To Sleep: Perchance to Break a Hip
Dr. Lin is an associate professor of family and community medicine at University of Nevada School of Medicine and an adjunct professor of family medicine and geriatrics at Touro University Nevada College of Medicine. He also serves as an advisory medical director for Infinity Hospice Care and as medical director of Lions HealthFirst Foundation. Dr. Lin maintains a small private practice in Las Vegas, NV. The posts represent the views of Dr. Lin, and in no way are to be construed as representative of the above listed organizations. Dr. Lin blogs about current medical literature and news at http://alvinblin.blogspot.com/.
Of late, much has been made of our need to get adequate sleep. We generally quote an average of 7 to 8 hours/night as being the minimum necessary for proper function. However, there are also studies suggesting that our sleep requirements change as we age. And yet, for many of our retired or institutionalized, they still adhere strictly to this dogma, despite having no absolute need to meet a schedule. And if they can't fall asleep at a time they consider “normal” or if they wake up earlier than they'd like, they put on the label of insomnia and demand some sedative-hypnotic, whether benzodiazepine or non-benzodiazepine. We generally look askance at the former with its potential for addiction and confusion. Yet, the non-benzodiazepines are not without fault.
In fact, a case-crossover study was published early online last week in JAMA Internal Medicine in which the authors noted that among nursing home residents, hip fracture risk was linked to non-benzodiazepine use. Let's be clear at the outset: this study cannot prove cause and effect, just an association. Specifically, the authors found 15,528 institutionalized patients (3 out of 4 of whom were female w/avg 81yo) who'd already sustained a hip fracture of which 1715 had been given a non-benzodiazepine sedative hypnotic prior to the fracture. These participants served as cases while controls were located in the cohort. The authors noted also that greatest risk for hip fracture within the first 2 weeks of starting this medication and continued out through the quarter, especially in those with cognitive impairment and/or functional impairment.
Bottom line: focus on sleep hygiene first (try to avoid napping during day which can upset sleep cycle). Then inquire as to a need to keep to a strict schedule, especially in those who've walked away from an 8AM to 5PM job. Without that need for sleep, there's no reason why our patients can't turn into night owls if they so choose, staying up late, and waking up late, too. So let them be, rather than increase their rate for hip fracture by sedating them enough to sleep.