Hypnotics in the elderly. What cause for concern?

At any age hypnotic drug use can give rise to 3 major problems: unwanted effects on daytime mood and behaviour associated with drug consumption; rebound effects associated with drug withdrawal; and dependency associated with long term drug use. For 2 reasons elderly hypnotic users are both more vulnerable and more exposed to each of these problems. Firstly, age-related changes in pharmacodynamic and pharmacokinetic processes amplify the behavioural impact of many hypnotics; and secondly, age-related changes in the structure and quality of sleep tend to increase the demand for, and the long term use of, sedative hypnotic compounds in old age. The existence of physical illness, cognitive impairment, or daytime behaviour already compromised by normal aging processes further increases the likelihood of hypnotic drugs detrimentally affecting well-being in later life. These important causes for concern emphasise the need for 2 separate clinical responses: the need for greater circumspection in the choice and use of hypnotic drugs among elderly patients, and the need for a more broadly based clinical approach to the management of sleep problems in old age.