Addendum Nov 14, 2012 Quality Indicators for the Care of Sleep Disorders in Vulnerable Elders:
Screen, sleep history, sleep hygiene, r/o sleep apnoea and restless leg and treat, avoid antihistamine, manage night time pain
Nonpharmacologic therapy is preferred. The most effective interventions are stimulus control, relaxation training, sleep restriction and moderate-intensity exercise. Good sleep hygiene" (waking up and going to bed at the same time every day, avoiding daytime naps, exercising regularly and discontinuing or reducing the consumption of alcohol, beverages containing caffeine, cigarettes and hypnotic drugs) is only moderately effective and should always be used in conjunction with other interventions.
i. Short acting
Triazolam 0.125-0.25 mg, hs $0.06-0.11/day
or Temazepam 15-30 mg, hs $0.12-0.14/day
ii. Long acting
Flurazepam 15-30 mg, hs $0.04/day
or Nitrazepam 5-10 mg, hs $0.09-0.14/day
Zopiclone 7.5 mg, hs $0.51/day
-Pharmacotherapy may offer temporary symptomatic relief for patients with transient or short-term insomnia. For patients with chronic insomnia, benzodiazepines have moderate effects on subjective sleep-onset latency (time getting to sleep), total sleep time, number of awakenings and sleep quality. However, on average, the mean duration of treatment with benzodiazepines in trials was only 7 days. Because the risks and benefits of long-term administration of hypnotic agents are poorly understood, long-term treatment is not usually recommended. Re-evaluate treatment after 2 weeks.
-Benzodiazepines add up to 1 h to total nightly sleep and reduce sleep-onset latency by 10 minutes. However, these gains must be weighed against the possibility of cognitive impairment or dependence/withdrawal/tolerance for individual patients and the disruption of sleep architecture.
-Although results from sleep laboratory studies show a short-term effect in elderly patients taking benzodiazepines, the effectiveness of treatment in the elderly recruited from primary care practice remains to be determined. If pharmacotherapy is used in the elderly it should be started at half the recommended dose.
-Benzodiazepines are variously indicated for anxiety, panic attacks, seizures and insomnia, but there is no evidence to suggest superior efficacy of one or more benzodiazepines for any of these conditions. Choice should be based on pharmacokinetics, side-effect profiles and knowledge of the individual patient (e.g., expected compliance, potential for abuse, etc.).
-Duration of action of benzodiazepines, including the effect of active metabolites: long acting >24 h, intermediate acting 12-24 h, short acting <12 h.
-No intermediate-acting benzodiazepine (alprazolam, bromazepam, lorazepam and oxazepam) is marketed as a hypnotic.
-Both short- and long-acting benzodiazepines have been associated with increased incidence of hip fracture in the elderly, suggesting that increased risk is primarily dose related.
-Rebound insomnia is more likely to occur with short-acting drugs; excessive daytime sedation is more likely to occur with long-acting drugs.
-Antidepressants should only be used to treat insomnia associated with depression. Little or no data exist regarding the efficacy and safety of antidepressants at low doses in the treatment of chronic primary insomnia. Antipsychotics such as chlorpromazine are normally inappropriate as hypnotics because of the risk of extrapyramidal effects such as tardive dyskinesia. Chloral hydrate is much less safe in overdose than second-line agents and has only slight benefits in sleep patterns.
-Occult caffeine in products such as acetaminophen/caffeine/codeine combinations may cause sleep problems in the elderly.
Quetiapine is not approved nor recommended for primary insomnia.
Quetiapine is commonly prescribed off-label as a sleep aid, but only one RCT examined its use in patients with insomnia. It found no benefit.
No published RCT evidence exists comparing quetiapine with other drugs for insomnia.
Management of primary insomnia should focus on education and encouragement of appropriate sleep habits. Drugs should be limited to short duration, intermittent use, or daily use only in exceptional cases.
- Psychiatry and Behaviour