A person seen in bed with a pillow over their face.
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  • Benzodiazepines such as Xanax can be prescribed as sleeping aids.
  • Use of benzodiazepines in older adults is associated with increased risks of car accidents, falls and fractures, hospitalization and death.
  • Benzodiasepines can help treat insomnia but they have a number of adverse effects, including a risk of dependency.

Use of a class of sleep aids called benzodiazepines increased in recent years in Beijing, according to Chinese researchers, including in older adults.

This occurred in spite of guidelines and expert consensus recommending against “routine” use of these medications in older adults due to the risk of adverse effects among this age group.

In contrast, a study by U.S. researchers found a drop in the prescribing of sleep medications in the country. However, this study ended before the start of the COVID-19 pandemic, which disrupted sleep for many around the world.

Sleeps aid use increased in China

In a study published Feb. 17 in JAMA Network Open, researchers examined data from over 550,000 adult outpatient visits for insomnia made to primary health care facilities in Beijing between 2016 and 2020.

They included only patients who received at least one prescription for a benzodiazepine receptor agonist (BZRA), a class of medications used to treat insomnia and anxiety.

Because some of these medications are also used to treat anxiety, researchers excluded patients who had been diagnosed with anxiety or depression.

BZRAs include benzodiazepines such as triazolam, estazolam and temazepam. These drugs are effective for treating insomnia, but have a number of adverse effects, including a risk of dependency.

Another group of BZRAs are known as nonbenzodiazepines, or Z-drugs. This includes eszopiclone (Lunesta), zaleplon (Sonata) and zolpidem (Ambien). These drugs also work as treatments for insomnia, but appear to have fewer adverse effects than benzodiazepines.

In the study, researchers found that the overall rate of prescriptions for benzodiazepines increased from 34.8% to 62.8% during the study period.

The largest increases occurred in patients 85 years or older, increasing to 68.3% in 2020; and in 75- to 84-year-olds, rising to 65.4% in 2020.

In 2020, prescriptions for benzodiazepines increased with patient age. In addition, older adults received prescriptions with a similar daily dosage as younger adults, researchers found.

Use of benzodiazepines in older adults is associated with increased risks of car accidents, falls and fractures, hospitalization and death.

Although guidelines recommend against routine use of benzodiazepines in older adults, “we still observed a more prominent increase of benzodiazepine prescribing in older adults despite their vulnerability to benzodiazepine-related adverse events,” the authors of the new paper wrote.

U.S. sees a drop in sleep med use

In the United States, prescriptions for sleep medications have been falling in recent years, possibly due to efforts to decrease the use of these drugs.

In a study published in 2022 in the Journal of Clinical Sleep Medicine, researchers examined data for over 29,000 participants in the 2013-2018 National Health and Nutrition Examination Survey.

During this time, use of prescription sleep medications decreased 31%, driven by a drop in the use of these drugs over medium- and long-term durations.

Researchers saw an even sharper decline (86%) in the use of prescription sleep medications among people 80 years or older.

Study author Christopher Kaufmann, PhD, an assistant professor in the Department of Health Outcomes and Biomedical Informatics at the University of Florida in Gainesville, said the results of the study were surprising.

“Prior studies have shown an increase in use of these agents from as early as the 1990s up into the mid-2010s,” he told Healthline.

Although it’s not clear what is behind the more recent downward trend, Dr. Kaufmann said there have been a number of efforts in the United States to reduce the prescribing of sleep medications, particularly to older adults, who are at greater risk of adverse effects.

“These efforts include de-prescribing programs, which are designed to help patients discontinue, or at minimum, taper their use [of these medications],” he said.

“There have also been efforts to increase availability of safer, behavioral treatments for sleep disturbances,” he said, including online programs and mobile apps.

Because data for the study only ran through 2018, it will also be important to look at trends in use of prescription sleep medications later on, said Kaufmann, such as during the COVID-19 pandemic.

Sleep aids appropriate for some patients

While prescription sleep medications have a number of adverse effects, there are times when doctors recommend these drugs for patients.

Dr. Karin Johnson, a professor of neurology and medical director of the sleep medicine program at Baystate Medical Center in Springfield, Mass., said in her practice, she typically recommends these medications for patients who have something else going on.

This might include sleep disruptions due to shift work, chronic pain or another medical condition.

“I tend to feel that cognitive behavioral therapy for insomnia [CBT-i] alone isn’t going to be enough for those people,” she told Healthline, “so likely they will need medication as well.”

Dr. Ronald Gavidia Romero, an assistant professor of neurology who specializes in sleep medicine at University of Michigan Health in Ann Arbor, said insomnia is frequently accompanied by other disorders that may exacerbate the symptoms.

“These issues should be treated in order to guarantee the best outcome with CBT-i, hypnotics [sleep aids], or a combination of both,” he told Healthline.

Sleep aids could also work for someone who needs help sleeping for a couple of days, said Johnson, such as after the death of a loved one.

However, she cautioned that these medications may not be appropriate for older adults, or for people who have a history of sleepwalking or other complex sleep behaviors, or a history of drug use.

In addition, benzodiazepines should not be used alongside opioids, because both kinds of drugs can cause sedation and suppress breathing.

Cognitive behavioral therapy for insomnia

For chronic, or long-term, insomnia, the preferred initial approach is CBT-i, said Gavidia Romero, which “has the advantage of not exposing the patient to the potential side effects of medications.”

In some cases, “depending on [a patient’s] goals, CBT-i can be combined with hypnotics, with the plan of tapering down the medication in the future,” he said.

One aspect of CBT-i is sleep hygiene, said Johnson, which includes creating a good sleep environment (aka cool, dark and quiet), avoiding caffeine and nicotine before bed, and setting up a regular sleep schedule.

The cognitive part of this therapy involves addressing negative sleep thoughts such as “I’m never going to be able to sleep,” or “what if I can’t get to sleep tonight.”

“Those [thoughts] are often drivers of difficult sleeping,” said Johnson. However, “they can be worked on [during CBT-i] to help treat chronic insomnia.”

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