Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits

• Published in: BMJ Vol. 331; no. 7526; pp. 1169 - 1173
• Main Authors: Glass, Jennifer, Lanctôt, Krista L, Herrmann, Nathan, Sproule, Beth A, Busto, Usoa E
• Format: Journal Article
• Language: English
• Published: London British Medical Journal Publishing Group 19-11-2005; British Medical Association; BMJ Publishing Group LTD; BMJ Publishing Group; BMJ Publishing Group Ltd
• Edition: International edition
• Subjects: Ataxia; Benzodiazepines; Biological and medical sciences; Clinical trials; Cognition & reasoning; Cognition Disorders - chemically induced; Cognitive ability; Confidence interval; Confidence intervals; Disorders of higher nervous function. Focal brain diseases. Central vestibular syndrome and deafness. Brain stem syndromes; Drug therapy; Fatigue; General aspects; Humans; Hypnotics; Hypnotics and Sedatives - adverse effects; Hypnotics and Sedatives - therapeutic use; Insomnia; Medical sciences; Meta analysis; Nervous system (semeiology, syndromes); Neurology; Older adults; Older people; Placebos; Psychomotor Disorders - chemically induced; Publication Bias; Quality; Randomized Controlled Trials as Topic; Risk factors; Sedatives; Sleep; Sleep disorders; Sleep Initiation and Maintenance Disorders - drug therapy; Studies; Variables; Human; Medicine; Nervous system diseases; Benefit risk analysis; Insomnia; Sleep disorder; Hypnotic; Review; Sedative; Neurological disorder; Elderly; Metaanalysis
• ISSN: 0959-8138; 0959-8146; 1468-5833; 1756-1833
• DOI: 10.1136/bmj.38623.768588.47

Objectives To quantify and compare potential benefits (subjective reports of sleep variables) and risks (adverse events and morning-after psychomotor impairment) of short term treatment with sedative hypnotics in older people with insomnia. Data sources Medline, Embase, the Cochrane clinical trials database, PubMed, and PsychLit, 1966 to 2003; bibliographies of published reviews and meta-analyses; manufacturers of newer sedative hypnotics (zaleplon, zolpidem, zopiclone) regarding unpublished studies. Selection criteria Randomised controlled trials of any pharmacological treatment for insomnia for at least five consecutive nights in people aged 60 or over with insomnia and otherwise free of psychiatric or psychological disorders. Results 24 studies (involving 2417 participants) with extractable data met inclusion and exclusion criteria. Sleep quality improved (effect size 0.14, P < 0.05), total sleep time increased (mean 25.2 minutes, P < 0.001), and the number of night time awakenings decreased (0.63, P < 0.001) with sedative use compared with placebo. Adverse events were more common with sedatives than with placebo: adverse cognitive events were 4.78 times more common (95% confidence interval 1.47 to 15.47, P < 0.01); adverse psychomotor events were 2.61 times more common (1.12 to 6.09, P > 0.05), and reports of daytime fatigue were 3.82 times more common (1.88 to 7.80, P < 0.001) in people using any sedative compared with placebo. Conclusions Improvements in sleep with sedative use are statistically significant, but the magnitude of effect is small. The increased risk of adverse events is statistically significant and potentially clinically relevant in older people at risk of falls and cognitive impairment. In people over 60, the benefits of these drugs may not justify the increased risk, particularly if the patient has additional risk factors for cognitive or psychomotor adverse events.