Hypnotics, Elderly, & the Risk of Falls

Research has shown that the prevalence of insomnia increases with age. The appropriate treatment of insomnia in older patients can be challenging for several reasons, including the prevalence of comorbid conditions, increased use of a variety of medications (espe­cially central nervous system active compounds), and a compromised ability to metabolize and/or excrete these medications. This compromised function has typically resulted in lower recommended doses for many therapies, especially for hypnotic agents for which starting doses for the elderly are often half or less than those for adults. The purpose of using lower doses is to minimize adverse events (eg, amnestic effects or residual sedation) and thereby maxi­mize daytime functioning and patient safety. “Minimizing the risks of falls and fall-related injuries is a paramount consideration in the treatment of insomnia in the elderly.” An important consideration for safety in the elderly popula­tion is the risk for falls and fall-related injuries. A recent article by Frey et al in the Journal of the American Geriatrics Society evaluated the effect of sleep inertia on balance and cognition during nighttime awakenings in both adults and the elderly. The authors found that zolpidem produced clinically significant balance and cognitive impairments upon awakening from sleep. However, the study did not directly evaluate the incidence of falls; instead, it used the results of performance on tandem walking as a predictor of falls. These tandem walks occurred 120 minutes after a scheduled sleep opportunity and, thus, were designed to test the effects of zolpidem and sleep inertia in the first half of the night when those effects would be greatest. While the study is methodologically sound, it...