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

Evaluation of Medications Used for Hospitalized Patients With Sleep Disturbances: A Frequency Analysis and Literature Review

PURPOSE

Poor sleep during hospitalization is common and implicated in worse patient outcomes. Despite implementation of non-pharmacologic techniques, medications are still frequently required. The study objective is to assess the frequency of new medications administered for sleep in hospitalized patients and to review literature evaluating these drug therapies in the inpatient setting.

METHODS

This retrospective study included adult inpatients if they received a new medication for sleep during a 5-day period. Patients were excluded if the medication was continued from home or if sleep was not the documented indication. For the literature review, a MEDLINE search was conducted to identify studies pertaining to pharmacotherapy for sleep in hospitalized patients.

RESULTS

Of 1,968 patient-days reviewed, a medication for sleep was given for 166 patient-days (8.4%) in 78 patients. Melatonin was most commonly received (70.5%), followed by benzodiazepines (9.6%). A review of antihistamines, benzodiazepines, melatonin, quetiapine, trazodone, and Z-drugs (non-benzodiazepine hypnotics) was conducted and 23 studies were included.

CONCLUSIONS

Despite widespread use of pharmacotherapy for sleep, there is a paucity of data evaluating use in the inpatient setting. Although there is significant heterogeneity among studies, melatonin has the strongest evidence for use and is an attractive option given its lack of adverse reactions and drug interactions. Benzodiazepines and Z-drugs were also frequently utilized; however, their reduced clearance in the elderly and potential for compounded sedative effects should be weighed heavily against potential sleep benefits. Antipsychotic agents cannot be recommended for routine use due to limited data and the potential for significant adverse effects.

Adding Insult to Injury: Sleep Deficiency in Hospitalized Patients

Sleep deficiency is a common problem in the hospital setting. Contributing factors include preexisting medical conditions, illness severity, the hospital environment, and treatment-related effects. Hospitalized patients are particularly vulnerable to the negative health effects of sleep deficiency that impact multiple organ systems. Objective sleep measurement is difficult to achieve in the hospital setting, posing a barrier to linking improvements in hospital outcomes with sleep promotion protocols. Key next steps in hospital sleep promotion include improvement in sleep measurement techniques and harmonization of study protocols and outcomes to strengthen existing evidence and facilitate data interpretation across studies.

Zolpidem: Efficacy and Side Effects for Insomnia

Purpose of Review

Insomnia is a common type of sleep disorder defined by an ongoing difficulty initiating or maintaining sleep or nonrestorative sleep with subsequent daytime impairment. The sleep disturbances in insomnia usually manifest as difficulty in falling asleep, maintaining the continuity of sleep, or waking up too early in the morning well before the desired time, irrespective of the adequate circumstances to sleep every night. Insomnia can significantly impact daytime functioning resulting in decreased workplace productivity, proneness to errors and accidents, inability to concentrate, frequent daytime naps, and poor quality of life.The treatment of insomnia should involve a multi-disciplinary approach, focusing on implementing behavioral interventions, improving sleep hygiene, managing psychological stressors, hypnotic treatment, and pharmacological therapy. The most effective therapies utilize cognitive behavioral therapy in conjunction with pharmacotherapy to minimize the needed dose and any resulting side effects. Non-benzodiazepine hypnotics such as zolpidem, eszopiclone, zaleplon are the most used as adjunctive treatment. One of the most used of these hypnotics is zolpidem. However, zolpidem has a wide variety of adverse effects and has some special considerations noted in the literature.

Recent Findings

Zolpidem has been associated with an increased risk of falls in hospitalized patients with an OR of 4.28 (P <0.001) when prescribed short-term for insomnia. The relative risk (RR) for hip fractures in patients taking zolpidem was described as 1.92 (95% CI 1.65-2.24; P<0.001), with hip fractures being the most commonly seen. A case series of 119 inpatients aged 50 or older demonstrated that a majority (80.8%) of ADRs were central nervous system (CNS)-related such as confusion, dizziness, and daytime sleepiness. A systematic review of 24 previous studies of sleepwalking associated with zolpidem demonstrated that the association was not dependent on age, dose, medical history, or even a history of sleepwalking at any time before zolpidem use. Suicide attempts and completion have been successfully linked with zolpidem use (OR 2.08; 95% CI 1.83-2.63) in patients regardless of the presence of comorbid psychiatric illness. There have been multiple cases reported of seizures following the withdrawal of zolpidem. Most cases have demonstrated that withdrawal seizures occurred in patients taking daily dosages of around 450-600mg/day, but some reported them as low as 160mg/day. Rebound insomnia has been a concern to prescribers of zolpidem. Sleep onset latency has been demonstrated to be significantly increased on the first night after stopping zolpidem (13.0 minutes; 95% CI 4.3-21.7; P<0.01). Women had a non-significantly higher mean plasma concentration than men after 8 hours for the 10mg IR (28 vs. 20 ng/mL) and the 12.5mg MR (33 vs. 28ng/mL). The FDA has classified zolpidem as a category C drug based on adverse outcomes seen in animal fetal development. In the mothers exposed to zolpidem, there was an increased incidence of low birth weight (OR = 1.39; P<0.001), preterm delivery (OR 1.49; P<0.001), small for gestational age (SGA) babies (OR = 1.34; P<0.001), and cesarean deliveries (OR =1.74; P<0.001). The rate of congenital abnormalities was not significantly increased with zolpidem (0.48 vs 0.65%; P = 0.329).

Summary

Insomnia is linked to fatigue, distractibility, mood instability, decreased satisfaction, and overall decreased quality of life. Optimal therapy can aid patients in returning to baseline and increase their quality of life. Zolpidem is a helpful drug for the treatment of insomnia in conjunction with cognitive-behavioral therapy. When prescribed to elderly patients, the dose should be adjusted to account for their slower drug metabolism. Still, zolpidem is considered a reasonable choice of therapy because it has a lower incidence of residual daytime sleepiness and risk of falls when compared to other drugs. The most concerning adverse effects, which are often the most publicized, include the complex behaviors that have been seen in patients taking Zolpidem, such as sleeping, hallucinations, increased suicidality, driving cars while asleep, and even a few cases of committing homicide. Even so, zolpidem could be a suitable pharmacological treatment for insomnia. Decisions for whether or not to prescribe it and the dosage should be made on a case-by-case basis, considering both the psychical and psychiatric risks posed to the patient with insomnia versus if the patient were to take zolpidem to treat their condition.

Risk of In-Hospital Falls among Medications Commonly Used for Insomnia in Hospitalized Patients

STUDY OBJECTIVES

To investigate the risk of in-hospital falls among patients receiving medications commonly used for insomnia in the hospital setting.

METHODS

Retrospective cohort study of all adult hospitalizations to a large academic medical center from 1/2007 to 7/2013. We excluded patients admitted for a primary psychiatric disorder. Medication exposures of interest, defined by pharmacy charges, included benzodiazepines, non-benzodiazepine benzodiazepine receptor agonists (BZRAs), trazodone, atypical antipsychotics, and diphenhydramine. In-hospital falls were ascertained from an online patient safety reporting system.

RESULTS

Among the 225,498 hospitalizations (median age = 57 years; 57.9% female) in our cohort, 84,911 (37.7%) had exposure to at least one of the five medication classes of interest; benzodiazepines were the most commonly used (23.5%), followed by diphenydramine (8.3%), trazodone (6.6%), BZRAs (6.4%), and atypical antipsychotics (6.3%). A fall occurred in 2,427 hospitalizations (1.1%). The rate of falls per 1,000 hospital days was greater among hospitalizations with exposure to each of the medications of interest, compared to unexposed: 3.6 versus 1.7 for benzodiazepines (adjusted hazard ratio [aHR] 1.8, 95%CI 1.6-1.9); 5.4 versus 1.8 for atypical antipsychotics (aHR 1.6, 95%CI 1.4-1.8); 3.0 versus 2.0 for BZRAs (aHR 1.5, 95%CI 1.3-1.8); 3.3 versus 2.0 for trazodone (aHR 1.2, 95%CI 1.1-1.5); and 2.5 versus 2.0 for diphenhydramine (aHR 1.2, 95%CI 1.03-1.5).

CONCLUSIONS

In this large cohort of hospitalizations at an academic medical center, we found an association between each of the sedating medications examined and in-hospital falls. Benzodiazepines, BZRAs, and atypical antipsychotics had the strongest associations.

Psychoactive Medications and Adverse Outcomes among Older Adults Receiving Hemodialysis

BACKGROUND

Guidelines recommend avoidance of several psychoactive medications such as hypnotics in older adults due to their adverse effects. Older patients on hemodialysis may be particularly vulnerable to complications related to use of these agents, but only limited data are available about the risks in this population.

OBJECTIVES

To evaluate the association between the use of psychoactive medications and time to first emergency department visit or hospitalization for altered mental status, fall, and fracture among older patients receiving hemodialysis.

DESIGN

Observational cohort study.

SETTING

National registry of patients receiving hemodialysis (US Renal Data System).

PARTICIPANTS

A total of 60 007 adults 65 years or older receiving hemodialysis with Medicare Part D coverage in 2011.

MEASUREMENTS

The predictors were use of sedative-hypnotics and anticholinergic antidepressants (modeled as separate time-varying exposures). The outcomes were time to first emergency department visit or hospitalization for altered mental status, fall, and fracture (modeled separately).

RESULTS

Overall, 17% and 6% used sedative-hypnotics and anticholinergic antidepressants, respectively, in 2011. In multivariable-adjusted Cox regression, anticholinergic antidepressant use was associated with a 25%, 27%, and 39% higher hazard of altered mental status, fall, and fracture, respectively, compared with no use. Use of sedative-hypnotics was not associated with adverse outcomes.

CONCLUSION

Anticholinergic antidepressants were associated with adverse outcomes in older hemodialysis patients, and alternative treatments should be considered. Sedative-hypnotics were not associated with the risks evaluated in this study, but further investigation of the harms of this class of agents is warranted before their recommendation as a treatment option for insomnia in this population. J Am Geriatr Soc 67:449-454, 2019.

Multicomponent Interventions Reduce High-Risk Medications for Delirium in Hospitalized Older Adults

Delirium threatens the functional independence and cognitive capacity of patients. Medications, especially those with strong anticholinergic effects, have been implicated as a preventable cause of delirium. We evaluated the effect of multicomponent interventions aimed at reducing the use of 9 target medications in hospitalized older adults at risk of delirium. This continuous quality improvement program was undertaken at a tertiary care facility and 4 community hospitals in a hospital system. We included 21, 541 hospital admissions with patients aged 70 and older on acute care medical or surgical units from the preintervention (2012) period, and 27,764 from the postintervention (2015) period. Implemented interventions include formulary and policy changes, technology-assisted medication review, age-conditional order set modifications, best practice alerts, and education. The proportion of hospital admissions with individual's receiving at least 1 target medication declined from 45.6% to 31.3% (relative reduction (RR)=31.4%) from before to after the intervention, meaning that target medication exposure was avoided in approximately 4,000 older adults. The greatest effect was observed for zolpidem (11.2% to 5.3%, RR=52.6%) and diphenhydramine (12.9% to 7.1%, RR=45%). Furthermore, the mean number of doses administered during all hospital admissions was reduced for 7 of 9 medications. Multicomponent interventions implemented in our hospital system were effective at reducing exposure to target medications in hospitalized older adults at risk of delirium. These systematic changes applied throughout the medication use process are sustained today.

Instruments to evaluate mobility capacity of older adults during hospitalization: A systematic review

Independent mobility is a key factor in predicting morbidity and determining hospital discharge readiness for older patients. The main objective was identify and appraise relevant instruments for the measurement of mobility of hospitalized geriatric patients. A systematic review was performed in two consecutive steps. Based on the definition of mobility of the International Classification of Functioning (ICF). Step 1 identified mobility measurement instruments used to assess patients 60 years of age and over hospitalized in acute care or intensive geriatric rehabilitation unit. Aim of the instrument, coverage of mobility construct, applicability (format, training required, administration time and use of assistive devices) were extracted. For each included instrument, Step 2 identified and appraised articles reporting about their measurement properties. Consensus-based Standards for the selection of health status Measurement INstruments (COSMIN) was used by two independent reviewers to critically appraise and compare the measurement properties. Step 1 resulted in 6350 articles, of which 28 articles reported about 17 different instruments. Step 2 retained 11 instruments with 70 articles reporting about their measurement properties in various settings. Judgement-based instruments (n=5) covered the ICF mobility construct more broadly than performance-based measures (n=6). Our results showed that 3 instruments (DEMMI, SPPB and Tinetti scale) had the most extensive and robust measurement properties, and from those, SPPB and DEMMI covered the mobility construct more broadly but SPPB had the longest administration (10-15min). Conclusion SPPB presents the best balance between mobility coverage, measurement properties and applicability to acute care or intensive geriatric rehabilitation unit.

Medical conditions and medications as risk factors of falls in the inpatient older people: a case-control study

OBJECTIVE

The majority of inpatient falls are older people who have various medical conditions and are on several medications. The purpose of this study was to examine the association between medical conditions and medications and falls in older people in hospital.

METHOD

Using a case-control design, we selected older people (aged 65 or over) who were reported to the Taiwan Patient-Safety Reporting System for the fall incidents in a large academic hospital in 2006 (n = 165). They were individually (1:1) matched for gender, age, and period of hospitalization with the control non-faller group. Bivariate and multivariate logistic regressions were used to compare the cases and controls to examine the association of medical conditions and medication exposure within 24 h before the falls.

RESULTS

Bivariate analyses showed that older people with cancer, or exposure medications such as zolpidem, benzodiazepines, narcotics, and antihistamines were significantly more likely to have falls during hospitalization. After controlling for cancer, zolpidem, narcotics, and antihistamine, we found benzodiazepine (Odds ratio (OR) = 2.26, 95% confidence interval (CI) = 1.21-4.23) and benzodiazepine doses ≥1 mg/day in diazepam equivalents (OR = 2.14, 95%CI = 1.04-4.39) were still significantly associated with the falls of older people in the hospital.

CONCLUSIONS

Strategies to prevent falls in older people in hospital should include minimizing the use of zolpidem, benzodiazepine, narcotics, and antihistamines, especially in cancer patients.

Sleep-related problems and use of hypnotics in inpatients of acute hospital wards

OBJECTIVE

Although sleep disorders are highly prevalent among patients with physical disorders, only limited information is available about the actual status of sleep-related problems in inpatients of acute hospital wards. We conducted a multicenter cross-sectional observational survey investigating the prevalence of sleep disorders and use of hypnotic-sedative drugs among inpatients of acute wards in 44 general hospitals in Japan.

METHOD

Questionnaire-, actigraph- and observation-based sleep evaluations were simultaneously performed in 557 adult inpatients [mean age 72.8 + or - 12.8 (S.D.) years] of acute wards during a one-month period in July 2007.

RESULTS

Of the 421 patients with data available, 22.3% had at least one of the following sleep disorders: sleep apnea syndrome, restless legs syndrome, periodic limb movement disorder and nocturnal behavior disorder. Similarly, 62.7% had insomnia, 6.9% had severe daytime sleepiness and 12.8% had other sleep-related symptoms. Only 13.8% were free of any sleep-related problem. Although 33.7% of insomnia patients were taking hypnotic-sedative drugs, 65.2% of them complained of residual insomnia symptoms.

CONCLUSION

The findings obtained in this study have revealed the remarkably high prevalence of sleep-related problems experienced by inpatients of acute hospital wards in Japan. Proper diagnosis of sleep disorders should be made among patients with physical disorders.

Late-life insomnia: a review

Aging is associated with substantial changes in sleep patterns, which are almost always negative in nature. Typical findings in the elderly include a reduction in the deeper stages of sleep and a profound increase in the fragmentation of nighttime sleep by periods of wakefulness. The prevalence of specific sleep disorders increases with age, such as a phase advance in the normal circadian sleep cycle, restless legs syndrome, and obstructive sleep apnea, which is increasingly seen among older individuals and is significantly associated with cardio- and cerebrovascular disease as well as cognitive impairment. Elderly patients with sleep disturbances are often considered difficult to treat; yet, they are among the groups with the greatest need of treatment. Management of sleep disturbances begins with recognition and adequate assessment. Hypnotic drugs have clearly been shown to improve subjective and objective sleep measures in short-term situations, but their role in chronic insomnia still remains to be further defined by research evidence. Non-pharmacological treatments, particularly stimulus control and sleep restriction, are effective for conditioned aspects of insomnia and are associated with a stable, long-term improvement in sleep. This review delineates the common causes of disordered sleep in older individuals, and effective diagnostic approaches and treatments for these conditions.

Magic bullets for insomnia? Patients' use and experiences of newer (Z drugs) versus older (benzodiazepine) hypnotics for sleep problems in primary care

BACKGROUND

Little is known about patients' perceptions of newer hypnotics.

AIM

To investigate use, experience, and perceptions of Z drug and benzodiazepine hypnotics in the community.

DESIGN OF STUDY

Cross-sectional survey of general practice patients who had received at least one prescription for a Z drug or benzodiazepine in the previous 6 months.

SETTING

Lincolnshire, UK.

METHOD

Self-administered postal questionnaire.

RESULTS

Of 1600 surveys posted, 935 (58.4%) responses were received, of which 705 (75.4%) were from patients taking drugs for insomnia. Of those 705 patients, 87.9% (n = 620) were first prescribed a hypnotic by their GP, and 94.9% (n = 669) had taken a sleeping tablet for 4 weeks or more. At least one side effect was reported in 41.8% (n = 295); 18.6% wished to come off hypnotic medication; and 48.5% had tried to stop treatment. Patients on Z drugs were more likely to express a wish to stop (22.7% versus 12.3%; odds ratio [OR] = 1.67, 95% confidence interval [CI] = 1.13 to 2.49), or to have attempted to come off medication, than those on benzodiazepines (52.4% versus 41.0%; OR = 1.54, 95% CI = 1.12 to 2.12). The two groups did not differ significantly in respect of benefits or adverse effects.

CONCLUSION

There were no significant differences in patients' perceptions of efficacy or side-effects reported by those on Z drugs compared to patients taking benzodiazepines. Side-effects were commonly reported, which may have contributed to a high proportion of responders, particularly patients on Z drugs who were wishing to stop, or who had previously tried to stop taking this medication. Reported prescribing practices were often at variance with the licence for short-term use.

Intractable nausea caused by zolpidem withdrawal: a case report

First launched in France in 1988, zolpidem (Ambien®) is a short-acting hypnotic agent. Early studies reported that that the development of physical dependence and tolerance to sedative-hypnotic drugs, such as the depressant and anticonvulsant effects evidenced with benzodiazepines, is not found with zolpidem. Direct to consumer advertising by the manufacturer continues to state that the risk for dependency is low; however, recent publications seem to contradict this. Additionally, adverse drug reactions affecting the central nervous system, gastrointestinal tract, and respiratory system have been reported. Other studies have examined the interactions of selective serotonin reuptake inhibitors and zolpidem as a possible cause of hallucinations. With continued physician marketing efforts touting the safety and efficacy of zolpidem, there is a high likelihood to overlook the risk of dependency and the symptoms related to zolpidem withdrawal. We report a case of a 41-year-old female who developed a dependency to zolpidem, who on her own decided to decrease her dosage, resulting in intractable nausea requiring hospitalization. Reported cases of zolpidem withdrawal have occurred with doses in excess of 160 mg per day, none of these have reported with intractable nausea as the sole symptom. In our reported case, although exceeding recommended dosage withdrawal phenomenon seemed to be severe after withdrawal from a comparatively low dose of zolpidem. Before zolpidem is prescribed, patient education should include warnings about the potential problems associated with dependency and abrupt discontinuation. Education about this common and likely underrecognized clinical phenomenon will help prevent future episodes and minimize the risk of misdiagnosis.