Strong sleeping pills known as ‘Z-drugs’ are linked with an increased risk of falls, fractures and stroke among people with dementia – according to research from the University of East Anglia.
Sleep disturbance is common among people with dementia and the impact for patients and their families is significant.
To date there are no proven effective treatments available, however people with dementia are often prescribed Z-drugs (zopiclone, zaleplon, and zolpidem).
But a new study published today reveals that stronger doses of these drugs are linked with an increased risk of adverse effects.
These adverse effects were found to be similar or greater than those for higher dose benzodiazepines or ‘benzos’ – which are also used to treat sleep disturbance, and are known to have several adverse effects.
The team say that patients already taking higher doses of Z-drugs should not stop taking their medication suddenly, however they should seek a review with their GP.
Prof Chris Fox, from UEA’s Norwich Medical School, said: “As many as 90 per cent of people with dementia suffer sleep disturbances and it has a big impact on their mental and physical health, as well as that of their carers.
“Z-drugs are commonly prescribed to help people sleep – however these medicines were never licensed for dementia and they have been associated with adverse events such as falls and fracture risks in older people.
“We wanted to find out how they affect people with dementia, who are frequently prescribed them to help with sleep disturbance.”
The team analysed data from 27,090 patients in England diagnosed with dementia between January 2000 and March 2016. The average age of the patients was 83 and 62 per cent were women.
They looked at the adverse events for 3,532 patients who had been prescribed Z-drugs and compared them to people suffering sleep disturbance who had not been prescribed sedatives, and patients who had been prescribed benzodiazepines.
They also looked to see whether Z-drug dosage played a part in adverse outcomes.
Prof Fox said: “We studied a range of adverse outcomes including fractures, falls, deep vein thrombosis, stroke and death – over two years. And we were particularly interested to see whether higher doses led to worse outcomes.”
Higher dose Z-drugs and benzodiazepines were defined as prescriptions equivalent to ≥7.5mg zopiclone or >5mg diazepam daily.
“For patients prescribed Z-drugs, 17 per cent were given higher doses. And we found that these patients on higher doses were more at risk of falls and fractures, particularly hip fractures, and stroke – compared with patients who were not taking any medication for sleep disturbance,” said Prof Fox.
Those on lower doses however (≤3.75mg zopiclone or equivalent) were not found to have an increased risk of adverse outcomes.
And there were no differences in adverse events for Z-drugs compared to benzodiazepines, except lower mortality rates with Z-drugs.
Prof Fox said: “This research shows us that higher dose Z-drugs should be avoided, if possible, in people living with dementia, and non-pharmacological alternatives preferentially considered.
“Patients already taking higher dose Z-drugs should not stop taking their medication, but we recommend that they should make an appointment to see their GP for a review,” he added.
Prof Clive Ballard, of the University of Exeter Medical School, who collaborated on the study, said: “Our findings serve an important caution regarding the harms of sleeping tablets in people with dementia.
“This research is a very timely and unfortunately necessary reminder that sedative medications are not a helpful way to manage social isolation during Covid-19.
“Our study also highlights the importance of research to develop non-drug approaches to help people with dementia to sleep – whether they are at home or in residential care.”
Dr Ian Maidment, Reader in Clinical Pharmacy at Aston University and lead pharmacist on the study, said: “Z-drugs are widely used to treat insomnia in people living with dementia, but are only recommended as a short-term treatment for the maximum of four weeks. Our work shows the importance of clinicians including GPs and pharmacists reviewing patients on long-term Z-drugs.”
The study was led by UEA, in collaboration with researchers from The Quadram Institute, Aston University, University College London, and the University of Exeter.
‘Adverse effects of Z-drugs for sleep disturbance in people living with dementia: a population-based cohort study’ is published in the journal BMC Medicine on November 24, 2020.
Smoking linked to stroke in new study
Adults who smoke, or are genetically predisposed to smoking behaviours, are more likely to experience a subarachnoid haemorrhage (SAH), new research has revealed.
The study found that while smokers are at a higher risk of SAH, that rises to over 60 per cent among those with genetic variants that predispose them to smoking.
The research, published in Stroke, a journal of the American Stroke Association, establishes a link between smoking and the risk of SAH for the first time.
While it has been proven in other types of stroke, this is pioneering research in its link with SAH – a type of stroke that occurs when a blood vessel on the surface of the brain ruptures and bleeds into the space between the brain and the skull.
Results of the study show:
- the relationship between smoking and SAH risk appeared to be linear, with those who smoked half a pack to 20 packs of cigarettes a year having a 27% increased risk;
- heavier smokers, those who smoked more than 40 packs of cigarettes a year, were nearly three times more at risk for SAH than those who did not smoke; and,
- people who were genetically predisposed to smoking behaviours were at a 63% greater risk for SAH.
Researchers also stated that while their findings suggest a more pronounced and harmful effect of smoking in women and adults with high blood pressure, they believe larger studies are needed to confirm these results.
“Previous studies have shown that smoking is associated with higher risks of SAH, yet it has been unclear if smoking or another confounding condition such as high blood pressure was a cause of the stroke,” says senior study author Guido Falcone, assistant professor of neurology at Yale School of Medicine.
“A definitive, causal relationship between smoking and the risk of SAH has not been previously established as it has been with other types of stroke.”
During the study, researchers analysed the genetic data of 408,609 people from the UK Biobank, aged 40 to 69 at time of recruitment (2006-2010).
Incidence of SAH was collected throughout the study, with a total of 904 SAHs occurring by the end of the study.
Researchers developed a genetic risk scoring system that included genetic markers associated with risk of smoking and tracked smoking behaviour data, which was collected at the time each participant was recruited.
“Our results provide justification for future studies to focus on evaluating whether information on genetic variants leading to smoking can be used to better identify people at high risk of having one of these types of brain haemorrhages,” said lead study author Julian N. Acosta, neurologist, postdoctoral research fellow at the Yale School of Medicine.
“These targeted populations might benefit from aggressive diagnostic interventions that could lead to early identification of the aneurysms that cause this serious type of bleeding stroke.”
New campaign to reduce stroke risk launched on Stroke Prevention Day
A 12-week campaign is being launched today – Stroke Prevention Day – to help raise awareness of how the risk of stroke can be reduced.
The campaign encourages people to make one small positive change to their lifestyle to reduce the possibility of stroke, which is the fourth highest cause of death in the UK.
According to the Stroke Association UK, 89 per cent – almost 9 in 10 – strokes are associated with modifiable risk factors in the Western countries, including lifestyle elements that can be changed to reduce risk, such as weight, diet and blood pressure.
New research commissioned by the charity, which is leading the campaign, has also revealed:
- Only 1 in 20 (6%) UK adults think they’re at high risk of a stroke, despite the fact that the global lifetime risk of stroke from the age of 25 years onward was approximately 25% among both men and women
- Almost half (47%) of the country don’t know that high blood pressure is a top risk factor for stroke
- 3 in 4 people (73%) said that they have had no information about stroke reduction recently, which rises to over 4 in 5 (85%) of over-65s, who are most at risk of having a stroke.
Blood pressure is the biggest cause of stroke, with 55 per cent of stroke patients having hypertension when they experience their stroke. Further, around 1 in 4 adults from 55 years of age will develop AFib.
“While these numbers are concerning, they also demonstrate that with increased awareness, we can all take simple steps to reduce our risk,” says Charlie Fox, sales director of OMRON Healthcare, who are supporting the Stroke Association campaign alongside Patients Know Best.
“As an incredibly important risk factor for stroke, having a healthy heart should be a top priority and remain front of mind.”
AFib can be asymptomatic and may not be present during a medical appointment as episodes can be occasional, which means it is often left undiagnosed.
But given its seriousness, those who may be at risk should routinely record electrocardiogram (ECG) measurements, according to current medical guidelines.
Through doing so at home will enable patients to become more in control of their health, with OMRON being one of the companies developing the technology to support them in doing so.
“The public wants and needs to be more in control of its health, which is why we create products and services that are suitable for use at home as part of our Going for Zero strokes pledge,” adds Fox.
“OMRON Complete, for example, is an upcoming, clinically validated home blood pressure monitor with a built-in ECG which can help detect AFib which we’re excited to launch in the coming months.
“It is our hope that through this awareness programme and by equipping the public with the tools it needs, we can make having an empowered and informed lifestyle the new normal.”
People with a Patients Know Best (PKB) Personal Health Record can also log readings to get a more complete picture of their health journey. This allows them to look back with ease and share readings with clinical teams and caregivers in a safe, secure and meaningful way.
Fox concludes: “Your blood pressure provides important health insights. Monitoring it regularly alongside your ECG readings empowers you with knowledge, helps you act sooner, and can even save your life”.
More information about the campaign and how you can make your one small change can be found here: www.stroke.org.uk/
What are the IDDSI Levels and why do they matter?
Dysphagia, more commonly known as swallowing difficulties, can be prevalent amongst those in neuro rehabilitation. For those in recovery, understanding how their swallowing has been affected, what solutions are available and which nutritional, delicious and above all, safe, meals they should be eating, is of paramount importance.
When someone starts to experience dysphagia, they are most commonly seen by a speech and language therapist (SLT) and a dietitian. Together, they will create a plan for the management of dysphagia. A speech and language therapist will explain in detail the importance of texture modified food and drinks and will work with you to carefully understand the right texture modification for you.
What is IDDSI?
This is where IDDSI can help you understand your recommended texture modified diet in more detail. IDDSI stands for International Dysphagia Diet Standardisation Initiative. This is a committee that have developed a framework of 8 levels which provide common terminology to describe food textures and the thickness of liquids for those living with dysphagia.
The purpose of IDDSI is to create standardised terminology and descriptors for texture modified foods and liquids that can be applied and understood globally – across all cultures and age spans.
Before the introduction of IDDSI, there were national descriptors in the UK which were formed by opinion rather than international standards. Having different terminology, categories and definitions in different countries caused some instances of food being of incorrect consistency. The IDDSI framework was fully adopted by food manufacturers and healthcare settings in the UK in March 2019.
The framework consists of levels for both drinks (liquids) and foods, some of which overlap as you can see in the image above. Here is a breakdown of each category in the IDDSI FOODS framework.
Level 3 – Liquidised/Moderately Thick
- Can be drunk from a cup
- Does not retain its shape
- Can be eaten with a spoon, not a fork
- Smooth texture with no ‘bits’
Level 4 – Pureed/Extremely Thick
- Usually eaten with a spoon (a fork is possible)
- Does not flow easily
- Does not require chewing
- Retains its shape
- No lumps
- Not a sticky consistency
Level 5 – Minced
- Can be eaten with either a fork or a spoon
- Can be scooped and shaped
- Small lumps are visible, but are easy to squash with tongue
- Biting is not required
- Minimal chewing required
Level 6 – Soft & Bite-Sized
- Can be eaten with fork or spoon
- Can be mashed/broken down with pressure
- Chewing is required before swallowing
How can I check my meals are made to IDDSI standards?
You can check to see whether your food is compliant with the IDDSI Framework by watching these IDDSI Food Test videos.
To discover a Softer Foods range which is IDDSI compliant and created with your patients’ needs in mind, register here for the opportunity to try some complimentary meals from Wiltshire Farm Foods.
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