Lullaby in a Bottle
How Safe are Sleep Medications?
By MARILYN PRIBUS
The ads are seductive. Softly fluttering moths. A
perfectly coiffed woman smiling in peaceful slumber. A hand-some,
energetic man greeting a sunny day. Small wonder we ask whether we might
benefit from “sleep aids.”
As we age, changes in sleep pat-terns are very
common, so older per-sons pay particular attention to such ads. People
who don’t fall asleep promptly or who waken during the night may believe
they have problems with insomnia, a perception increasingly influenced
by advertising for the multi-billion-dollar prescription sleep
medication industry.
Jon Schommer, Ph.D., a professor at the University of
Minnesota’s College of Pharmacy, laments what he terms the “medicalization”
of ordinary human experience—the idea that there is a pill for every
ill. “In the normal aging process, we will be sad sometimes, our hair
may fall out. But now drugs are increasingly available to treat aliments
or symptoms once considered a normal part of life.”
Uneven slumber may have as simple a cause as a
restless or snoring sleep partner. Other common situational reasons
include short-term anxiety, stress and jet lag.
Medical reasons include reaction to various
prescription and over-the-counter medications, allergies, pain from
arthritis or other conditions, heart disease, asthma, Alzheimer’s or
Parkinson’s disease, high blood pres-sure, sleep apnea, restless leg
syndrome and other less common problems.
An unfortunate outcome of this pill-for-every-ill
perception, Schommer notes, is both the trivial-ization of drugs and a
minimization of healthy living and healthy behaviors.
“After all,” he says, “if there’s a solution in a
pill, people think maybe they don’t have to worry about what they eat or
whether they exercise.”
“Talk to Your Doctor”
Ads for sleep-inducing medications often include a
list of questions that elicits at least one “yes” answer from almost
everyone. Readers are then advised to consult their health-care
provider. While this can open important patient-physician communication,
it also implies that every “yes” means a medical problem.
The Food and Drug Administration requires that ads
present a fair balance of information about benefits and risks. But
Schommer cites the tendency to remember what you heard first and what
you heard last.
“Risks are mentioned,” he says, “but [on TV] it’s in
the middle, when the ad gets very boring.” In magazines or newspapers,
risks are disclosed in bifocal-defying small print.
Risks Increase with Age
And there are risks. Statistics show that people 65
and older have the highest percentage usage of sleep medications and
also are most likely to experience side effects.
“One of the most common complaints when using [sleep
aid] medications is a ‘hangover’ of drowsiness into the daytime,
especially after first awakening,” says Cynthia Brown, M.D., of the
University of Virginia. “In that case, it would be important to discuss
with the prescribing doctor whether a lower dose may be appropriate.”
Other possible side effects include dizziness,
confusion, memory impairment, lack of alertness during the day and
problems with liver or kidney function. Less-likely side effects include
hallucinations, deepening of depression, agitation, suicidal thoughts
and sleepwalking.
Older persons suffer more side effects for several
reasons. For one thing, metabolism often slows with age—meaning
medications stay in the system longer—and older people are frequently
taking other drugs that may interact badly with sleep medications.
Since older persons are likely to have a decreased
thirst sensation or to deliberately restrict fluids to minimize bathroom
visits, dehydration can affect the action of medications. In addition,
they tend to rise more frequently during the night when drowsiness or
dizziness, compounded by medication, can lead to falls.
Dependence Not a Big
Issue In addition to side effects, some people
experience “rebound insomnia.” This is the result of increasing
tolerance—that is, the body requiring more of a drug to achieve the same
effect. Then, if the medication is suddenly discontinued, the person
gets much less sleep.
“Newer agents such as Lunesta, Ambien and Sonota have
less potential for dependence than [older] drugs such as Restoril,
Halcyon or Ativan,” says Brown. “Research has shown the regular use of
Ambien for one year did not lead to development of tolerance or rebound
worsening of insomnia.”
In any case, rebound insomnia “usually resolves
itself over several nights,” says Thomas Balkin, Ph.D., a
sleep-disorders expert at Walter Reed Army Institute of Research. He
adds, “People who experience this might tend to stay on medications for
long periods of time, feeling [incorrectly] they are incapable of
sleeping without it.”
Medication Can Help
There are, of course, good reasons to take
sleep-inducing drugs at times. “Insomnia is often caused by initial
grieving, stressful events or pain, and these medications are
particularly good for those situations,” Balkin says.
Brown notes that significant health or life changes
often precipitate a change in sleep patterns. Talking with a health care
provider can help people with problems deter-mine whether or not
medication is appropriate, she says. “In many instances, changes in
sleep behavior may lead to improvements in sleep quality without the use
of a sleep aid.”
If you conclude that sleep medicine is best for your
situation, Brown cautions that when such medications are first
prescribed, it’s important to take them only when you are ready for bed
and have at least eight hours to devote to sleep since each person
reacts differently.
And don’t let the peaceful images of fluttering moths
and sleeping beauties distract you from the most important guidelines:
read the information which comes with any prescription, follow
the directions absolutely and never exceed the recommended dosage.
Marilyn Pribus lives, writes and sleeps in
Charlottesville.
Alternatives to Sleep Medications
Simple lifestyle changes can make a real difference
for most people. You probably know about avoiding daytime naps and
keeping the bedroom cool, dark and quiet, using it only for sleep and
intimacy. Here are some other strategies.
During the Day
• Rise at the same time every morning to maintain a
constant sleep/wake rhythm, even if you’ve been up late the night
before.
• Eliminate all caffeine (coffee, tea, chocolate,
some soft drinks and medications) for at least two weeks for a true
test.
• Limit liquor. Alcohol can cause drowsiness, but the
body’s reaction to alcohol’s depressive effects often causes wakefulness
after four or five hours.
• If anxiety is a problem, set a specific Worry
Period each day—for example, 4 to 4:15 p.m. If concerns arise at other
times, save them for your Worry Period. Determine possible courses of
action, then dismiss worries from the mind. (This proved extraordinarily
effective for my father, a self-proclaimed “worry wart.” In less than
two weeks he was sleeping better and actually for-getting his Worry
Period.)
• Exercise vigorously during the day. Many people try
to sleep when they are not physically tired.
In the Evening
• Try warm milk or a small, high-carbohydrate snack
such as cereal or toast before bed.
• Have a relaxing bedtime routine. Instead of
housework, watching TV or checking e-mail, take a warm bath, read a book
or play solitaire.
In Bed
• Yawn. Consciously deepen your breathing pattern.
Count backwards from 100 with one number for each slow full breath.
• Keep a pad next to the bed for a “to-do” list. Once
written down, those thoughts disappear.
• Instead of thinking about future plans such as
tomorrow’s engagements or an upcoming vacation, reminisce about a
pleasant event in the past. One woman reports that she mentally walks
through her childhood home and is usually asleep before she reaches her
upstairs bedroom.
