Abstract
Hypnosedatives are used extensively in older people, although their usage has fallen since the early 1970s. Increasing consumer concerns now risk underuse of these drugs, even in appropriate situations. High quality prescribing of hypnosedatives requires consideration of the pharmacokinetics and pharmacodynamics of these drugs, an understanding of their adverse effects, efficacy and clinical situations in which they may be of use, and an appreciation of the role of non-pharmacological therapy. If these issues are adequately addressed, hypnosedatives can be used effectively to treat insomnia and some anxiety disorders. Hypnosedative prescribing can be improved through regular audits, and the development of a local prescribing policy and educational programmes.
Benzodiazepines are the most commonly used hypnosedatives. They are used for the treatment of both insomnia and anxiety disorders, but can be associated with a number of adverse effects in older individuals including confusion, falls and fractures (particularly agents that have a long elimination half-life) and injurious car crashes. Increased mortality has also been reported in older individuals taking these drugs. Tolerance and dependency are concerns with poor prescribing of all benzodiazepines and withdrawal effects can be extreme when there is inappropriate clinical management of the cessation of very short half-life agents.
Zopiclone and zolpidem are nonbenzodiazepine agents but they bind to the same receptors as benzodiazepines. They are used for the treatment of insomnia, and may be better tolerated than benzodiazepines in some older people.
Other hypnosedatives, such as melatonin, chloral hydrate and chlormethiazole, are less suitable for the treatment of insomnia in older patients, but may be considered. Buspirone and antidepressants are specifically indicated in some anxiety disorders, but are generally not first-line hypnosedatives. Antipsychotics should not be used as hypnosedatives.
Individual drug choice is affected by consideration of speed of onset, withdrawal effects, half-life and hangover effects, efficacy data and cost. Initial dosages should be low, and increases made slowly. Duration of therapy should generally be limited to 2 weeks in the first instance. It is often appropriate to withdraw hypnosedatives in long term users and this may be assisted by substituting short half-life agents with those that have a longer half-life.
Similar content being viewed by others
References
Wysowski DK, Baum C. Patient use of prescription sedative — hypnotic drugs in the United States, 1970 through 1989. Arch Intern Med 1991; 151: 1779–83
Walsh JK, Engelhardt CL. Trends in the pharmacological treatment of insomnia. J Clin Psychol 1992; 53 (Dec Suppl. ): 10–7
Olfson M, Pincus HA. Use of benzodiazepines in the community. Arch Intern Med 1994; 154: 1235–40
Baum C, Kennedy DL, Knapp DE, et al. Prescription drug use in 1984 and changes over time. Med Care 1988; 26: 105–14
Lockwood A, Berbatis CG. Psychotropic drugs in Australia: consumption pattern. Med J Aust 1990; 153: 604–11
Brayley J, Bradshaw G, Pols R. Guidelines for the prevention and management of benzodiazepine dependence. National Health and Medical Research Council Monograph Series No. 3. Canberra, Australia: Australian Government Printing Service, 1991
Lyndon R, Russell J. Can over use of psychotropic drugs by the elderly be prevented? Aust NZ J Psychol 1990; 24: 77–81
Howes JB, Ryan J, Fairbrother G, et al. Benzodiazepine prescribing in a Sydney teaching hospital. Med J Aust 1996; 165: 305–8
Spore D, Mor V, Hiris J, et al. Psychotropic use among older residents of board and care facilities. J Am Geriatr Soc 1995; 43: 1403–9
Beardsley RS, Larson DB, Burns BJ, et al. Prescribing of psychotropics in the elderly nursing home patient. J Am Geriatr Soc 1989; 36: 327–30
Waldron I. Increased prescribing of valium, librium and other drugs — an example of the influence of economic and social factors on the practice of medicine. Int J Health Serv 1977; 7: 37–62
Rodrigo EK, King MB, Williams P. Health of long-term benzodiazepine users. BMJ 1988; 296: 603–6
Shorr RI, Robin DW. Rational use of benzodiazepines in the elderly. Drugs Aging 1994; 4: 9–20
Greenblatt DJ, Harmatz JS, Shader RI. Clinical pharmacokinetics of anxiolytics and hypnotics in the elderly: therapeutics consideration. Clin Pharmacokinet 1991; 21: 165–77; 262-73
du Souich P, Verges J, Erill S. Plasma protein binding and pharmacological response. Clin Pharmacokinet 1993; 24: 435–40
Sotaniemi EA, Arranto AJ, Pelkonen O, et al. Age and cytochrome P450 — linked drug metabolism in humans: an analysis of 226 subject with equal histopathological conditions. Clin Pharmacol Ther 1997; 61: 331–9
Woodhouse KW, James OFW. Hepatic drug metabolism and ageing. Br Med Bull 1990; 46: 22–35
Schmucker DR, Woodhouse KW, Wang RK, et al. Effects of age and gender on in vitro properties of human liver microsomal monooxygenases. Clin Pharmacol Ther 1990; 48: 365–74
Hunt CM, Westerkam WR, Stave GM. Effect of age and gender on the activity of human hepatic CYP3A. Biochem Pharmacol 1992; 44: 275–83
Greenblatt DJ, Divoll M, Abernethy DR, et al. Benzodiazepine kinetics: implications for therapeutics and pharmacogeriatrics. Drug Metab Rev 1983; 14: 251–92
Greenblatt DJ, Divoll M, Harmatz JS, et al. Kinetics and clinical effects of flurazepam in young and elderly noninsomniacs. Clin Pharmacol Ther 1981; 30: 475–86
Klotz H, Arvant GR, Hoyumpa A, et al. The effects of age and liver disease on the disposition and elimination of diazepam in adult man. J Clin Invest 1975; 55: 347–59
Kruse WHM. Problems and pitfalls in the use of benzodiazepines in the elderly. Drug Saf 1990; 5: 328–44
Cook PJ, Flanagan R, James IM. Diazepam tolerance: effect of age, regular sedation, and alcohol. BMJ 1984; 289: 351–3
Pomara N, Stanley B, Block R, et al. Increased sensitivity of the elderly to the central depressant effects of diazepam. J Clin Psychol 1985; 46: 185–7
Pomara N, Deptula D, Medel M, et al. Effects of diazepam on recall memory: relationship to ageing, dose and duration of treatment. Psychopharmacol Bull 1989; 25: 144–8
Castleden CM, George CF, Marcer D, et al. Increased sensitivity to nitrazepam in old age. BMJ 1977; 1: 10–2
Ghoneim MM, Mewaldt SP. Benzodiazepines and human memory: a review. Anaesthesiology 1990; 72: 926–38
Swift CG, Swift MR, Hamley J, et al. Side-effect ‘tolerance’ in elderly long-term recipients of benzodiazepine hypnotics. Age Aging 1987; 13: 335–43
Rummans TA, Davis LJ, Morse RM. Learning and memory impairment in older, detoxified diazepine-dependent patients. Mayo Clin Proc 1993; 68: 731–7
Nikaido AM, Ellinworth Jr EH, Heatherly DG, et al. Differential CNS effects of diazepam in elderly adults. Pharmacol Biochem Behav 1987; 27: 273–81
Swift CG, Ewen JM, Clarke P. Responsiveness to oral diazepam in the elderly: relationship to total and free plasma concentrations. Br J Clin Pharmacol 1985; 29: 111–8
Cutson TM, Gray SL, Hughes MA. Effect of a single dose of diazepam on balance measures in older people. J Am Geriatr Soc 1997; 43: 435–40
Larson EB, Kukull WA, Buchner D, et al. Adverse drug reactions associated with global cognitive impairment in elderly persons. Ann Intern Med 1987; 107: 169–73
Ray WA, Griffin MR, Schaffner W, et al. Psychotropic drug use and the risk of hip fractures. N Engl J Med 1987; 316: 363–9
Ray WA, Griffin MR, Downey W. Benzodiazepines of long and short elimination half life and the risk of hip fracture. JAMA 1989; 262: 3303–7
Neutel CI, Hirdes JP, Maxwell CJ. New evidence on benzo-diazepine use and falls: the time factor. Age Aging 1996; 25: 273–8
Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. N Engl J Med 1988; 319(26): 1701–7
Hering RMC, Stricker BH, Deboer A, et al. Benzodiazepines and the risk of falling leading to femur fractures. Arch Intern Med 1995; 155: 1801–7
Ray WA, Fought RL, Decker MD. Psychoactive drugs and the risk of injurious motor vehicle crashes in elderly drivers. Am J Epidemiol 1992; 136: 873–83
Barbone F, McMahon AD, Davey PG, et al. Association of road-traffic accidents with benzodiazepine use. Lancet 1998; 352(9137): 1331–6
Zisselman MH, Rovner BW, Yuen EJ, et al. Sedative-hypnotic use and increased hospital stay and costs in older people. J Am Geriatr Soc 1996; 44: 1371–4
Kripke DF, Simons RN, Garfinkel L, et al. Short and long sleep and sleeping pills. Is increased mortality associated? Arch Gen Psychiatry 1979; 36: 103–16
Ried LD, Johnson RE, Gettman DA. Benzodiazepine exposure and functional status in older people. J Am Geriatr Soc 1998; 46(1): 71–6
Ashton M. Guidelines for the rational use of benzodiazepines. Drugs 1994; 48: 25–40
Petursson H, Lader MH. Benzodiazepine dependence. Br J Addict 1981; 76: 133–45
Woods JM, Katz JL, Winger G. Abuse liability of benzodiazepines. Pharmacol Rev 1987; 39: 251–419
Woods JH, Katz JL, Winger G. Benzodiazepines: use, abuse and consequences. Pharmacol Rev 1992; 44: 151–347
Tyrer P. Withdrawal from hypnotic drugs. BMJ 1993; 306: 706–8
Lader MH, Petursson H. Benzodiazepine derivatives — side-effects and dangers. Biol Psychiatry 1981; 16: 1195–201
Schweizer E, Case G, Rickeis K. Benzodiazepine dependence and withdrawal in elderly patients. Am J Psychiatry 1989; 146: 529–31
Ashton H. Benzodiazepine withdrawal: outcome in 50 patients. Br J Addict 1987; 82: 665–71
Kerr JS, Dawe RA, Parkin C, et al. Zopiclone in elderly patients: efficacy and safety. Hum Psychopharmacol 1995; 10: 221–9
Noble S, Langtry HD, Lamb HM. Zopiclone: an update of its pharmacology, clinical efficacy and tolerability in the treatment of insomnia. Drugs 1988: 55: 277–302
Inman W, Kubota K, Pearce G, et al. PEM Report Number 10. Zopiclone. Pharmacoepidemiol Drug Saf 1993; 2: 499–521
Brynes JJ, Greenblatt DJ, Miller LG. Benzodiazepine receptor binding of nonbenzodiazepines in vitro: alpidem, zolpidem and zopiclone. Brain Res Bull 1992; 29: 905–8
Berlin I, Warot D, Hergueta T et al. Comparison of the effects of zolpidem and triazolam on memory functions, psychomotor performances, and postural sway in healthy subject. J Clin Psychopharm 1993; 13: 100–6
Roehrs T, Merlotti L, Zorick F, et al. Sedative, memory and performance effects of hypnotics. Psychopharmacology 1994; 116: 130–4
Rush CR, Griffiths RR. Zolpidem, triazolam and temazepam: behavioural and subject — rated effects in normal volunteers. J Clin Psychopharm 1996; 16: 146–59
Mintzer M, Frey JM, Yingling JE, et al. Triazolam and zolpidem: a comparison of their psychomotor, cognitive and subjective effects in healthy volunteers. Behav Pharmacol 1997; 8: 561–74
Hoehns JD, Perry PJ. Zolpidem: a nonbenzodiazepine hypnotic for treatment of insomnia. Clin Pharm 1993; 12: 814–28
Langtry HD, Benfield P. Zolpidem: a review of its pharmaco-dynamic and pharmacokinetic properties and therapeutic potential. Drugs 1990; 40: 291–313
Kummer J, Guendel L, Linden J, et al. Long-term polysom-nographic study of the efficacy and safety of zolpidem in elderly psychiatric inpatients with insomnia. J Int Med Res 1993; 21: 171–84
Mattila M, Seppala T, Mattila MJ. Combined effects of buspirone and diazepam on objective and subjective tests of performance in healthy volunteers. Clin Pharmacol Ther 1986; 40: 620–6
Greenblatt DJ, Harmatz JS, Gouthro T, et al. Distinguishing a benzodiazepine agonist (triazolam) from a monagonist anxiolytic (buspirone) by electroencephalography: kinetic — dynamic studies. Clin Pharmacol Ther 1994; 56: 100–11
Lader M. Can buspirone induce rebound, dependence or abuse? Br J Psychiatry 1991; 159 Suppl. 12: 45–51
Goa KL, Ward A. Buspirone: a preliminary review of its pharmacological properties and therapeutic efficacy as an anxiolytic. Drugs 1986; 32: 114–29
Arendt J. Melatonin. Clin Endocrinol 1988; 29: 205–29
Caranasos GC. Sleep disorders. In: Ham R, editor. Geriatric medicine annual. Bradell: NJ Medical Economics, 1987:135–59
Woodward MC. The management of insomnia in older people. Aust J Hosp Pharm 1996; 26: 462–5
Mellinger GD, Balten MB, Uhlentruth EH. Insomnia and its treatment. Arch Gen Psychiatry 1985; 42: 225–32
Weyerer A, Dilling M. Prevalence and treatment of insomnia in the community: results from the Upper Bavarian Field Study. Sleep 1991; 14: 392–8
McDowell JA, Mion LC, Lydon TJ, et al. A nonpharmacological sleep protocol for hospitalized older patients. J Am Geriatr Soc 1998; 46(6): 700–5
Campbell SS, Dawson D, Anderson MW. Alleviation of sleep maintenance insomnia with timed exposure to bright light. J Am Geriatr Soc 1993; 41: 829–36
Haimov I, Laudon M, Zisapel N, et al. Sleep disorders and melatonin rhythms in elderly people [research report]. BMJ 1994; 309(6948): 167
Weiss KJ. Optimal management of anxiety in older patients. Drugs Aging 1996; 9: 191–201
Shader RI, Greenblatt MD. Use of benzodiazepines in anxiety disorders. N Engl J Med 1993; 328: 1398–405
Anon. Zopiclone: an acceptable alternative to benzodiazepines. Drug Ther Perspect 1993; 2: 4-6
Divoll M, Greenblatt DJ, Harmatz JS, et al. Effects of age and gender disposition on temazepam. J Pharmacol Sci 1981; 70: 104–7
Smith RB, Divoli M, Gillespe WR, et al. Effects of subject age on the pharmacokinetics of oral triazolam and temazepam. J Clin Psychopharmacol 1983; 3: 172–6
Greenblatt DJ, Harmatz JS, Engelhardt N, et al. Pharmacokinetic determinants of dynamic differences among three benzodiazepine hypnotics. Arch Gen Psych 1989; 46: 326–32
Kales A, Soldates CR, Bixler EO, et al. Early morning insomnia with rapidly eliminated benzodiazepines. Science 1983; 220: 95–7
Kales A, Manfredi RL, Vgontzas AN, et al. Rebound insomnia after only brief and intermittent use of rapidly eliminated benzodiazepines. Clin Pharmacol Ther 1991; 46: 468–76
Patterson JE. Triazolam syndrome in the elderly. South Med J 1987; 80: 1425–6
Cowley G, Springer K, Iarovici D, et al. Sweet dreams or nightmares? Newsweek 1991; August: 44
Greenblatt DJ, Harmatz JS, Shapiro L, et al. Sensitivity to triazolam in the elderly. N Engl J Med 1991; 324: 1691–8
Jonas JM. Idiosyncratic side effects of short half-life benzodiazepine hypnotics: fact or fancy? Hum Psychopharmacol 1992; 7: 205–16
Mamelek M, Csima A, Buck L, et al. A comparative study on the effects of brotizolam and flurazepam on sleep and performance in the elderly. J Clin Psychopharmacol 1989; 9: 260–7
Kales A, Soldatos CR, Bixler EO. Diazepam effects on sleep and withdrawal phenomenon. J Clin Psychopharmacol 1988; 8: 340–6
Lemoine P, Allain H, Janus C, et al. Gradual withdrawal of zopiclone (7.5mg) and zolpidem (10mg) in insomniacs treated for at least three months. Eur Psychiatry 1995; 10 Suppl. 3: 161–5
Carskadon MA, Seidel WF, Greenblatt DJ, et al. Daytime carryover of triazolam and flurazepam in elderly insomniacs. Sleep 1982; 5: 361–71
Grad RM. Benzodiazepines for insomnia in community-dwelling elderly: a review of benefit and risk. J Fam Pract 1995; 41: 473–81
Hollister LE, Müller-Oerlinghausen B, Rickeis K, et al. Clinical Uses of Benzodiazepines. J Clin Psychopharmacol 1993; 13 Suppl. 1: 1S–169S
Agnoli A, Manna V, Martucci N. Double-blind study on the hypnotic and antianxiety effects of zopiclone compared with nitrazepam in the treatment of insomnia. Int J Clin Pharmacol Res 1989; 9: 277–81
Committee on the reviews of Medicines. Systematic review of the benzodiazepines. BMJ 1980; 1: 910–2
Ankier SI, Goa KL. Quazepam: a preliminary review of its pharmacodynamic and pharmacokinetic properties, and therapeutic efficacy in insomnia. Drugs 1980; 35(1): 42–62
Agnini E, Parravicini L, Bamonte F, et al. Pharmacological studies with quazepam, a new benzodiazepine hypnotic. Arzneimittelforschung 1982; 32: 1456–9
Barnett A, Iorio LC, Ongini E. The sedative-hypnotic properties of quazepam, a new hypnotic agent. Arzneimittelforschung 1982; 32: 1452–5
Garfinkel D, Laudon M, Nof D, et al. Improvement of sleep quality in elderly people by controlled-release melatonin. Lancet 1995; 346: 541–4
Haimov I, Lavie P. Potential of melatonin replacement therapy in older patients with sleep disorders. Drugs Aging 1995; 7: 75–8
Schlich D, L’Heritier C, Coquelin JP. Long-term treatment of insomnia with zolpidem: a multicentre general practitioner study of 107 patients. J Int Med Res 1991; 19: 271–9
Kales A, Bixler EO, Kales JD, et al. Comparative effectiveness of nine hypnotic drugs: sleep laboratory studies. J Clin Pharmacol 1977: 17: 207–13
Balter MB, Uhlenhuth EH. The beneficial and adverse effects of hypnotics. J Clin Psychol 1991; 52: 16–23
Hecker R, Burr M, Newbury G. Risk of benzodiazepine dependence resulting from hospital admission. Drug Alcohol Rev 1992; 11: 131–5
Shorr RI, Bauwens S, Landefeld CS. Failure to limit quantities of benzodiazepine hypnotic drugs for outpatients: placing the elderly at risk. Am J Med 1990; 89: 725–31
Woodward MC. Drug prescribing for older people — can we get it right [commentary]? Aust J Ageing 1994; 13: 27
Woodward MC. (Convenor of expert panel). Medication and the older person. National Health and Medical Research Council. Series of clinical management in the elderly. No. 7. Canberra, Australia: Australian Government Printing Service, 1994
Gilbert A, Innes JM, Owen N, et al. Trial of an intervention to reduce chronic benzodiazepine use among residents of aged-care accommodation. Aust NZ J Med 1993; 23: 343–7
Griffith DNW, Robinson M. Prescribing practice and policy for hypnotics: a model of pharmacy audit. Age Aging 1996; 25: 490–2
Batty GM, Oborne CA, Swift CG. Reduction in inappropriate prescribing of benzodiazepines by verbal multidisciplinary intervention [abstract P274]. J Am Geriat Soc 1997; 45: S80
Weintraub M, Singh S, Byrne L, et al. Consequences of the 1989 New York State triplicate benzodiazepine prescription regulations. JAMA 1991; 266: 2392–7
Shader RI, Greenblatt DJ, Balter MB. Appropriate use and regulatory control of benzodiazepine. J Clin Pharmacol 1991; 31: 781–4
Stoppe G, Sandwlzer H, Staedt J, et al. Sleep disturbances in the demented elderly: treatment in ambulatory care. Sleep 1995; 18: 844–8
Shelton PS, Hocking LB. Zolpidem for dementia-related insomnia and night-time wandering. Ann Pharmacother 1997; 31: 319–22
Murciano P, Armengaud MH, Cramer PH, et al. Acute effects of zolpidem, triazolam and flunitrazepam on arterial blood gases and control of breathing in severe COPD. Eur Respir J 1993; 6: 625–9
Camacho ME, Morin CM. The effect of temazepam on respiration in elderly insomniacs with mild sleep apnoea. Sleep 1995; 18: 644–5
Schnelle JF, Ouslander JG, Simmons F, et al. Night-time sleep and bed mobility among incontinent nursing home residents. J Am Geriatr Soc 1993; 41: 903–9
Woo E, Proulx SM, Greenblatt DJ. Differential side-effect profile of triazolam versus flurazepam in elderly patients undergoing rehabilitation therapy. J Clin Pharmacol 1991; 31: 168–73
Salzman C, editor. Clinical geriatric psychopharmacology. 3rd ed. Baltimore: Williams and Wilkins, 1998
Nelson JC, editor. Geriatric psychopharmacology. New York: Marcel Dekker, 1998
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Woodward, M. Hypnosedatives in the Elderly. Mol Diag Ther 11, 263–279 (1999). https://doi.org/10.2165/00023210-199911040-00003
Published:
Issue Date:
DOI: https://doi.org/10.2165/00023210-199911040-00003