0
Get Alert
Please Wait... Processing your request... Please Wait.
You must sign in to sign-up for alerts.

Please confirm that your email address is correct, so you can successfully receive this alert.

1
Letters   |    
Insomnia and Risk of Falling in Older Adults
Nahla Mahgoub, M.D.; Petra Majdak, M.S.; David B. Friedman; Sibel Klimstra, M.D.
The Journal of Neuropsychiatry and Clinical Neurosciences 2012;24:E5-E6. doi:10.1176/appi.neuropsych.11070159
View Author and Article Information

The authors have no direct financial interests in the subject materials discussed in the article.

Assistant Professor of Psychiatry Weill Medical College of Cornell University, Westchester Division White Plains, NY
Weill Cornell Institute of Geriatric Psychiatry White Plains, NY
Psychiatry Research Department Weill Cornell Institute of Geriatric Psychiatry White Plains, NY

Geriatric Psychiatry Fellowship Program

Associate Vice Chair for Graduate Medical Education

Weill Medical College of Cornell University

White Plains, NY

To the Editor: Falls are one of the leading causes of morbidity and mortality in older adults, and can result in fractures, decreased independence in daily living activities, and nursing home placement.1,2 Epidemiological studies have identified older age, use of prescription medications, chronic medical conditions, poor balance, and sensory impairments as common risk factors for falls.2,3 Among prescription medications, hypnotics have been associated with an increased risk of falls.1,4 However, accumulating evidence suggests that insomnia itself may increase the likelihood of falls. For older patients requiring pharmacotherapy for insomnia, guidelines can be challenging. This report, while not eliminating clinical concerns about hypnotic-related falls and other side effects, discusses the pharmacologic treatment of insomnia in elderly patients.

According to the 1990 National Institutes of Health (NIH) Consensus Statement, hypnotics should be used for a short-term period and should only be used for older adults with short-lived insomnia.5 The Food and Drug Administration (FDA) has approved 10 medications for the treatment of insomnia. This includes benzodiazepines, non-benzodiazepines, and a melatonin receptor-agonist.6 None of these medications is specifically approved for the older population. The majority of studies suggesting hypnotics as a risk factor for falls did not investigate the possibility that insomnia itself, rather than the hypnotic, could be the reason for falling.1 There are several possible mechanisms by which insomnia may contribute to falls in elderly persons. These include increased activity in the dark, compounded by age-related impaired psychomotor performance, decreased balance, and decreased reaction-time.1,3

The underlying mechanisms of hypnotic medication-related falls appear to be related to psychomotor impairment, loss of balance, and next-day residual effects.3 The deleterious effects of hypnotics on psychomotor performance may be related to the individual pharmacodynamic and/or pharmacokinetic characteristics. The hypnotic effect is mediated through enhancement of GABA’s inhibitory effects on neuronal excitation, via binding to the α1 subunits of GABAA receptors.7 Benzodiazepines have nonselective affinity for GABAA receptors and may also bind to α2, α3, and α5 subunits,7 resulting in psychomotor impairment.8

On the contrary, the non-benzodiazepine hypnotics bind selectively to the GABAA receptor α1 subunits (zolpidem and zaleplon) or bind less preferentially to the GABAA receptor complex in the brain (zopiclone).7,8,9,10 Therefore, it reasonable to propose that non-benzodiazepine hypnotics have a lower tendency to impair psychomotor performance than benzodiazepine hypnotics. However, comparative data among the non-benzodiazepine hypnotics are not available in older adults with insomnia.7,8,10

Ramelteon, recently approved by the FDA, functions as a selective melatonin MT1 and MT2 agonist in the suprachiasmatic nucleus in the brain. It is effective in the treatment of circadian-rhythm sleep disorders; however, its efficacy in treating primary insomnia is limited. Since ramelteon does not show substantial binding to GABAA receptors, it is unlikely to affect psychomotor performance or cause next-day residual effects.11

Side effects may be minimized when hypnotics are administered at recommended doses and at bedtime.8,10 Reduced dosages are advised in older patients because of pharmacokinetic differences such as prolonged half-life, reduced drug clearance, increased bioavailability, and increased sensitivity to peak effects. It appears that next-day residual effects increase when using a hypnotic with a very long half-life or when administering a hypnotic late at night. However, The Study of Osteoporotic Fractures, found no statistically significant difference between long-acting and short-acting benzodiazepines on the risk of falls.3

The 2005 NIH State-of-the-Science Conference on Insomnia found no significant effectiveness for the off-label use of antidepressants, antipsychotics, anticonvulsants, and antihistamines for the treatment of insomnia, and concluded that their risks outweigh the benefits.6,12 It is essential to note that antidepressants, antipsychotics, and anticonvulsants have been implicated in falls.13

In summary, insomnia itself increases the likelihood of falls, and effective treatment of insomnia in older adults may help prevent falls. In the absence of well-controlled randomized trials, cautious use of hypnotic medications in older adults may provide treatment with a favorable side effect profile, including fall minimization. Medication factors to be considered include GABAA receptor α1 subunit selectivity, short elimination half-life and minimal next-day residual effects, bedtime administration, and age-adjusted dosing in older adults.

Avidan  AY;  Fries  BE;  James  ML  et al:  Insomnia and hypnotic use, recorded in the minimum data set, as predictors of falls and hip fractures in Michigan nursing homes.  J Am Geriatr Soc 2005; 53:955–962
[CrossRef] | [PubMed]
 
Brassington  GS;  King  AC;  Bliwise  DL:  Sleep problems as a risk factor for falls in a sample of community-dwelling adults aged 64-99 years.  J Am Geriatr Soc 2000; 48:1234–1240
[PubMed]
 
Stone  KL;  Ensrud  KE;  Ancoli-Israel  S:  Sleep, insomnia, and falls in elderly patients.  Sleep Med 2008; 9(Suppl 1):S18–S22
[CrossRef] | [PubMed]
 
Tinetti  ME;  Speechley  M;  Ginter  SF:  Risk factors for falls among elderly persons living in the community.  N Engl J Med 1988; 319:1701–1707
[CrossRef] | [PubMed]
 
NIH Consensus Statement 1990 Mar 26-28;8:1–22. The Treatment of Sleep Disorders of Older People.
 
Bloom  HG;  Ahmed  I;  Alessi  CA  et al:  Evidence-based recommendations for the assessment and management of sleep disorders in older persons.  J Am Geriatr Soc 2009; 57:761–789
[CrossRef] | [PubMed]
 
Holm  KJ;  Goa  KL:  Zolpidem: an update of its pharmacology, therapeutic efficacy and tolerability in the treatment of insomnia.  Drugs 2000; 59:865–889
[CrossRef] | [PubMed]
 
Dooley  M;  Plosker  GL:  Zaleplon: a review of its use in the treatment of insomnia.  Drugs 2000; 60:413–445
[CrossRef] | [PubMed]
 
Allain  H;  Bentué-Ferrer  D;  Polard  E  et al:  Postural instability and consequent falls and hip fractures associated with use of hypnotics in the elderly: a comparative review.  Drugs Aging 2005; 22:749–765
[CrossRef] | [PubMed]
 
Noble  S;  Langtry  HD;  Lamb  HM:  Zopiclone. An update of its pharmacology, clinical efficacy and tolerability in the treatment of insomnia.  Drugs 1998; 55:277–302
[CrossRef] | [PubMed]
 
Pandi-Perumal  SR;  Srinivasan  V;  Spence  DW  et al:  Ramelteon: a review of its therapeutic potential in sleep disorders.  Adv Ther 2009; 26:613–626
[CrossRef] | [PubMed]
 
National Institutes of Health:  National Institutes of Health State of the Science Conference statement on Manifestations and Management of Chronic Insomnia in Adults, June 13–15, 2005.  Sleep 2005; 28:1049–1057
[PubMed]
 
Lavsa  SM;  Fabian  TJ;  Saul  MI  et al:  Influence of medications and diagnoses on fall risk in psychiatric inpatients.  Am J Health Syst Pharm 2010; 67:1274–1280
[CrossRef] | [PubMed]
 
References Container
+

References

Avidan  AY;  Fries  BE;  James  ML  et al:  Insomnia and hypnotic use, recorded in the minimum data set, as predictors of falls and hip fractures in Michigan nursing homes.  J Am Geriatr Soc 2005; 53:955–962
[CrossRef] | [PubMed]
 
Brassington  GS;  King  AC;  Bliwise  DL:  Sleep problems as a risk factor for falls in a sample of community-dwelling adults aged 64-99 years.  J Am Geriatr Soc 2000; 48:1234–1240
[PubMed]
 
Stone  KL;  Ensrud  KE;  Ancoli-Israel  S:  Sleep, insomnia, and falls in elderly patients.  Sleep Med 2008; 9(Suppl 1):S18–S22
[CrossRef] | [PubMed]
 
Tinetti  ME;  Speechley  M;  Ginter  SF:  Risk factors for falls among elderly persons living in the community.  N Engl J Med 1988; 319:1701–1707
[CrossRef] | [PubMed]
 
NIH Consensus Statement 1990 Mar 26-28;8:1–22. The Treatment of Sleep Disorders of Older People.
 
Bloom  HG;  Ahmed  I;  Alessi  CA  et al:  Evidence-based recommendations for the assessment and management of sleep disorders in older persons.  J Am Geriatr Soc 2009; 57:761–789
[CrossRef] | [PubMed]
 
Holm  KJ;  Goa  KL:  Zolpidem: an update of its pharmacology, therapeutic efficacy and tolerability in the treatment of insomnia.  Drugs 2000; 59:865–889
[CrossRef] | [PubMed]
 
Dooley  M;  Plosker  GL:  Zaleplon: a review of its use in the treatment of insomnia.  Drugs 2000; 60:413–445
[CrossRef] | [PubMed]
 
Allain  H;  Bentué-Ferrer  D;  Polard  E  et al:  Postural instability and consequent falls and hip fractures associated with use of hypnotics in the elderly: a comparative review.  Drugs Aging 2005; 22:749–765
[CrossRef] | [PubMed]
 
Noble  S;  Langtry  HD;  Lamb  HM:  Zopiclone. An update of its pharmacology, clinical efficacy and tolerability in the treatment of insomnia.  Drugs 1998; 55:277–302
[CrossRef] | [PubMed]
 
Pandi-Perumal  SR;  Srinivasan  V;  Spence  DW  et al:  Ramelteon: a review of its therapeutic potential in sleep disorders.  Adv Ther 2009; 26:613–626
[CrossRef] | [PubMed]
 
National Institutes of Health:  National Institutes of Health State of the Science Conference statement on Manifestations and Management of Chronic Insomnia in Adults, June 13–15, 2005.  Sleep 2005; 28:1049–1057
[PubMed]
 
Lavsa  SM;  Fabian  TJ;  Saul  MI  et al:  Influence of medications and diagnoses on fall risk in psychiatric inpatients.  Am J Health Syst Pharm 2010; 67:1274–1280
[CrossRef] | [PubMed]
 
References Container
+
+

CME Activity

There is currently no quiz available for this resource. Please click here to go to the CME page to find another.
Submit a Comments
Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
Comments are moderated and will appear on the site at the discertion of APA editorial staff.

* = Required Field
(if multiple authors, separate names by comma)
Example: John Doe



Related Content
Books
The American Psychiatric Publishing Textbook of Psychopharmacology, 4th Edition > Chapter 60.  >
The American Psychiatric Publishing Textbook of Psychiatry, 6th Edition > Chapter 35.  >
The American Psychiatric Publishing Textbook of Geriatric Psychiatry, 4th Edition > Chapter 22.  >
Gabbard's Treatments of Psychiatric Disorders, 4th Edition > Chapter 56.  >
Gabbard's Treatments of Psychiatric Disorders, 4th Edition > Chapter 56.  >
Topic Collections
Psychiatric News
Read more at Psychiatric News >>
PubMed Articles