This paper reviews the use of sleep-promoting medications in
nursing home residents with reference to risks versus benefits. Up to two-thirds of elderly people living in institutions experience sleep disturbance. The aetiology of sleep disturbance includes poor sleep hygiene, medical and
psychiatric disorders, sleep apnoea, periodic limb movements and
restless leg syndrome. One key factor in the development of sleep disturbance in the
nursing home is the environment, particularly with respect to high levels of night-time noise and light, low levels of daytime light, and care routines that do not promote sleep. Clinical assessment should include a comprehensive medical, psychiatric and sleep history including a review of prescribed medications. Nonpharmacological interventions for
insomnia are underutilised in many clinical settings despite evidence that they are often highly effective. International studies suggest that 50-80% of
nursing home residents have at least one prescription for psychotropic medication. Utilisation rates vary dramatically from country to country and from institution to institution. The most commonly prescribed medications for sleep are
benzodiazepines and nonbenzodiazepine
hypnotics (Z-drugs). The vast majority of studies of these medications are short-term, i.e. < or =2 weeks, although some longer extension trials have recently been carried out. Clinicians are advised to avoid long-acting
benzodiazepines and to use
hypnotics for as brief a period as possible, in most cases not exceeding 2-3 weeks of treatment. Patients receiving
benzodiazepines are at increased risk of daytime sedation, falls, and cognitive and
psychomotor impairment.
Zaleplon,
zolpidem,
zopiclone and
eszopiclone may have some advantages over the
benzodiazepines, particularly with respect to the development of tolerance and dependence.
Ramelteon, a novel agent with high selectivity for
melatonin receptors, has recently been approved in the US. Use of the
antidepressant trazodone for sleep in nondepressed patients is somewhat controversial. Atypical
antipsychotics should not be used to treat
insomnia unless there is also evidence of severe behavioural symptoms or
psychosis.