Use of sedative-hypnotics and the risk of Alzheimer's dementia: A retrospective cohort study

Use of Drugs Affecting GABAA Receptors and the Risk of Developing Alzheimer's Disease and Dementia: a Meta-Analysis and Literature Review

The gamma-aminobutyric acid (GABA) system is known for its role in cognitive functions and memory processes. However, the activity of GABAA receptors and their associated pathways influence the accumulation of β-amyloid peptide (Aβ), a key hallmark in the development and prognosis of research examining the relationship between the use of drugs affecting GABAA receptors and the risk of developing Alzheimer's disease (AD) and dementia. This study aimed to examine the association between GABAA receptor-affecting drugs and the risk of AD and dementia, focusing on benzodiazepines, zolpidem, and anesthetics. This meta-analysis included all English articles on AD, dementia, and GABAA receptor agonist medications published before May 2024. The articles were identified through searches conducted on PubMed and Scopus databases. The extracted data were analyzed using STATA software (version 14.2). Q statistics and the I2 index were used to evaluate heterogeneity, while Egger's test and funnel plot were utilized to detect publication bias. A total of 19 articles (10 case-control and 9 cohort articles) were eligible for the analysis, involving 2,953,980 patients. The use of GABA agonists was found to have a statistically significant relationship with the development of dementia (RR = 1.15, 95% CI: 1.02-1.29, I2 = 87.6%) and AD (RR = 1.21, 95% CI: 1.04-1.40, I2 = 97.6%). In the drug-based subgroup, we observed that zolpidem consumption was associated with an increased incidence of AD and dementia (RR = 1.28, 95% CI: 1.08-1.52, I2 = 24.3%), similar to the effects of benzodiazepines (BZDs; RR = 1.11, 95% CI: 1.04-1.18, I2 = 87.2%). Meta-regression analysis showed that the duration of follow-up, which ranged from 5 to 11 years across the studies, was significantly associated with heterogeneity (P = 0.036). Our findings indicate that the use of zolpidem and BZD is associated with an increased risk of dementia and AD.

Long-Term Insomnia Treatment with Benzodiazepines and Alzheimer's Disease: A Systematic Review

Alzheimer's disease is the most common form of dementia. Benzodiazepines are the most widely used pharmacological class in the treatment of insomnia and other sleep disorders. Some literature suggests that the chronic use of benzodiazepines is associated with the development of cognitive decline. This review aims to evaluate the use of benzodiazepines and its association with the development of Alzheimer's disease. A systematic review of the literature was carried out using the MEDLINE and Embase databases. Protocols followed the PRISMA-P 2020 methodology, and, after the analysis of the included studies, a narrative synthesis of the results was carried out. Only two cohort studies were identified that met defined eligibility criteria. In the retrospective study, a significant risk of developing Alzheimer's disease after treatment with benzodiazepines was found. In the prospective study, the prevalence of Alzheimer's disease was not associated with treatment with benzodiazepines. Results suggest that only the largest study presented a significant risk of developing Alzheimer's disease. Given the scarce scientific evidence found, it is concluded that further research on this topic is necessary.

Medication Exposure and Risk of Dementia and Alzheimer's Disease

Alzheimer's disease (AD), a complex neurodegenerative disease (ND), is the most predominant cause of dementia among the elderly. Generally, elderly people have multiple chronic health conditions, like hypertension, arthritis, diabetes, insomnia, bowel problems, and depression. Although prescribed medications have beneficial therapeutic compositions, some may have side effects that could hinder cognitive function or worsen cognitive decline. Hence, we should evaluate those medications to guarantee their safety. In the present mechanistic review, we discussed frequently used categories of medication (analgesics, anticholinergics, benzodiazepines, proton pump inhibitors, and statins), concerning their possible involvement in increasing AD and dementia risks. This review summarized the results of various observational studies, meta-analyses, randomized case-control studies, and systematic reviews. As the results were contradictory, it was difficult to ascertain the clear associations between medication usage and increased risks of dementia or AD. The blood-based biomarkers (BBMs) offer a low-cost and accessible alternative for early diagnosis of AD. Systematic reviews combined with meta-analysis would be crucial tools for accurately assessing and summarizing the efficacy of health interventions, yet randomized clinical trials have always been the best way to help with clinical care decisions. Thus, an open discussion is necessary to help individuals determine whether the advantages of utilizing medications outweigh the possible drawbacks.

Association between CNS-active drugs and risk of Alzheimer's and age-related neurodegenerative diseases

Objective

As neuropsychiatric conditions can increase the risk of age-related neurodegenerative diseases (NDDs), the impact of CNS-active drugs on the risk of developing Alzheimer's Disease (AD), non-AD dementia, Multiple Sclerosis (MS), Parkinson's Disease (PD) and Amyotrophic Lateral Sclerosis (ALS) was investigated.

Research design and methods

A retrospective cohort analysis of a medical claims dataset over a 10 year span was conducted in patients aged 60 years or older. Participants were propensity score matched for comorbidity severity and demographic parameters. Relative risk (RR) ratios and 95% confidence intervals (CI) were determined for age-related NDDs. Cumulative hazard ratios and treatment duration were determined to assess the association between CNS-active drugs and NDDs at different ages and treatment duration intervals.

Results

In 309,128 patients who met inclusion criteria, exposure to CNS-active drugs was associated with a decreased risk of AD (0.86% vs 1.73%, RR: 0.50; 95% CI: 0.47-0.53; p <.0001) and all NDDs (3.13% vs 5.76%, RR: 0.54; 95% CI: 0.53-0.56; p <.0001). Analysis of impact of drug class on risk of AD indicated that antidepressant, sedative, anticonvulsant, and stimulant medications were associated with significantly reduced risk of AD whereas atypical antipsychotics were associated with increased AD risk. The greatest risk reduction for AD and NDDs occurred in patients aged 70 years or older with a protective effect only in patients with long-term therapy (>3 years). Furthermore, responders to these therapeutics were characterized by diagnosed obesity and higher prescriptions of anti-inflammatory drugs and menopausal hormonal therapy, compared to patients with a diagnosis of AD (non-responders). Addition of a second CNS-active drug was associated with greater reduction in AD risk compared to monotherapy, with the combination of a Z-drug and an SNRI associated with greatest AD risk reduction.

Conclusion

Collectively, these findings indicate that CNS-active drugs were associated with reduced risk of developing AD and other age-related NDDs. The exception was atypical antipsychotics, which increased risk. Potential use of combination therapy with atypical antipsychotics could mitigate the risk conferred by these drugs. Evidence from these analyses advance precision prevention strategies to reduce the risk of age-related NDDs in persons with neuropsychiatric disorders.

Anxiety disorders, benzodiazepine prescription, and incident dementia

BACKGROUND

Prescribing benzodiazepines to older patients is controversial. Anxiety disorders and benzodiazepines have been associated with dementia, but literature is inconsistent. It is unknown if anxiety treated with a benzodiazepine, compared to anxiety disorder alone is associated with dementia risk.

METHODS

A retrospective cohort study (n = 72,496) was conducted using electronic health data from 2014 to 2021. Entropy balancing controlled for bias by indication and other confounding factors.

PARTICIPANTS

Eligible patients were ≥65 years old, had clinic encounters before and after index date and were free of dementia for 2 years prior to index date. Of the 72,496 eligible patients, 85.6% were White and 59.9% were female. Mean age was 74.1 (SD ± 7.1) years.

EXPOSURE

Anxiety disorder was a composite of generalized anxiety disorder, anxiety not otherwise specified, panic disorder, and social phobia. Sustained benzodiazepine use was defined as at least two separate prescription orders in any 6-month period.

MAIN OUTCOME AND MEASURES

ICD-9 or ICD-10 dementia diagnoses.

RESULTS

Six percent of eligible patients had an anxiety diagnosis and 3.6% received sustained benzodiazepine prescriptions. There were 6640 (9.2%) incident dementia events. After controlling for confounders, both sustained benzodiazepine use (HR 1.28, 95% CI: 1.11-1.47) and a diagnosis of anxiety (HR 1.19, 95% CI: 1.06-1.33) were associated with incident dementia in patients aged 65-75. Anxiety disorder with sustained benzodiazepine, compared to anxiety disorder alone, was not associated with incident dementia (HR 1.18, 95% CI: 0.92-1.51) after controlling for confounding. Results were not significant when limiting the sample to those ≥75 years of age.

CONCLUSIONS

Benzodiazepines and anxiety disorders are associated with increased risk for dementia. In patients with anxiety disorders, benzodiazepines were not associated with additional dementia risk. Further research is warranted to determine if benzodiazepines are associated with a reduced or increased risk for dementia compared to other anxiolytic medications in patients with anxiety disorders.

The epidemiology of new persistent hypnotic/sedative use after surgical procedures: a retrospective cohort study

The use of hypnotic and sedative medication for sleep improvement is common and long-term use has been associated with an increased risk of adverse events and mortality. A proportion of patients might develop long-term use after initiating new persistent use following surgery. This retrospective cohort study aimed to determine the incidence of new persistent hypnotic/sedative use after surgical procedures and associated patient and procedural factors. Data on prescriptions for hypnotic and sedative medications used for sleep improvement were retrieved from the National Prescription Medicine Registry. Medication naivety was defined as not filling a prescription for hypnotics/sedatives from 365 days through 31 days preceding surgery, new use was defined as medication naivety followed by filling a prescription for hypnotic/sedative medication from 30 days before surgery through 14 days after surgery. New persistent hypnotic/sedative use was defined as new use followed by filling another hypnotic/sedative prescription from 15 days through 365 days after surgery. Of 55,414 patients included in the study, 43,297 were naive to hypnotic/sedative medications. Of those naive patients, 4.6% met the criteria for new peri-operative use, of whom 51.6% developed new persistent hypnotic/sedative use. Patient and procedural factors associated with increased risk of new persistent use were older age; female sex; the presence of malignant neoplasm; ischaemic heart disease; and having undergone either cardiac or thoracic surgery. The hazard of long-term mortality was higher for patients with new persistent use (1.39, 95%CI 1.22-1.59) compared with patients who remained naive. While a small ratio of surgical patients initiates the use of hypnotics/sedatives in the peri-operative period, a substantial proportion of these develop persistent use, which is associated with adverse outcomes. Over time, the proportion of patients using hypnotics/sedatives has declined, but the risk of persistent use within this group has remained stable.

The promise of portable remote auditory stimulation tools to enhance slow-wave sleep and prevent cognitive decline

Dementia is the seventh leading cause of mortality, and a major source of disability and dependency in older individuals globally. Cognitive decline (and, to a lesser extent, normal ageing) are associated with sleep fragmentation and loss of slow-wave sleep. Evidence suggests a bidirectional causal link between these losses. Phase-locked auditory stimulation has emerged as a promising non-invasive tool to enhance slow-wave sleep, potentially ameliorating cognitive decline. In laboratory settings, auditory stimulation is usually supervised by trained experts. Different algorithms (simple amplitude thresholds, topographic correlation, sine-wave fitting, phase-locked loop, and phase vocoder) are used to precisely target auditory stimulation to a desired phase of the slow wave. While all algorithms work well in younger adults, the altered sleep physiology of older adults and particularly those with neurodegenerative disorders requires a tailored approach that can adapt to older adults' fragmented sleep and reduced amplitudes of slow waves. Moreover, older adults might require a continuous intervention that is not feasible in laboratory settings. Recently, several auditory stimulation-capable portable devices ('Dreem®', 'SmartSleep®' and 'SleepLoop®') have been developed. We discuss these three devices regarding their potential as tools for science, and as clinical remote-intervention tools to combat cognitive decline. Currently, SleepLoop® shows the most promise for scientific research in older adults due to high transparency and customizability but is not commercially available. Studies evaluating down-stream effects on cognitive abilities, especially in patient populations, are required before a portable auditory stimulation device can be recommended as a clinical preventative remote-intervention tool.

The Role of Sleep in Cognitive Function: The Value of a Good Night's Rest

As a universal, evolutionarily conserved phenomenon, sleep serves many roles, with an integral role in memory. This interplay has been examined in a variety of research. The purpose of this article will be to review the literature of sleep, aging, cognition, and the impact of two common clinical conditions (obstructive sleep apnea and insomnia) on cognitive impairment. This article will review data from meta-analyses, population studies, smaller cohort studies, neuropsychological studies, imaging, and bench data. Considerations are given to the current data trends and their limitations. This paper will explore the impact of sleep on cognitive impairment. Finally, we will conclude with integrating the separate mechanisms towards more generalized common pathways: disruption of sleep quality and reduction in sleep quantity lead to excessive neuronal activity without sufficient time for homeostasis. Sleep apnea and chronic insomnia can lead to oxidative stress and neuronal damage. These changes predispose and culminate in the development of cognitive impairment.

Protective Effect of Renin-Angiotensin System Inhibitors on Parkinson's Disease: A Nationwide Cohort Study

Background: Renin-angiotensin system (RAS) inhibitors have been suggested as protective agents in Parkinson's disease (PD). However, epidemiological evidence on the association between RAS inhibitors and the development of PD is inconsistent. Objectives: To investigate the effect of RAS inhibitors on PD risk in patients with ischemic heart disease (IHD) by type and cumulative duration of RAS inhibitors and their degree of blood-brain barrier (BBB) penetration ability. Methods: This was a propensity score-matched retrospective cohort study using 2008-2019 healthcare claims data from the Korean Health Insurance Review and Assessment database. The association between RAS inhibitor use and PD in patients with IHD was evaluated using multivariate Cox proportional hazard regression analysis. The risks are presented as adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs). Results: Over a 10-year follow-up, 1,086 of 62,228 IHD patients developed PD. The Cox regression model showed that the use of RAS inhibitors was significantly associated with a lower risk of PD (aHR = 0.75; 95% CI 0.66-0.85) than the non-use of RAS inhibitors. Specifically, this reduced risk of PD only remained with the use of BBB-crossing angiotensin II receptor blockers (ARBs) (aHR = 0.62; 95% CI = 0.53-0.74), and this association was more definite with an increasing cumulative duration. A significantly reduced risk of PD was not observed with the use of BBB-crossing angiotensin-converting enzyme inhibitors. Conclusions: The use of ARBs with BBB-penetrating properties and a high cumulative duration significantly reduces the risk of PD in IHD patients. This protective effect could provide insight into disease-modifying drug candidates for PD.

Transcranial magnetic stimulation for sleep disorders in Alzheimer's disease: A double-blind, randomized, and sham-controlled pilot study

BACKGROUND

Sleep disorders are commonly comorbid with Alzheimer's disease (AD), And these disorders interfere with each other in many aspects. To date, pharmacological treatments for sleep disorders are still limited, and studies investigating repetitive transcranial magnetic stimulation (rTMS) for sleep disorders in AD are still lacking.

METHOD

A single-center, randomized, double-blind, parallel-arm, and sham-controlled pilot study was conducted in AD patients with sleep disorders. Seventy subjects were randomly divided into the following two groups: the sham group (SG) and the intervention group (IG). We evaluated sleep changes using the Pittsburgh Sleep Quality Index (PSQI) before and after the intervention. We also assessed the patients' cognitive function by the Alzheimer's Disease Assessment Scale-Cognitive section (ADAS-Cog). The intervention period was four weeks, and the patients were followed up in the 8th week to test the persistence of the effect of the rTMS intervention.

RESULT

Significant differences in the PSQI scores were found between the SG and IG at the end of the 4-week intervention (P = 0.001) and the 8-week follow-up (P < 0.001). There was also significant improvement in ADAS-Cog scores (4 weeks: P = 0.048, 8 weeks: P = 0.038). Activities of daily living (ADL) did not significantly differ between the SG and IG.

CONCLUSION

rTMS can effectively ameliorate sleep disorders in AD patients.

Association Between Z Drugs Use and Risk of Cognitive Impairment in Middle-Aged and Older Patients With Chronic Insomnia

Background: Benzodiazepines (BZDs) and Non-BZDs (NBZDs) have been widely used for patients with chronic insomnia. Long-term uses of BZDs may cause cognitive impairment and increase the risk for dementia in older patients. NBZD as an agonist of the GABA_A receptor complex includes eszopiclone, zopiclone, zolpidem, and zaleplon, also collectively known as Z drugs. However, evaluations for an association between cognitive impairment and Z drug use have been limitedly performed. This study aimed to investigate the association between the risk of cognitive decline and exposure to Z drugs in middle-aged and older patients with chronic insomnia.

Methods: Investigations were performed on patients with chronic insomnia who visited the outpatient Department of Neurology, Beijing Friendship Hospital, and were assessed for the global cognitive function (MoCA) and memory (AVLT), executive function (TMT-B), visuospatial ability (CDT), verbal function (BNT-30), and attention (DST). Multiple regression analysis was conducted to determine the independent factors of cognition and evaluated the effect of Z drug use (zolpidem and zopiclone) on cognition.

Results: A total of 120 subjects were identified. In our analysis, BZD exposure density (P = 0.025, OR = 1.43, 95% CI, 1.25–1.86) was an independent risk factor of cognitive impairment in middle-aged and older patients with chronic insomnia. Neither Z drug use (P = 0.103) nor Z drug exposure density (P = 0.765) correlated with global cognitive function. Moreover, there was a positive association between Z drug use and attention [(P = 0.002, OR = 0.42, 95% CI, 0.24–0.73)]. Additionally, income level (P = 0.001, OR = 0.23, 95% CI, 0.10–0.53), severity of insomnia (P = 0.019, OR = 1.20, 95% CI, 1.03–1.40) and age (P = 0.044, OR = 1.07, 95% CI, 1.00–1.14) were also independent factors of global cognitive function.

Conclusion: BZD exposure density was an independent risk factor of cognitive impairment in middle-aged and older patients with chronic insomnia, but no correlation was found between Z drug use and cognitive impairment. Moreover, the use of Z drugs seemed to be associated with protection for attention. The use for prescription of BZDs, in this case, should be avoided or limited to low doses. Due to the addiction and tolerance, Z drugs should also be prescribed with great caution in middle-aged and elderly patients.

Understanding the unmet needs in insomnia treatment: a systematic literature review of real-world evidence

STUDY OBJECTIVE

The objective of this study was to define and characterize the unmet needs in the pharmacological management of insomnia.

METHODS

A systematic literature review was conducted to identify relevant literature reporting real-world evidence in insomnia, published from January 2009 to April 2020. Pharmacological treatments - both prescription (benzodiazepines, 'Z-drugs' and suvorexant) and off-label (antidepressants, antipsychotics, and antihistamines) - were considered.

RESULTS

Overall, 108 publications describing the humanistic (n = 59) and economic burden (n = 20) of insomnia, off-label treatment patterns (n = 28) and factors influencing treatment adherence or persistence (n = 8) were identified. A high prevalence of comorbid conditions was reported in patients with insomnia resulting in significantly lower health-related QoL compared to those with insomnia or a comorbidity alone. Current treatment options were associated with adverse events, including reduced sleep quality and next-day somnolence. An increased risk of accidents/injuries was also associated with insomnia and its treatment. Furthermore, safety concerns and perceived lack of efficacy for approved treatments have led to frequent off-label prescribing, despite a lack of clinical evidence of risk/benefit ratios. Safety concerns associated with benzodiazepines include risk of dependence, leading to prolonged treatment persistence and exacerbated adverse events, making them unsuitable for use in patients with chronic insomnia. Finally, the substantial economic burden of insomnia was evident, with reduced work productivity demonstrated in patients with insomnia compared to the general population.

CONCLUSIONS

This review highlights a clear unmet need for insomnia therapies that improve sleep quality without resulting in next-day impairment and/or dependence.

Long-term benzodiazepines and z-drug prescribing in Australian general practice between 2011 and 2018: A national study

Despite reducing benzodiazepine prescribing, benzodiazepine-involving deaths have substantially increased in Australia. This study aimed to explore patterns in long-term prescribing of medications (benzodiazepine and z-drugs [BZD]) used for sleep-issues/insomnia in Australia to better understand these changes. Open cohort study using de-identified electronic health records of 1 414 593 adult patients regularly attending 404 Australian general practices from 2011 to 2018 (MedicineInsight). We used logistic regression adjusted for patient and practice characteristics to; (1) estimate long-term BZD prescribing prevalence (≥3 prescriptions in 6 months) and the associated sociodemographic factors, and (2) Poisson regression to compute annual changes in prescribing rates. Long-term BZD prescribing changed from 4.4% in 2011 to 5.8% in 2015, remaining relatively stable until 2018 (annual increase +2.5% [95% CI +2.0%;+3.0%]). Long-term BZD prescribing in any year was up to six times more likely in elderly rather than in younger patients and 30%-43% more prevalent in females, or patients living in or attending a practice located in more disadvantaged areas. The increase was more pronounced among males, adults aged 35-49 years, and individuals living in advantaged areas. The median duration among incident cases decreased from 1183 to 322 days between 2011 and 2017, and was up to 197 days longer among elderly females than males. Despite a slight increase and recent stability in long-term BZD prescribing, the higher rates and durations among elderly patients, women, or those living in more disadvantaged areas are concerning and highlights the need for interventions that reduce the potential harms of long-term BZD use in vulnerable groups.

Benzodiazepine and Z-Drug Use and the Risk of Developing Dementia

BACKGROUND

Benzodiazepines (BZDs) and Z-drugs (BZDRs) are among the most prescribed medications for anxiety and insomnia, especially among older adults. Our objective was to investigate the association between the use of BZDRs and the risk of dementia.

METHODS

A community-based retrospective cohort study was conducted based on the data available from 2002 to 2015 in Catalan Health Service. This cohort included all BZDR users (N = 83 138) and nonusers (N = 84 652) older than 45 years. A minimum 5-year lag window and an adjustment for psychiatric problems were applied for the data analysis.

RESULTS

The hazard ratio (HR) for the risk of incident dementia among BZDR users was 1.22 (95% CI = 1.15 to 1.31). This risk was not significant after adjusting the data confounding factors (HR = 1.01; 95% CI = 0.94 to 1.08). We observed a higher risk with short-to-intermediate half-life BZDs (HR = 1.11; 95% CI = 1.04 to 1.20) and Z-drugs (HR = 1.20; 95% CI = 1.07 to 1.33) than for intermediate-to-long half-life BZDs (HR = 1.01; 95% CI = 0.94 to 1.08). We demonstrated a higher risk of incident dementia (HR = 1.23; 95% CI = 1.07 to 1.41 and odds ratio = 1.38; 95% CI = 1.27 to 1.50, respectively) in patients who received 91 to 180 defined daily doses (DDDs) and >180 DDDs compared with patients who received <90 DDD. Regarding patient sex, the risk of dementia was higher in women than in men.

CONCLUSION

We found that the incidence of dementia was not higher among all BZDR users. Short half-life BZDs and Z-drugs increased the risk of dementia at the highest doses, especially in female patients, showing a dose-response relationship.

Effect of chemotherapy and radiotherapy on cognitive impairment in colorectal cancer: evidence from national representative longitudinal database

Objectives

We aimed to assess the risk of chemotherapy- and radiotherapy-related cognitive impairment in colorectal cancer patients.

Methods

Medical use data of colorectal cancer patients were obtained from Korean National Health Insurance Database (NHID), 2004-2018. We randomly selected 40% of colorectal cancer patients (N=148,848). Cognitive impairment cases were defined as having one or more ICD-10 diagnostic codes for dementia or mild cognitive impairment. Patients aged 18 or younger, patients diagnosed with cognitive impairment before colorectal cancer diagnosis (N=8,225) and those who did not receive primary resection (N=45,320) were excluded. The effects of each chemotherapy regimen on cognitive impairment were estimated. We additionally estimated the effect of radiotherapy in rectal cancer patients. Time-dependent competing risk Cox regression was conducted to estimate overall and age-specific hazard ratios (HR) separately for colon and rectal cancer. Landmark analyses with different lag times were conducted as sensitivity analyses.

Results

Chemotherapy did not increase the risk of cognitive impairment in colorectal cancer (colon cancer: HR=0.92, 95% CI 0.83-1.03; rectal cancer: HR=0.88, 95% CI 0.75-1.04). Radiotherapy was negatively associated with cognitive impairment in rectal cancer (HR=0.01, 95% CI 0.84-0.99). Heterogeneous direction of association by regimen combination was detected. Adverse cognitive effect of certain chemotherapy regimen was more prominent in elderly patients.

Conclusion

Chemotherapy and radiotherapy did not increase the risk of cognitive impairment. Elderly patients with low cognitive reserve could be affected by adverse cognitive effects of chemotherapy. Folate administration showed protective effect against possible cognitive impairment.

Use of sedative-hypnotic medications and risk of dementia: A systematic review and meta-analysis

AIMS

Growing evidence suggests an association between the use of sedative-hypnotic medications and risk of dementia. The aim of this study is to examine this association using a meta-analysis approach.

METHODS

MEDLINE (PubMed) and Scopus were systematically searched for studies published in English only. The quality of studies was evaluated using the Newcastle-Ottawa scale, and an overall odds ratio was pooled using a random-effects model.

RESULTS

A total of 35 articles were included in the analysis. Pooled odds ratios (ORs) for dementia from all records were (OR; 1.33, 95% CI 1.19-1.49) for benzodiazepine (BZD) combined use (Subgroup-1), (OR: 1.46, 95% CI 1.23-1.73) for short-acting BZD use (Subgroup-2), (OR: 1.72, 95% CI 1.48-1.99) for long-acting BZD use (Subgroup-3), (OR: 1.13, 95% CI 0.97-1.32) for BZDs without specification of duration of action (Subgroup-4), (OR: 1.64, 95% CI 1.13-2.38) for the combined BZDs and Z-drugs, (OR: 1.43, 95% CI 1.17-1.74) for Z-drugs only, (OR: 1.14, 95% CI 0.88-1.46) for antidepressant use, (OR: 0.97, 95% CI 0.68-1.39) for antipsychotic use and (OR: 0.98, 95% CI 0.85-1.13) for anticonvulsant use. When sensitivity analysis was performed, association between overall use of BZDs and short-acting BZDs with the increased risk of dementia disappeared after exclusion of studies that were not adjusted for age covariate (OR: 1.2, 95% CI 1.0-1.44) and (OR: 1.22, 95% CI 0.75-2.01), respectively. Adjustment for protopathic bias by introduction of a lag period showed no evidence of increased risk of dementia with the use of BZDs (Subgroup-1) (OR: 1.14, 95% CI 0.82-1.58), Z-drugs (OR: 1.29, 95% CI 0.78-2.13), and combined BZDs and Z-drugs (OR: 1.51, 95% CI 0.91-2.53). Combined use of BZDs and Z-drugs showed more positive association when only studies of non-user design were analysed (OR: 2.75, 95% CI 2.23-3.39).

CONCLUSIONS

All the investigated sedative-hypnotics showed no association with increased risk of dementia except for BZDs. However, the observed association with BZDs did not persist after exclusion of studies with potential reverse causation and confounding by indication. Therefore, this association needs to be assessed carefully in future research.

Mind-Body Therapies for Cancer Patients Living with Depression, Anxiety or Insomnia (MIRACLE): A Systematic Review with Individual Participant Data Network Meta-Analysis

Depression, anxiety, and insomnia are common in cancer patients. Mind-body therapies (MBTs) are promising forms of treatment for cancer patients living with depression, anxiety, and insomnia. The objective of this study is to assess the effectiveness and acceptability of MBTs in cancer patients living with depression, anxiety, or insomnia. EMBase, PubMed, Cinahl, PsychINFO, IndMED, CSI-NISCAIR, CNKI, Clinicaltrial.gov, ChiCTR, and CTRI will be searched until October 2020 for relevant studies. Randomized controlled studies in which MBTs were tested in a cancer population will be selected. The authors of the selected studies will be contacted to obtain individual participant data. The participants who reached a defined clinical threshold for depression, anxiety, or insomnia will be selected for the three sub-studies on depression, anxiety, and insomnia, respectively. Pairwise and network meta-analyses will be used to assess the changes in depression, anxiety, sleep quality, and completion rate. We will assess the effect of the treatment dose (number and frequency of interventions) on effectiveness. The results of this study will inform clinical decision-making for the treatment of psychological disturbances in cancer patients. If MBTs are found effective, they will potentially be recommended as treatments for cancer patients with psychological symptoms.

Correlation between cardiovascular risk factors and cognitive decline

The number of people suffering from dementia in the world is progressively increasing due to the expansion of the geriatric population in which this clinical condition is more frequent. The appearance of a variable degree of cognitive decline up to full-blown dementia does not, however, represent the inevitable fate of those who age, as the studies conducted in the centenarians clearly indicate. Indeed, the age-specific incidence of dementia has progressively decreased in many geographical areas, probably due to an improvement in lifestyles and health care. In fact, a growing number of scientific evidence shows how chronic exposure over the course of life, starting from young adulthood, to various risk factors—arterial hypertension, diabetes mellitus, obesity, tobacco smoke, sleep disorders—contribute significantly to the development of cognitive decline and dementia in the course of senescence. These risk factors, in fact, can trigger and amplify the various neuropathological mechanisms underlying the development of decline, progressively reducing the functional reserve of the brain. Although definitive evidence deriving from ad hoc intervention studies is not currently available, it is legitimate to assert that the early control of cardiovascular risk factors can represent today the most effective tool for the prevention of dementia.

Impact of Pharmacotherapy on Insomnia in Patients with Alzheimer's Disease

Insomnia is a pervasive sleep disorder affecting numerous patients across diverse demographical populations and comorbid disease states. Contributing factors are often a complex interaction of biological, psychological, and social components, requiring a multifaceted approach in terms of both diagnosis and management. In the setting of Alzheimer’s disease, insomnia is an even more complicated issue, with a higher overall prevalence than in the general population, greater complexity of contributing etiologies, and differences in diagnosis (at times based on caregiver observation of sleep disruption rather than subjective complaints by the individual with the disorder), and requiring more discretion in terms of treatment, particularly in regard to adverse effect profile concerns. There also is growing evidence of the bidirectional nature of sleep disruption and Alzheimer’s disease, with insomnia potentially contributing to disease progression, making the condition even more paramount to address. The objective of this review was to provide the clinician with an overview of treatment strategies that may have value in the treatment of disturbed sleep in Alzheimer’s disease. Nonpharmacological approaches to treatment should be exhausted foremost; however, pharmacotherapy may be needed in certain clinical scenarios, which can be a challenge for clinicians given the paucity of evidence and guidelines for treatment in the subpopulation of Alzheimer’s disease. Agents such as sedating antidepressants, melatonin, and site-specific γ-aminobutyric acid agonists are often employed based on historical usage but are not necessarily supported by high-quality trials. Newer agents such as dual orexin receptor antagonists have demonstrated some promise but still need further evaluation.

Sex differences in psychotropic and analgesic drug use before and after initiating treatment with acetylcholinesterase inhibitors

BACKGROUND/AIMS

The aim was to explore the impact of sex on prevalence, patterns and trends in the prescription of psychotropics and analgesics in users of acetylcholinesterase inhibitors (AChEIs), before and after AChEI initiation, compared to the general population.

METHODS

A prospective study applying data from the Norwegian Prescription Database (NorPD) in the period 2004-2016. Prescription of antidepressants, antipsychotics, analgesics including opioids, benzodiazepines and z-hypnotics in persistent AChEI users was studied in a follow-up period from four years before to two years after AChEI initiation in men and women of four age groups: 37-64, 65-72, 73-80 and 81-88 years.

RESULTS

Use of antidepressants, antipsychotics and weaker analgesics increased in both sexes during the follow-up period in 11.764 persistent AChEI users. Women with pre-dementia and dementia stages of AD showed a prescription pattern with more use of psychotropics and opioids than men, except for antipsychotics.

CONCLUSION

Female sex showed to have a significant influence on the prescriptions of psychotropics and analgesics in AD patients in a pre-dementia and dementia stage. The exception is for antipsychotics, that men used more than women. The prescription pattern showed a higher extent of polypharmacy of psychotropics and/or opioids in women than in men. The total prescription pattern of analgesics could indicate an undertreatment of pain in pre-dementia and dementia stages, most pronounced in men.

Impact of transdermal trigeminal electrical neuromodulation on subjective and objective sleep parameters in patients with insomnia: a pilot study

PURPOSE

Transcutaneous trigeminal electrical neuromodulation (TTEN) is a new treatment modality that has a potential to improve sleep through the suppression of noradrenergic activity. This study aimed to explore the changes of subjective and objective sleep parameters after 4-weeks of daily session of transcutaneous trigeminal electrical neuromodulation in a group of patients with insomnia.

METHODS

In a group of patients with insomnia, TTEN targeting the ophthalmic division of the trigeminal nerve was utilized to test the effects of transcutaneous trigeminal electrical neuromodulation. Patients went through daily 20-min sessions of TTEN for 4 weeks. Polysomnography parameters, Pittsburgh sleep quality index, insomnia severity index, and Epworth sleepiness scale were obtained pre- and post-intervention. Changes in these parameters were compared and analyzed.

RESULTS

Among 13 patients with insomnia there was a statistically significant reduction in Pittsburgh sleep quality index, insomnia severity index, and Epworth sleepiness scale scores after 4-week daily sessions of TTEN. There were no differences in polysomnography parameters pre- and post-intervention.

CONCLUSION

This is the first study to demonstrate the effects of TTEN in a group of insomnia patients. TTEN may improve subjective parameters in patients with insomnia. Further replication studies are needed to support this finding.

TRIAL REGISTRATION

The data presented in the study are from a study exploring the effect of TTEN on insomnia ( www.clinicaltrials.gov , registration number: NCT04838067, date of registration: April 8, 2021, "retrospectively registered").

Association Between the Use of Hypnotics and the Risk of Alzheimer's Disease

BACKGROUND

Hypnotics, including benzodiazepines, are extensively and inappropriately prescribed for older people to treat anxiety and sleep disorders, despite the adverse health outcomes associated with their use.

OBJECTIVE

This study aimed to examine the association of the use of long- and short-acting hypnotics with the risk of Alzheimer's disease.

METHODS

Data from 234,634 participants, derived from the Korean National Health Insurance Service National Sample Cohort from 2002 to 2013, were examined. Individuals over the age of 50 years were included in the study. The dependent variable was the risk of Alzheimer's disease. Hypnotics were categorized by the period of the prescription of benzodiazepines, i.e., either till the participants were diagnosed with Alzheimer's disease or the end of the study period (December 31, 2013). Cox regression model was built to analyze the association between variables.

RESULTS

Individuals who used long-acting hypnotics were found to have a higher risk of Alzheimer's disease than non-users. Moreover, among individuals with sleep disorders, those who used hypnotics had a higher risk of Alzheimer's disease than those who did not.

CONCLUSION

This study identified an association between the use of hypnotics and the risk of Alzheimer's disease among South Korean middle-aged and older people.

Emulated Clinical Trials from Longitudinal Real-World Data Efficiently Identify Candidates for Neurological Disease Modification: Examples from Parkinson's Disease

Real-world healthcare data hold the potential to identify therapeutic solutions for progressive diseases by efficiently pinpointing safe and efficacious repurposing drug candidates. This approach circumvents key early clinical development challenges, particularly relevant for neurological diseases, concordant with the vision of the 21st Century Cures Act. However, to-date, these data have been utilized mainly for confirmatory purposes rather than as drug discovery engines. Here, we demonstrate the usefulness of real-world data in identifying drug repurposing candidates for disease-modifying effects, specifically candidate marketed drugs that exhibit beneficial effects on Parkinson's disease (PD) progression. We performed an observational study in cohorts of ascertained PD patients extracted from two large medical databases, Explorys SuperMart (N = 88,867) and IBM MarketScan Research Databases (N = 106,395); and applied two conceptually different, well-established causal inference methods to estimate the effect of hundreds of drugs on delaying dementia onset as a proxy for slowing PD progression. Using this approach, we identified two drugs that manifested significant beneficial effects on PD progression in both datasets: rasagiline, narrowly indicated for PD motor symptoms; and zolpidem, a psycholeptic. Each confers its effects through distinct mechanisms, which we explored via a comparison of estimated effects within the drug classification ontology. We conclude that analysis of observational healthcare data, emulating otherwise costly, large, and lengthy clinical trials, can highlight promising repurposing candidates, to be validated in prospective registration trials, beneficial against common, late-onset progressive diseases for which disease-modifying therapeutic solutions are scarce.

Immediate and lasting effects of aerobic exercise on the actigraphic sleep parameters of female nurses: A randomized controlled trial

Sleep disturbance is highly prevalent among shift-working nurses. We aimed to evaluate whether aerobic exercise (i.e., walking combined with jogging) improves objective sleep parameters among female nurses who met eligibility criterion as poor sleepers at the end of an 8-week exercise program and 4 weeks after study completion. This single-blinded, parallel-design, randomized controlled trial was conducted in a classroom of a hospital in northern Taiwan. Sixty eligible female nurses were randomly assigned to either the aerobic exercise (n = 30) or usual activity status (n = 30) group. A moderate-intensity aerobic exercise program was administered over 5 days (60 min per day) a week for 8 weeks after the nurses' day shifts. Objective sleep outcomes including total sleep time (TST), sleep onset latency (SOL), wake after sleep onset (WASO), and sleep efficiency (SE) were retrieved using an actigraph device. A generalized estimating equation model was used for data analysis. The aerobic exercise group exhibited improvements in TST and SE at 4 and 8 weeks compared with the baseline evaluation (TST: B = 70.49 and 55.96; SE: B = 5.21 and 3.98). Between-group differences were observed in SOL and WASO at 4 weeks but not 8 weeks compared with the baseline evaluation (SOL: B = -7.18; WASO: B = -11.38). Positive lasting effects for TST were observed only until the 4-week follow-up. To improve sleep quality and quantity, we encourage female nurses who sleep poorly to regularly perform moderate-intensity aerobic exercise.

Sleep and its regulation: An emerging pathogenic and treatment frontier in Alzheimer's disease

A majority of patients with Alzheimer's disease (AD) experience some form of sleep disruption, including nocturnal sleep fragmentation, increased daytime napping, decreased slow-wave sleep (SWS, stage N3), and decreased rapid-eye-movement sleep (REM). Clinical studies are investigating whether such sleep disturbances are a consequence of the underlying disease, and whether they also contribute to the clinical and pathological manifestations of AD. Emerging research has provided a direct link between several of these sleep disruptions and AD pathophysiology, suggesting that treating sleep disorders in this population may target basic mechanisms of the disease. Here, we provide a comprehensive review of sleep disturbances associated with the spectrum of AD, ranging from the preclinical stages through dementia. We discuss how sleep interacts with AD pathophysiology and, critically, whether sleep impairments can be targeted to modify the disease course in a subgroup of affected AD patients. Ultimately, larger studies that fully utilize new diagnostic and experimental tools will be required to better define the most relevant sleep disturbance to target in AD, the interventions that best modulate this target symptom, and whether successful early intervention can modify AD risk and prevent dementia.

Effects of Chinese herbal medicines on dementia risk in patients with sleep disorders in Taiwan

ETHNOPHARMACOLOGICAL RELEVANCE

Sleep disorders affect an estimated 150 million people worldwide and result in adverse health, safety, and work performance-related outcomes that have important economic consequences. In Taiwan, Chinese herbal medicine (CHM) is a complementary natural medicine and has been widely used as an adjunctive therapy.

AIM OF THE STUDY

This study aimed to investigate the effect of CHM on dementia risk in patients with sleep disorders in Taiwan.

MATERIALS AND METHODS

We identified 124,605 patients with sleep disorders between the ages of 20 and 60 years. Of these, 5876 CHM users and 5876 non-CHM users were matched according to age and gender. The chi-squared test, Cox proportional hazard model, Kaplan-Meier method, and log-rank test were used for the comparisons. Association rule mining and network analysis were applied to determine a CHM pattern specialized for sleep disorders.

RESULTS

More CHM users did not use sleeping pills than non-CHM users. CHM users had a lower risk of dementia than non-CHM users after adjusting for age, gender, and sleeping pill use (hazard ratio (HR): 0.469, 95% CI = 0.289-0.760; p-value = 0.002). The cumulative incidence of dementia was lower among CHM users (long-rank test, p-value < 0.001). Association rule mining and network analysis showed that Ye-Jiao-Teng (YJT; Caulis Polygoni Multiflori; Polygonum multiflorum Thunb), Suan-Zao-Ren-Tang (SZRT), Jia-Wei-Xiao-Yao-San (JWXYS), He-Huan-Pi (HHP; Cortex Albizziae; Albizia julibrissin Durazz.), and Suan-Zao-Ren (SZR; Semen Zizyphi Spinosae; Ziziphus jujuba Mill.) were important CHMs for patients with sleep disorders in Taiwan.

CONCLUSIONS

A comprehensive list of herbal medicines may be useful for the clinical treatment of patients with sleep disorders, and for future scientific investigations into the prevention of dementia in these patients.

Psychotropic drug use in residents with dementia living in small-scaled special care facilities; a longitudinal study

Objectives: Over the past decade, a trend has been noticed in the Netherlands to replace large-scaled special care units (SCUs) caring for 20-30 residents with dementia by small-scaled SCUs caring for up to 8 residents. Systematic evaluations, however, have yielded a differentiated picture of the effects. As the impact on psychotropic drug use has hardly been addressed thus far, we examined the (potential) impact of psychotropic drug use when moving residents with dementia from large-scaled to small-scaled SCUs.Methods: We conducted a non-randomized, controlled study with a six-month follow-up. Among 145 residents with dementia living a large-scaled SCUs for dementia caring for 20-30 residents per unit, a total of 77 residents were moved to small-scaled SCUs caring for up to 8 residents per unit. Psychotropic drug use, classified according to the Anatomical Therapeutic Chemical Classification (ATC) system was monitored at 2 months before replacement, as well as at 3 and 6 months thereafter. Repeated measures ANOVAs were conducted for the mean Defined Daily Doses (DDDs) of both groups.Results: No significant differences between both groups in psychotropic medication use were found over a period of 8 months.Conclusion: Prescription of psychotropic drugs does not change after a transfer from a large-scaled SCU to a small-scaled SCU of patients with moderate to severe dementia.Current Controlled Trials: ISRCTN11151241.

Therapy for Insomnia and Circadian Rhythm Disorder in Alzheimer Disease

PURPOSE OF THE REVIEW

There is strong evidence for a bidirectional association between sleep disorders and Alzheimer's disease (AD). In particular, insomnia may be a potentially modifiable risk factor for AD. The present review summarizes recent advances in treatment of sleep disorders in AD.

RECENT FINDINGS

Some studies investigated the efficacy and safety of hypnotic agents as ramelteon and mirtazapine to treat sleep disorders in AD but no significant therapeutic effects have been observed. Benzodiazepines are the most frequently used medication for treatment of insomnia but they may cause significant side effects in old subjects. Suvorexant, an orexin receptor antagonist, showed a positive effect on AD insomnia. Recent report suggests an association between trazodone use and delayed cognitive decline in AD. With respect to circadian rhythm disorders, non-pharmacological treatments, especially bright light therapy, could be useful and safe options for treatment in AD. Some pharmacological and non-pharmacological treatments might have benefits in AD patients with sleep disturbances, but further well-designed controlled trials are needed.

Association Between the Use of Non-benzodiazepine Hypnotics and Cognitive Outcomes: A Systematic Review

Purpose of Review

Adverse effects of sedative-hypnotic medications on cognition are concerning. Past studies have examined benzodiazepine (BZD) use and cognitive outcomes; however, few studies have examined newer non-BZD hypnotic agents (nBHs; e.g. zolpidem). This systematic review examined observational studies assessing the association between nBH use and cognitive outcomes.

Recent Findings

Five studies met eligibility requirements and were included in the review. Most studies did not find an association between nBH use and dementia diagnosis; however, we found no studies assessing other cognitive outcomes such as cognitive performance (e.g., word recall tasks). Characterization of nBH use mostly consisted of incident new use; one study assessed nBH dosing; none examined duration of use. Studies included were of strong quality.

Summary

This review found no association between nBH use and dementia diagnosis, although there is a need for more research on more cognitive outcomes and nBH use patterns.

Benzodiazepines and Related Drugs as a Risk Factor in Alzheimer's Disease Dementia

Benzodiazepines (BZDs) and Z-drugs are compounds widely prescribed in medical practice due to their anxiolytic, hypnotic, and muscle relaxant properties. Yet, their chronic use is associated with cases of abuse, dependence, and relapse in many patients. Furthermore, elderly people are susceptible to alterations in pharmacodynamics, pharmacokinetics as well as to drug interaction due to polypharmacy. These situations increase the risk for the appearance of cognitive affectations and the development of pathologies like Alzheimer's disease (AD). In the present work, there is a summary of some clinical studies that have evaluated the effect of BZDs and Z-drugs in the adult population with and without AD, focusing on the relationship between their use and the loss of cognitive function. Additionally, there is an assessment of preclinical studies focused on finding molecular proof on the pathways by which these drugs could be involved in AD pathogenesis. Moreover, available data (1990-2019) on BZD and Z-drug use among elderly patients, with and without AD, was compiled in this work. Finally, the relationship between the use of BZD and Z-drugs for the treatment of insomnia and the appearance of AD biomarkers was analyzed. Results pointed to a vicious circle that would worsen the condition of patients over time. Likewise, it put into relevance the need for close monitoring of those patients using BZDs that also suffer from AD. Consequently, future studies should focus on optimizing strategies for insomnia treatment in the elderly by using other substances like melatonin agonists, which is described to have a much more significant safety profile.

Impact of Sleep Disorder as a Risk Factor for Dementia in Men and Women

Sleep is an essential physiological process, especially for proper brain function through the formation of new pathways and processing information and cognition. Therefore, when sleep is insufficient, this can result in pathophysiologic conditions. Sleep deficiency is a risk factor for various conditions, including dementia, diabetes, and obesity. Recent studies have shown that there are differences in the prevalence of sleep disorders between genders. Insomnia, the most common type of sleep disorder, has been reported to have a higher incidence in females than in males. However, sex/gender differences in other sleep disorder subtypes are not thoroughly understood. Currently, increasing evidence suggests that gender issues should be considered important when prescribing medicine. Therefore, an investigation of the gender-dependent differences in sleep disorders is required. In this review, we first describe sex/gender differences not only in the prevalence of sleep disorders by category but in the efficacy of sleep medications. In addition, we summarize sex/gender differences in the impact of sleep disorders on incident dementia. This may help understand gender-dependent pathogenesis of sleep disorders and develop therapeutic strategies in men and women.

Longitudinal analysis of risk factors for dementia based on Mild Cognitive Impairment Screen results and questionnaire responses from healthy Japanese individuals registered in an online database

Introduction

Despite an urgent need for developing remedial measures against dementia, no disease-modifying drugs have been developed. Efficient protocols for participant recruitment need to be established for conducting clinical trials. To meet this need, a large-scale online registry system, the Integrated Registry of Orange Plan (IROOP®), was created for healthy individuals. Although the risk factors for dementia have been discussed in our previous studies for a short interval of 6 months, some factors remain controversial. The present study aimed to explore factors affecting longitudinal changes in cognitive function for a longer interval of 18 months using the IROOP® data.

Methods

This study assessed the longitudinal changes in the collated data for predicting the risk of dementia and included 473 individuals (175 men and 298 women; mean age 59.6 ± 10.1 years) registered in the IROOP® between July 5, 2016 and January 15, 2018 who completed the initial questionnaire and brief assessment of cognitive function (Mild Cognitive Impairment Screen) at baseline and the regular questionnaire and the Mild Cognitive Impairment Screen at least once after baseline. Statistical analyses were performed using IBM SPSS, version 23.0, for Windows for demographic data and the MIXED procedure in SAS, version 9.4, for the linear mixed-effect model. In each analysis, the statistical significance level was set at P < .05.

Results

Mood, sleep, quality of life, and medical histories including cognition were found to influence longitudinal changes in cognitive function.

Discussion

Given the multifactorial etiology of dementia, preventive measures targeting multiple domains are required for maintaining cognitive function, instead of focusing on one lifestyle factor.

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Mood consistently influences on longitudinal changes of cognitive function.

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Sleep is also an important factor for maintaining cognitive function.

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Given the multifactorial etiology of dementia, multidomain prevention is required.

Correction: Use of sedative-hypnotics and the risk of Alzheimer's dementia: A retrospective cohort study

[This corrects the article DOI: 10.1371/journal.pone.0204413.].