Saturday, December 3, 2016

New guidelines say sleep aids should only be used short-term; physicians recommends "cognitive behavioral therapy"

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Sleep aids are readily available to the one-third of adults who suffer from insomnia, but health-care providers are beginning to steer patients away from them because of the risks the drugs pose, Laura Landro reports for The Wall Street Journal.

“Drugs don’t provide a natural sleep, and the side effects are significant,” Nitin Damle, an internist and president of the American College of Physicians, told Landro.“It’s true in all age groups, but even more problematic for older adults."

After reviewing more than 15 years of evidence, the physicians' group issued new guidelines in May for the management of chronic insomnia, recommending cognitive behavioral therapy as the first-line of treatment for adults. Cognitive behavioral therapy determines patient's actions that may be prohibiting sleep, and then develops a customized list of "do"s and "don’t"s for optimal sleeping.

The guidelines also say that drugs should only be used if therapy is unsuccessful, should only be used short-term, defined as four to five weeks, and only after the benefits and risks have been discussed with the patient. “The intent is for them to be on a short course, and then get off of it,” David Maness, a professor of family medicine at the University of Tennessee Health Science Center in Memphis, told Landro.

“But then the problem is perpetuated, and before you know it, it’s 10 years later, and it keeps getting refilled and no one has reviewed it.” In addition to their addictive properties, prescription sleep aids can cause fuzzy thinking, short-term memory loss, and diminished liver and kidney function, which can cause fatigue, weakness and impaired balance, in older patients. Longer term, sleep drugs may contribute to more serious mental-function issues, Landro reports.

Benzodiazepines, like Halcion, and non-benzodiazapenes, like Ambien, Lunesta and Sonata, are the most commonly prescribed sleeping pills. These drugs, called sedative hypnotics, slow activity in the brain to bring on sleep.

"The American Geriatrics Society recommends against using benzodiazepines or other sedative hypnotics in older adults as first choice for insomnia because large-scale studies consistently show that the risk or motor-vehicle accidents, falls and hip fractures leading to hospitalization and death can more than double in older adults taking the drugs," Landro writes.

There is a new class of sleeping pills that act differently than sedative hypnotics, but are not physically addictive and don't have withdrawal symptoms after stopping the drug. However, they do have some side-effects like drowsiness the next day, sleepwalking and performing activities while sleeping.

Landro reports that over-the-counter drugs can also be risky because many of them use the antihistamine diphenhydramine, which is a type of drugs known as anticholinergics. "A study last year in JAMA Internal Medicine suggested higher cumulative use of anticholinergics, which can impair memory and attention, is associated with an increased risk for dementia," she writes.

Patients who are dependent on sleeping pills should not stop them abruptly, but should taper off of them, Sean Jeffrey, director of clinical pharmacy services at Hartford Healthcare and a clinical professor at the University of Connecticut School of Pharmacy, told Landro.

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