Evidence‐Based Recommendations for the Assessment and Management of Sleep Disorders in Older Persons (2009)

To the Editor: The May 2009 supplement to the Journal of the American Geriatrics Society on sleep disorders1 improves on the prior sleep supplement2 in one important way; the current authors pose as their first question for future research, “Does improving insomnia in older adults result in improvements in daytime functioning?”1 The prior authors claimed, in response to a question, “There have been a number of studies in which medication treatment of insomnia has led to improvements in daytime function.”3 In my view, this is a critical improvement. The primary benefit of sleeping pills is to render the patient unconscious for an interval that patient and physician deem suitable. Despite many promotional claims and suggestions to the contrary, there is no serious evidence to show that patients function better (e.g., vigilance, alertness, problem solving) the day after getting “a good night's sleep” with a pill. The current supplement falls short in some important areas. The authors somehow fail to emphasize that, with one exception, the Food and Drug Administration has approved sleeping pills for short-term use only. Their summary of an important meta-analysis4 lists the benefits and downplays the side effects of sedative–hypnotics. In contrast, the meta-analysis refers to the size of the benefits as “small,” citing, as a representative example, a score of 3.7 for the treatment group and 3.8 for the placebo group (lower scores being better) on a 7-point sleep-quality scale (nothing about function); this is statistically significant but meaningless. The analysis considers the risk of adverse events as “potentially clinically relevant”; the odds ratio with treatment for adverse cognitive effect (a functional outcome), for example, was 4.8. Table 3 claims that “Nonbenzodiazepines and melatonin receptor agonists are the safest and most efficacious hypnotic drugs currently available.” Britain's National Institute of Clinical Excellence says this: “It is recommended that, because of the lack of compelling evidence to distinguish between zaleplon, zolpidem, zopiclone or the shorter acting benzodiazepine hypnotics, the drug with the lowest purchase cost (taking into account daily required dose and product price per dose) should be prescribed.”5 Table 4 states that “The older sedative-hypnotics should not be prescribed for patients with confirmed OSA [obstructive sleep apnea], and patients should be advised to avoid drinking alcohol within 2 hours of bedtime.” Here is something delicately unspoken; might there be newer hypnotic drugs that should be prescribed for OSA? Sleep is fascinating, poorly understood, and dearly beloved. The adverse effects of sleeping pills are significant, and their legitimate clinical role would not be profitable enough to support their concerted promotion by industry through direct-to-consumer advertising, industry-sponsored research, and supplements such as these. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the author and has determined that the author has no financial or any other kind of personal conflicts with this letter. Author Contributions: The author is the sole contributor to this letter. Sponsor's Role: None.