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

Reprint of: An assessment of a sleep aid and sleep promotion practices in hospitalized medical patients

BACKGROUND

Half of patients admitted to medicine units report sleep disruption, which increases the risk of sleep deprivation. Non-pharmacological interventions are the first step to improving sleep. However, utilization of sleep aids continues to be prevalent. Limited data are available on sleep aid prescribing practices across transitions of care.

OBJECTIVES

The aim of this study was to describe the current practices for assessing sleep and prescribing pharmacologic agents to promote sleep in the adult medicine population.

METHODS

This study was designed as a single-center, retrospective, observational cohort study of all patients discharged by the general medicine teams over a 3-month period (September 2019- November 2019). Prior to admission, inpatient and discharge prescriptions for sleep aids were recorded, and documentation of sleep assessments and non-pharmacological interventions were evaluated.

RESULTS

Of 754 patients included, 211 (28%) were prescribed a sleep aid while inpatient. During hospitalization, 124 (16%) patients had at least one documented sleep assessment, and only 22 (3%) were ordered the institutional non-pharmacological sleep promotion order set. The most prescribed sleep aid in inpatients was melatonin (50%), as well as prior to admission (35%) and at discharge (25%). Overall, the relative reduction in sleep aid prescriptions between admission and discharge was 67%.

CONCLUSION

Inpatient sleep aid prescribing is common in medical patients. Despite this, sleep assessments and the standard of care of non-pharmacological interventions are rarely utilized. Future efforts should focus on implementation of strategies to make sleep assessments and non-pharmacological sleep promotion routine and consistent in the inpatient setting.

An assessment of a sleep aid and sleep promotion practices in hospitalized medical patients

BACKGROUND

Half of patients admitted to medicine units report sleep disruption, which increases the risk of sleep deprivation. Non-pharmacological interventions are the first step to improving sleep. However, utilization of sleep aids continues to be prevalent. Limited data are available on sleep aid prescribing practices across transitions of care.

OBJECTIVES

The aim of this study was to describe the current practices for assessing sleep and prescribing pharmacologic agents to promote sleep in the adult medicine population.

METHODS

This study was designed as a single-center, retrospective, observational cohort study of all patients discharged by the general medicine teams over a 3-month period (September 2019- November 2019). Prior to admission, inpatient and discharge prescriptions for sleep aids were recorded, and documentation of sleep assessments and non-pharmacological interventions were evaluated.

RESULTS

Of 754 patients included, 211 (28%) were prescribed a sleep aid while inpatient. During hospitalization, 124 (16%) patients had at least one documented sleep assessment, and only 22 (3%) were ordered the institutional non-pharmacological sleep promotion order set. The most prescribed sleep aid in inpatients was melatonin (50%), as well as prior to admission (35%) and at discharge (25%). Overall, the relative reduction in sleep aid prescriptions between admission and discharge was 67%.

CONCLUSION

Inpatient sleep aid prescribing is common in medical patients. Despite this, sleep assessments and the standard of care of non-pharmacological interventions are rarely utilized. Future efforts should focus on implementation of strategies to make sleep assessments and non-pharmacological sleep promotion routine and consistent in the inpatient setting.

The Administration of Lemborexant at Admission is Not Associated with Inpatient Falls: A Multicenter Retrospective Observational Study

Purpose

There has been no large-scale investigation into the association between the use of lemborexant, suvorexant, and ramelteon and falls in a large population. This study, serving as a pilot investigation, was aimed at examining the relationship between inpatient falls and various prescribed hypnotic medications at admission.

Patients and Methods

This study was a sub-analysis of a multicenter retrospective observational study conducted over a period of 3 years. The target population comprised patients aged 20 years or above admitted to eight hospitals, including chronic care, acute care, and tertiary hospitals. We extracted data on the types of hypnotic medications prescribed at admission, including lemborexant, suvorexant, ramelteon, benzodiazepines, Z-drugs, and other hypnotics; the occurrence of inpatient falls during the hospital stay; and patients' background information. To determine the outcome of inpatient falls, items with low collinearity were selected and included as covariates in a forced-entry binary logistic regression analysis.

Results

Overall, 150,278 patients were included in the analysis, among whom 3,458 experienced falls. The median age of the entire cohort was 70 years, with men constituting 53.1%. Binary logistic regression analysis revealed that the prescription of lemborexant, suvorexant, and ramelteon at admission was not significantly associated with inpatient falls.

Conclusion

The administration of lemborexant, suvorexant, and ramelteon at admission may not be associated with inpatient falls.

The effectiveness of non-pharmacological sleep interventions for improving inpatient sleep in hospital: A systematic review and meta-analysis

BACKGROUND

Sleep disturbance is common in hospital. The hospital environment can have a negative impact on sleep quality, through factors such as noise, light, temperature, and nursing care disruptions. Poor sleep can lead to delays in recovery, wound healing, and increase risk of post-operative infection.

METHODS

We conducted a systematic review evaluating the effectiveness of non-pharmacological sleep interventions for improving inpatient sleep. The primary outcome was sleep quality, the secondary outcome was length of hospital stay, the harm outcome was adverse events. MEDLINE, Embase, CINAHL, PsycINFO and the Cochrane Library were searched from inception to 17^th February 2022. Meta-analysis was conducted using a fixed effects model, with narrative synthesis for studies with no useable data. Risk of bias was assessed with the Cochrane tool.

RESULTS

76 studies identified with 5375 people randomised comparing 85 interventions. Interventions focused on physical sleep aids (n = 26), relaxation (n = 25), manual therapy (n = 12), music (n = 9), psychological therapy (n = 5), light therapy (n = 3), sleep protocols (n = 2), milk and honey (n = 1), exercise (n = 1), and nursing care (n = 1). In meta-analysis, medium to large improvements in sleep quality were noted for sleep aids, relaxation, music, and manual therapies. Results were generally consistent in studies at lower risk of bias. Length of hospital stay and adverse events were reported for some studies, with benefit in some trials but this was not consistent across all interventions.

CONCLUSIONS

Physical sleep aids, relaxation, manual therapy and music interventions have a strong evidence base for improving inpatient sleep quality. Research is needed to evaluate how to optimise interventions into routine care.

Effect of Vitamin E Supplementation on Chronic Insomnia Disorder in Postmenopausal Women: A Prospective, Double-Blinded Randomized Controlled Trial

Chronic insomnia disorder is one of the most common problems in postmenopausal women, exacerbated by underdiagnosis and improper treatment. This double-blinded, randomized, placebo-controlled trial was conducted to evaluate the potential of vitamin E to treat chronic insomnia as an alternative to sedative drugs and hormonal therapy. The study enrolled 160 postmenopausal women with chronic insomnia disorder, divided randomly into two groups. The vitamin E group received 400 units of mixed tocopherol daily, while the placebo group received an identical oral capsule. The primary outcome of this study was sleep quality assessed by the Pittsburgh Sleep Quality Index (PSQI), a self-evaluated and standardized questionnaire. The secondary outcome was the percentage of participants using sedative drugs. There were no significant differences in baseline characteristics between the study groups. However, the median PSQI score at baseline was slightly higher in the vitamin E group compared with the placebo (13 (6, 20) vs. 11 (6, 20); p-value 0.019). After one month of intervention, the PSQI score was significantly lower (indicating better sleep quality) in the vitamin E group compared with the placebo (6 (1, 18) vs. 9 (1, 19); p-value 0.012). Moreover, the improvement score was significantly higher in the vitamin E group compared with the placebo (5 (-6, 14) vs. 1 (-5,13); p-value < 0.001). In addition, there was a significant reduction in the percentage of patients using sedative drugs in the vitamin E group (15%; p-value 0.009), while this reduction was not statistically significant in the placebo group (7.5%; p-value 0.077). This study demonstrates vitamin E's potential as an excellent alternative treatment for chronic insomnia disorder that improves sleep quality and reduces sedative drug use.

High dose melatonin increases sleep duration during nighttime and daytime sleep episodes in older adults

Aging is associated with changes in sleep, and improving sleep may have important consequences for the health, cognition, and quality of life of older adults. Many prescription sleep aids increase the risk of nighttime falls, have adverse effects on next-day cognition, and are associated with increased mortality. Melatonin, a hormone secreted at night, increases sleep duration in young adults but only when administered during the day when endogenous levels are low. In a month-long cross-over study, we randomized 24 healthy older (age >55, mean 64.2 ± 6.3 years) participants to receive 2 weeks of placebo and 2 weeks of either a low (0.3 mg) or high (5.0 mg) dose of melatonin 30 min before lights out. Sleep was polysomnographically recorded and was scheduled during both the biological day and night using a forced desynchrony design. Although 0.3 mg melatonin had a trend towards increasing sleep efficiency (SE) overall, this was due to its effects on sleep during the biological day. In contrast, 5 mg melatonin significantly increased SE during both biological day and night, mainly by increasing the duration of Stage 2 non-rapid eye movement sleep and slightly shortening awakenings. Melatonin should be further explored as a sleep aid for older adults.

Cardiac events and economic burden among patients with hypertension and treated insomnia in the USA

Background: Cardiovascular (CV) event risk, healthcare resource utilization (HCRU) and costs have not been elucidated among hypertension patients with treated insomnia (H + TI). Materials & methods: Adult patients with H + TI were identified in IBM MarketScan databases. H + TI patients were matched 1:1 on age and sex to controls with hypertension but without sleep disorders. Multivariable models were used to estimate associations between treated insomnia and CV event risk, HCRU and costs. Results: In total, 81,502 H + TI patients (mean age = 62 years, 53% female) were matched. Relative to controls, H + TI patients were 2.4 times as likely to have CV events. H + TI patients incurred higher costs per patient per month (US$2343 vs US$1013). Conclusion: Treated insomnia was associated with higher costs and HRCU in hypertension patients.

Fall predictors in hospitalized patients living with cancer: a case-control study

PURPOSE

To identify fall predictors and develop an assessment tool to be used for screening hospitalized cancer patients at risk for fall.

METHODS

A retrospective case-control study was conducted in 2018 at a cancer center in Northern Italy. The study participants were 448 adult cancer patients admitted to the oncology ward from 2009 to 2013. The case group consisted of 112 patients presenting at least one fall, while controls were randomly chosen by matching each case for age, sex, and admission period with three patients who did not fall. Data for the fall predictors were extracted from the electronic medical records. Conditional logistic regression was used to evaluate the association between patient's characteristics and fall risk.

RESULTS

The overall prevalence of patients having at least one candidate fall predictor was high (98%). Seven of the studied variables showed an independent association with fall risk at multivariate analysis. These were tumor site, the presence of neurologic diseases, gait imbalance disorders, fatigue, and the assumption of certain medications such as diuretics, hypnotics, and opioids (odds ratios and 95% confidence intervals in brackets were 3.78 (1.78-8.13), 2.26 (1.08-4.77), 4.22 (1.87-9.52), 2.76 (1.45-5.26), 2.66 (1.52-4.66), 2.41 (1.20-4.85), and 3.03 (1.68-5.45), respectively).

CONCLUSIONS

In this study, we identified falling risk factors in an Italian population of hospitalized cancer patients and developed a new risk assessment tool. An external validation is necessary before implementing our screening tool in clinical practice.

Insomnia Diagnosis, Prescribed Hypnotic Medication Use, and Risk for Serious Fall Injuries in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study

STUDY OBJECTIVES

Insomnia is common among older adults and associated with an increased risk for falls. Determining if falls are more strongly associated with insomnia or prescribed hypnotic medications could be used to guide interventions to reduce falls risk.

METHODS

We examined the prospective association of a diagnosis of insomnia and/or prescribed hypnotic medication use with the risk for serious fall injuries among 9087 Reasons for Geographic and Racial Differences in Stroke (REGARDS) study participants aged 65 years or older with Medicare fee-for-service health insurance at baseline (2003-2007). A diagnosis of insomnia was based on ICD-9 codes in Medicare claims and prescribed hypnotic medication use was determined through a pill bottle review. Serious fall injuries were identified by Medicare claims between baseline and December 31, 2018.

RESULTS

Over a median of 6.8 years, 1660 (18.3%) participants had a serious fall injury. The incidence rates for a serious fall injury per 1000 person-years were 24.8 (95%CI: 23.5, 26.1), 28.8 (95%CI: 18.6, 38.9), 32.6 (95%CI: 28.2, 37.0), and 46.6 (95%CI: 26.7, 66.5) for participants without insomnia or taking prescribed hypnotic medication (-insomnia/-hypnotics), with insomnia only (+insomnia/-hypnotics), taking prescribed hypnotic medication only (-insomnia/+hypnotics), and with insomnia and taking prescribed hypnotic medication (+insomnia/+hypnotics), respectively. Compared with the -insomnia/-hypnotic group, the multivariable-adjusted hazard ratios for a serious fall injury were 1.13 (95%CI: 0.79, 1.61), 1.29 (95%CI: 1.11, 1.50), and 1.60 (95%CI: 1.01, 2.56) for +insomnia/-hypnotics, -insomnia/+hypnotics, and +insomnia/+hypnotics, respectively.

CONCLUSIONS

The risk for serious fall injuries was higher for those taking prescribed hypnotic medications but not with an insomnia diagnosis.