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Hypnotics association with
Charles Heaney
• Volume 2, Issue 1, 2012
Cohort Study
matching 10,500 patient’s (mean age of 54)
who were prescribed hypnotics with
23,500 matched controls and followed
them for 2.5 years.
• Clear association between patient’s
prescribed any hypnotic, and higher risk of
death, even at low doses
• Risks were elevated for different hypnotics
including benzodiazepines, barbituates,
and anti-histamines, and each was
associated with an increased rate of death
Association with Cancer
• Also, there is an increased association
with cancer with hypnotic use in the upper
• Author claims results were robust within
groups suffering each co-morbidty
indicating that the hazard was not
attributable to pre-existing disease.
• Receiving hypnotic prescriptions is
associated with greater then threefold
increase in hazard of death, even when
prescribed less then 18 pills per year
BJGP 2011
• 61:558
Systemic review of RCT’s
of minimal intervention’s
• Sending a brief letter
• Self Help Information
• Consultation with a G.P.
• All of these explained concern over long
term use, their potential side affects, and
advise on gradual dose reduction
• NNT, showed that for every 12 older
people who receive a letter, one will
cease Benzodiazepine use.
• 50% of patient who attend primary care
have insomnia
• 30-40% of the population
• 50% had Depression
• 48% had Anxiety
• 43% had General Physical Health
• 22% Restless Leg Syndrome
• 9% had Obstructive Sleep Apnoea
• 12% had ethanol and substance missuse
• 12% have Primary Insomnia
• 2% have Delayed Sleep Phase Disorder
• All three methods found a twice a
reduction in benzodiapines compared to
control groups
• NNT, 12 letters to older people need to
receive one letter for one to cease
General Approach
• Treatment for any underlying medical
condition, psychiatric illness, and
substance abuse.
• Behavioural Therapies
• Medications
• Combination therapy
Sleep Hygiene
• Sleep as long as to get rested and then
get out of bed
• External Stimuli
• Regular Sleep Cycle
• Try not to force sleep
• Avoid caffeinated beverages after lunch
• Avoid smoking, particularly in the evening
Stimulus Control
• Bed is primarily for sleeping
Sleep Restriction Therapy
• Some patient’s stay in bed longer to make
up for lost sleep
Contraindications to meds
Alcohol consumption
Renal or hepatic disease
Pulmonary disease or sleep apnea
Night time decision makers
Older Patients
Hypnotic Drugs
• Shorter Acting Drugs, such as Zolpidem
are preferred for insomnia with delayed
sleep latency
• Medium Acting, such as Zopiclone and
Temazepam, if they wake at night
• Long Acting, such as Clonazepam, if they
have insomnia with day time anxiety
• Advise max 3 times a week
• Sedating anti-depressants have not have
problems with dependence, there is less
evidence of eifficacy and side affects
• Antipsychotics
• Barbiturates
• Herbal Products
Adverse Affect
• sedation, drowsiness, dizziness,
lightheadedness, cognitive impairment,
motor incoordination, and dependence
• habit forming and rebound insomnia may
occur when some short-acting medications
are discontinued.
• Older Patient’s, threefold increase in
hazards of death, even when less then 18
pills per year
• In March of 2007, the FDA requested that
the manufacturers of sedative-hypnotic
medications strengthen their labeling to
include stronger language about the risks
of severe allergic reactions and complex
sleep-related behaviors (eg, driving,
making telephone calls, eating, having sex
while not fully awake).
Ciracdian Rythem Disorders
Jet Lag
• Speed of onset — The most important
distinction among the benzodiazepines, in
the context of abuse potential, is the
speed of onset .
• Drugs that more rapidly reach peak brain
levels after oral administration are
relatively more likely to produce brain
reward or euphoria, and are therefore
more likely to be abused.
Increased body temperature
Elevated blood pressure
Increased respiratory rate and heart rate
Aroused level of consciousness or frank
Increased reflexes
Psychotic behavior including hallucinations