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Hypnotics association with Mortality Charles Heaney 19/02/2013

BMJ 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.

Outcome 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 third

Author claims results were robust within groups suffering each co-morbidty indicating that the hazard was not attributable to pre-existing disease.

Conclusion Receiving hypnotic prescriptions is associated with greater then threefold increase in hazard of death, even when prescribed less then 18 pills per year

BJGP :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

Results NNT, showed that for every 12 older people who receive a letter, one will cease Benzodiazepine use.

Epidemiology 50% of patient who attend primary care have insomnia 30-40% of the population

Co-exisiting 50% had Depression 48% had Anxiety 43% had General Physical Health Problems 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

Outcome 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 benzodiazepines.

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 Pregnancy 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

Antidepressants 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 Phototherapy Chronotherapy Cirrhosis 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.

Withdrawal Increased body temperature Elevated blood pressure Increased respiratory rate and heart rate Aroused level of consciousness or frank delirium Tremulousness Increased reflexes Disorientation Psychotic behavior including hallucinations