Prescribed Hypnotic Medications, Not Insomnia Diagnosis, Cause Increased Risk for Serious Falls

Author(s):

Findings showed that, although risk for serious fall injury was not mitigated by insomnia diagnosis, individuals with active insomnia taking prescribed hypnotic medication may be a particularly high-risk subgroup.

S. Justin Thomas, PhD

Using data from the REGARDS study (REasons for Geographic And Racial Differences in Stroke), recently published findings showed a higher incidence of participants taking vs not taking a prescribed hypnotic medication regardless of whether they had an insomnia diagnosis. Notably, the combination of insomnia diagnosis and use of a hypnotic medication accounted for the highest cumulative incidence of serious fall injury.¹

Lead author S. Justin Thomas, PhD, assistant professor, University of Alabama at Birmingham, and colleagues concluded that “these results suggest behavioral interventions for insomnia may be preferred over prescribed hypnotic medications in the treatment of insomnia among older adults and underscore the importance of including the risk for serious fall injuries when considering pharmacological treatment." They also added that, "decreased use or cessation of prescribed hypnotic medications may be an appropriate strategy for reducing fall risk among older adults with and without an insomnia diagnosis."¹

Among a cohort of 9087 individuals aged 65 years or older, 1660 (18.3%) participants had a serious fall injury over a median of 6.8 years. The incidence of a serious fall injury was highest among those with both insomnia and on hypnotics (+insomnia/+hypnotics), with 46.6 per 1000 person-years (PY; 95% CI, 26.7-66.5), followed by those without insomnia and on hypnotics, with 32.6 per 1000 PY (95% CI 28.2-37.0); those with insomnia without hypnotics, with 28.8 per 1000 PY (95% CI, 18.6-38.9); and those without insomnia nor on hypnotics, with 24.8 per 1000 PY (95% CI, 23.5-26.1).

The reference group, those without insomnia or on hypnotics, had a lower risk for serious fall injury relative to all other groups after initial adjustment for age, sex, race, geographic region of residence, education, household income, and current cigarette smoking. After further adjustment for medication use and comorbidities, the hazard ratio (HR) for a serious fall injury was 1.11 (95% CI, 0.75, 1.64), 1.23 (95% CI, 1.05, 1.45), and 1.33 (95% CI, 0.77, 2.30) among participants in the +insomnia/–hypnotics (n = 151), –insomnia/+hypnotics (n = 983), and +insomnia/+hypnotics (n = 80) groups, respectively, compared with their counterparts in the reference group (n = 7873).

Overall, those with a diagnosis of insomnia had a higher incidence for a serious fall injury (34.0 per 1000 PY; 95% CI, 24.8-43.3) than those without (25.6 per 1000 PY; 95% CI, 24.4-26.9); however, a multivariable adjustment revealed no evidence of an association between an insomnia diagnosis and serious fall injury. Additionally, those taking a prescribed hypnotic medication had a higher incidence rate for a serious fall injury (35.5 per 1000 PY; 95% CI, 29.2-37.8) than those not taking a prescribed hypnotic medication (24.9 per 1000 PY; 95% CI, 23.6-26.2).

For those diagnosed with insomnia also receiving hypnotics, the most used medications included benzodiazepines (57.5%), zolpidem (31.3%), and temazepam (12.5%). When removing diagnosis of insomnia, benzodiazepines (56.5%) remained the most common prescribed hypnotic medications, however, amitriptyline (19.3%) was the second most, followed by zolpidem (12.1%).

Although this study did not find an association between insomnia diagnosis and serious fall injuries, previous studies have reported differently. In a 2005 study of 34,163 nursing home residents, hypnotic use did not predict falls (adjusted odds ratio [aOR], 1.13; 95% CI, 0.98-1.30) while insomnia did predict future falls (aOR, 1.52; 95% CI, 1.38-1.66).² "This discrepancy may be due to previous studies not accounting for hypnotic medication use or the participants had a greater severity of insomnia or levels of frailty that may have also contributed to fall risk," Thomas et al wrote.¹

REFERENCES
1. Thomas SJ, Sakhuja S, Colantonio LD, et al. Insomnia diagnosis, prescribed hypnotic medication use, and risk for serious fall injuries in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study. SLEEP. 2022;45(5). doi:10.1093/sleep/zsac063
2. Avidan AY, Fries BE, James ML, Szafara KL, Wright GT, Chervin RD. Insomnia and hypnotic use, recorded in the minimum data set, as predictors of falls and hip fractures in Michigan nursing homes. J Am Geriatr Soc. 2005;53(6):955-62. doi:10.1111/j.1532-5415.2005.53304.x