolled 42 patients, and 32 patients completed the first period. Their mean HbA1c was 6.7%, and global PSQI score was 8.1 on average. HbA1c level did not change but global PSQI score improved from 8.1 to 7.2 by ramelteon (P = 0.030). Thirty-one patients completed the second period. HbA1c level did not change in the continuation group, but it increased from 6.7% to 6.9% (P = 0.003) in the discontinuation group. Global PSQI score did not change in each group. There was no rebound insomnia.

Conclusion

Treatment with ramelteon did not change the HbA1c level but improved sleep quality in type 2 diabetic patients with insomnia. Discontinuation of ramelteon slightly increased the HbA1c level and did not worsen sleep quality.

Too little sleep and too much sleep among older adults: Associations with self-reported sleep medication use, sleep quality and healthcare utilization

AIM

The present study examined relationships among older adults' sleep duration (1-5 h and ≥10 h vs 6-9 h), sleep medication use, sleep quality and healthcare use.

METHODS

The 2013 USA National Health Interview Survey provided data on a sample of 7196 community-dwelling individuals aged ≥65 years. Bivariate analyses and multivariate regression analyses were used to examine study questions.

RESULTS

Of the sample, 85% slept 6-9 h on average, 8% slept 1-5 h and 7% slept ≥10 h. One-sixth of optimal sleepers, one-quarter of short sleepers and one-fifth of long sleepers used sleep medications at least once in the preceding week. Medication intake of one to two times, as opposed to non-use, was associated with a greater risk of short than optimal sleep (RRR 1.60, 95% CI 1.03-2.48). Short sleep was positively, but long sleep was negatively associated with trouble falling asleep and staying asleep. Any medication use was positively associated with trouble falling asleep and staying asleep. Short sleep was associated with greater odds of emergency department visits (OR 1.36, 95% CI 1.06-1.77), whereas long sleep was associated with greater odds of an overnight hospital stay (OR 1.48, 95% CI 1.04-2.11) and home care use (OR 2.46, 95% CI 1.37-4.41). Medication intake one to two times was associated with greater odds of emergency department visits (OR 1.48, 95% CI 1.11-1.98).

CONCLUSIONS

Sleep medication use does not appear to promote sleep health. Both short and long sleep durations are associated with a higher likelihood of healthcare use. Clinicians need to examine older adults' sleep health and medication use, and their effects on healthcare use. Geriatr Gerontol Int 2017; 17: 545-553.

Sleep and agitation in nursing home residents with and without dementia

BACKGROUND

The prevalence of dementia in Australian nursing homes is high. A large proportion of residents express themselves through agitated behaviors, with substantial interpersonal and day-to-day variance. One factor that may increase agitation is poor sleep. The current study aimed to determine if sleep influences symptoms of agitation in nursing home residents, and whether this effect differed by dementia status. As benzodiazepines are used widely as hypnotic medication, their impact was also considered.

METHODS

Actigraph devices worn on residents' non-dominant wrists for three days were used to obtain objective measures of sleep. Symptoms of agitation were assessed using staff responses to two standardized questionnaires - the Cohen-Mansfield Agitation Inventory (CMAI) and the Neuropsychiatric Inventory - nursing home version (NPI-NH). Presence of dementia and benzodiazepine use were obtained from resident medical charts.

RESULTS

Forty-nine residents (mean age: 85.57 years) from four nursing homes in Tasmania were included in the study. Results indicated that residents were in bed for an average of 11.04 h and slept for 10.14 h per day. Significant relationships between sleep and verbal as well as non-aggressive agitation were found. No relationships between sleep and aggressive agitation were detected. A significant moderation effect of dementia was found, in which residents without dementia expressed verbal agitation when obtaining less sleep, but not residents with dementia. Benzodiazepine use did not result in significantly more sleep.

CONCLUSIONS

These results suggest that sleep could play an important role in explaining agitation, but more research is needed to explore the relationship between sleep and benzodiazepines in nursing home residents.

The impact of chronic benzodiazepine use on cognitive evolution in nursing home residents

OBJECTIVE

Chronic use of benzodiazepines and Z-drugs (BZD/Zs) has been linked to cognitive decline. In this one-year prospective cohort study, we explored the impact of chronic BZD/Z use on cognitive decline compared to nonusers.

METHODS

In cognitively capable BZD/Z users and nonusers in 10 Belgian nursing homes, we investigated cognition with the MiniMentalStateExamination(MMSE) at baseline and one year. A decrease of ≥ 4 points on the MMSE (clinically relevant decrease) was used in multiple logistic regression. We collected baseline demographics, functional, psychometric and social characteristics potentially influencing cognition.

RESULTS

In both the 131 BZD/Z users and 95 nonusers, the cognition decreased significantly over time, but without significant difference between the groups. Clinically relevant decrease was present in 34% BZD/Z users and 27% nonusers (NS). Controlled for age, gender, education and BZD/Z use, the significant risk factors for clinically relevant cognitive decline were depression, hearing and functional impairment. Frequent reading was associated with less MMSE decrease. Our findings could not demonstrate with statistical significance that BZD/Z use was associated with fast cognitive decline. The risk factors for fast decline were depression, hearing and functional impairment, and the absence of a reading attitude. In addition, BZD/Z use and depression were associated, indicating a complex relationship.

Feasibility of discontinuing chronic benzodiazepine use in nursing home residents: a pilot study

PURPOSE

Guidelines discourage chronic benzodiazepines and related Z drugs (BZD/Zs) for sleep problems. However, prevalence among nursing home residents remains high. Discontinuing these drugs is widely recommended but seems difficult to implement. The aim of our study was to evaluate the overall feasibility in the nursing home, in terms of willingness towards discontinuation and success rate at 8 months, together with the impact on withdrawal symptoms, change in sleep quality, quality of life and medication use.

METHODS

In a convenience sample of five nursing homes (823 residents), we included cognitively competent residents with chronic BZD/Z use for insomnia. We investigated sleep quality [with Pittsburgh Sleep Quality Index (PSQI)], quality of life (EQ-5D) and withdrawal symptoms [Benzodiazepine Withdrawal Symptom Questionnaire (BWSQ)]. Success rate was analysed with survival analysis.

RESULTS

Of the 135 eligible residents, both general physician (GP) and resident were willing to initiate discontinuation in 38 residents. Reasons for refusing to initiate discontinuation among GPs was the unmotivated patient and among residents the reluctance towards change. At 8 months, 66.0% were successful discontinuers, with the subjective PSQI component evolving favourably (p = 0.013) and a decreasing number of midnight awakenings (p = 0.041). In the relapse group (n = 13), the quality of life decreased (p = 0.012), with mainly an increase of problems with activities and pain/discomfort. In both groups, the withdrawal symptoms, functionality and medication use did not change.

CONCLUSION

Discontinuation of chronic BZD/Z use is feasible in the nursing home setting without noticeable withdrawal symptoms, without a switch in medication use, without detrimental effect on quality of life and with a positive effect on the self-perceived sleep quality.