Adverse effects of Z-drugs for sleep disturbance in people living with dementia: a population-based cohort study

Incident Benzodiazepine and Z-Drug Use and Subsequent Risk of Serious Infections

BACKGROUND AND OBJECTIVES

Animal studies have suggested a link between benzodiazepine and related Z-drug (BZDR) use and immune dysfunction. Corresponding evidence in humans is limited and focuses mainly on pneumonia. This study aimed to assess the association of incident BZDR use with subsequent development of serious infections.

METHODS

This Swedish register-based study included a population-based demographically matched cohort, a co-twin control cohort, and an active comparator cohort. Out of 7,362,979 individuals aged below 65 years who were BZDR naïve by 2007, 713,896 BZDR recipients with incident dispensation of any BZDRs between 2007 and 2019 were 1:1 matched to 713,896 nonrecipients from the general population; 9197 BZDR recipients were compared with their 9298 unexposed co-twins/co-multiples; and 434,900 BZDR recipients were compared with 428,074 incident selective serotonin reuptake inhibitor (SSRI) recipients. The outcomes were identified by the first inpatient or specialist outpatient diagnosis of serious infections in the National Patient Register, or death from any infections recorded as the underlying cause in the Cause of Death Register. Cox proportional hazards regression models were fitted and controlled for multiple confounders, including familial confounding and confounding by indication. To study a possible dose-response association, the cumulative dosage of BZDRs dispensed during the follow-up was estimated for each BZDR recipient and modeled as a time-varying exposure with dose categories in tertiles [≤ 20 defined daily doses (DDDs), > 20 DDDs ≤ 65, and > 65 DDDs). The risk of infections was assessed in BZDR recipients within each category of the cumulative BZDR dosage compared to their demographically matched nonrecipients.

RESULTS

In the demographically matched cohort (average age at incident BZDR use 42.8 years, 56.9% female), the crude incidence rate of any serious infections in BZDR recipients and matched nonrecipients during 1-year follow-up was 4.18 [95% confidence intervals (CI) 4.13-4.23] and 1.86 (95% CI 1.83-1.89) per 100 person-years, respectively. After controlling for demographic, socioeconomic, clinical, and pharmacological confounders, BZDR use was associated with 83% relative increase in risk of any infections [hazard ratio (HR) 1.83, 95% CI 1.79-1.89]. The risk remained increased, although attenuated, in the co-twin cohort (HR 1.55, 95% CI 1.23-1.97) and active comparator cohort (HR 1.33, 95% CI 1.30-1.35). The observed risks were similar across different types of initial BZDRs and across individual BZDRs, and the risks increased with age at BZDR initiation. We also observed a dose-response association between cumulative BZDR dosage and risk of serious infections.

CONCLUSIONS

BZDR initiation was associated with increased risks of serious infections, even when considering unmeasured familial confounding and confounding by indication. The exact pathways through which BZDRs may affect immune function, however, remain unclear. Further studies are needed to explore the neurobiological mechanisms underlying the association between BZDR use and serious infections, as it can lead to safer therapeutic strategies for patients requiring BZDR.

Psychotropic Drug Use and Associated Factors Among Acutely Admitted Older People: A Cross-Sectional Study of a Clinical Sample

INTRODUCTION

Older people are on average more susceptible to the adverse effects of psychotropic drugs, but addressing older people as a homogenous group based on age alone can be misleading when exploring psychotropic drug use. This study aimed to describe psychotropic drug use and associated factors among community-dwelling older people who had been acutely admitted to hospital.

METHODS

This cross-sectional study was based on a sample of 300 community-dwelling people 75 years or older who had been admitted to the acute medical ward at Umeå University Hospital at any time from September 2018 to October 2021. Data on medication use were obtained from electronic medical charts, and psychotropic drug use was presented as user proportions, both in terms of individual substances and drug classes. Associations between psychotropic drug use and factors comprising sex, age, cohabitation, comorbidities and multi-dose dispensing (MDD) of medicines were analysed through logistic regression.

RESULTS

Approximately 50% of the individuals used at least one psychotropic drug, and 18% used two or more such medicines. Zopiclone displayed the highest user proportion of all psychotropics (18.3%), followed by mirtazapine (11.3%) and zolpidem (9.7%). Of note, zolpidem was more prevalent among the females than among the males (p = 0.006). Regarding other sex differences, 55 and 38% of the females and males, respectively, used at least one psychotropic drug (p = 0.004). A similar pattern was observed regarding sedatives and hypnotic drugs exclusively (p = 0.048). In the regression analysis, female sex (adjusted odds ratio [OR] 2.05 [95% confidence interval {CI} 1.22-3.42]) and MDD (adjusted OR 2.20 [95% CI 1.23-3.93]) were positively associated with psychotropic drug use.

CONCLUSION

The most common psychotropic drugs used by community-dwelling older people admitted to the acute medical ward were hypnotic drugs and antidepressants. Regarding patient factors, female sex and MDD system were positively associated with psychotropic drug use. Further studies concerning those two factors in relation to potential overprescribing could provide a better picture on how to optimize psychotropic drug use among acutely admitted vulnerable older people.

Sleep disorders and risk of alzheimer's disease: A two-way road

Substantial sleep impairment in patients with Alzheimer's disease (AD) is one of the emerging points for continued efforts to better understand the disease. Individuals without cognitive decline, an important marker of the clinical phase of AD, may show early alterations in the sleep-wake cycle. The objective of this critical narrative review is to explore the bidirectional pathophysiological correlation between sleep disturbances and Alzheimer's Disease. Specifically, it examines how the disruption of sleep homeostasis in individuals without dementia could contribute to the pathogenesis of AD, and conversely, how neurodegeneration in individuals with Alzheimer's Disease might lead to dysregulation of the sleep-wake cycle. Recent scientific results indicate that sleep disturbances, particularly those related to impaired glymphatic clearance, may act as an important mechanism associated with the genesis of Alzheimer's Disease. Additionally, amyloid deposition and tau protein hyperphosphorylation, along with astrocytic hyperactivation, appear to trigger changes in neurotransmission dynamics in areas related to sleep, which may explain the onset of sleep disturbances in individuals with AD. Disruption of sleep homeostasis appears to be a modifiable risk factor in Alzheimer's disease. Whenever possible, the use of non-pharmacological strategies becomes important in this context. From a different perspective, additional research is needed to understand and treat the dysfunction of the sleep-wake cycle in individuals already affected by AD. Early recognition and correction of sleep disturbances in this population could potentially mitigate the progression of dementia and improve the quality of life for those with AD.

Effect of Earthing Mats on Sleep Quality in Rats

Grounding, a therapeutic technique involving direct contact with the earth, has been proposed by various studies to potentially have beneficial effects on pressure, sleep quality, stress, inflammation, and mood. However, the scientific evidence supporting its sedative effects remains incomplete. This study examined the sedative effectiveness of an earthing mat on sleep quality and investigated the underlying neural mechanisms using electroencephalography (EEG) analysis in rodents, focusing on orexin and superoxide dismutase (SOD) levels in the brain. Rats were randomly assigned to four groups: the naïve normal group (Nor), the group exposed to an earthing mat for 7 days (A-7D), the group exposed to an earthing mat for 21 days (A-21D), and the group exposed to an electronic blanket for 21 days (EM). EEG results revealed that the A-21D group exhibited significantly reduced wake time and increased rapid eye movement (REM), non-rapid eye movement (NREM), and total sleep time compared to the Nor group (p < 0.05). Moreover, the A-21D group demonstrated a significant increase in NREM sleep (p < 0.001), REM sleep (p < 0.01), and total sleep time (p < 0.001), along with a decrease in wake time compared to the EM group (p < 0.001). The orexin level in the A-21D group was significantly lower compared to the Nor group (p < 0.01), while SOD1 expression was markedly elevated in the A-21D group compared to the Nor group (p < 0.001). These results suggest that the earthing mat may represent a promising new method for promoting sleep quality and could serve as an effective therapeutic technique.

Risk of falls or fall-related injuries associated with potentially inappropriate medication use among older adults with dementia

BACKGROUND

Potentially inappropriate medications (PIMs) are prevalent in older adults with dementia and subsequent falls or fall-related injuries. The present study determined the risk of falls or fall-related injuries associated with PIM use in older adults with dementia.

METHODS

The National Health Insurance Service-Elderly Cohort Database 2.0 (NHIS-ECDB 2.0) was used for this self-controlled case series (SCCS) study. This study included 1430 participants who went through exposure and non-exposure periods of PIM application among patients with dementia and experienced outcome events of falls or fall-related injuries between January 2016 and December 2019. The incidence of falls or fall-related injuries during the exposure and post-exposure periods was compared with that during the non-exposure period. Beers Criteria were used to define PIMs in patients with dementia. Negative binomial regression was conducted. The incidence rate ratio (IRR) was used to determine the risk of falls or fall-related injuries.

RESULTS

During the exposure periods in which falls or fall-related injuries occurred, the mean number of PIMs among patients with dementia was 3.76 (SD = 2.99), and the most commonly used PIMs among patients with dementia were first-generation antihistamines (n = 283; 59.1%). Compared to the non-exposure period, the adjusted IRR during the exposure period was 1.57 (95% CI = 1.39-1.76). The risk of falls or fall-related injuries was increased when PIM use in patients with dementia was initiated (1-14 days: IRR = 2.76, 95% CI = 2.31-3.28; 15-28 days: IRR = 1.95, 95% CI = 1.48-2.56; ≥ 29 days: IRR = 1.17, 95% CI = 1.01-1.35). Especially, an increased risk of falls or fall-related injuries was associated with greater PIM use among patients with dementia.

CONCLUSION

Among older adults with dementia, PIMs significantly increase the risk of falls and fall-related injuries. Therefore, strategies should be developed to manage PIM prescriptions in patients with dementia to prevent falls.

Comparative analysis of psychiatric medications and their association with falls and fractures: A systematic review and network meta-analysis

An association between psychiatric medications and falls and fractures in people taking them has been demonstrated, but which class or medication leads to the greatest risk of falls or fractures should be further investigated. The aim of this study was to compare and rank the magnitude of risk of falls and fractures due to different psychiatric medications. Eight databases were searched for this meta-analysis and evaluated using a frequency-based network meta-analysis. The results included a total of 28 papers with 14 medications from 5 major classes, involving 3,467,314 patients. The results showed that atypical antipsychotics were the class of medications with the highest risk of falls, and typical antipsychotics were the class of medications with the highest risk of resulting in fractures. Quetiapine ranked first in the category of 13 medications associated with risk of falls, and class Z drugs ranked first in the category of 6 medications associated with risk of fractures. The available evidence suggests that atypical antipsychotics and typical antipsychotics may be the drugs with the highest risk of falls and fractures, respectively. Quetiapine may be the medication with the highest risk of falls, and class Z drugs may be the medication with the highest risk of fractures.

The effect of weighted blankets on sleep and related disorders: a brief review

Background

Sleep disorders such as insomnia can lead to a range of health problems. The high risk of side effects and drug abuse of traditional pharmacotherapy calls for a safer non-pharmacotherapy.

Aims

To examine the use and efficacy of weighted blankets in improving sleep and related disorders in different populations and explore the possible mechanisms.

Methods

A literature search was conducted using PubMed, Embase, Web of Science, MEDLINE, Cochrane Library and CNKI databases. Eligible studies included an intervention with weighted blankets and outcomes covering sleep and/or related disorders (behavioral disturbance, negative emotions and daytime symptoms). Studies using other deep pressure, compression, or exercise-related interventions were excluded.

Conclusions

Most of the included studies showed that weighted blankets could effectively improve sleep quality and alleviate negative emotions and daytime symptoms in patients with sleep disorders, attention deficit hyperactivity disorder, autism spectrum disorder, and other related disorders, with a possible mechanism of deep pressure touch.

Recommendations

Weighted blankets might be a promising tool for sleep interventions among individuals with sleep disorders in clinical settings. More high-quality and large-scale randomized controlled trials are needed to further validate the safety and efficacy of weighted blankets and explore precise mechanisms.

Sleep disturbance in people living with dementia or mild cognitive impairment: a realist review of general practice

BACKGROUND

Sleep disturbance is a prevalent condition among people living with dementia (PLwD) or mild cognitive impairment (MCI). Its assessment and management within primary care is complex because of the comorbidities, older age, and cognitive impairment typical of this patient group.

AIM

To explore how primary care clinicians assess, understand, and manage sleep disturbance for PLwD or MCI; if and why such initiatives work; and how people and their carers experience sleep disturbance and its treatment.

DESIGN AND SETTING

A realist review of existing literature conducted in 2022.

METHOD

Six bibliographic databases were searched. Context-mechanism-outcome configurations (CMOCs) were developed and refined.

RESULTS

In total, 60 records were included from 1869 retrieved hits and 19 CMOCs were developed. Low awareness of and confidence in the treatment of sleep disturbance among primary care clinicians and patients, combined with time and resource constraints, meant that identifying sleep disturbance was difficult and not prioritised. Medication was perceived by clinicians and patients as the primary management tool, resulting in inappropriate or long-term prescription. Rigid nursing routines in care homes were reportedly not conducive to good-quality sleep.

CONCLUSION

In primary care, sleep disturbance among PLwD or MCI is not adequately addressed. Over-reliance on medication, underutilisation of non-pharmacological strategies, and inflexible care home routines were reported as a result of low confidence in sleep management and resource constraints. This does not constitute effective and person-centred care. Future work should consider ways to tailor the assessment and management of sleep disturbance to the needs of individuals and their informal carers without overstretching services.

Role of sleep in neurodegeneration: the consensus report of the 5th Think Tank World Sleep Forum

Sleep abnormalities may represent an independent risk factor for neurodegeneration. An international expert group convened in 2021 to discuss the state-of-the-science in this domain. The present article summarizes the presentations and discussions concerning the importance of a strategy for studying sleep- and circadian-related interventions for early detection and prevention of neurodegenerative diseases. An international expert group considered the current state of knowledge based on the most relevant publications in the previous 5 years; discussed the current challenges in the field of relationships among sleep, sleep disorders, and neurodegeneration; and identified future priorities. Sleep efficiency and slow wave activity during non-rapid eye movement (NREM) sleep are decreased in cognitively normal middle-aged and older adults with Alzheimer's disease (AD) pathology. Sleep deprivation increases amyloid-β (Aβ) concentrations in the interstitial fluid of experimental animal models and in cerebrospinal fluid in humans, while increased sleep decreases Aβ. Obstructive sleep apnea (OSA) is a risk factor for dementia. Studies indicate that positive airway pressure (PAP) treatment should be started in patients with mild cognitive impairment or AD and comorbid OSA. Identification of other measures of nocturnal hypoxia and sleep fragmentation could better clarify the role of OSA as a risk factor for neurodegeneration. Concerning REM sleep behavior disorder (RBD), it will be crucial to identify the subset of RBD patients who will convert to a specific neurodegenerative disorder. Circadian sleep-wake rhythm disorders (CSWRD) are strong predictors of caregiver stress and institutionalization, but the absence of recommendations or consensus statements must be considered. Future priorities include to develop and validate existing and novel comprehensive assessments of CSWRD in patients with/at risk for dementia. Strategies for studying sleep-circadian-related interventions for early detection/prevention of neurodegenerative diseases are required. CSWRD evaluation may help to identify additional biomarkers for phenotyping and personalizing treatment of neurodegeneration.

Long-term use of benzodiazepines in chronic insomnia: a European perspective

Chronic insomnia occurs in ~10% of the general population and has numerous negative health effects. The recommended first line treatment of cognitive behavior therapy for insomnia is not widely available for patients in Europe, so pharmacotherapies such as benzodiazepine receptor agonist agents (benzodiazepines and Z-drugs) are commonly used. However, their use is only recommended for ≤4 weeks due to unproven long-term efficacy in treatment of chronic insomnia, and the risk of tolerance, and the potential for dependence and misuse. In Europe, recommendations limiting the use of benzodiazepines (lowest dose and shortest duration) in chronic insomnia are not always followed, likely due to the lack of approved effective alternative therapies. Here we present a recent pilot survey of the pharmacological treatment landscape in chronic insomnia in five European countries (France, Germany, Italy, Spain, and the United Kingdom) and physicians' attitude toward treatment. The results suggest that benzodiazepines and Z-drugs are the most widely used treatments in chronic insomnia and are being used for longer than their recommended duration. Country variations in prescription rates were observed. Due to the known association between long-term benzodiazepine use and potential for developing dependence, further analysis of the literature was performed on the use and misuse of benzodiazepines. The results show that long-term use of benzodiazepines is associated with multiple consequences of treatment, including dependence, but also that previous use of benzodiazepines may increase the risk of opioid use disorder.

Short report: relationship between self-reported sleep characteristics and falls-associated fractures in elderly individuals: a population-based study

Currently, the data for effect of sleep on falls-associated fractures in elderly individuals are still limited. This current study was aimed to assess the link between self-reported sleep characteristics and falls-associated fractures in elderly individuals. This study included a total of 20,497 participants from National Health and Nutritional Examination Survey (NHANES) 2005-2008, and 6,174 participants aged 45 years and older were identified. Self-reported sleep characteristics and conditions of falls-associated fractures of individuals were obtained via the method of personal questionnaires. In a total of 610 participants with exact history of fractures, 168 individuals with falls-associated fractures were identified, and the prevalence was 27.5%. The mean age of falls-associated fractures group was (72.1 ± 8.8) years, and the female (P < 0.001) occupied a higher proportion. Factors of living alone (P = 0.003), combined with hypertension (P = 0.003) and osteoporosis (P < 0.001), sleeping less or more (P = 0.009), and frequent snoring (P = 0.007) were linked to falls-associated fractures. Compared with sleep duration of 6 to 8 h/night, sleep duration of ≤4 h/night (odds ratio [OR] 1.858, 95% confidence interval [CI] 1.115-3.094) and of ≥9 h/night (OR 1.932, 95% CI 1.195-3.123) were related to an increased risk of falls-associated fractures. Collectively, our nationwide data noted that sleep characteristics were closely related to falls-associated fractures in elderly individuals, and a longer sleep duration may exhibit a protective effect against the falls-associated fractures, but it should be limited within 9 h/night.

Understanding primary care diagnosis and management of sleep disturbance for people with dementia or mild cognitive impairment: a realist review protocol

INTRODUCTION

The increasingly ageing population is associated with greater numbers of people living with dementia (PLwD) and mild cognitive impairment (MCI). There are an estimated 55 million PLwD and approximately 6% of people over 60 years of age are living with MCI, with the figure rising to 25% for those aged between 80 and 84 years. Sleep disturbances are common for this population, but there is currently no standardised approach within UK primary care to manage this. Coined as a 'wicked design problem', sleep disturbances in this population are complex, with interventions supporting best management in context.

METHODS AND ANALYSIS

The aim of this realist review is to deepen our understanding of what is considered 'sleep disturbance' in PLwD or MCI within primary care. Specifically, we endeavour to better understand how sleep disturbance is assessed, diagnosed and managed. To co-produce this protocol and review, we have recruited a stakeholder group comprising individuals with lived experience of dementia or MCI, primary healthcare staff and sleep experts. This review will be conducted in line with Pawson's five stages including the development of our initial programme theory, literature searches and the refinement of theory. The Realist and Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) quality and reporting standards will also be followed. The realist review will be an iterative process and our initial realist programme theory will be tested and refined in response to our data searches and stakeholder discussions.

ETHICS AND DISSEMINATION

Ethical approval is not required for this review. We will follow the RAMESES standards to ensure we produce a complete and transparent report. Our final programme theory will help us to devise a tailored sleep management tool for primary healthcare professionals, PLwD and their carers. Our dissemination strategy will include lay summaries via email and our research website, peer-reviewed publications and social media posts.

PROSPERO REGISTRATION NUMBER

CRD42022304679.

How do care home staff use non-pharmacological strategies to manage sleep disturbances in residents with dementia: The SIESTA qualitative study

Background

Sleep disturbances affect 38% of care home residents living with dementia. They are often treated with medication, but non-pharmacological interventions may be safer and effective yet more difficult to implement. In the SIESTA study (Sleep problems In dEmentia: interviews with care home STAff) we explored care home staffs’ experience of managing sleep disturbances in their residents living with dementia.

Methods

We conducted one-to-one semi-structured interviews in four UK care homes, and purposively recruited a maximum variation sample of 18 nurses and care assistants, who were each interviewed once. We used a topic guide and audio-recorded the interviews. Two researchers independently analysed themes from transcribed interviews.

Results

Staff used a range of techniques that often worked in improving or preventing residents’ sleep disturbance. During the daytime, staff encouraged residents to eat well, and be physically active and stimulated to limit daytime sleep. In the evening, staff settled residents into dark, quiet, comfortable bedrooms often after a snack. When residents woke at night, they gave them caffeinated tea or food, considered possible pain and discomfort, and reassured residents they were safe. If residents remained unsettled, staff would engage them in activities. They used telecare to monitor night-time risk. Staff found minimising daytime napping difficult, described insufficient staffing at night to attend to reorient and guide awake residents and said residents frequently did not know it was night-time.

Conclusions

Some common techniques, such as caffeinated drinks, may be counterproductive. Future non-pharmacological interventions should consider practical difficulties staff face in managing sleep disturbances, including struggling to limit daytime napping, identifying residents’ night-time needs, day-night disorientation, and insufficient night-time staffing.

The impact of medication reviews by general practitioners on psychotropic drug use and behavioral and psychological symptoms in home-dwelling people with dementia: results from the multicomponent cluster randomized controlled LIVE@Home.Path trial

BACKGROUND

There is limited knowledge regarding the process of deprescribing psychotropic drugs to people with dementia (PwD) conducted by general practitioners (GP). We investigated the impact of a multicomponent intervention, emphasizing medication reviews, on psychotropic drugs and behavioral and psychological symptoms (BPSD) in home-dwelling PwD and quantified change in patient-GP communication evaluated by their informal caregivers.

METHODS

LIVE@Home.Path is a stepped-wedge closed-cohort cluster randomized controlled trial for people with mild to moderate dementia aged ≥65 and their informal caregivers (dyads) in Norway. Complementary to health care as usual (control condition), municipal coordinators implemented the multicomponent LIVE intervention: Learning, Innovation, Volunteer support, and Empowerment (including medication review by the PwD's regular GPs). Block-randomization was used to allocate dyads in three groups receiving the intervention sequentially in periods of 6 months duration. Prepandemic data from the first period is reported, resulting in a 1:2 intervention-to-control ratio. Primary outcome was change in psychotropic drug use. Secondary outcomes were changes in BPSD by Neuropsychiatric Inventory and Cornell Scale of Depression in Dementia and patient-GP communication by an adaption of the Clinical Global Impression of Change.

RESULTS

Four hundred thirty-eight dyads were screened, 280 included, and 237 participated at 6 months (intervention group n=67; control condition n=170). At baseline, 63% used psychotropic medication regularly: antidementia drugs (47%), antidepressants (13%), hypnotics/sedatives (13%), antipsychotics (5%), and anxiolytics (2%). At 6 months, medication reviews were more frequently conducted in the intervention group compared to control (66% vs 42%, P=0.001). We found no differences regarding a change in drug use and BPSD. Patient-GP communication enhanced in the intervention group (mean score 0.95 [standard deviation 1.68] vs 0.41 [1.34], P=0.022). In the intervention group, control group, and overall sample, the informal caregivers of those who had their medications reviewed reported improved patient-GP communication compared to those who did not.

CONCLUSIONS

Change in psychotropic drug use and BPSD did not differ, even though patient-GP communication improved with medication reviews. Restricted psychotropic drug use among PwD likely reflects more judicious prescribing practices in recent years. Nevertheless, medication reviews could be cultivated to optimize pharmacologic treatment for this complex population.

TRIAL REGISTRATION

ClinicalTrials.gov : NCT04043364 ; registered 15/03/2019.

The Role of Different Behavioral and Psychosocial Factors in the Context of Pharmaceutical Cognitive Enhancers' Misuse

In an effort for better memory, greater motivation, and concentration, otherwise healthy individuals use pharmaceutical cognitive enhancers (PCEs), medicines for the treatment of cognitive deficits of patients with various disorders and health problems, to achieve greater productivity, efficiency, and performance. We examined the use of PCEs among 289 students at the Slovenian Faculty of Electrical Engineering and Computer Science in the behavioral and psychosocial context (students' attitudes towards study, parents, health, leisure time, and work). Furthermore, we also addressed the immediate reasons, or the hypothesized connections of behavioral and psychosocial aspects, related to PCE misuse. The study consisted of a structured questionnaire, and chi-squared tests were used. An analysis of student statements revealed differences in students' and parents' attitudes toward good academic grades. In addition, students chose among 17 values related to relationships with parents, friends, partners, careers, study obligations, leisure, hobbies, material goods, appearance, and the future, and assessed their importance. Regardless of the group they belonged to, young people cited the same values among the most important. Good grades and parental opinions have proven to be key factors in the context of PCE abuse. This research was the first study to examine the relation between PCE misuse and the role of different behavioral and psychosocial factors.

Effects of music interventions on sleep in people with dementia: A systematic review

Poor sleep health is a risk factor for and a common symptom of dementia. Music has been shown to improve sleep across a wide range of clinical and community populations. However, it is unclear whether and to what extent music interventions may also help alleviate sleep problems in people with dementia. This systematic review is the first review examining the effects of music on sleep outcomes among people with dementia. In accordance with PRISMA guidelines, we extracted 187 articles from nine databases (Academic Search Premier, Ageline, APA PsycArticles, PsycINFO, CINAHL, Embase, PubMed, Scopus, and Web of Science). Eight studies were eligible for this systematic review (Range sample sizes: 1-59 people with dementia). Results revealed that assessments of sleep in the current literature were limited and mainly focused on sleep duration, subjective sleep quality, or nighttime sleep disturbances. Intervention delivery, music selection, and findings varied. Positive effects of music on sleep outcomes were observed in six out of the eight studies (75%), specifically there were decreases in nighttime sleep disturbances, increases in daytime alertness, and improvements in sleep quality. The remaining two studies found no statistically significant change in sleep outcomes (i.e., daytime sleepiness and quality). Study limitations included small sample sizes and the use of proxy reporters (e.g., caregiver, researcher, blinded clinician) which may reduce the accuracy of the sleep measures. Future research may want to incorporate objectively measured sleep to better understand the role of sleep in dementia care. More research is needed to determine whether music interventions are effective in improving sleep in people with dementia and whether improvements in sleep can slow the progression of dementia.

Stakeholders' views on the use of psychotropic medication in older people: a systematic review

Background

psychotropic medication use has been shown to increase with age and has been associated with increased risk of falls, strokes and mortality. Various guidelines, regulations and tools have been developed to reduce inappropriate prescribing, but this remains high. In order to understand the reasons for this, we aimed to systematically review healthcare professionals’, patients’ and family caregivers’ attitudes towards the use of psychotropic medication in older people.

Methods

a systematic literature search was carried out from inception to September 2020 using PUBMED, EMBASE, PsycINFO and CINAHL and hand-searching of reference lists. Included studies investigated stakeholder views on psychotropic in adults over the age of 65. Findings were thematically synthesised.

Results

overall, there was an acceptance of long-term psychotropic medication for older people both living in the community and in residential care. While healthcare professionals were aware of guidelines for the use of benzodiazepines and psychotropic medicines, they identified barriers to following them on individual, team and organisational levels. Alternative non-pharmacological approaches were not always available or accepted by patients.

Conclusion

psychotropic medicine use in older adults remains a complex issue, which needs to be addressed on a broad level. Attitudes of older people and healthcare professionals encourage long-term use. Meanwhile, various internal and external factors act as barriers to the use of non-drug alternatives in this population. In order to reduce overprescribing of psychotropics, there is a need to increase the acceptability and accessibility of alternative interventions in both care homes and the community.

Delirium and Its Pharmacological Causes in Older People, Part Three

Delirium is a syndrome that can arise from many causes or underlying conditions, and though it has been reported in younger patients, it is more prevalent in older people, though it can occur in other age groups as well. Identifying delirium is challenging in older people because of the coexistence of underlying dementia or depression, which may further complicate the presentation. Drug-induced delirium is one of the major causes of delirium, and evaluation of this potential cause or contribution is an important component of the evaluation process, since it can lead to poor patient outcomes. Part one of this three part series reviewed the epidemiology, pathophysiology, evaluation, diagnostic process, and causes of delirium in older people. Parts two and three continued to review the pharmacological classes of medications that cause or contribute to delirium in older people.

Impact of Pharmacotherapy on Insomnia in Patients with Alzheimer's Disease

Insomnia is a pervasive sleep disorder affecting numerous patients across diverse demographical populations and comorbid disease states. Contributing factors are often a complex interaction of biological, psychological, and social components, requiring a multifaceted approach in terms of both diagnosis and management. In the setting of Alzheimer’s disease, insomnia is an even more complicated issue, with a higher overall prevalence than in the general population, greater complexity of contributing etiologies, and differences in diagnosis (at times based on caregiver observation of sleep disruption rather than subjective complaints by the individual with the disorder), and requiring more discretion in terms of treatment, particularly in regard to adverse effect profile concerns. There also is growing evidence of the bidirectional nature of sleep disruption and Alzheimer’s disease, with insomnia potentially contributing to disease progression, making the condition even more paramount to address. The objective of this review was to provide the clinician with an overview of treatment strategies that may have value in the treatment of disturbed sleep in Alzheimer’s disease. Nonpharmacological approaches to treatment should be exhausted foremost; however, pharmacotherapy may be needed in certain clinical scenarios, which can be a challenge for clinicians given the paucity of evidence and guidelines for treatment in the subpopulation of Alzheimer’s disease. Agents such as sedating antidepressants, melatonin, and site-specific γ-aminobutyric acid agonists are often employed based on historical usage but are not necessarily supported by high-quality trials. Newer agents such as dual orexin receptor antagonists have demonstrated some promise but still need further evaluation.

Effectiveness and safety of acupuncture in treating sleep disturbance in dementia patients: A PRISMA-compliant systematic review and limitations of current evidence

BACKGROUND

Dementia is of increasing importance, as it is a major public health problem worldwide. Sleep disturbance is common in dementia patients and may be associated with worse cognitive symptoms or behavioral and psychological symptoms of dementia. Non-pharmacological approaches, such as acupuncture, for treating this clinical condition are gaining importance. This study aimed to comprehensively search and analyze randomized controlled clinical trials (RCTs) of acupuncture in treating sleep disturbance or sleep disorders in dementia patients.

METHODS

A comprehensive search was conducted from 12 electronic databases on December 2, 2020. We included RCTs reporting the effectiveness and safety of acupuncture in treating sleep disorders or disturbance in dementia patients. The methodological quality of the included studies was assessed using the Cochrane Collaboration's risk-of-bias tool.

RESULTS

Five articles with four original RCTs met the inclusion criteria. These studies reported clinical data suggesting that adjuvant acupuncture for hypnotics, and ear acupressure in dementia patients with sleep disorders or sleep disturbance may have clinical benefits in certain sleep-related parameters and total effective rate (TER). Only 1 study reported the safety profile of the intervention, and no acupuncture-related adverse reactions were reported. Some studies compared 2 kinds of acupuncture methods, and found that specific acupuncture methods were superior to conventional acupuncture in improving sleep-related parameters, cognitive function and TER. The methodological quality of the included clinical studies was not high.

CONCLUSIONS

There were limited acupuncture studies on this topic. Given the number of studies included and their sample size, methodological quality, and heterogeneities, clinically relevant conclusions could not be drawn. Further clinical studies are needed in this field considering its urgency and importance.