Abstract & Commentary
Comment by Barbara A. Phillips, MD, FACP, Professor of Medicine, University of Kentucky, Director, Sleep Disorders Center, Samaritan Hospital, Lexington, KY, and Associate Editor of Internal Medicine Alert.
Synopsis: Insomnia is associated with an increased risk of falls in nursing home residents. The use of hypnotics is not.
Source: Avidan AY, et al. J Am Geriatr Soc. 2005. doi:10.1111/j.1532-5415.2005.53304.x (epub).
Avidan and colleagues used data from the Long-Term Care Facility Resident Assessment Instrument forms. Completion of these forms is required of all nursing homes in Michigan that receive federal funding. These forms contain 350 items on demographics and health status, and are completed at least annually. The study sample was 34,163 nursing home residents whose mean age was 84 years; 76% were women. The primary outcome measures were reports of any fall or hip fracture over a 6 month follow-up period. Because of the detail included in the assessment form, Avidan et al were able to control for functional status—activities of daily living, cognitive status, intensity of resource utilization, proximity to death (if applicable!), illness burden, vision impairment, number of medications, emergency room visits, age, and gender.
An astonishing 43% of participants were reported to fall over a 6-month period, and 2.5% sustained a hip fracture. Only 5.5% of subjects reported moderate insomnia (1-5 nights a week), and 0.81% reported severe insomnia (> 6 nights a week). Hypnotic use was reported for 2.6% of subjects, and was strongly associated with reported insomnia. Increasing age, unsteady balance, use of more medications, recent changes in health status, need for ER visits, and increased health care burden all increased the risk of falls or hip fracture over a 6-month period. Interesting relationships emerged between fall risk and impairment. For example, when impairment became severe, fall risk was reduced, probably because the subjects became bedridden at that point. Similarly, visual problems increased the risk of falls only for those residents who were capable of independent locomotion.
With regard to falls, insomnia, but not hypnotic use, predicted a 6-month risk after controlling for confounders; there was a dose-response relationship, with a 47% increase in fall risk for those who reported moderate insomnia and an 86% increase in fall risk for those with severe insomnia. Those who took hypnotics but did not report insomnia (had treated insomnia?) did not have an increased risk of falls. With regard to hip fractures, neither insomnia, hypnotic use, nor insomnia plus hypnotic use predicted an increased risk of fractures after controlling for confounders. Reported falls were a robust predictor of subsequent hip fracture (P < 0.001).
Comment
This paper is important because of the frequency and importance of falls in nursing home residents (and the elderly in general). Avidan et al found that nearly half of nursing home residents fell during a 6-month period; more than one third of adults older than age 65 fall each year.1 One in 100 falls causes a hip fracture, which begins a downward spiral of reduced mobility, increased dependence, increased risk of death and mind boggling cost; estimated annual cost of falls in older persons is $2 billion.2
Avidan et al challenge the time-honored belief that hypnotics cause an increase risk of falls in nursing home residents. Their careful analysis, controlling for variables in a way that few other studies have been able to do, shows that insomnia, but not hypnotics, is a risk factor for falls. Further, neither insomnia nor use of hypnotics was a risk factor for hip fracture in this large, carefully done analysis. The data actually support the notion that hypnotic use had a protective effect, since those participants who took hypnotics, but did not have insomnia, did not have an increased risk of falls, suggesting that treatment of insomnia not only relieves the insomnia but also reduces the fall risk associated with it. Avidan et al speculate that hypnotics, by keeping patients asleep instead of wandering, protect them from falling.
This paper has already received a far amount of attention in the lay press. The first author, Dr. Avidan, says, "Many physicians assume that when an older patient has insomnia and is given a hypnotic drug to help induce sleep, the drug will make the patient likely to fall and develop a hip fracture. But our findings suggest that people whose insomnia is effectively treated are less likely to fall than untreated insomniacs."
The senior author, Dr. Ron Chervin, pointed out, "One study by itself isn’t enough to eliminate current concerns about hypnotics and falls, but many previous studies that raised these concerns did not look to see whether insomnia, rather than the drugs themselves, might be the problem. Our results should encourage older people and their caregivers to pay attention to insomnia, and to seek help for it."
Of note, in response to my e-mail query, both of these authors stated that neither they nor this study were funded by industry.
What does this mean for the practitioner? It may be time to rethink the notion that hypnotics are risky for geriatric patients. This is particularly true since newer, safer hypnotics (the Z drugs) have become more widely used since this data was collected and analyzed. Now, insomnia treatment is not only a quality of life issue, but perhaps a safety issue as well.
References
1. Hausdorff JM, et al. Arch Phys Med Rehabil. 2001;82: 1050-1056.
2. National Center for Injury Prevention and Control. Falls and Hip Fractures Among Older Adults (online). www.cdc.gov/ncipc/factsheets/falls.htm. Accessed 05/05/05.
Insomnia is associated with an increased risk of falls in nursing home residents. The use of hypnotics is not.
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