AcuteCare Telemedicine Blog


Insomnia: Limiting the Use of Sedatives and Hypnotics

Insomnia is the most commonly encountered sleep disorder or complaint, with a wide prevalence range reported to be between 10 and 40 percent  (the variance is due to differences in the definition of insomnia). Suffice it to say, millions of individuals are affected by insomnia at some point in their lives. Because of the significant increased rate of comorbidity associated with insomnia, the burden placed on society by way of increased utilization of health care resources, poor work performance, and missed work days, it is essential that insomnia is appropriately and efficiently managed.

Individuals who suffer from insomnia frequently seek help from medical professionals and this help is often provided in the form of a sedative/hypnotic medication. Significant risks are associated with the use of sedatives and hypnotics, such as dependency, falls (particularly in the elderly), and even an increase in cancer and death rates, as shown by a recent study. Prescription medications do have a role in the treatment of some individuals with insomnia, as well as those with conditions and situations that may call for temporary use, such as time zone changes and jet lag. However, these medications are often over prescribed and/or misused due to insufficient patient evaluation.

It is well understood that when evaluating a patient with complaints of insomnia, an underlying medical and or psychiatric disorder should be considered. Ruling out and treating underlying etiologies is requisite. With resolution or control of the causative medical or psychiatric condition, the insomnia will often times abate. When thorough evaluations are performed in the setting of insomnia, sedative use can be potentially limited, if not completely avoided.

Complaints of insomnia may also be indicative of another (primary) sleep disorder such as restless leg syndrome (RLS) and periodic limb movements (PLMs), delayed sleep phase disorder (DSPD), or obstructive sleep apnea (OSA). Sleep onset and maintenance difficulties may be the result of both PLMs and OSA. The inability to fall asleep at the desired sleep time will be seen in individuals with DSPD. Patients with the above conditions will frequently complain of daytime sleepiness, a complaint not usually expressed in individuals with primary insomnia. These sleep disorders can all be treated without the use of sedatives. Furthermore, the use of sedatives in these cases will only serve to mask and possibly exacerbate the primary sleep disorder, leading to increased morbidity and mortality rates.

In the July 2010 issue of SLEEP, a study was published showing that the prevalence of sedative use in the general Canadian population had more than doubled between 1994 and 2003. Interestingly, this increase had occurred moreso in men, non-elderly, and obese individuals. The study concluded that “the greater odds of sedative medication use found among morbidly obese men may reflect the presence of underlying obstructive sleep apnea, which may in turn serve to explain in part the known relationship between sedative medications and mortality.” When patients with untreated sleep apnea are prescribed sedative/hypnotic medications, apneic events typically worsen, setting up for poorer outcomes and placing them in danger of respiratory arrest.

When underlying etiologies of insomnia have been ruled out and sedatives are needed, they should be used sparingly and temporarily. When possible, alternative treatment modalities such as cognitive behavioral therapy should be employed to avoid or limit the use of sedative and hypnotic medications.

 

 

 

 


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