Risk and Benefit Assessment of Hypnotic Agents for Sleep Disorders Among Elderly

Study Overview
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Brief Summary
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The aims of this study are to (1) examine the medication use patterns of commonly prescribed hypnotics and the factors that were associated with the long-term and short-term use patterns among the elderly population in Taiwan; (2)investigate the associations of using hypnotics with the elderly patients' disease statuses, efficacy and safety, as well as its pharmacokinetic and pharmacogenetic characteristics;(3) determine the clinical, economic and humanistic outcomes of using hypnotics and the corresponding contributing factors for the elderly in Taiwan.

Detailed Description
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Aging is associated with the changes in the sleep structure, continuity, and timing while it also affects the elderly's physiological and psychological health statuses. Despite the fact that hypnotics are beneficial for the short-term management of insomnia, it is inconclusive about the risk and benefit ratios of long-term use for the elderly. The objectives of this study are to (1)examine the medication use patterns of prescribed hypnotics and the factors that were associated with the use patterns among the elderly population; (2)investigate the associations of using prescribed hypnotics with the elderly patients' disease statuses, efficacy and safety, as well as their pharmacokinetic and pharmacogenetic characteristics;(3)determine the clinical, economic and humanistic outcomes and corresponding factors of using hypnotics for long-term and short-term use in Taiwanese elderly. This proposed study is the second part of a larger project that consists of two main phases across four years. The first part will include a retrospective database analysis to examine the medication use patterns for sleep disorders and corresponding outcomes using three data sets. Elderly patients aged 65 or older and who received hypnotics for insomnia will be selected from Taiwan's National Health Insurance Research Database, National Health Interview Survey and China Medical University Hospital (CMUH) in-house databases. Focus will be placed on benzodiazepines (BZD) and BZD-receptor specific non-BZD agents (Z-drugs), but Chinese traditional medication used for insomnia will also be examined. This study is the second part of the larger project. The investigators will conduct a longitudinal, prospective, observational cohort study over a period of two years. The focus of this study is the use of hypnotic BZD and Z-drugs on elderly insomnia patients. The study cohorts include elderly patients, aged 65 years or older, who have received services in the outpatient departments of China Medical University Hospital, Taichung, Taiwan, and who have been prescribed with a selected BZD or Z-drug for insomnia for at least one week. A control group cohort will also be recruited. Each recruited patient will be monitored and evaluated periodically for at least one year. Economic, clinical, and humanistic outcomes, as well as adherence to the hypnotics will be assessed and monitored. Safety and tolerability will be assessed by occurrence of adverse drug reactions. Pharmacokinetic properties and genotyping patterns will be also be evaluated using snapshot blood sampling after the 6th month of enrollment in the study. The clinical and humanistic outcomes measures will include changes in insomnia status, functional status changes, depression status, as well as over-all well-being using EuroQol 5D. Economic evaluation will compare total insurance and out-of-pocket expenses at baseline and at 12 months follow up.

Official Title
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Risk and Benefit Assessment of Hypnotic Agents for Sleep Disorders Among Elderly; A Prospective Cohort Study at a Taiwanese Academic Medical Center

Conditions
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Sleep Disorders

Intervention / Treatment
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* Drug: Exposure to sedative-hypnotic drugs


Participation Criteria
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Eligibility Criteria
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Inclusion criteria Patients who have received services in the outpatient departments in CMUH for at least six months persistently before the recruitment, who are diagnosed with any types of sleep disorders within the outpatient medical records, using ICD-9 codes to identify. who have been prescribed, for at least one week before the index date of observation, with one of the selected BZD or Z-drugs: estazolam, lorazepam, diazepam, alprazolam, flunitrazepam, zolpidem or zopiclone. who agree to participate in this observation study and have signed informed consent Exclusion criteria Those elderly patients who were diagnosed with cancers, seizures, specific psychiatric disorders (e.g., dementia, schizophrenia, panic disorder, alcohol withdrawal syndrome) and neurological disorders (e.g., Parkinson) in the baseline and during observation period

Ages Eligible for Study
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Minimum Age: 65 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Estazolam<br>Exposure to sedative-hypnotic drugs; Patients who have taken estazolam for at least one week before the first date of enrollment | Drug: Exposure to sedative-hypnotic drugs<br>* These patients will have been prescribed a sedative-hypnotic drug for at least one week prior to enrollment.<br>* Other names: Medication Exposure;|
| Lorazepam<br>Exposure to sedative-hypnotic drugs; Patients who have taken lorazepam for at least one week before the first date of enrollment | Drug: Exposure to sedative-hypnotic drugs<br>* These patients will have been prescribed a sedative-hypnotic drug for at least one week prior to enrollment.<br>* Other names: Medication Exposure;|
| Diazepam<br>Exposure to sedative-hypnotic drugs; Patients who have taken Diazepam for at least one week before the first date of enrollment | Drug: Exposure to sedative-hypnotic drugs<br>* These patients will have been prescribed a sedative-hypnotic drug for at least one week prior to enrollment.<br>* Other names: Medication Exposure;|
| Alprazolam<br>Exposure to sedative-hypnotic drugs; Patients who have taken Alprazolam for at least one week before the first date of enrollment | Drug: Exposure to sedative-hypnotic drugs<br>* These patients will have been prescribed a sedative-hypnotic drug for at least one week prior to enrollment.<br>* Other names: Medication Exposure;|
| Flunitrazepam<br>Exposure to sedative-hypnotic drugs; Patients who have taken Flunitrazepam for at least one week before the first date of enrollment | Drug: Exposure to sedative-hypnotic drugs<br>* These patients will have been prescribed a sedative-hypnotic drug for at least one week prior to enrollment.<br>* Other names: Medication Exposure;|
| Zolpidem<br>Exposure to sedative-hypnotic drugs; Patients who have taken Zolpidem for at least one week before the first date of enrollment | Drug: Exposure to sedative-hypnotic drugs<br>* These patients will have been prescribed a sedative-hypnotic drug for at least one week prior to enrollment.<br>* Other names: Medication Exposure;|
| Zopiclone<br>Exposure to sedative-hypnotic drugs; Patients who have taken Zopiclone for at least one week before the first date of enrollment | Drug: Exposure to sedative-hypnotic drugs<br>* These patients will have been prescribed a sedative-hypnotic drug for at least one week prior to enrollment.<br>* Other names: Medication Exposure;|
| Control Group<br>Patients not taking any of the included or any other anxiety-hypnotic agents | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Changes from baseline in sleep quality at 12 months | Clinical outcome, measured by a Chinese version of the Pittsburgh Sleep Quality Index | after 12 months of enrollment | 
| Number of participants with an occurrence of associated ADR | Safety and tolerably, as measured by patients that experience falls, hip/limb fracture, cognitive impairment, etc. during the 12 months of enrollment | after 12 months of enrollment | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Snapshot measurement of plasma drug and drug metabolite concentrations | Pharmacokinetic evaluation by determining the levels of drug and metabolite in the patients plasma after established use | after 6 months of enrollment | 
| Snapshot measurement of urine drug and metabolite concentrations | Pharmacokinetic evaluation by determining the levels of drug and metabolite in the patients plasma after established use -- and clearance after the sixth-month recruitments. | after 6 months of enrollment | 
| Calculation of drug clearance using snapshot plasma and urine concentrations | Pharmacokinetic evaluation by determining the patient's clearance of the drug after established use | after 6 months of enrollment | 
| Proportion of patients with CYP3A5 mutations | Pharmacogenetic evaluation and and genotyping of CYP3A5 enzyme for all enrolled patients with consent | after 6 months of enrollment | 
| Changes from baseline in sleep quality at 6 months | Clinical outcome, measured by a Chinese version of the Pittsburgh Sleep Quality Index | after 6 months of enrollment | 
| Changes from baseline in Barthel Index at 6 months | Clinical outcome, as a measure of independence, measured by Barthel Index | after 6 months of enrollment | 
| Changes from baseline in Barthel Index at 12 months | Clinical outcome, as a measure of independence, measured by Barthel Index | after 12 months of enrollment | 
| Changes from baseline in IADL at 6 months | Clinical outcome, as a measure of functional ability, measured by Instrumental Activities of Daily Living | after 6 months of enrollment | 
| Changes from baseline in IADL at 12 months | Clinical outcome, as a measure of functional ability, measured by Instrumental Activities of Daily Living | after 12 months of enrollment | 
| Changes from baseline in EQ-5D-5L & EQ-5D-VAS at 6 months | Changes in humanistic variables, as measured by the EuroQol 5D tool | after 6 months of enrollment | 
| Changes from baseline in EQ-5D-5L & EQ-5D-VAS at 12 months | Changes in humanistic variables, as measured by the EuroQol 5D tool | after 12 months of enrollment | 
| Changes from baseline in MMAS-8 after 6 months | Changes in medication adherence, as measured by the Morisky Medication Adherence | after 6 months of enrollment | 
| Changes from baseline in MMAS-8 after 12 months | Changes in medication adherence, as measured by the Morisky Medication Adherence | after 12 months of enrollment | 
| Change from baseline in economic healthcare costs using NHI and out-of-pocket expenses at 12months | NHI covered costs for inpatient and outpatient care taken from NHI data for the twelve months prior to enrollment, compared to the 12 months during enrollment. Added with patients' out of pocket expenses on health care. | At 12 months after enrollment | 
| Changes from baseline in insomnia at 6 months | Clinical outcome, measured by a Chinese version of the Athens Insomnia Scale | After 6 months of enrollment | 
| Changes from baseline in insomnia at 12 months | Clinical outcome, measured by a Chinese version of the Athens Insomnia Scale | After 12 months of enrollment | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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hypnotic agents, sleep disorders, elderly