In nursing homes across the country, elderly people with insomnia often go untreated, because of the perception that sleeping pills increase the risk of falls and injuries that are a bane of old age.
But a large new University of Michigan Health System study suggests that the real culprit may be the underlying insomnia, rather than the medications used to treat it. Residents with untreated, or partially treated, sleeplessness have a much higher risk of falls than those who take sleep medications and get relief from their insomnia.
Even though medications are only one way of treating insomnia, the new finding has implications for the way sleep problems are addressed -- or not addressed -- in nursing homes, and perhaps for the prevention of falls that often trigger major health crises in the elderly.
"Many physicians assume that when an older patient has insomnia, and is given a hypnotic drug to help induce sleep, the drug will make the patient likely to fall and develop a hip fracture," says U-M sleep specialist Alon Avidan, M.D., MPH, first author of the study published online by the Journal of the American Geriatrics Society. "But our findings suggest that people whose insomnia is effectively treated are less likely to fall than untreated insomniacs."
Hypnotic drugs are sleep-aiding medications that include many older, long-lasting drugs such as benzodiazepines and barbiturates, as well as newer, shorter lasting and commonly advertised drugs with fewer side effects.
The study included more than 34,000 Michigan nursing home residents over age 65. Data were collected over six months as part of ongoing mandatory assessments by nursing home staff.
Individuals who had untreated insomnia at the start of the study period were 90 percent more likely to fall in the next six months compared with those who did not have insomnia. In contrast, those who were taking hypnotic drugs to treat their insomnia at the start were only 29 percent more likely to fall.
The difference was even more striking when the researchers took into account a wide range of complicating factors -- such things as age, sex, health problems, thinking problems and trouble with daily activities – all of which affect the risk of falls.
Nursing home residents who were on sleep medications and reported no problems sleeping at the start of the study had about the same risk of falling in the next six months as those who slept well without drugs.
But those with insomnia who weren't on sleep medications had a 55 percent greater risk of falling, and those who took sleep drugs but still reported insomnia had a 32 percent greater risk of falls.
"One study by itself isn't enough to eliminate current concerns about hypnotics and falls, but many previous studies that raised these concerns did not look to see whether insomnia, rather than the drugs themselves, might be the problem," says senior author Ronald Chervin, M.D., M.S. "Our results should encourage older people and their caregivers to pay attention to insomnia, and to seek help for it."
Chervin, an associate professor of neurology who directs the U-M's Sleep Disorders Center, notes that the new study is by far the largest and most comprehensive ever to focus on the relationship between sleep, falls and hypnotic drug use among nursing home residents. The data in the study came from the Minimum Data Set, a federally mandated effort to record information about nursing home residents. They were made available by the Michigan Department of Community Health.
"We are excited to continue to find valuable lessons in these data, primarily collected for care planning purposes but now usable for understanding ways to improve the care in our nation's nursing homes," says Brant Fries, Ph.D., a professor at the U-M School of Public Health and Institute of Gerontology, who was both a study author and helped develop the Minimum Data Set for the federal government.
The study is also the first to take a longitudinal look at fall risk over a period of time. And, it's the first to take into account so thoroughly the many factors that can complicate the picture. Previous studies that suggested a higher risk of falls associated with hypnotic use were smaller and lacked this kind of complex analysis. They also were performed before newer sleep drugs were available.
In all, Chervin says, "Hypnotic drugs may be appropriate in some cases, and we in the medical community may not need to have the fear of them in older patients that we currently have." He adds that the study did not look at patients who were prescribed powerful sedatives to help them sleep, such as morphine, nor did it include patients taking anxiety drugs that also aid sleeping ability.
Sleep-aiding medications, Chervin and Avidan note, are only one way to deal with persistent insomnia, and in fact are not the first tactic most patients should try. Behavioral therapy, whether one-on-one or in groups, has been shown to work as well as or better than medication. And almost everyone with insomnia would benefit from better "sleep hygiene" -- including quiet, dark bedrooms and pre-bedtime habits such as low-key activity and abstaining from caffeine, alcohol or exercise for several hours before bed.
Insomnia, which includes trouble falling asleep, trouble staying asleep, frequent night-time waking and early waking, affects more than 40 percent of adults over age 50 and half of adults over age 70, compared to 30 percent of adults in their 40s, and less than 20 percent of teens and young adults. About one in every five adults over 65 has persistent insomnia, and many studies have linked common diseases of older adults with sleep problems, including heart and lung problems, arthritis and acid reflux. Incontinence, dementia and Parkinson's disease also affect sleep.
"In many older adults, complaints of insomnia may be the tip of the iceberg, resulting from many other coexisting problems," says Avidan, an assistant professor of Neurology at the U-M Medical School. "We also know that many older adults are being prescribed hypnotic drugs to help them sleep, because the elderly as a group account for 30 percent of all such prescriptions."
Meanwhile, he says, falls are also a major problem for the elderly, especially those living in nursing homes. "One in three adults over 65 falls each year, and falls are the leading cause of injury-related deaths, nonfatal injuries and trauma-related hospital admissions in this group," he says.
About one percent of all falls in the elderly cause a hip fracture, which often restricts a person's mobility, raises the cost of their medical care substantially, and increases the risk of death within a few months. Although the new study did not show a correlation between insomnia and hip fractures, it also didn't show a relationship between hypnotic drug use and hip fracture.
Avidan and Chervin note that there are many possible ways in which insomnia, combined with other mental and physical factors, could lead to falls. People with insomnia may get out of bed in the middle of the night, running into or tripping over objects in the dark or just becoming confused about their surroundings. Insomnia is known to cause daytime sleepiness and clumsiness, as well as cognitive deficits. It slows down a person's reaction time, which could reduce the likelihood of quick corrective maneuvers that might prevent a fall from happening.