Use of sleep medications and risk of cancer: a matched case-control study

Sleep patterns and awareness of the consequences of sleep deprivation in Saudi Arabia

PURPOSE

Sleep deprivation is a growing challenge in modern society and places a burden on people's physical and mental well-being. However, only a few studies have investigated sleep patterns and awareness of the associated risks of sleep deprivation in Middle Eastern countries. This study aimed to explore these issues in adults in Saudi Arabia.

METHODS

This was a quantitative cross-sectional study. We collected information on the participants' demographic characteristics, sleep hours, and sense of feeling sleep-deprived over the previous 3 months regardless of sleep duration. Current knowledge of the health consequences associated with chronic sleep deprivation and attitudes toward seeking in-person health care for sleep deprivation symptoms were additionally assessed.

RESULTS

Among 1449 adults, only 41% of the participants slept for the recommended duration for adults of 7 h or more. However, 70% reported feeling sleep-deprived at least some of the time regardless of their sleep duration. Smokers, students, and those on sleep medications were more likely to report feeling sleep-deprived. Most participants (strongly) agreed that chronic sleep deprivation had a negative effect on their health (92%) and social (88%) and professional lives (91%), yet only 10% of our sample had visited a doctor for their sleep deprivation symptoms.

CONCLUSIONS

We found a high level of sleep deprivation among residents of Saudi Arabia and a strong awareness of the association between chronic sleep deprivation and negative consequences, yet a lower awareness of the association with specific medical comorbidities. Our findings also suggested a lack of health care engagement among sleep-deprived participants.

Association of sleep duration and sleeping pill use with mortality and life expectancy: A cohort study of 484,916 adults

OBJECTIVES

To compare mortality risk and life expectancy among individuals with different sleep durations and sleeping pill use.

METHODS

A cohort of 484,916 community-dwelling adults in Taiwan was recruited into a health screening program from 1994 to 2011. Subjects were categorized by daily sleep duration into 4 groups: extremely short (<4 hours), short (4-6 hours), medium (6-8 hours), and long (>8 hours). Cox proportional hazards models were used to investigate the associations of mortality risk with sleep duration and sleeping pill use. Models were adjusted for sociodemographic characteristics, lifestyle, and comorbidities. Life expectancy tables were calculated among sleeping pill users and nonusers with different sleep durations.

RESULTS

With 6- 8 hours of daily sleep, sleeping pill nonusers had the lowest mortality risk. Sleeping pill users, even with this optimal amount of sleep, had a 55% (p < .001, 95% CI, 1.38-1.73) higher mortality risk than nonusers. The life expectancy of 30-year-old male sleeping pill users with extremely short or long sleep durations was 12-13 years shorter than sleeping pill nonusers who had 6-8 hours of sleep. On average, life expectancy in individuals using sleeping pills (vs. nonusers) was shorter by 5.3 (95% CI, 4.10-6.32) years in men and 5.7 (95% CI, 5.28-7.98) years in women.

CONCLUSIONS

This study suggests that the use of sleeping pills is associated with an increased risk of mortality and shortened life expectancy, especially in extreme sleepers. Regular users should be aware of potential harms from sleeping pills.

Associations of Late-Life Sleep Medication Use With Incident Dementia in the Atherosclerosis Risk in Communities Study

BACKGROUND

Sleep medications may contribute to dementia development or indicate sleep disturbances that are markers of or contributors to neurologic disease. The objective of this study was to examine the use of sleep medications and incident dementia in a community-based cohort of older adults. We hypothesize late-life sleep medication use is associated with a greater risk of dementia.

METHODS

The Atherosclerosis Risk in Communities (ARIC) study is an ongoing community-based cohort study. ARIC participants taking barbiturates, benzodiazepines, antidepressants, non-benzodiazepine receptor agonists (Z-drugs), or other hypnotics in 2011-2013 were categorized as sleep medication users. Participants were followed through 2019 for incident dementia. Logistic regression propensity scores were used to match sleep medication users with nonusers (1:2). Cox proportional hazards regression models were used to estimate hazard ratios (HR) for time to dementia diagnosis with adjustment for demographics, lifestyle characteristics, and cardiovascular risk factors.

RESULTS

One-quarter of the eligible ARIC participants used sleep medications. In the matched sample (N = 4 197; 69% female; mean age 75.3 + 5.0 years), 632 dementia cases were ascertained over a median follow-up of 6.5 years. In the fully adjusted model, sleep medication use compared to nonuse was associated with a 48% greater risk of dementia (HR: 1.48; 95% confidence interval (CI): 1.26-1.74).

CONCLUSION

To expand on these findings, studies with longer follow-up and earlier assessment of sleep medication use are needed. Furthermore investigation of the potential dose-response association of multiple sleep medications and the potential causal role of sleep medications in the development of dementia may be clinically meaningful.

Trends, correlates, and disease patterns of sedative-hypnotic use among elderly persons in Taiwan

OBJECTIVE

The population-based National Health Insurance database was adopted to investigate the prevalence, correlates, and disease patterns of sedative-hypnotic use in elderly persons in Taiwan.

METHODS

The National Health Research Institutes provided a database of 1,000,000 random subjects in the National Health Insurance program. We adopted this sample of subjects who were older than 65 years from 1997 to 2005 and examined the proportions of psychiatric and nonpsychiatric disorders with regard to sedative-hypnotic use.

RESULTS

The 1-year prevalence of sedative-hypnotic use in elderly individuals increased from 1.7% in 1997 to 5.5% in 2005. The 1-year prevalence rates of benzodiazepine (BZD) and non-BZD hypnotics were 3.2 and 3.1%, respectively, in 2005. The overall hypnotic use was highest in ≥85-year-olds, males, those with lower amounts of insurance or higher Charlson Comorbidity Index scores and those living in eastern Taiwan. Both BZD and non-BZD hypnotic use were most commonly used in nonpsychiatric disorders instead of psychiatric disorders. Among the psychiatric disorders, the disorders that accounted for higher BZD and non-BZD hypnotic use were senile and presenile organic psychotic conditions (3.4 and 3.4%, respectively). Higher BZD and non-BZD use was for diseases of the respiratory system (30.4 and 17.8%, respectively), the circulatory system (20.4 and 22.4%, respectively), and neoplasms (12.6 and 13.8%, respectively).

CONCLUSION

The prevalence rates of both BZD and non-BZD sedative-hypnotic use increased from 1997 to 2005 in the elderly. The risk factors for sedative-hypnotic use were aging, male sex, lower insurance amount, and higher Charlson Comorbidity Index scores. Most BZD and non-BZD sedative-hypnotic users were persons with nonpsychiatric disorders.

Non-GABA sleep medications, suvorexant as risk factors for falls: Case-control and case-crossover study

The aim of this study was to examine the risk of falls associated with the use of non-gamma amino butyric acid (GABA) sleep medications, suvorexant and ramelteon. This case-control and case-crossover study was performed at the Kudanzaka Hospital, Chiyoda Ward, Tokyo. A total of 325 patients who had falls and 1295 controls matched by sex and age were included. The inclusion criteria for the case group were hospitalized patients who had their first fall and that for the control were patients who were hospitalized and did not have a fall, between January 2016 and November 2018. The internal sleep medications administered were classified as suvorexant, ramelteon, non-benzodiazepines, benzodiazepines, or kampo. In the case-control study, age, sex, clinical department, the fall down risk score, and hospitalized duration were adjusted in the logistic regression model. In the case-control study, multivariable logistic regression showed that the use of suvorexant (odds ratio [OR]: 2.61, 95% confidence interval [CI]: 1.29-5.28), nonbenzodiazepines (OR: 2.49, 95% CI: 1.73-3.59), and benzodiazepines (OR: 1.65, 95% CI: 1.16-2.34) was significantly associated with an increased OR of falls. However, the use of ramelteon (OR: 1.40, 95% CI: 0.60-3.16) and kampo (OR: 1.55, 95% CI: 0.75-3.19) was not significantly associated with an increased OR of falls. In the case-crossover study, the use of suvorexant (OR: 1.78, 95% CI: 1.05-3.00) and nonbenzodiazepines (OR: 1.63, 95% CI: 1.17-2.27) was significantly associated with an increased OR of falls. Similar patterns were observed in several sensitivity analyses. It was suggested that suvorexant increases the OR of falls. This result is robust in various analyses. This study showed that the risk of falls also exists for non-GABA sleep medication, suvorexant, and thus it is necessary to carefully prescribe hypnotic drugs under appropriate assessment.

Use of Hypnotics and Risk of Cancer: A Meta-Analysis of Observational Studies

Background

Previous observational epidemiological studies have shown inconsistent results on the relationship between hypnotics use and risk of cancer. To determine the association between hypnotics use and risk of cancer, we conducted a meta-analysis of available literature.

METHODS

We searched databases PubMed, EMBASE, and the bibliographies of relevant articles to locate additional publications in February 2016. Three evaluators independently reviewed and selected eligible studies based on pre-determined selection criteria.

RESULTS

A total of six observational epidemiological studies including three case-control studies and three cohort studies, which involved 1,830,434 participants (202,629 hypnotics users and 1,627,805 non-users), were included in the final analyses. In a random-effects meta-analysis, compared with non-use of hypnotics, the odds ratio for overall hypnotics use was 1.29 for various cancers (95% confidence interval, 1.08-1.53). Subgroup meta-analyses by various factors such as study design, type of case-control study, study region, and methodological quality of study revealed consistent findings.

CONCLUSION

Our findings from a meta-analysis of low-biased epidemiological studies suggested evidence linking the use of hypnotics to an increased risk of cancers. The results should be cautiously interpreted because of considerable heterogeneity with a high I square value.

Trajectories in hypnotic use and approaching death: a register linked case-control study

PURPOSE

Whether the association between hypnotic and increased mortality risk is created by causation or confounding, has been long debated. We further examined the possibility of confounding by indication with a comprehensive approach.

METHODS

The National FINRISK Study cohorts of 1997, 2002, and 2007 (25,436 participants aged 25-74) were followed up until July 2012. There were 1822 deaths, and at least one gender, baseline age and cohort matched 'control' was found for 1728 'cases' yielding a final analytical sample of 3955 individuals. An index age, equivalent to the age at death of their respective cases' was set for each control. Hypnotic drug purchases were followed from the Finnish nationwide register during a 36-month run-up period before the date of death/index date. The prevalence and incidence of hypnotic purchases were compared between cases and matched controls. Moreover, latent developmental trajectories of purchases were modelled and their relations with specific and all-cause death risks were analysed.

RESULTS

An increasing difference between cases and controls was observed as regards the use of hypnotic drugs. During the last 30 months before the date of death/index date, the rate ratio of incident purchases between cases and controls was 2.37 (95% CL, 1.79-3.12) among older and 3.61 (95% CL, 2.37-5.89) among younger individuals. The developmental trajectories of hypnotic drug purchases were differently and by interpretation plausibly associated with specific mortality risks.

CONCLUSIONS

In most cases the association between hypnotics and mortality risk is created by symptomatic treatment when death is approaching.

Sleep Duration and Risk of Liver Cancer in Postmenopausal Women: The Women's Health Initiative Study

BACKGROUND

Sleep duration has been associated with nonalcoholic fatty liver disease, but its association with liver cancer remains unknown.

MATERIAL AND METHODS

In the prospective Women's Health Initiative Study, 139,368 postmenopausal women reported sleep habits at baseline (1993-1998). We ascertained 175 incident liver cancer cases during an average 13.8 years of follow-up through August 2014. We used multivariable Cox proportional hazard regression models to estimate a hazard ratio (HR) and its 95% confidence interval (95% CI) for risk of liver cancer in association with nocturnal sleep duration.

RESULTS

Compared to women reporting 6-8 hours of sleep, the HR for liver cancer was 1.94 (95% CI 1.07-3.53) for women reporting ≥9 hours of sleep. Among the obese women, the HR associated with ≥9 hours of sleep was 3.18 (95% CI 1.84-8.60). The HR was 0.93 (95% CI 0.34-2.53) among nonobese women (p value for interaction = 0.18). Short sleep duration (≤5 hours) was not associated with liver cancer risk.

CONCLUSION

Long sleep duration was associated with a moderate increase in liver cancer risk in obese postmenopausal women in the United States. Larger study is needed to confirm our observation on effect modification by adiposity status.

Zolpidem Administration and Risk of Hepatocellular Carcinoma: A Case-Control Study in Taiwan

Background/Objectives: Previous studies showed that zolpidem use could be associated with increased cancer risk, but the role of zolpidem on hepatocellular carcinoma (HCC) risk remains undetermined. The study purpose was to examine the association between HCC risk and zolpidem use in Taiwan. Methods: Using the database from the Taiwan National Health Insurance Program, we designed a case-control study which consisted of 77986 subjects aged 20 years or older with newly diagnosed HCC as the case group, and 77986 subjects without HCC as the control group, from 2000 to 2011. Ever use of zolpidem was defined as a subject who had at least a prescription for zolpidem before the index date. Never use was defined as a subject who did not have a prescription for zolpidem before the index date. The association between HCC risk and zolpidem use was determined by the odds ratio (OR) and 95% confidence interval (CI) in a multivariable logistic regression model. Results: After adjustment for confounding factors, the adjusted OR of HCC was 1.05 (95% CI 0.97, 1.13) for subjects with ever use of zolpidem, compared with never use of zolpidem. The adjusted OR of HCC was 1.01 for subjects with increasing cumulative duration of zolpidem use for every 1 year (95% CI 0.99, 1.03), compared with never use of zolpidem. Conclusion: There is no significant association between HCC risk and zolpidem use. There is no duration-dependent effect of zolpidem use on HCC risk.

Integrative Medicine for Insomnia

Difficulty initiating and/or maintaining sleep is a common issue. Patients experiencing insomnia symptoms frequently self-treat their symptoms with sleep medications. However, there remains concern regarding the short- and long-term health impacts of sleep medications. This article discusses the evidence supporting integrative approaches to insomnia treatment, including cognitive-behavioral therapy and mind-body therapies (mindfulness meditation, yoga, tai chi), as well as emerging data for use of other less well supported approaches (dietary supplements, acupuncture).

External adjustment of unmeasured confounders in a case-control study of benzodiazepine use and cancer risk

AIMS

Previous studies have reported diverging results on the association between benzodiazepine use and cancer risk.

METHODS

We investigated this association in a matched case-control study including incident cancer cases during 2002-2009 in the Danish Cancer Registry (n = 94 923) and age- and sex-matched (1:8) population controls (n = 759 334). Long-term benzodiazepine use was defined as ≥500 defined daily doses 1-5 years prior to the index date. We implemented propensity score (PS) calibration using external information on confounders available from a survey of the Danish population. Two PSs were used: The error-prone PS using register-based confounders and the calibrated PS based on both register- and survey-based confounders, retrieved from the Health Interview Survey.

RESULTS

Register-based data showed that cancer cases had more diagnoses, higher comorbidity score and more co-medication then population controls. Survey-based data showed lower self-rated health, more self-reported diseases, and more smokers as well as subjects with sedentary lifestyle among benzodiazepine users. By PS calibration, the odds ratio for cancer overall associated with benzodiazepine use decreased from 1.16 to 1.09 (95% confidence interval 1.00-1.19) and for smoking-related cancers from 1.20 to 1.10 (95% confidence interval 1.00-1.21).

CONCLUSION

We conclude that the increased risk observed in the solely register-based study could partly be attributed to unmeasured confounding.

Mortality Risk of Hypnotics: Strengths and Limits of Evidence

Sleeping pills, more formally defined as hypnotics, are sedatives used to induce and maintain sleep. In a review of publications for the past 30 years, descriptive epidemiologic studies were identified that examined the mortality risk of hypnotics and related sedative-anxiolytics. Of the 34 studies estimating risk ratios, odds ratios, or hazard ratios, excess mortality associated with hypnotics was significant (p < 0.05) in 24 studies including all 14 of the largest, contrasted with no studies at all suggesting that hypnotics ever prolong life. The studies had many limitations: possibly tending to overestimate risk, such as possible confounding by indication with other risk factors; confusing hypnotics with drugs having other indications; possible genetic confounders; and too much heterogeneity of studies for meta-analyses. There were balancing limitations possibly tending towards underestimates of risk such as limited power, excessive follow-up intervals with possible follow-up mixing of participants taking hypnotics with controls, missing dosage data for most studies, and over-adjustment of confounders. Epidemiologic association in itself is not adequate proof of causality, but there is proof that hypnotics cause death in overdoses; there is thorough understanding of how hypnotics euthanize animals and execute humans; and there is proof that hypnotics cause potentially lethal morbidities such as depression, infection, poor driving, suppressed respiration, and possibly cancer. Combining these proofs with consistent evidence of association, the great weight of evidence is that hypnotics cause huge risks of decreasing a patient's duration of survival.

The Quest for Mindful Sleep: A Critical Synthesis of the Impact of Mindfulness-Based Interventions for Insomnia

Mindfulness-Based Interventions (MBIs) for insomnia and sleep disturbances are receiving increasing clinical and research attention. This paper provides a critical appraisal of this growing area investigating the application of MBIs for people with insomnia and sleep disturbance. First, we discuss the theoretical justification for how mindfulness meditation practice may affect sleep processes. Second, we provide a focused review of literature published between January 1, 2012 and April 1, 2016 examining the impact of MBIs on sleep, broken down by whether insomnia or sleep disturbance was a primary or secondary outcome. Recommendations for future research are discussed.

Hypnotic drug risks of mortality, infection, depression, and cancer: but lack of benefit

This is a review of hypnotic drug risks and benefits, reassessing and updating advice presented to the Commissioner of the Food and Drug Administration (United States FDA). Almost every month, new information appears about the risks of hypnotics (sleeping pills). The most important risks of hypnotics include excess mortality, especially overdose deaths, quiet deaths at night, infections, cancer, depression and suicide, automobile crashes, falls, and other accidents, and hypnotic-withdrawal insomnia. Short-term use of one-two prescriptions is associated with greater risk per dose than long-term use. Hypnotics have usually been prescribed without approved indication, most often with specific contraindications, but even when indicated, there is little or no benefit. The recommended doses objectively increase sleep little if at all, daytime performance is often made worse, not better, and the lack of general health benefits is commonly misrepresented in advertising. Treatments such as the cognitive behavioral treatment of insomnia and bright light treatment of circadian rhythm disorders offer safer and more effective alternative approaches to insomnia.

Hypnotic drug risks of mortality, infection, depression, and cancer: but lack of benefit

This is a review of hypnotic drug risks and benefits, reassessing and updating advice presented to the Commissioner of the Food and Drug Administration (United States FDA). Almost every month, new information appears about the risks of hypnotics (sleeping pills). This review includes new information on the growing USA overdose epidemic, eight new epidemiologic studies of hypnotics' mortality not available for previous compilations, and new emphasis on risks of short-term hypnotic prescription. The most important risks of hypnotics include excess mortality, especially overdose deaths, quiet deaths at night, infections, cancer, depression and suicide, automobile crashes, falls, and other accidents, and hypnotic-withdrawal insomnia. The short-term use of one-two prescriptions is associated with greater risk per dose than long-term use. Hypnotics are usually prescribed without approved indication, most often with specific contraindications, but even when indicated, there is little or no benefit. The recommended doses objectively increase sleep little if at all, daytime performance is often made worse, not better, and the lack of general health benefits is commonly misrepresented in advertising. Treatments such as the cognitive behavioral treatment of insomnia and bright light treatment of circadian rhythm disorders might offer safer and more effective alternative approaches to insomnia.

Hypnotic drug risks of mortality, infection, depression, and cancer: but lack of benefit

This is a review of hypnotic drug risks and benefits. Almost every month, new information appears about the risks of hypnotics (sleeping pills). The most important risks of hypnotics include excess mortality (especially overdose deaths, quiet deaths at night, and suicides), infections, cancer, depression, automobile crashes, falls, other accidents, and hypnotic-withdrawal insomnia. Short-term use of one-two prescriptions is associated with even greater risk per dose than long-term use. Hypnotics have usually been prescribed without approved indication, most often with specific contraindications, but even when indicated, there is little or no benefit. The recommended doses objectively increase sleep little if at all, daytime performance is often made worse (not better) and the lack of general health benefits is commonly misrepresented in advertising. Treatments such as the cognitive behavioral treatment of insomnia and bright light treatment of circadian rhythm disorders offer safer and more effective alternative approaches to insomnia.