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Sleep pattern and predictors of daily versus as-needed hypnotics use in middle-aged and older adults with insomnia

Sleep pattern and predictors of daily versus as-needed hypnotics use in middle-aged and older... Introduction: This study aims to examine the sleep pattern and predictors of daily vs. as-needed use of hypnotics in middle-aged and older adults with insomnia. Methods: Patients aged 50–75 who use hypnotics for insomnia were identified via electronic medical records and were recruited. Data about sociodemographics, mood and cognitive screening measures, and questions related to sleep patterns were collected through an interview conducted over the phone. Results: A sample of 66 participants was recruited, of which 69.7% were females. Three quarters (49/66, 74.2%) used hypnotics daily, with 43% (21/49) of daily hypnotics users sleeping more than 8 h per night. Two-fifths (26/66, 39.4%) of participants still had clinically significant insomnia even after taking hypnotics. After adjusting for age, years of hypnotics use, sleeping hours per night, PHQ-2 score, and frequency of pain at night, the logistic regression model showed that younger age (p = 0.023) and longer sleeping hours per night (p = 0.025) were significantly associated with daily hypnotics use when compared to as needed hypnotics use. Conclusion: Many hypnotic users still have clinically significant insomnia and poor quality of sleep as reflected by perceived longer sleep duration and more daytime napping which could be related to drug-related residual seda- tion. Hypnotic use may not be the best solution for insomnia treatment in an older population, and physicians should regularly reassess the use of hypnotics. Introduction symptoms: at least 3 months, associated with dissatisfac- Insomnia symptoms are common in older adults. These tion with sleep and daytime consequences) [1, 2]. symptoms are termed sleep disturbance when they Estimates of the prevalence of insomnia are variable in result into daytime consequences or patient dissatisfac- the literature because of inconsistency in definitions used tion, impacting the quality of life [1]. Insomnia disorder and limitations in accurately estimating incidence and is diagnosed when insomnia symptoms of a patient with remission rate of insomnia [3]. The prevalence of insom - sleep disturbance meet the Diagnostic and Statistical nia, in older adults, is estimated to be between 13 and Manual of Mental Disorders Criteria of Insomnia (Fre- 47% [3]. The high prevalence of insomnia in older adults quency of symptoms: 3 or more nights/week, Duration of can be explained by sleep pattern changes that occur with age. As people age, their total sleep time (TST) decreases [4, 5], their sleep efficiency worsens, and they wake up *Correspondence: ga62@aub.edu.lb more frequently than younger people [4, 6, 7]. Due to Department of Family Medicine, American University of Beirut Medical Center, Hamra, Beirut, Lebanon physiological changes that occur with age, older adults Full list of author information is available at the end of the article © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Tanielian et al. BMC Primary Care (2022) 23:98 Page 2 of 8 require less sleep time at night than younger adults. comorbid psychiatric disorders [23, 24], no articles to our According to the National Sleep Foundation’s sleep time knowledge studied the predictors of daily vs. as-needed duration recommendations, sleeping 7–9 h per night for use of hypnotics on sleep patterns. However since age adults and 7–8 h per night for older adults is appropriate [1–3], depressed mood [25, 26], and pain [25] are highly [8]. It has been shown that both short or long sleep dura- associated with insomnia in the literature, it could also be tion (≤6 or ≥ 9 h per night) could have negative possible that these factors might predict the frequency health outcome [9–11]. In a systematic review with meta- of use of hypnotics for insomnia (Daily vs As needed). analysis sleep duration (both short and long) was associ- In addition length of time the hypnotic pill used (extent ated with all-cause mortality [12]. of its chronicity) and the length of sleeping time at night Treating insomnia in older adults is a clinical challenge. (Effected by hypnotic use) [27] might also predict the fre - Before starting treatment for insomnia, it is crucial to quency of hypnotic use (Daily vs as needed). identify clinical insomnia from typical age-related sleep This cross-sectional study aims to examine the sleep pattern changes [13]. If clinical insomnia is detected, it is patterns of middle-aged and older adults with insomnia important to rule out secondary causes of insomnia such who use hypnotics and to study whether a set of factors as psychiatric illness or other medical conditions and (Age, pain, mood, sleep duration, chronicity of hypnotic treat accordingly. For primary clinical insomnia, non- use) predict daily hypnotic use compared to an as-needed pharmacologic treatments are recommended to be tried basis use. Understanding the sleep patterns of older first [14–16]. For example, multicomponent cognitive- adults who use hypnotics for insomnia and understand- behavioral therapy for insomnia (CBTi) is effective when ing the predictors of frequency of hypnotic use (daily vs. delivered in primary care and has successfully treated as needed) will help physicians better address the sleep insomnia in older adults [14–17]. Although hypnotic use problems of older adults who use hypnotics with behav- has been reported frequently among community-dwell- ioral interventions. This knowledge could help them in ing older adults, it is not recommended in this age group tapering and eventually stopping hypnotic use. [18, 19]. Older patients have multiple chronic conditions and are at increased risk of polypharmacy. Polyphar- macy is associated with an increased risk of inappropri- Methods ate prescribing and adverse drug events [18–20]. Beers Study population and design criteria, published by the American Geriatrics Society, The study has a cross-sectional design and was approved recommends that older adults avoid hypnotics, including by the American University of Beirut Institutional benzodiazepines and non-benzodiazepine gamma-amin- Review Board (IRB). Electronic medical records were obutyric acid agonists sometimes referred to as “Z-Drugs used to generate the names and contact information of “due to their association with increased risk of delirium, patients who met the inclusion criteria. Patients aged falls, fractures, and cognitive impairment [19]. 50 to 75 who visited the American University of Bei- Few articles in the literature compare the effect of hyp - rut Medical Center (AUBMC) Family Medicine Clinics notic use on sleep patterns compared to placebo in older between September 1, 2018, and May 1, 2021, and who adults [20–22]. A meta-analysis of 24 studies of hypnotic were taking hypnotics for insomnia were included in the use in older adults (2417 participants) showed that the study. Hypnotics use for insomnia was defined as any magnitude of the effect of improvement in sleep is small of the following medications for insomnia: Benzodiaz- [20], and its use is associated with adverse cognitive epines, non-benzodiazepine gamma-aminobutyric acid and psychomotor events and daytime fatigue compared agonists, flupentixol, and melitracen combined, doxepin, to placebo [20]. Sleep quality improvement (effect size amitriptyline, imipramine, desipramine, mirtazapine, 0.14), total sleep time increase (a mean of 25.2 min), and diphenhydramine, doxylamine, and hydroxyzine. Exclu- decrease in the number of nighttime awakenings (0.63) sion criteria included: patients younger than 50 years old were significant in hypnotic users compared to placebo or older than 75 years old, patients who were not taking but with a small effect size. According to the same meta- hypnotics or taking hypnotics for reasons other than analysis, 13 people need to be treated with a hypnotic insomnia, impaired decisional capacity to give consent or drug for only one person to benefit, whereas six people understand required questions, and severe hearing loss. need to be treated for one person to be harmed, indicat- After being contacted and screened for inclusion and ing that the risk of harm is more than twice as likely as exclusion criteria, eligible patients were invited to par- benefit [20, 21].. ticipate in the research study. Oral consent was obtained. Although several predictors of chronic hypnotic use Trained researchers collected sociodemographic data, have been described, including alcohol consumption, mood and cognitive screening measures, and questions smoking, sleep difficulties, old age, female gender, and about their sleep patterns. T anielian et al. BMC Primary Care (2022) 23:98 Page 3 of 8 Since the study involves less than minimal risk, an Mid sleep is Midpoint between sleep onset and explicit assessment of decisional capacity was not wake time. MSF is calculated by the following formula: assessed. However, the patient’s decisional capacity to MSF = (Sleep onset + sleep duration)/2. MSFsc is cal- consent to participate in the study was measured by a 2 culated by the following formula: MSFsc = MSF- (Sleep step process. The first step involves a quick determina - duration on free days-average weekly sleep duration)/2. tion of the need for a detailed assessment —the subject was asked: “Can you tell me what this study is about?” An adequate answer to this question may eliminate the Depression and cognitive screening measures necessity for further evaluation of the decisional capac- Patient Health Questionnaire 2 (PHQ-2), a short 2 item ity. If the patient fails to give an acceptable answer, the questionnaire, was used to screen for depression [33]. research assistant will proceed to step two and the sub- The two questions are each on a 4 point Likert scale. ject will be asked to answer the University of Califor- PHQ-2 scores range from 0 to 6. If the score was three or nia Brief Assessment of Capacity to Consent (UBACC) greater, major depressive disorder was considered likely, which is a 10-item questionnaire with a maximum score and the patient was asked to fill the Patient Health Ques - of 20 [28] (13). A score of ≤12 disqualifies the patient tionnaire-9 (PHQ-9). PHQ-9 is a 9 item questionnaire from participating in the study. Once the patient is with a 4 point Likert scale for each item. Total scores of determined to have the decisional capacity and consents 5, 10, 15, and 20 represent cut points for mild, moderate, to participate in the study, a researcher asked them the moderately severe, and severe depression, respectively research questions. [34]. Participants who have met the criteria for moderate or severe depression by PHQ-9 and were not already fol- lowing up for depression were informed about the results Sleep pattern measures and instructed to follow up with their primary care physi- Insomnia severity was determined using the Insomnia cian for further investigation and treatment. Severity Index (ISI) [29, 30]. ISI is a validated, reliable Patients were asked to repeat five words (table, sky, cat, tool for evaluating perceived sleep difficulties in the gen - table, car) and were instructed to remember them and eral population with adequate internal consistency. It has recall the five words 5 min. later. The 5-word recall test a 7 question inventory with a one-month recall period. is a short and simple screening test to assess for episodic A 5 point scale is used to rate each question. The score memory. The more words patients were able to recall, ranges from 0 to 28. The interpretation of the score is as the better their episodic memory was considered [35]. follows: 0–7 no clinically significant insomnia, 8–14 sub - Depression assessment was done (PHQ-2 questionnaire) threshold insomnia, 15–21 moderate insomnia, 22–28 between encoding and recall. severe insomnia. The first 3 questions of ISI, which The ISI, PHQ-2, and PHQ-9 were previously translated include difficulty falling asleep, difficulty staying asleep to Arabic and validated in Arabic-speaking populations and the problem with waking up too early are interpreted in the literature [36–38]. The MCTQ was translated to separately in addition to the global ISI score. Arabic by a certified translator and was content-validated Chronotype and other detailed sleep parameters were by an expert committee of sleep specialists at AUBMC. determined by the Munich Chronotype Questionnaire (MCTQ) [31, 32]. MCTQ is a questionnaire that meas- ures chronotype. Chronotype is the natural inclination of Pain and hypnotic use measures one’s body to sleep at a particular time. Some older adults Pain frequency and intensity were measured as follows: have an inclination to go to sleep early at night (These We asked the participants whether they had pain at night are called M-types or morning types), others have an (yes/no) and if yes, how frequent is it per week and how inclination to go to sleep late at night (These are called intense is it. Pain frequency/week choices were measured E-types or evening types). MCTQ consists of several on a scale from 1 to 3. 1.- no pain 2.- pain only few days questions about the bed and sleep-related time separately per week, 3.- pain half days per week or more. For pain on workdays and off days. MSFSc (Mid-sleep on off days intensity, participants were asked to give a scale to their corrected for sleep debt on workdays) was used to meas- pain from 0 to 10. ure working older adults’ chronotype, while MSF (Mid- Hypnotic use coded as daily use or non-daily use. The sleep on off days) was used for chronotype measurement patients were asked if they have previously tried to stop in non-working participants. Both of these measures the pill and the answer is documented as yes or no. The are included in MCTQ. MSFsc or MSF scores below patients were also asked if they had a current wish to 2.17 are classified as extreme M-types (Morning types), stop the pill and similarly the answer is documented as and MSFsc or MSF scores above 7.25 were classified as yes or no. extreme E-types (Evening types). Tanielian et al. BMC Primary Care (2022) 23:98 Page 4 of 8 Statistical analysis Table 1 General characteristics of participants (n = 66) Descriptive statistics included frequencies and pro- Variables Number (%) portions for categorical data and means with standard Age deviations (SD) for continuous data. Pearson correla- 50–65 39 (59.1%) tion was performed to find the association between ISI 66–75 24 (36.4%) and PHQ-2 and PHQ-9. Logistic regression analysis was Gender performed to explore whether a set of five factors may Male 20 (30.3%) predict daily hypnotic users compared to as-needed hyp- notic users. The dependent variable was daily hypnotic Female 46 (69.7%) use vs. as-needed hypnotic use. The independent vari - Marital status ables were Age, PHQ-2 score, pain at night, duration of Married 41 (62.1%) hypnotics used, and sleep duration. SPSS statistical pack- Single 6 (9.1%) age (SPSS Inc., Chicago, IL, USA, version 27) was used Divorced 4 (6.1%) for data analysis. Using G*Power 3.1.9.7, a sample size Widowed 15 (22.7%) of 68 was needed for 5 predictors and effect size meas - Education ured by Cohen’s f2 of 0.15 with an alpha level of 0.05 and Below high school 17 (25.8%) power of 80%. High school 21 (31.8%) College 9 (13.6%) Bachelor 18 (27.3%) Results Employed General characteristics of participants Yes 17 (25.8%) A sample of 66 participants was recruited, of which No 49 (74.2%) 69.7% (46/66) were females. The mean age of participants Daily use of caffeinated drinks was 63.5 years, and 74.2% (49/66) were unemployed. yes 64 (97%) Table  1 shows the baseline characteristics of the partici- No 2 (3%) pants. Daily use of hypnotics was reported among three- Alcohol use quarters of the participants (49/66, 74.2%), while the rest Less than weekly 59 (89.4%) (17, 25.8%) used hypnotics as needed during the week Weekly or more 6 (9.1%) (At least once per week). More than half (34/66, 51.5%) Smoking have previously tried to stop the hypnotic, and one-third yes 40 (60.6%) (20/66, 30.3%) have present wishes to do so. Benzodi- no 26 (39.4%) azepines were the most often used hypnotics for sleep Frequency of hypnotics use (48/66, 72.7%). Non-benzodiazepine gamma-aminobu- Daily 49 (74.2%) tyric acid agonist users accounted for 27 (40.9%) of par- As needed 17 (25.8%) ticipants. Other drugs used by the remaining 11 (16.6%) Duration of hypnotics use participants included tricyclic antidepressants (TCAs), < 1 4 (6.1%) quetiapine, and flupentixol and melitracen combined. 1–5 29 (43.9%) Of all participants, 26 (39.4%) still had clinically 5.1–10 12 (18.2%) significant insomnia even after taking hypnotics, > 10 16 (24.2%) of which 15 (22.7%) had subthreshold insomnia, 9 Previous trial to stop hypnotics (13.6%) had moderate severity clinical insomnia, and 2 Yes 34 (51.5%) (3%) had severe clinical insomnia. Two-thirds (43/66, No 32 (48.5%) 65%) reported they take daily naps. Around one third Current wish to stop hypnotics of participants (21/66, 31.8%) reported they need more Yes 20 (30.3%) than 30 min to fall sleep. Two-thirds (46/66, 69.7%) No 46 (69.7%) reported they wake up at least once in the middle of PHQ-2 score the night. One-third (23/66, 34.8%) wake up more than 2 or less 36 (54.5%) two times in the middle of the night. When the par- 3 or more 30 (45.5%) ticipants were asked how much time in general they Pain at night require to fall sleep once they wake up in the middle None 34 (51.5%) of the night during each awakening, One third (21/66, Some days (Less than half of days per week) 10 (15.2%) 31.8%) of participants did not answer the question. Half of days per week or more 22 (33.3%) Three quarter of those who answered the question T anielian et al. BMC Primary Care (2022) 23:98 Page 5 of 8 Table 1 (continued) Table 2 Sleep-related parameters stratified by frequency of hypnotics use (daily vs. as-needed) Variables Number (%) Daily As-needed use of Total Financial difficulty use of hypnotics N = 17 N = 66 (%) None 16 (24.2%) hypnotics (%) N = 49 (%) Mild 12 (18.2%) Moderate 24 (36.4%) Age Severe 14 (21.2%) 50–65 33 (67.3%) 6 (35.3%) 39 (59%) 66–75 16 (32.7%) 11 (64.7%) 27 (41%) Gender Male 15 (30.6%) 5 (29.4%) 20 (30%) (36/45, 80%) indicated they need less than 30 min to Female 34 (69.4%) 12 (70.6%) 46 (70%) fall back to sleep and one quarter (9/45, 20%) indicated Pain at night they need more than 30 min to fall back to sleep. The No pain 24 (49%) 10 (58.8%) 34 (51.5%) most common sleep complaint was trouble staying Few days per week 5 (10.2%) 5 (29.4%) 10 (15.2%) asleep by 27 participants (40.9%), followed by trouble Half days per week 20 (40.8%) 2 (11.8%) 22 (33.3%) falling asleep by 19 participants (28.78%) and early or more morning awakening by 11 participants (16.6%). One- Sleep duration (hours) third (22/66, 33%) slept more than 8 h per night. The Up to 8 28 (57%) 16 (94%) 44 (66.7%) mean extra sleeping time in those who slept more than More than 8 21 (43%) 1 (6%) 22 (33.3%) 8 h per night was 84 min (Range: 15–398 extra minutes Time to fall sleep above the 8 h maximum recommended sleep time). Up to 30 min 35 (71.4%) 10 (58.8%) 45 (68.2%) There was no association between the insomnia sever - More than 30 min 14 (28.6%) 7 (41.2%) 21 (31.8%) ity (ISI) and the various demographics except for depres- Waking up in middle of night sion. There was a positive correlation between ISI and No 17 (34%) 3 (17.6%) 20 (30.3%) PHQ-2 (Pearson correlation 0.294, P = 0.017) and a posi- Yes 32 (64%) 14 (82.4%) 46 (69.7%) tive correlation between ISI and PHQ-9 (Pearson correla- Approximate time to fall asleep after each awakening in the mid- tion 0.624, P < 0.0001). a dle of the night Sleep-related parameters stratified by frequency of Up to 30 min 27 (81.8%) 9 (75%) 36 (80%) hypnotics use (daily vs. as-needed) are presented in More than 30 min 6 (18.2%) 3 (25%) 9 (20%) Table 2. Daily Naps yes 33 (67.3%) 10 (58.8%) 43 (65.1%) No 16 (32.7%) 7 (41.2%) 23 (34.9%) Predictors of daily versus as-needed hypnotics use Duration of hypnotics used (in years) Logistic regression was performed to predict if the above- 0–10 30 (67%) 15 (94%) 45 (73.7%) mentioned five independent variables (Age, PHQ-2, pain Above 10 15 (33%) 1 (6%) 16 (26.3%) at night, duration of hypnotics used, and sleep duration) PHQ-2 score predict the daily use of hypnotics use compared to as- 0–2 25 (51%) 11 (64.7%) 36 (54.5%) needed use of hypnotics. The logistic regression model 3 and above 24 (49%) 6 (35.3%) 30 (45.5%) was statistically significant, X [2] (5) = 24.648, p  < 0.0001. Chronotype The model explained 48.6% (Nagelkerke R [2]) of the var - Less than 2.17 7 (14.3%) 2 (11.8%) 9 (13.6%) iance in daily vs as-needed hypnotic use. 2.17–7.25 42 (85.7%) 15 (88.2%) 57 (86.4%) Multivariate analysis model revealed that relatively Insomnia severity index (ISI) younger age and longer sleeping hours per night sig- 0–7 30 (61.2%) 10 (58.8%) 40 (60.6%) nificantly predicted daily use of hypnotics compared 8–28 19 (38.8%) 7 (41.2%) 26 (39.4%) to as-needed use of hypnotics (Table  3). A second- There are 21 missing values in this sleep parameter. Also to note this does not ary analysis was performed by adding two additional represent the WASO (Total wakefulness time after sleep onset). This represents variables in the above mentioned logistic regression the maximum time someone stays awake after each waking up in the middle of the night model. The two added continuous variables were “time it takes to fall sleep” and “number of waking up in the middle of the night”. The model with 7 variables was value = 0.023) remained the only two significant predic - analyzed and remained statistically significant, X [2] tors of daily use of hypnotics compared to as-needed use (5) = 26.235, p  < 0.0001. In this model, still younger age of hypnotics. (P value = 0.024) and longer sleeping hours per night (P Tanielian et al. BMC Primary Care (2022) 23:98 Page 6 of 8 Table 3 Multivariate analysis of factors associated with the day were reported by 65% of the participants. Day- frequency of hypnotics use (daily vs. as-needed use)*** time naps could contribute to self-perpetuating night- time insomnia [43] and subsequent hypnotics use. This Variables Odds Ratio 95% CI P-Value vicious cycle in which disturbed sleep leads to daytime Age 0.866 0.764–0.980 0.023 napping and disturbed nighttime sleep may be improved Duration of hypnotics used 1.134 0.988–1.302 0.074 by behavioral therapies, such as sleep hygiene counseling. Pain at night 1.370 0.901–2.081 0.141 Younger age was also found to be associated with an Sleep duration 1.010 1.001–1.018 0.025 increased risk of daily hypnotic use. In contrast to the PHQ-2 0.849 0.563–1.281 0.436 literature, advanced age has been associated with long- Pain at night is a scale that ranges from 0 to 5, where 0 is no pain on any day term hypnotics use [17, 23]. Most of the studies exploring during the week, and 5 is pain every day during the week hypnotics use in older patients with insomnia were con- Sleep duration is the time between when the patient falls to sleep at night and ducted in high-income countries [22]. While there has wakes up in the morning; it is a continuous variable measured in minutes been an increased use of long-term hypnotics during the ***The significance of this model is (P < 0.0001) 21st century among all age groups, psychotropic drug use varies according to the socio-cultural context and the reg- Discussion ulatory environment [44–46]. In our sample, we hypoth- We found that around 40% of the study sample had esize that the younger age group may have a more “liberal clinically significant insomnia, as measured by ISI score, and relaxed” attitude towards daily hypnotics. As studies despite hypnotics use. Considering that as-needed users have shown that there is a stigma surrounding the use of of the hypnotic were asked to answer the ISI questions sleeping pills and the older age group may have moral based only on the nights when they take the hypnotic objections towards their use [47, 48]. Given the changing pills, high ISI scores indicate residual insomnia despite regulatory environment, access to hypnotics may now be using the hypnotic pill. The high prevalence of insomnia more feasible for younger patients, which may not have in this sample of older adults who use hypnotics (either been the case for older patients. The younger age group daily or as needed) highlights the lack of effectiveness of is more likely to continue long-term hypnotics use into hypnotics as a treatment for insomnia in older adults. older age as studies have shown that more than half of These results are consistent with previous studies show - chronic insomnia patients who are started on hypnotics ing that prescription hypnotics are ineffective in treating are likely to continue taking them long-term [49]. insomnia in older adults over the long term [39]. Sleep Approximately half of our sample have attempted but maintenance was found to be the most common sleep failed to stop taking hypnotics in the past, and 30.3% have complaint in our study sample in concordance with the expressed a current desire to stop. Our findings were literature [40]. In a randomized controlled trial com- concordant with previous studies showing that grad- paring sleep maintenance between older persons (50– ual taper of hypnotics alone is less likely to be success- 60 years old) and young adults (20–30 years old) using an ful [50]. Multicomponent Cognitive Behavioral Therapy electroencephalograph, older adults wake up more fre- for Insomnia (CBTi) is considered the first-line therapy quently at night than their younger counterparts [41]. for patients with chronic insomnia and was shown to be The results of the logistic regression showed that par - effective in older adults [51]. A recent meta-analysis of ticipants who took the hypnotics daily slept more hours eight randomized controlled trials that all investigated at night than participants who took the hypnotics on CBT-I found that short-term (less than 3 months) CBT-I an as-needed basis. In addition, 43% of those who used combined with gradual tapering was more effective than hypnotics daily slept more than 8 h per night, which gradual tapering alone for ceasing hypnotics and reduc- means they slept more than the daily sleep time duration ing insomnia symptoms [52, 53]. Helping patients discon- hour recommended for their age group according to the tinue their hypnotics can be done by specialists, primary National Sleep Foundation’s sleep time duration recom- care physicians, and trained nurses. For instance, a hyp- mendations. Despite complaining of insomnia and tak- notic withdrawal program led by primary care nurses had ing hypnotic pills, sleeping more than the recommended been successful in helping older adults stop hypnotics sleep hours for age could be attributed to residual seda- use, with no associated reduction in sleep quality after tion from hypnotics or inadequate sleep. Approximately discontinuation [54]. three-quarters of our study population used benzodi- There were several limitations to this study. First, it has azepine hypnotic, which is known to be associated with a cross-sectional design and consequently, we are unable daytime sedative effects, excessive sedation [27], and to infer causal relationships. The study was conducted at a deep sleep suppression, compromising sleep’s restora- family medicine department at a single tertiary care aca- tive effects [42]. Furthermore, frequent naps throughout demic center with a possible sampling bias. The sample T anielian et al. BMC Primary Care (2022) 23:98 Page 7 of 8 Consent for publication is relatively small which limits generalizability. A larger Not applicable. sample size would have made it feasible to assess more variables that could potentially affect our outcome. The Competing interests All the authors declare no competing interests. data on sleep patterns and hypnotics was self-reported and did not include drug dosages used by patients for Author details insomnia which may have impacted our findings. In Department of Family Medicine, American University of Beirut Medical Center, Hamra, Beirut, Lebanon. Faculty of Medicine, American University addition, medical comorbidities of patients which might of Beirut Medical Center, Beirut, Lebanon. Department of Academic Internal affect sleep, including sleep apnea, were not addressed in Medicine and Geriatrics, the University of Illinois at Chicago, Chicago, IL, USA. this research. Future replication studies using objective Received: 28 September 2021 Accepted: 19 April 2022 measures such as actigraphy or polysomnographic study to examine sleep patterns and reviewing medical records for drug dosages and duration are important to further examine the effect of hypnotics use on sleep patterns and References quality of sleep in older patients with insomnia. 1. Irwin MR, Vitiello MV. Implications of sleep disturbance and inflammation for alzheimer’s disease dementia. Lancet Neurol. 2019;18(3):296–306. 2. American Psychiatric Association D, American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-5. Vol 5. Conclusion American psychiatric association Washington, DC; 2013. Many hypnotic users still have clinically significant 3. Doghramji K. The epidemiology and diagnosis of insomnia. Am J Manag Care. 2006;12(8):S214. insomnia and poor quality of sleep as reflected by per - 4. Monk TH, Reynolds CF III, Buysse DJ, et al. Circadian characteristics of ceived longer sleep duration and more daytime napping healthy 80-year-olds and their relationship to objectively recorded sleep. which could be related to drug-related residual sedation. J Gerontol. 1991;46(5):M171–5. 5. Březinová V. The number and duration of the episodes of the various Hypnotic use may not be the best solution for insomnia EEG stages of sleep in young and older people. Electroencephalogr Clin treatment in an older population, and physicians should Neurophysiol. 1975;39(3):273–8. regularly reassess the use of hypnotics. 6. Hirshkowitz M, Moore CA, Hamilton CR,3rd, Rando KC, Karacan I. Poly- somnography of adults and elderly: sleep architecture, respiration, and leg movement. J Clin Neurophysiol. 1992;9(1):56–62. 7. Zepelin H, McDonald CS. Age differences in autonomic variables during Abbreviations sleep. J Gerontol. 1987;42(2):142–6. AUBMC: American University of Beirut Medical Center; CBTi: Cognitive- 8. Hirshkowitz M, Whiton K, Albert SM, et al. National sleep foundation’s Behavioral Therapy for insomnia; ISI: Insomnia Severity Index; MCTQ: Munich sleep time duration recommendations: methodology and results sum- Chronotype Questionnaire; MSF: Mid-sleep on off days; MSFSc: Mid-sleep on mary. Sleep Health. 2015;1(1):40–3. off days corrected for sleep debt on workdays; PHQ-2: Patient Health Ques- 9. Ma Y, Liang L, Zheng F, Shi L, Zhong B, Xie W. Association between sleep tionnaire 2; PHQ-9: Patient Health Questionnaire-9; SD: Standard Deviations; duration and cognitive decline. JAMA Netw Open. 2020;3(9):e2013573–3. TST: Total Sleep Time. 10. Patel SR, Zhu X, Storfer-Isser A, et al. Sleep duration and biomarkers of inflammation. Sleep. 2009;32(2):200–4. Acknowledgments 11. Butler JZ, Slopen N, Redline S, et al. Abstract P085: Extremes of sleep None. duration and type II diabetes in older women participating in the women’s health study. Circulation. 2019;139(Suppl_1):AP085-AP085. Authors’ contributions 12. da Silva AA, de Mello, Renato Gorga Bandeira, Schaan CW, Fuchs FD, Red- M.T., G.A., and J.A. conceived, planned, and designed the study. M.T., M.S., A.H., line S, Fuchs SC. Sleep duration and mortality in the elderly: A systematic M.H., and K.H. carried out the study and did the data collection. G.A. oversaw review with meta-analysis. BMJ Open. 2016;6(2):e008119. the study implementation. J.A. performed the statistical analysis. M.T. took 13. Nau SD, McCrae CS, Cook KG, Lichstein KL. Treatment of insomnia in older the lead in writing the manuscript. All authors discussed the results, provided adults. Clin Psychol Rev. 2005;25(5):645–72. critical feedback, and contributed to the writing and final version of the manu- 14. McCurry SM, Logsdon RG, Teri L, Vitiello MV. Evidence-based psychologi- script. The author(s) read and approved the final manuscript. cal treatments for insomnia in older adults. Psychol Aging. 2007;22(1):18. 15. Lichstein KL, Riedel BW, Wilson NM, Lester KW, Aguillard RN. Relaxation Funding and sleep compression for late-life insomnia: a placebo-controlled trial. J None. Consult Clin Psychol. 2001;69(2):227. 16. Davidson JR, Dickson C, Han H. Cognitive behavioural treatment for insom- Availability of data and materials nia in primary care: A systematic review of sleep outcomes. Br J Gen Pract. The datasets generated and/or analysed during the current study are available 2019;69(686):e657-e664. doi: https:// doi. org/ 10. 3399/ bjgp1 9X705 065. in the open science framework repository (https:// osf. io/). 17. Brewster GS, Riegel B, Gehrman PR. Insomnia in the older adult. Sleep https:// mfr. osf. io/ render? url= https% 3A% 2F% 2Fosf. io% 2Fhrn qu% 2Fdow nload Med Clin. 2018;13(1):13–9. 18. Linjakumpu TA, Hartikainen SA, Klaukka TJ, et al. Sedative drug use in the Declarations home-dwelling elderly. Ann Pharmacother. 2004;38(12):2017–22. 19. Tseng H, Yu S, Lee C, et al. Sedative–hypnotic drug use among commu- Ethics approval and consent to participate nity-dwelling elderly in Taiwan. Int Psychogeriatr. 2018;30(7):957–65. This study was approved by the ethical committee of the American University 20. Thorell K, Midlöv P, Fastbom J, Halling A. Use of potentially inappropriate of Beirut. Since the participants were contacted over the phone, IRB waived medication and polypharmacy in older adults: a repeated cross-sectional written consent and approved verbal consent. All participants provided study. BMC Geriatr. 2020;20(1):1–9. informed verbal consent before the telephone interview. This study complies 21. American Geriatrics Society 2015 Beers Criteria Update Expert Panel, with the Declaration of Helsinki. Fick DM, Semla TP, et al. American geriatrics society 2015 updated beers Tanielian et al. BMC Primary Care (2022) 23:98 Page 8 of 8 criteria for potentially inappropriate medication use in older adults. J Am 46. Zito JM, Safer DJ, Janhsen K, et al. A three-country comparison of psycho- Geriatr Soc. 2015;63(11):2227–2246. tropic medication prevalence in youth. Child Adolesc Psychiatry Ment 22. Glass J, Lanctot KL, Herrmann N, Sproule BA, Busto UE. Sedative hypnotics Health. 2008;2(1):1–8. in older people with insomnia: Meta-analysis of risks and benefits. BMJ. 47. Kanayama G, Hudson JI, Pope HG,Jr. Culture, psychosomatics and sub- 2005;331(7526):1169. stance abuse: The example of body image drugs. Psychother Psychosom. 23. McMillan JM, Aitken E, Holroyd-Leduc JM. Management of insomnia 2012;81(2):73–78. https:// doi. org/ 10. 1159/ 00033 0415. and long-term use of sedative-hypnotic drugs in older patients. CMAJ. 48. Gabe J, Coveney CM, Williams SJ. Prescriptions and proscriptions: Moralis- 2013;185(17):1499–1505. https:// doi. org/ 10. 1503/ cmaj. 130025. ing sleep medicines. Sociol Health Illn. 2016;38(4):627–44. 24. Chiu H, Lee H, Liu J, et al. Comparative efficacy and safety of hypnotics for 49. Kaufmann CN, Spira AP, Depp CA, Mojtabai R. Long-term use of benzodi- insomnia in older adults: A systematic review and network meta-analysis. azepines and nonbenzodiazepine hypnotics, 1999–2014. Psychiatr Serv. Sleep. 2021;44(5):zsaa260. 2018;69(2):235–8. 25. Enomoto M, Kitamura S, Tachimori H, Takeshima M, Mishima K. Long-term 50. Takaesu Y, Komada Y, Asaoka S, Kagimura T, Inoue Y. Factors associated use of hypnotics: analysis of trends and risk factors. Gen Hosp Psychiatry. with long-term use of hypnotics among patients with chronic insomnia. 2020;62:49–55. PLoS One. 2014;9(11):e113753. 26. Nordfjærn T, Bjerkeset O, Bratberg G, Moylan S, Berk M, Gråwe R. Socio- 51. Irwin MR, Cole JC, Nicassio PM. Comparative meta-analysis of behavioral demographic, lifestyle and psychological predictors of benzodiazepine interventions for insomnia and their efficacy in middle-aged adults and and z-hypnotic use patterns. Nordic J Psychiatry. 2014;68(2):107–16. in older adults 55 years of age. Health Psychol. 2006;25(1):3. 27. Finan PH, Smith MT. The comorbidity of insomnia, chronic pain, and 52. Takaesu Y, Utsumi T, Okajima I, et al. Psychosocial intervention for discon- depression: dopamine as a putative mechanism. Sleep Med Rev. tinuing benzodiazepine hypnotics in patients with chronic insomnia: a 2013;17(3):173–83. systematic review and meta-analysis. Sleep Med Rev. 2019;48:101214. 28. Baglioni C, Battagliese G, Feige B, et al. Insomnia as a predictor of depres- 53. Anderson KN. Insomnia and cognitive behavioural therapy-how to assess sion: a meta-analytic evaluation of longitudinal epidemiological studies. J your patient and why it should be a standard part of care. J Thorac Dis. Aec ff t Disord. 2011;135(1–3):10–9. 2018;10(Suppl 1):S94-S102. https:// doi. org/ 10. 21037/ jtd. 2018. 01. 35. 29. Schroeck JL, Ford J, Conway EL, et al. Review of safety and efficacy of 54. Lopez-Peig C, Mundet X, Casabella B, Del Val JL, Lacasta D, Diogene E. sleep medicines in older adults. Clin Ther. 2016;38(11):2340–72. Analysis of benzodiazepine withdrawal program managed by primary 30. Jeste DV, Palmer BW, Appelbaum PS, et al. A new brief instrument for care nurses in Spain. BMC Res Notes. 2012;5(1):1–8. assessing decisional capacity for clinical research. Arch Gen Psychiatry. 2007;64(8):966–74. Publisher’s Note 31. Bastien CH, Vallières A, Morin CM. Validation of the insomnia sever- Springer Nature remains neutral with regard to jurisdictional claims in pub- ity index as an outcome measure for insomnia research. Sleep Med. lished maps and institutional affiliations. 2001;2(4):297–307. 32. Morin CM, Belleville G, Bélanger L, Ivers H. The insomnia severity index: psychometric indicators to detect insomnia cases and evaluate treat- ment response. Sleep. 2011;34(5):601–8. 33. Ryu H, Joo EY, Choi SJ, Suh S. Validation of the munich ChronoType questionnaire in korean older adults. Psychiatry Investig. 2018;15(8):775– 782. https:// doi. org/ 10. 30773/ pi. 2018. 04. 09. 34. Roenneberg T, Wirz-Justice A, Merrow M. Life between clocks: daily tem- poral patterns of human chronotypes. J Biol Rhythm. 2003;18(1):80–90. 35. Arroll B, Goodyear-Smith F, Crengle S, et al. Validation of PHQ-2 and PHQ-9 to screen for major depression in the primary care population. Ann Fam Med. 2010;8(4):348–353. https:// doi. org/ 10. 1370/ afm. 1139. 36. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606–13. 37. Dubois B, Touchon J, Portet F, Ousset PJ, Vellas B, Michel B. "the 5 words": a simple and sensitive test for the diagnosis of alzheimer’s disease. Presse Med. 2002;31(36):1696–9. 38. Suleiman KH, Yates BC. Translating the insomnia severity index into arabic. J Nurs Scholarsh. 2011;43(1):49–53. 39. Sawaya H, Atoui M, Hamadeh A, Zeinoun P, Nahas Z. Adaptation and ini- tial validation of the patient health questionnaire–9 (PHQ-9) and the gen- eralized anxiety disorder–7 questionnaire (GAD-7) in an arabic speaking lebanese psychiatric outpatient sample. Psychiatry Res. 2016;239:245–52. 40. Albanna M, Yehya A, Khairi A, et al. Validation and cultural adaptation of the arabic versions of the mini-mental status examination - 2 and mini- cog test. Neuropsychiatr Dis Treat. 2017;13:793–801. https:// doi. org/ 10. 2147/ NDT. S1268 25. Re Read ady y to to submit y submit your our re researc search h ? Choose BMC and benefit fr ? Choose BMC and benefit from om: : 41. Ohayon MM, Caulet M, Arbus L, et al. Are prescribed medications effective in the treatment of insomnia complaints? J Psychosom Res. fast, convenient online submission 1999;47(4):359–68. thorough peer review by experienced researchers in your field 42. McCall WV. Sleep in the elderly: Burden, diagnosis, and treatment. Prim Care Companion J Clin Psychiatry. 2004;6(1):9–20. https:// doi. org/ 10. rapid publication on acceptance 4088/ pcc. v06n0 104. support for research data, including large and complex data types 43. Webb WB. Sleep in older persons: sleep structures of 50-to 60-year-old • gold Open Access which fosters wider collaboration and increased citations men and women. J Gerontol. 1982;37(5):581–6. 44. Holbrook A, Crowther R, Lotter A, Endeshaw Y. The role of benzodiaz- maximum visibility for your research: over 100M website views per year epines in the treatment of insomnia: Meta-analysis of benzodiazepine use in the treatment of insomnia. J Am Geriatr Soc. 2001;49(6):824–6. At BMC, research is always in progress. 45. Frisoni GB, De Leo D, Rozzini R, Trabucchi M. Napping in the elderly and Learn more biomedcentral.com/submissions its association with night sleep and psychological status. 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Sleep pattern and predictors of daily versus as-needed hypnotics use in middle-aged and older adults with insomnia

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Abstract

Introduction: This study aims to examine the sleep pattern and predictors of daily vs. as-needed use of hypnotics in middle-aged and older adults with insomnia. Methods: Patients aged 50–75 who use hypnotics for insomnia were identified via electronic medical records and were recruited. Data about sociodemographics, mood and cognitive screening measures, and questions related to sleep patterns were collected through an interview conducted over the phone. Results: A sample of 66 participants was recruited, of which 69.7% were females. Three quarters (49/66, 74.2%) used hypnotics daily, with 43% (21/49) of daily hypnotics users sleeping more than 8 h per night. Two-fifths (26/66, 39.4%) of participants still had clinically significant insomnia even after taking hypnotics. After adjusting for age, years of hypnotics use, sleeping hours per night, PHQ-2 score, and frequency of pain at night, the logistic regression model showed that younger age (p = 0.023) and longer sleeping hours per night (p = 0.025) were significantly associated with daily hypnotics use when compared to as needed hypnotics use. Conclusion: Many hypnotic users still have clinically significant insomnia and poor quality of sleep as reflected by perceived longer sleep duration and more daytime napping which could be related to drug-related residual seda- tion. Hypnotic use may not be the best solution for insomnia treatment in an older population, and physicians should regularly reassess the use of hypnotics. Introduction symptoms: at least 3 months, associated with dissatisfac- Insomnia symptoms are common in older adults. These tion with sleep and daytime consequences) [1, 2]. symptoms are termed sleep disturbance when they Estimates of the prevalence of insomnia are variable in result into daytime consequences or patient dissatisfac- the literature because of inconsistency in definitions used tion, impacting the quality of life [1]. Insomnia disorder and limitations in accurately estimating incidence and is diagnosed when insomnia symptoms of a patient with remission rate of insomnia [3]. The prevalence of insom - sleep disturbance meet the Diagnostic and Statistical nia, in older adults, is estimated to be between 13 and Manual of Mental Disorders Criteria of Insomnia (Fre- 47% [3]. The high prevalence of insomnia in older adults quency of symptoms: 3 or more nights/week, Duration of can be explained by sleep pattern changes that occur with age. As people age, their total sleep time (TST) decreases [4, 5], their sleep efficiency worsens, and they wake up *Correspondence: ga62@aub.edu.lb more frequently than younger people [4, 6, 7]. Due to Department of Family Medicine, American University of Beirut Medical Center, Hamra, Beirut, Lebanon physiological changes that occur with age, older adults Full list of author information is available at the end of the article © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Tanielian et al. BMC Primary Care (2022) 23:98 Page 2 of 8 require less sleep time at night than younger adults. comorbid psychiatric disorders [23, 24], no articles to our According to the National Sleep Foundation’s sleep time knowledge studied the predictors of daily vs. as-needed duration recommendations, sleeping 7–9 h per night for use of hypnotics on sleep patterns. However since age adults and 7–8 h per night for older adults is appropriate [1–3], depressed mood [25, 26], and pain [25] are highly [8]. It has been shown that both short or long sleep dura- associated with insomnia in the literature, it could also be tion (≤6 or ≥ 9 h per night) could have negative possible that these factors might predict the frequency health outcome [9–11]. In a systematic review with meta- of use of hypnotics for insomnia (Daily vs As needed). analysis sleep duration (both short and long) was associ- In addition length of time the hypnotic pill used (extent ated with all-cause mortality [12]. of its chronicity) and the length of sleeping time at night Treating insomnia in older adults is a clinical challenge. (Effected by hypnotic use) [27] might also predict the fre - Before starting treatment for insomnia, it is crucial to quency of hypnotic use (Daily vs as needed). identify clinical insomnia from typical age-related sleep This cross-sectional study aims to examine the sleep pattern changes [13]. If clinical insomnia is detected, it is patterns of middle-aged and older adults with insomnia important to rule out secondary causes of insomnia such who use hypnotics and to study whether a set of factors as psychiatric illness or other medical conditions and (Age, pain, mood, sleep duration, chronicity of hypnotic treat accordingly. For primary clinical insomnia, non- use) predict daily hypnotic use compared to an as-needed pharmacologic treatments are recommended to be tried basis use. Understanding the sleep patterns of older first [14–16]. For example, multicomponent cognitive- adults who use hypnotics for insomnia and understand- behavioral therapy for insomnia (CBTi) is effective when ing the predictors of frequency of hypnotic use (daily vs. delivered in primary care and has successfully treated as needed) will help physicians better address the sleep insomnia in older adults [14–17]. Although hypnotic use problems of older adults who use hypnotics with behav- has been reported frequently among community-dwell- ioral interventions. This knowledge could help them in ing older adults, it is not recommended in this age group tapering and eventually stopping hypnotic use. [18, 19]. Older patients have multiple chronic conditions and are at increased risk of polypharmacy. Polyphar- macy is associated with an increased risk of inappropri- Methods ate prescribing and adverse drug events [18–20]. Beers Study population and design criteria, published by the American Geriatrics Society, The study has a cross-sectional design and was approved recommends that older adults avoid hypnotics, including by the American University of Beirut Institutional benzodiazepines and non-benzodiazepine gamma-amin- Review Board (IRB). Electronic medical records were obutyric acid agonists sometimes referred to as “Z-Drugs used to generate the names and contact information of “due to their association with increased risk of delirium, patients who met the inclusion criteria. Patients aged falls, fractures, and cognitive impairment [19]. 50 to 75 who visited the American University of Bei- Few articles in the literature compare the effect of hyp - rut Medical Center (AUBMC) Family Medicine Clinics notic use on sleep patterns compared to placebo in older between September 1, 2018, and May 1, 2021, and who adults [20–22]. A meta-analysis of 24 studies of hypnotic were taking hypnotics for insomnia were included in the use in older adults (2417 participants) showed that the study. Hypnotics use for insomnia was defined as any magnitude of the effect of improvement in sleep is small of the following medications for insomnia: Benzodiaz- [20], and its use is associated with adverse cognitive epines, non-benzodiazepine gamma-aminobutyric acid and psychomotor events and daytime fatigue compared agonists, flupentixol, and melitracen combined, doxepin, to placebo [20]. Sleep quality improvement (effect size amitriptyline, imipramine, desipramine, mirtazapine, 0.14), total sleep time increase (a mean of 25.2 min), and diphenhydramine, doxylamine, and hydroxyzine. Exclu- decrease in the number of nighttime awakenings (0.63) sion criteria included: patients younger than 50 years old were significant in hypnotic users compared to placebo or older than 75 years old, patients who were not taking but with a small effect size. According to the same meta- hypnotics or taking hypnotics for reasons other than analysis, 13 people need to be treated with a hypnotic insomnia, impaired decisional capacity to give consent or drug for only one person to benefit, whereas six people understand required questions, and severe hearing loss. need to be treated for one person to be harmed, indicat- After being contacted and screened for inclusion and ing that the risk of harm is more than twice as likely as exclusion criteria, eligible patients were invited to par- benefit [20, 21].. ticipate in the research study. Oral consent was obtained. Although several predictors of chronic hypnotic use Trained researchers collected sociodemographic data, have been described, including alcohol consumption, mood and cognitive screening measures, and questions smoking, sleep difficulties, old age, female gender, and about their sleep patterns. T anielian et al. BMC Primary Care (2022) 23:98 Page 3 of 8 Since the study involves less than minimal risk, an Mid sleep is Midpoint between sleep onset and explicit assessment of decisional capacity was not wake time. MSF is calculated by the following formula: assessed. However, the patient’s decisional capacity to MSF = (Sleep onset + sleep duration)/2. MSFsc is cal- consent to participate in the study was measured by a 2 culated by the following formula: MSFsc = MSF- (Sleep step process. The first step involves a quick determina - duration on free days-average weekly sleep duration)/2. tion of the need for a detailed assessment —the subject was asked: “Can you tell me what this study is about?” An adequate answer to this question may eliminate the Depression and cognitive screening measures necessity for further evaluation of the decisional capac- Patient Health Questionnaire 2 (PHQ-2), a short 2 item ity. If the patient fails to give an acceptable answer, the questionnaire, was used to screen for depression [33]. research assistant will proceed to step two and the sub- The two questions are each on a 4 point Likert scale. ject will be asked to answer the University of Califor- PHQ-2 scores range from 0 to 6. If the score was three or nia Brief Assessment of Capacity to Consent (UBACC) greater, major depressive disorder was considered likely, which is a 10-item questionnaire with a maximum score and the patient was asked to fill the Patient Health Ques - of 20 [28] (13). A score of ≤12 disqualifies the patient tionnaire-9 (PHQ-9). PHQ-9 is a 9 item questionnaire from participating in the study. Once the patient is with a 4 point Likert scale for each item. Total scores of determined to have the decisional capacity and consents 5, 10, 15, and 20 represent cut points for mild, moderate, to participate in the study, a researcher asked them the moderately severe, and severe depression, respectively research questions. [34]. Participants who have met the criteria for moderate or severe depression by PHQ-9 and were not already fol- lowing up for depression were informed about the results Sleep pattern measures and instructed to follow up with their primary care physi- Insomnia severity was determined using the Insomnia cian for further investigation and treatment. Severity Index (ISI) [29, 30]. ISI is a validated, reliable Patients were asked to repeat five words (table, sky, cat, tool for evaluating perceived sleep difficulties in the gen - table, car) and were instructed to remember them and eral population with adequate internal consistency. It has recall the five words 5 min. later. The 5-word recall test a 7 question inventory with a one-month recall period. is a short and simple screening test to assess for episodic A 5 point scale is used to rate each question. The score memory. The more words patients were able to recall, ranges from 0 to 28. The interpretation of the score is as the better their episodic memory was considered [35]. follows: 0–7 no clinically significant insomnia, 8–14 sub - Depression assessment was done (PHQ-2 questionnaire) threshold insomnia, 15–21 moderate insomnia, 22–28 between encoding and recall. severe insomnia. The first 3 questions of ISI, which The ISI, PHQ-2, and PHQ-9 were previously translated include difficulty falling asleep, difficulty staying asleep to Arabic and validated in Arabic-speaking populations and the problem with waking up too early are interpreted in the literature [36–38]. The MCTQ was translated to separately in addition to the global ISI score. Arabic by a certified translator and was content-validated Chronotype and other detailed sleep parameters were by an expert committee of sleep specialists at AUBMC. determined by the Munich Chronotype Questionnaire (MCTQ) [31, 32]. MCTQ is a questionnaire that meas- ures chronotype. Chronotype is the natural inclination of Pain and hypnotic use measures one’s body to sleep at a particular time. Some older adults Pain frequency and intensity were measured as follows: have an inclination to go to sleep early at night (These We asked the participants whether they had pain at night are called M-types or morning types), others have an (yes/no) and if yes, how frequent is it per week and how inclination to go to sleep late at night (These are called intense is it. Pain frequency/week choices were measured E-types or evening types). MCTQ consists of several on a scale from 1 to 3. 1.- no pain 2.- pain only few days questions about the bed and sleep-related time separately per week, 3.- pain half days per week or more. For pain on workdays and off days. MSFSc (Mid-sleep on off days intensity, participants were asked to give a scale to their corrected for sleep debt on workdays) was used to meas- pain from 0 to 10. ure working older adults’ chronotype, while MSF (Mid- Hypnotic use coded as daily use or non-daily use. The sleep on off days) was used for chronotype measurement patients were asked if they have previously tried to stop in non-working participants. Both of these measures the pill and the answer is documented as yes or no. The are included in MCTQ. MSFsc or MSF scores below patients were also asked if they had a current wish to 2.17 are classified as extreme M-types (Morning types), stop the pill and similarly the answer is documented as and MSFsc or MSF scores above 7.25 were classified as yes or no. extreme E-types (Evening types). Tanielian et al. BMC Primary Care (2022) 23:98 Page 4 of 8 Statistical analysis Table 1 General characteristics of participants (n = 66) Descriptive statistics included frequencies and pro- Variables Number (%) portions for categorical data and means with standard Age deviations (SD) for continuous data. Pearson correla- 50–65 39 (59.1%) tion was performed to find the association between ISI 66–75 24 (36.4%) and PHQ-2 and PHQ-9. Logistic regression analysis was Gender performed to explore whether a set of five factors may Male 20 (30.3%) predict daily hypnotic users compared to as-needed hyp- notic users. The dependent variable was daily hypnotic Female 46 (69.7%) use vs. as-needed hypnotic use. The independent vari - Marital status ables were Age, PHQ-2 score, pain at night, duration of Married 41 (62.1%) hypnotics used, and sleep duration. SPSS statistical pack- Single 6 (9.1%) age (SPSS Inc., Chicago, IL, USA, version 27) was used Divorced 4 (6.1%) for data analysis. Using G*Power 3.1.9.7, a sample size Widowed 15 (22.7%) of 68 was needed for 5 predictors and effect size meas - Education ured by Cohen’s f2 of 0.15 with an alpha level of 0.05 and Below high school 17 (25.8%) power of 80%. High school 21 (31.8%) College 9 (13.6%) Bachelor 18 (27.3%) Results Employed General characteristics of participants Yes 17 (25.8%) A sample of 66 participants was recruited, of which No 49 (74.2%) 69.7% (46/66) were females. The mean age of participants Daily use of caffeinated drinks was 63.5 years, and 74.2% (49/66) were unemployed. yes 64 (97%) Table  1 shows the baseline characteristics of the partici- No 2 (3%) pants. Daily use of hypnotics was reported among three- Alcohol use quarters of the participants (49/66, 74.2%), while the rest Less than weekly 59 (89.4%) (17, 25.8%) used hypnotics as needed during the week Weekly or more 6 (9.1%) (At least once per week). More than half (34/66, 51.5%) Smoking have previously tried to stop the hypnotic, and one-third yes 40 (60.6%) (20/66, 30.3%) have present wishes to do so. Benzodi- no 26 (39.4%) azepines were the most often used hypnotics for sleep Frequency of hypnotics use (48/66, 72.7%). Non-benzodiazepine gamma-aminobu- Daily 49 (74.2%) tyric acid agonist users accounted for 27 (40.9%) of par- As needed 17 (25.8%) ticipants. Other drugs used by the remaining 11 (16.6%) Duration of hypnotics use participants included tricyclic antidepressants (TCAs), < 1 4 (6.1%) quetiapine, and flupentixol and melitracen combined. 1–5 29 (43.9%) Of all participants, 26 (39.4%) still had clinically 5.1–10 12 (18.2%) significant insomnia even after taking hypnotics, > 10 16 (24.2%) of which 15 (22.7%) had subthreshold insomnia, 9 Previous trial to stop hypnotics (13.6%) had moderate severity clinical insomnia, and 2 Yes 34 (51.5%) (3%) had severe clinical insomnia. Two-thirds (43/66, No 32 (48.5%) 65%) reported they take daily naps. Around one third Current wish to stop hypnotics of participants (21/66, 31.8%) reported they need more Yes 20 (30.3%) than 30 min to fall sleep. Two-thirds (46/66, 69.7%) No 46 (69.7%) reported they wake up at least once in the middle of PHQ-2 score the night. One-third (23/66, 34.8%) wake up more than 2 or less 36 (54.5%) two times in the middle of the night. When the par- 3 or more 30 (45.5%) ticipants were asked how much time in general they Pain at night require to fall sleep once they wake up in the middle None 34 (51.5%) of the night during each awakening, One third (21/66, Some days (Less than half of days per week) 10 (15.2%) 31.8%) of participants did not answer the question. Half of days per week or more 22 (33.3%) Three quarter of those who answered the question T anielian et al. BMC Primary Care (2022) 23:98 Page 5 of 8 Table 1 (continued) Table 2 Sleep-related parameters stratified by frequency of hypnotics use (daily vs. as-needed) Variables Number (%) Daily As-needed use of Total Financial difficulty use of hypnotics N = 17 N = 66 (%) None 16 (24.2%) hypnotics (%) N = 49 (%) Mild 12 (18.2%) Moderate 24 (36.4%) Age Severe 14 (21.2%) 50–65 33 (67.3%) 6 (35.3%) 39 (59%) 66–75 16 (32.7%) 11 (64.7%) 27 (41%) Gender Male 15 (30.6%) 5 (29.4%) 20 (30%) (36/45, 80%) indicated they need less than 30 min to Female 34 (69.4%) 12 (70.6%) 46 (70%) fall back to sleep and one quarter (9/45, 20%) indicated Pain at night they need more than 30 min to fall back to sleep. The No pain 24 (49%) 10 (58.8%) 34 (51.5%) most common sleep complaint was trouble staying Few days per week 5 (10.2%) 5 (29.4%) 10 (15.2%) asleep by 27 participants (40.9%), followed by trouble Half days per week 20 (40.8%) 2 (11.8%) 22 (33.3%) falling asleep by 19 participants (28.78%) and early or more morning awakening by 11 participants (16.6%). One- Sleep duration (hours) third (22/66, 33%) slept more than 8 h per night. The Up to 8 28 (57%) 16 (94%) 44 (66.7%) mean extra sleeping time in those who slept more than More than 8 21 (43%) 1 (6%) 22 (33.3%) 8 h per night was 84 min (Range: 15–398 extra minutes Time to fall sleep above the 8 h maximum recommended sleep time). Up to 30 min 35 (71.4%) 10 (58.8%) 45 (68.2%) There was no association between the insomnia sever - More than 30 min 14 (28.6%) 7 (41.2%) 21 (31.8%) ity (ISI) and the various demographics except for depres- Waking up in middle of night sion. There was a positive correlation between ISI and No 17 (34%) 3 (17.6%) 20 (30.3%) PHQ-2 (Pearson correlation 0.294, P = 0.017) and a posi- Yes 32 (64%) 14 (82.4%) 46 (69.7%) tive correlation between ISI and PHQ-9 (Pearson correla- Approximate time to fall asleep after each awakening in the mid- tion 0.624, P < 0.0001). a dle of the night Sleep-related parameters stratified by frequency of Up to 30 min 27 (81.8%) 9 (75%) 36 (80%) hypnotics use (daily vs. as-needed) are presented in More than 30 min 6 (18.2%) 3 (25%) 9 (20%) Table 2. Daily Naps yes 33 (67.3%) 10 (58.8%) 43 (65.1%) No 16 (32.7%) 7 (41.2%) 23 (34.9%) Predictors of daily versus as-needed hypnotics use Duration of hypnotics used (in years) Logistic regression was performed to predict if the above- 0–10 30 (67%) 15 (94%) 45 (73.7%) mentioned five independent variables (Age, PHQ-2, pain Above 10 15 (33%) 1 (6%) 16 (26.3%) at night, duration of hypnotics used, and sleep duration) PHQ-2 score predict the daily use of hypnotics use compared to as- 0–2 25 (51%) 11 (64.7%) 36 (54.5%) needed use of hypnotics. The logistic regression model 3 and above 24 (49%) 6 (35.3%) 30 (45.5%) was statistically significant, X [2] (5) = 24.648, p  < 0.0001. Chronotype The model explained 48.6% (Nagelkerke R [2]) of the var - Less than 2.17 7 (14.3%) 2 (11.8%) 9 (13.6%) iance in daily vs as-needed hypnotic use. 2.17–7.25 42 (85.7%) 15 (88.2%) 57 (86.4%) Multivariate analysis model revealed that relatively Insomnia severity index (ISI) younger age and longer sleeping hours per night sig- 0–7 30 (61.2%) 10 (58.8%) 40 (60.6%) nificantly predicted daily use of hypnotics compared 8–28 19 (38.8%) 7 (41.2%) 26 (39.4%) to as-needed use of hypnotics (Table  3). A second- There are 21 missing values in this sleep parameter. Also to note this does not ary analysis was performed by adding two additional represent the WASO (Total wakefulness time after sleep onset). This represents variables in the above mentioned logistic regression the maximum time someone stays awake after each waking up in the middle of the night model. The two added continuous variables were “time it takes to fall sleep” and “number of waking up in the middle of the night”. The model with 7 variables was value = 0.023) remained the only two significant predic - analyzed and remained statistically significant, X [2] tors of daily use of hypnotics compared to as-needed use (5) = 26.235, p  < 0.0001. In this model, still younger age of hypnotics. (P value = 0.024) and longer sleeping hours per night (P Tanielian et al. BMC Primary Care (2022) 23:98 Page 6 of 8 Table 3 Multivariate analysis of factors associated with the day were reported by 65% of the participants. Day- frequency of hypnotics use (daily vs. as-needed use)*** time naps could contribute to self-perpetuating night- time insomnia [43] and subsequent hypnotics use. This Variables Odds Ratio 95% CI P-Value vicious cycle in which disturbed sleep leads to daytime Age 0.866 0.764–0.980 0.023 napping and disturbed nighttime sleep may be improved Duration of hypnotics used 1.134 0.988–1.302 0.074 by behavioral therapies, such as sleep hygiene counseling. Pain at night 1.370 0.901–2.081 0.141 Younger age was also found to be associated with an Sleep duration 1.010 1.001–1.018 0.025 increased risk of daily hypnotic use. In contrast to the PHQ-2 0.849 0.563–1.281 0.436 literature, advanced age has been associated with long- Pain at night is a scale that ranges from 0 to 5, where 0 is no pain on any day term hypnotics use [17, 23]. Most of the studies exploring during the week, and 5 is pain every day during the week hypnotics use in older patients with insomnia were con- Sleep duration is the time between when the patient falls to sleep at night and ducted in high-income countries [22]. While there has wakes up in the morning; it is a continuous variable measured in minutes been an increased use of long-term hypnotics during the ***The significance of this model is (P < 0.0001) 21st century among all age groups, psychotropic drug use varies according to the socio-cultural context and the reg- Discussion ulatory environment [44–46]. In our sample, we hypoth- We found that around 40% of the study sample had esize that the younger age group may have a more “liberal clinically significant insomnia, as measured by ISI score, and relaxed” attitude towards daily hypnotics. As studies despite hypnotics use. Considering that as-needed users have shown that there is a stigma surrounding the use of of the hypnotic were asked to answer the ISI questions sleeping pills and the older age group may have moral based only on the nights when they take the hypnotic objections towards their use [47, 48]. Given the changing pills, high ISI scores indicate residual insomnia despite regulatory environment, access to hypnotics may now be using the hypnotic pill. The high prevalence of insomnia more feasible for younger patients, which may not have in this sample of older adults who use hypnotics (either been the case for older patients. The younger age group daily or as needed) highlights the lack of effectiveness of is more likely to continue long-term hypnotics use into hypnotics as a treatment for insomnia in older adults. older age as studies have shown that more than half of These results are consistent with previous studies show - chronic insomnia patients who are started on hypnotics ing that prescription hypnotics are ineffective in treating are likely to continue taking them long-term [49]. insomnia in older adults over the long term [39]. Sleep Approximately half of our sample have attempted but maintenance was found to be the most common sleep failed to stop taking hypnotics in the past, and 30.3% have complaint in our study sample in concordance with the expressed a current desire to stop. Our findings were literature [40]. In a randomized controlled trial com- concordant with previous studies showing that grad- paring sleep maintenance between older persons (50– ual taper of hypnotics alone is less likely to be success- 60 years old) and young adults (20–30 years old) using an ful [50]. Multicomponent Cognitive Behavioral Therapy electroencephalograph, older adults wake up more fre- for Insomnia (CBTi) is considered the first-line therapy quently at night than their younger counterparts [41]. for patients with chronic insomnia and was shown to be The results of the logistic regression showed that par - effective in older adults [51]. A recent meta-analysis of ticipants who took the hypnotics daily slept more hours eight randomized controlled trials that all investigated at night than participants who took the hypnotics on CBT-I found that short-term (less than 3 months) CBT-I an as-needed basis. In addition, 43% of those who used combined with gradual tapering was more effective than hypnotics daily slept more than 8 h per night, which gradual tapering alone for ceasing hypnotics and reduc- means they slept more than the daily sleep time duration ing insomnia symptoms [52, 53]. Helping patients discon- hour recommended for their age group according to the tinue their hypnotics can be done by specialists, primary National Sleep Foundation’s sleep time duration recom- care physicians, and trained nurses. For instance, a hyp- mendations. Despite complaining of insomnia and tak- notic withdrawal program led by primary care nurses had ing hypnotic pills, sleeping more than the recommended been successful in helping older adults stop hypnotics sleep hours for age could be attributed to residual seda- use, with no associated reduction in sleep quality after tion from hypnotics or inadequate sleep. Approximately discontinuation [54]. three-quarters of our study population used benzodi- There were several limitations to this study. First, it has azepine hypnotic, which is known to be associated with a cross-sectional design and consequently, we are unable daytime sedative effects, excessive sedation [27], and to infer causal relationships. The study was conducted at a deep sleep suppression, compromising sleep’s restora- family medicine department at a single tertiary care aca- tive effects [42]. Furthermore, frequent naps throughout demic center with a possible sampling bias. The sample T anielian et al. BMC Primary Care (2022) 23:98 Page 7 of 8 Consent for publication is relatively small which limits generalizability. A larger Not applicable. sample size would have made it feasible to assess more variables that could potentially affect our outcome. The Competing interests All the authors declare no competing interests. data on sleep patterns and hypnotics was self-reported and did not include drug dosages used by patients for Author details insomnia which may have impacted our findings. In Department of Family Medicine, American University of Beirut Medical Center, Hamra, Beirut, Lebanon. Faculty of Medicine, American University addition, medical comorbidities of patients which might of Beirut Medical Center, Beirut, Lebanon. Department of Academic Internal affect sleep, including sleep apnea, were not addressed in Medicine and Geriatrics, the University of Illinois at Chicago, Chicago, IL, USA. this research. Future replication studies using objective Received: 28 September 2021 Accepted: 19 April 2022 measures such as actigraphy or polysomnographic study to examine sleep patterns and reviewing medical records for drug dosages and duration are important to further examine the effect of hypnotics use on sleep patterns and References quality of sleep in older patients with insomnia. 1. Irwin MR, Vitiello MV. Implications of sleep disturbance and inflammation for alzheimer’s disease dementia. Lancet Neurol. 2019;18(3):296–306. 2. American Psychiatric Association D, American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-5. Vol 5. Conclusion American psychiatric association Washington, DC; 2013. Many hypnotic users still have clinically significant 3. Doghramji K. The epidemiology and diagnosis of insomnia. Am J Manag Care. 2006;12(8):S214. insomnia and poor quality of sleep as reflected by per - 4. Monk TH, Reynolds CF III, Buysse DJ, et al. Circadian characteristics of ceived longer sleep duration and more daytime napping healthy 80-year-olds and their relationship to objectively recorded sleep. which could be related to drug-related residual sedation. J Gerontol. 1991;46(5):M171–5. 5. Březinová V. The number and duration of the episodes of the various Hypnotic use may not be the best solution for insomnia EEG stages of sleep in young and older people. Electroencephalogr Clin treatment in an older population, and physicians should Neurophysiol. 1975;39(3):273–8. regularly reassess the use of hypnotics. 6. Hirshkowitz M, Moore CA, Hamilton CR,3rd, Rando KC, Karacan I. Poly- somnography of adults and elderly: sleep architecture, respiration, and leg movement. J Clin Neurophysiol. 1992;9(1):56–62. 7. Zepelin H, McDonald CS. Age differences in autonomic variables during Abbreviations sleep. J Gerontol. 1987;42(2):142–6. AUBMC: American University of Beirut Medical Center; CBTi: Cognitive- 8. Hirshkowitz M, Whiton K, Albert SM, et al. National sleep foundation’s Behavioral Therapy for insomnia; ISI: Insomnia Severity Index; MCTQ: Munich sleep time duration recommendations: methodology and results sum- Chronotype Questionnaire; MSF: Mid-sleep on off days; MSFSc: Mid-sleep on mary. Sleep Health. 2015;1(1):40–3. off days corrected for sleep debt on workdays; PHQ-2: Patient Health Ques- 9. Ma Y, Liang L, Zheng F, Shi L, Zhong B, Xie W. Association between sleep tionnaire 2; PHQ-9: Patient Health Questionnaire-9; SD: Standard Deviations; duration and cognitive decline. JAMA Netw Open. 2020;3(9):e2013573–3. TST: Total Sleep Time. 10. Patel SR, Zhu X, Storfer-Isser A, et al. Sleep duration and biomarkers of inflammation. Sleep. 2009;32(2):200–4. Acknowledgments 11. Butler JZ, Slopen N, Redline S, et al. Abstract P085: Extremes of sleep None. duration and type II diabetes in older women participating in the women’s health study. Circulation. 2019;139(Suppl_1):AP085-AP085. Authors’ contributions 12. da Silva AA, de Mello, Renato Gorga Bandeira, Schaan CW, Fuchs FD, Red- M.T., G.A., and J.A. conceived, planned, and designed the study. M.T., M.S., A.H., line S, Fuchs SC. Sleep duration and mortality in the elderly: A systematic M.H., and K.H. carried out the study and did the data collection. G.A. oversaw review with meta-analysis. BMJ Open. 2016;6(2):e008119. the study implementation. J.A. performed the statistical analysis. M.T. took 13. Nau SD, McCrae CS, Cook KG, Lichstein KL. Treatment of insomnia in older the lead in writing the manuscript. All authors discussed the results, provided adults. Clin Psychol Rev. 2005;25(5):645–72. critical feedback, and contributed to the writing and final version of the manu- 14. McCurry SM, Logsdon RG, Teri L, Vitiello MV. Evidence-based psychologi- script. The author(s) read and approved the final manuscript. cal treatments for insomnia in older adults. Psychol Aging. 2007;22(1):18. 15. Lichstein KL, Riedel BW, Wilson NM, Lester KW, Aguillard RN. Relaxation Funding and sleep compression for late-life insomnia: a placebo-controlled trial. J None. Consult Clin Psychol. 2001;69(2):227. 16. Davidson JR, Dickson C, Han H. Cognitive behavioural treatment for insom- Availability of data and materials nia in primary care: A systematic review of sleep outcomes. Br J Gen Pract. The datasets generated and/or analysed during the current study are available 2019;69(686):e657-e664. doi: https:// doi. org/ 10. 3399/ bjgp1 9X705 065. in the open science framework repository (https:// osf. io/). 17. Brewster GS, Riegel B, Gehrman PR. Insomnia in the older adult. Sleep https:// mfr. osf. io/ render? url= https% 3A% 2F% 2Fosf. io% 2Fhrn qu% 2Fdow nload Med Clin. 2018;13(1):13–9. 18. Linjakumpu TA, Hartikainen SA, Klaukka TJ, et al. Sedative drug use in the Declarations home-dwelling elderly. Ann Pharmacother. 2004;38(12):2017–22. 19. Tseng H, Yu S, Lee C, et al. Sedative–hypnotic drug use among commu- Ethics approval and consent to participate nity-dwelling elderly in Taiwan. Int Psychogeriatr. 2018;30(7):957–65. This study was approved by the ethical committee of the American University 20. Thorell K, Midlöv P, Fastbom J, Halling A. Use of potentially inappropriate of Beirut. Since the participants were contacted over the phone, IRB waived medication and polypharmacy in older adults: a repeated cross-sectional written consent and approved verbal consent. All participants provided study. BMC Geriatr. 2020;20(1):1–9. informed verbal consent before the telephone interview. This study complies 21. American Geriatrics Society 2015 Beers Criteria Update Expert Panel, with the Declaration of Helsinki. Fick DM, Semla TP, et al. American geriatrics society 2015 updated beers Tanielian et al. BMC Primary Care (2022) 23:98 Page 8 of 8 criteria for potentially inappropriate medication use in older adults. J Am 46. Zito JM, Safer DJ, Janhsen K, et al. A three-country comparison of psycho- Geriatr Soc. 2015;63(11):2227–2246. tropic medication prevalence in youth. Child Adolesc Psychiatry Ment 22. Glass J, Lanctot KL, Herrmann N, Sproule BA, Busto UE. Sedative hypnotics Health. 2008;2(1):1–8. in older people with insomnia: Meta-analysis of risks and benefits. BMJ. 47. Kanayama G, Hudson JI, Pope HG,Jr. Culture, psychosomatics and sub- 2005;331(7526):1169. stance abuse: The example of body image drugs. Psychother Psychosom. 23. McMillan JM, Aitken E, Holroyd-Leduc JM. Management of insomnia 2012;81(2):73–78. https:// doi. org/ 10. 1159/ 00033 0415. and long-term use of sedative-hypnotic drugs in older patients. CMAJ. 48. Gabe J, Coveney CM, Williams SJ. Prescriptions and proscriptions: Moralis- 2013;185(17):1499–1505. https:// doi. org/ 10. 1503/ cmaj. 130025. ing sleep medicines. Sociol Health Illn. 2016;38(4):627–44. 24. Chiu H, Lee H, Liu J, et al. Comparative efficacy and safety of hypnotics for 49. Kaufmann CN, Spira AP, Depp CA, Mojtabai R. Long-term use of benzodi- insomnia in older adults: A systematic review and network meta-analysis. azepines and nonbenzodiazepine hypnotics, 1999–2014. Psychiatr Serv. Sleep. 2021;44(5):zsaa260. 2018;69(2):235–8. 25. Enomoto M, Kitamura S, Tachimori H, Takeshima M, Mishima K. Long-term 50. Takaesu Y, Komada Y, Asaoka S, Kagimura T, Inoue Y. Factors associated use of hypnotics: analysis of trends and risk factors. Gen Hosp Psychiatry. with long-term use of hypnotics among patients with chronic insomnia. 2020;62:49–55. PLoS One. 2014;9(11):e113753. 26. Nordfjærn T, Bjerkeset O, Bratberg G, Moylan S, Berk M, Gråwe R. Socio- 51. Irwin MR, Cole JC, Nicassio PM. Comparative meta-analysis of behavioral demographic, lifestyle and psychological predictors of benzodiazepine interventions for insomnia and their efficacy in middle-aged adults and and z-hypnotic use patterns. Nordic J Psychiatry. 2014;68(2):107–16. in older adults 55 years of age. Health Psychol. 2006;25(1):3. 27. Finan PH, Smith MT. The comorbidity of insomnia, chronic pain, and 52. Takaesu Y, Utsumi T, Okajima I, et al. Psychosocial intervention for discon- depression: dopamine as a putative mechanism. Sleep Med Rev. tinuing benzodiazepine hypnotics in patients with chronic insomnia: a 2013;17(3):173–83. systematic review and meta-analysis. Sleep Med Rev. 2019;48:101214. 28. Baglioni C, Battagliese G, Feige B, et al. Insomnia as a predictor of depres- 53. Anderson KN. Insomnia and cognitive behavioural therapy-how to assess sion: a meta-analytic evaluation of longitudinal epidemiological studies. J your patient and why it should be a standard part of care. J Thorac Dis. Aec ff t Disord. 2011;135(1–3):10–9. 2018;10(Suppl 1):S94-S102. https:// doi. org/ 10. 21037/ jtd. 2018. 01. 35. 29. Schroeck JL, Ford J, Conway EL, et al. Review of safety and efficacy of 54. Lopez-Peig C, Mundet X, Casabella B, Del Val JL, Lacasta D, Diogene E. sleep medicines in older adults. Clin Ther. 2016;38(11):2340–72. Analysis of benzodiazepine withdrawal program managed by primary 30. Jeste DV, Palmer BW, Appelbaum PS, et al. A new brief instrument for care nurses in Spain. BMC Res Notes. 2012;5(1):1–8. assessing decisional capacity for clinical research. Arch Gen Psychiatry. 2007;64(8):966–74. Publisher’s Note 31. Bastien CH, Vallières A, Morin CM. Validation of the insomnia sever- Springer Nature remains neutral with regard to jurisdictional claims in pub- ity index as an outcome measure for insomnia research. Sleep Med. lished maps and institutional affiliations. 2001;2(4):297–307. 32. Morin CM, Belleville G, Bélanger L, Ivers H. The insomnia severity index: psychometric indicators to detect insomnia cases and evaluate treat- ment response. Sleep. 2011;34(5):601–8. 33. Ryu H, Joo EY, Choi SJ, Suh S. Validation of the munich ChronoType questionnaire in korean older adults. Psychiatry Investig. 2018;15(8):775– 782. https:// doi. org/ 10. 30773/ pi. 2018. 04. 09. 34. Roenneberg T, Wirz-Justice A, Merrow M. Life between clocks: daily tem- poral patterns of human chronotypes. J Biol Rhythm. 2003;18(1):80–90. 35. Arroll B, Goodyear-Smith F, Crengle S, et al. Validation of PHQ-2 and PHQ-9 to screen for major depression in the primary care population. Ann Fam Med. 2010;8(4):348–353. https:// doi. org/ 10. 1370/ afm. 1139. 36. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606–13. 37. Dubois B, Touchon J, Portet F, Ousset PJ, Vellas B, Michel B. "the 5 words": a simple and sensitive test for the diagnosis of alzheimer’s disease. Presse Med. 2002;31(36):1696–9. 38. Suleiman KH, Yates BC. Translating the insomnia severity index into arabic. J Nurs Scholarsh. 2011;43(1):49–53. 39. Sawaya H, Atoui M, Hamadeh A, Zeinoun P, Nahas Z. Adaptation and ini- tial validation of the patient health questionnaire–9 (PHQ-9) and the gen- eralized anxiety disorder–7 questionnaire (GAD-7) in an arabic speaking lebanese psychiatric outpatient sample. Psychiatry Res. 2016;239:245–52. 40. Albanna M, Yehya A, Khairi A, et al. Validation and cultural adaptation of the arabic versions of the mini-mental status examination - 2 and mini- cog test. Neuropsychiatr Dis Treat. 2017;13:793–801. https:// doi. org/ 10. 2147/ NDT. S1268 25. Re Read ady y to to submit y submit your our re researc search h ? Choose BMC and benefit fr ? Choose BMC and benefit from om: : 41. Ohayon MM, Caulet M, Arbus L, et al. Are prescribed medications effective in the treatment of insomnia complaints? J Psychosom Res. fast, convenient online submission 1999;47(4):359–68. thorough peer review by experienced researchers in your field 42. McCall WV. Sleep in the elderly: Burden, diagnosis, and treatment. Prim Care Companion J Clin Psychiatry. 2004;6(1):9–20. https:// doi. org/ 10. rapid publication on acceptance 4088/ pcc. v06n0 104. support for research data, including large and complex data types 43. Webb WB. Sleep in older persons: sleep structures of 50-to 60-year-old • gold Open Access which fosters wider collaboration and increased citations men and women. J Gerontol. 1982;37(5):581–6. 44. Holbrook A, Crowther R, Lotter A, Endeshaw Y. The role of benzodiaz- maximum visibility for your research: over 100M website views per year epines in the treatment of insomnia: Meta-analysis of benzodiazepine use in the treatment of insomnia. J Am Geriatr Soc. 2001;49(6):824–6. At BMC, research is always in progress. 45. Frisoni GB, De Leo D, Rozzini R, Trabucchi M. Napping in the elderly and Learn more biomedcentral.com/submissions its association with night sleep and psychological status. Int Psychogeri- atr. 1996;8(3):477–87.

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