Use of hypnotics in high risk patient groups

This is the authors' abstract. We don't add key points for this paper.

Treatment of insomnia with hypnotics often requires careful consideration by a physician treating a high-risk patient. This is particularly true for pregnant women, paediatric patients and elderly patients, in part because there are not always clear practice guidelines on what hypnotic could be chosen and how it should be administered, if at all. There are three principal groups of medication that have a hypnotic (soporific) effect - benzodiazepines and nonbenzodiazepine GABA agonists (Z-hypnotics), melatonin agonists and secondary hypnotics (neurotropic medication with a secondary hypnotic property). Review of recent literature suggests that the odds for major foetal malformations, serious complications in pregnant women and serious complications in the newborn, in situations when the mother is taking hypnotics during pregnancy, is comparable to odds of the naturally occurring adverse events. Large cohort studies suggest that the relative risk for occurrence of serious adverse events increases towards the third trimester. Use of hypnotics in paediatric patients also presents a challenge, this from a different perspective. Some of the hypnotics with the favourable profile, in terms of the pharmacokinetics and infrequent or mild adverse reactions, may aggravate conditions typically present in children, such is the case of Z-hypnotics and parasomnia. The adolescent population is even more difficult to treat because of the added caveats, mainly related to the increased risk of medication abuse and amplified adverse reactions, such as paradoxical psychomotor agitation or pronounced confusion and daytime somnolence as a result of the 'carry-over effect'. The large cohort studies show increased use of hypnotics in this group, mainly as a result of an increase of melatonin use. Elderly patients have an increased need for hypnotic use on one hand, and a higher incidence of adverse events as result of such practice on the other. Use of benzodiazepines may lead to an increased risk of falls and injuries; the risk is marginally lower with the use of Z-hypnotics. Use of alternative hypnotics may be a better option for this group of patients, mainly in the form of use of melatonin agonists and soporific non-tricyclic antidepressants. Generally, and particularly within the group of elderly patients, medical conditions such as renal, cardiac, hepatic and lung diseases, and recent hospitalization present the situation where the use of hypnotics, and principally benzodiazepines, comes with the highest risk for occurrence of major adverse events. At the end, the decision whether the hypnotic should be prescribed should not be governed by the unnecessary caution and based on unsubstantiated information - the failure to treat insomnia may result in serious consequences, and may negatively affects patient's every-day life and his well-being. Such decision should rather be made based on the scientific principles and established evidence, meaning that the physician must always stay current. It also means that the considerations should include all of the available modalities of insomnia treatment, including both the pharmacological and non-pharmacological therapy, and implementation of measures of good sleep hygiene.