Sleeping pills and sedatives: risks you should know
Risky SubstancesKey points
- Sleeping pills in people 60+: sleep only about 25 minutes longer on average.
- Cognitive side effects about 4.8 times and psychomotor side effects about 2.6 times more common.
- Number needed to treat: 13; number needed to harm: 6.
- First-line treatment for insomnia is CBT-I.
What the research shows
A meta-analysis of 24 randomized trials of sedative hypnotics (benzodiazepines and Z-drugs) in people aged 60 and older found that sleep quality improved and total sleep increased by an average of about 25 minutes. But adverse cognitive events were 4.8 times more common and psychomotor events, such as falls and accidents, 2.6 times more common. For every 13 people treated, one had improved sleep; for every 6 people treated, one had an adverse event (Glass et al., 2005).
What guidelines recommend
The American College of Physicians recommends CBT-I as the initial treatment for chronic insomnia and suggests medications only when CBT-I alone has not worked, after discussing benefits, harms and costs (Qaseem et al., 2016). The European guideline makes similar recommendations and advises against long-term use of benzodiazepines and Z-drugs (Riemann et al., 2017).
In practice
- Ask about CBT-I first.
- If you take sleeping pills, use the lowest dose for the shortest time.
- Never mix them with alcohol or opioids.
- Review all your medications with your doctor or pharmacist yearly.
Frequently asked questions
Are over-the-counter sleep aids safer?
Not necessarily. Many contain diphenhydramine or doxylamine, which the American Geriatrics Society advises older adults to avoid because of confusion, constipation and fall risk.
What about "Z-drugs" like zolpidem?
They carry FDA boxed warnings about complex sleep behaviors such as sleepwalking and sleep driving, which can cause serious injuries.
Sources
- Glass et al. (2005). Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits. BMJ 331(7526):1169. doi:10.1136/bmj.38623.768588.47
- Qaseem et al. (2016). Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline From the American College of Physicians. Annals of Internal Medicine 165(2):125-133. doi:10.7326/M15-2175
- Riemann et al. (2017). European guideline for the diagnosis and treatment of insomnia. Journal of Sleep Research 26(6):675-700. doi:10.1111/jsr.12594
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