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An assessment of quality of sleep and the use of drugs with sedating properties in hospitalized adult… Frighetto, Luciana; Marra, Carlo; Bandali, Shakeel; Wilbur, Kerry; Naumann, Terryn; Jewesson, Peter Mar 24, 2004

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ralHealth and Quality of Life OutcomesssBioMed CentOpen AcceResearchAn assessment of quality of sleep and the use of drugs with sedating properties in hospitalized adult patientsLuciana Frighetto1, Carlo Marra1, Shakeel Bandali1, Kerry Wilbur1, Terryn Naumann1 and Peter Jewesson*1,2Address: 1Pharmaceutical Sciences Clinical Service Unit, Vancouver Hospital and Health Sciences Center (Vancouver General Hospital), 855 West 12th Avenue, Vancouver BC, Canada and 2Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver BC, CanadaEmail: Luciana Frighetto - frighett@interchange.ubc.ca; Carlo Marra - cmarra@interchange.ubc.ca; Shakeel Bandali - pjj@interchange.ubc.ca; Kerry Wilbur - kwilbur@interchange.ubc.ca; Terryn Naumann - tnaumann@vanhosp.bc.ca; Peter Jewesson* - pjj@interchange.ubc.ca* Corresponding author    AbstractBackground: Hospitalization can significantly disrupt sleeping patterns. In consideration of the previous reports ofinsomnia and apparent widespread use of benzodiazepines and other hypnotics in hospitalized patients, we conducted astudy to assess quality of sleep and hypnotic drug use in our acute care adult patient population. The primary objectivesof this study were to assess sleep disturbance and its determinants including the use of drugs with sedating properties.Methods: This single-centre prospective study involved an assessment of sleep quality for consenting patients admittedto the general medicine and family practice units of an acute care Canadian hospital. A validated Verran and Snyder-Halpern (VSH) Sleep Scale measuring sleep disturbance, sleep effectiveness, and sleep supplementation was completeddaily by patients and scores were compared to population statistics. Patients were also asked to identify factorsinfluencing sleep while in hospital, and sedating drug use prior to and during hospitalization was also assessed.Results: During the 70-day study period, 100 patients completed at least one sleep questionnaire. There was a relativelyeven distribution of males versus females, most patients were in their 8th decade of life, retired, and suffered frommultiple chronic diseases. The median self-reported pre-admission sleep duration for participants was 8 hours and ourreview of PharmaNetR profiles revealed that 35 (35%) patients had received a dispensed prescription for a hypnotic orantidepressant drug in the 3-month period prior to admission. Benzodiazepines were the most common sedating drugsprescribed. Over 300 sleep disturbance, effective and supplementation scores were completed. Sleep disturbance scoresacross all study days ranged 16–681, sleep effectiveness scores ranged 54–402, while sleep supplementation scoresranged between 0–358. Patients tended to have worse sleep scores as compared to healthy non-hospitalized US adultsin all three scales. When compared to US non-hospitalized adults with insomnia, our patients demonstrated sleepdisturbance and supplementation scores that were similar on Day 1, but lower (i.e. improved) on Day 3, while sleepeffectiveness were higher (i.e. better) on both days. There was an association between sleep disturbance scores and thenumber of chronic diseases, the presence of pain, the use of bedtime tricyclic antidepressants, and the number of chronicdiseases without pain. There was also an association between sleep effectiveness scores and the length of hospitalization,the in hospital use of bedtime sedatives and the presence of pain. Finally, an association was identified between sleepsupplementation scores and the in hospital use of bedtime sedatives (tricyclic antidepressants and loxapine), and age.Twenty-nine (29%) patients received a prescription for a hypnotic drug while in hospital, with no evidence of pre-admission hypnotic use. The majority of these patients were prescribed zopiclone, lorazepam or another benzodiazepine.Conclusions: The results of this study reveal that quality of sleep is a problem that affects hospitalized adult medicalservice patients and a relatively high percentage of these patients are being prescribed a hypnotic prior to and duringPublished: 24 March 2004Health and Quality of Life Outcomes 2004, 2:17Received: 20 August 2003Accepted: 24 March 2004This article is available from: http://www.hqlo.com/content/2/1/17© 2004 Frighetto et al; licensee BioMed Central Ltd. This is an Open Access article: verbatim copying and redistribution of this article are permitted in all media for any purpose, provided this notice is preserved along with the article's original URL.Page 1 of 10(page number not for citation purposes)hospitalization.Health and Quality of Life Outcomes 2004, 2 http://www.hqlo.com/content/2/1/17BackgroundSleep is essential for health and quality of life. [1] Insom-nia is a subjective complaint of dissatisfaction with thequantity, quality or timing of sleep. [2,3] This disorder isestimated to occur in approximately 12% to 25% of thegeneral population, although this is probably an underes-timate as there is evidence that many adults do not reporttheir sleep problems to a health care professional. [4,5] Itis well recognized that hospitalization can significantlydisrupt sleeping patterns. [3,6,7] In hospitalized patients,the most common causes of acute insomnia include theeffects of illness, environmental sleep disruption, medica-tion, anxiety, and depression. Investigators have shownthat insomnia in the hospitalized patient leads toincreased fatigue, irritability, and aggressiveness as well asdecreased pain tolerance. [3]Treatment of insomnia in the institutional setting is gen-erally aimed at correcting underlying medical disorders,reducing environmental sleep disruptions, and loweringanxiety with psychological interventions and relaxationtraining or pharmacotherapy. [8]Benzodiazepines are the most common drugs used for thepharmacological management of acute insomnia in bothinstitutionalized and ambulant patients. [9-20] Of theavailable agents, short and intermediate-acting benzodi-azepines such as lorazepam and oxazepam have becomethe most commonly prescribed for this indication. Whilethese agents have proven to be efficacious and relativelysafe, benzodiazepines are associated with a multitude ofadverse effects which are most commonly observed withhigher doses and prolonged use. [11] Common sideeffects include residual daytime sedation ("hangover"),anterograde amnesia, and respiratory depression. [9]Rebound insomnia has also been associated with benzo-diazepines. Tolerance to the hypnotic effects of the shortand intermediate-acting agents can develop within one totwo weeks of use and abrupt discontinuation can result inwithdrawal symptoms such as anxiety, confusion, disori-entation, insomnia, and perceptual changes. [9] Benzodi-azepines have been frequently implicated in drug-associated hospital admissions. [11] Non-benzodi-azepine hypnotics are now receiving attention as alterna-tives to our traditional armamentarium for the treatmentof insomnia. In addition to new agents such as zopiclone,zolpidem, and zaleplon, nonprescription products suchas diphenhydramine, doxylamine, and melatonin appearto be potential alternatives for short-term use. [17]Sleep quality in a hospitalized patient can be measured bya variety of methods including the use of movement mon-itoring devices, brain electrical activity, sleep diaries andpatients. The Verran and Snyder-Halpern (VSH) SleepScale represents one such scale that has been used tomeasure sleep quality in hospitalized patients [3,7,21].This validated scale encompasses the different parametersof sleep such as sleep disturbances, number of awaken-ings, difficulty in falling asleep and time spent sleeping isa valuable instrument.In consideration of the previous reports of insomnia andapparent widespread use of benzodiazepines and otherhypnotics in hospitalized patients, we conducted a studyto assess quality of sleep (as defined by the VSH SleepScale) and hypnotic drug use in our acute care adultpatient population. The primary objectives of this studywere to assess sleep disturbance and its determinantsincluding the use of drugs with sedating properties. Thesecondary objectives of this study included an assessmentof the degree of sleep effectiveness and supplementationand their determinants. Finally, a comparison of ourstudy patient results to previously published results in dif-ferent patient samples was conducted.MethodsThis study was conducted at an 800-bed adult tertiarycare, Canadian teaching institution over a 70-day period(February – April 2001). The study received university eth-ics committee and hospital research committee approvalsprior to initiation.PatientsAdult patients who were admitted to the general medicineor family practice wards during the study period were con-sidered eligible for the study. Inclusion criteria forenrollment included age (18 years or older), ability tocomplete the sleep assessment questionnaires and a will-ingness to provide written informed consent. For eachpatient, the ability to complete the sleep questionnaireswas assessed by one of the study investigators through areview of the health record (to assess past medical history,history of present illness, reason for admission and Eng-lish language skills) and discussion with members of theprimary health care team.Data collection and schedule of evaluationUpon enrollment, consenting patients were interviewedusing a subject information questionnaire (please seeadditional file, Appendix 1) to capture information per-taining to patient demographics, pre-admission sleepcharacteristics and pre-admission use of sedating drugs ator around bedtime. Patients were explicitly asked to pro-vide information as to whether their illness had led tosleep loss or disruption in normal sleep times during thelast two months; whether they had any routine assistancePage 2 of 10(page number not for citation purposes)sleep scales. A sleep scale is an effective method of objec-tively determining the quality of sleep in hospitalizedfor achieving sleep; whether they had (or were planningto) work a night shift with daytime sleeping within theHealth and Quality of Life Outcomes 2004, 2 http://www.hqlo.com/content/2/1/17last two months and whether or not they were currentlyexperiencing any stress which might disrupt their normalsleep patterns.Each patient was then requested to complete a daily ques-tionnaire (commencing on the day of enrollment) con-taining the VSH Sleep Scale and questions regarding sleepdisturbances and potential adverse reactions to any sedat-ing drugs administered during hospitalization (please seeadditional file, Appendix 2). Using this questionnaire,patients provided an assessment of the quality of theirprevious night's sleep. Finally, patients were also asked toidentify three potential causes of sleep disruption accord-ing to causes that we previously identified from the litera-ture. These included pain, shortness of breath, or havingto use the washroom that resulted in awakening.In an attempt to improve the accuracy of their recollec-tion, patients were requested to complete their sleepassessments for the previous 24 hours before 1200 hrs onthe next day. When necessary, the investigators respondedto patient requests to clarify questions and/or assistedwith the physical marking of the sleep scale. No attemptwas made to influence the response to any question.Patients were requested to complete the daily sleep ques-tionnaires until discharge or withdrawn from the study.Measurement of sleep qualityThe VSH Sleep Scale utilizes three scales (sleep distur-bance, sleep effectiveness, and sleep supplementation) tocharacterize overall sleep quality. [3] Psychometric testingof this sleep scale has been conducted in ambulatory andhospitalized patient populations. [22] Sleep quality (asmeasured by the sleep disturbance scale) was consideredthe primary study outcome parameter. The sleep distur-bance scale characterizes sleep fragmentation and latencyas measured by seven sleep properties. Fragmentationcharacteristics include mid-sleep awakening, wake aftersleep onset, movement during sleep, soundness of sleep,and quality of disturbance while latency characteristicsinclude sleep latency and quality of latency. Each charac-teristic is measured using a 100 mm visual analogue scaleand the total score for the primary outcome of sleep dis-turbance is a sum of the scores from each scale (total scoremaximum 700). A lower total score on this scale indicatesa lower degree of sleep disturbance. [3]The secondary outcome parameters for this studyincluded the degree of sleep effectiveness and sleep sup-plementation (and their determinants) as measured bythe VSH Sleep Scale. The sleep effectiveness scale meas-ures both quality and length of sleep as perceived by thepatient using the following five characteristics: rest uponual analogue scale is used to measure each of the fiveitems and these scores are summed to represent a totalscore. The maximum possible total score is 500 with ahigher score representing greater sleep effectiveness. [3]The sleep supplementation scale measures the degree towhich the bulk sleep period is augmented with additionalsleep time. The four characteristics measured are daytimesleep, morning sleep, afternoon sleep, and wake after finalarousal. The scores from each of these scales are summedto obtain a total score (total score maximum 400). Inaddition, the total sleep period is calculated by adding thescores from wake after sleep onset and total sleep time. Ahigher total score on this scale represents a worse out-come, as more supplemental sleep was needed. [3]Drug use assessmentDuring hospitalization, information regarding adminis-tration of hypnotic drugs or other medications that mayhave affected sleep was extracted by the investigators fromthe health record and confirmed through discussions withthe health care team and patient. This information wasrecorded using a standard data collection form.To augment self-reported information regarding pre-admission drug use, we accessed a provincial communityprescription database (PharmaNetR) to identify prescrip-tion hypnotics (benzodiazepines or zopiclone) and anti-depressants (any class) that had been dispensed by apharmacy during the 3-month period prior to admission.Statistical analysisA sample of 100 patients with one or more completedsleep questionnaires was considered to be adequate forthe purpose of characterizing the quality of sleep and itsdeterminants based on previous studies and the analyticmethods employed. Descriptive analyses of patient demo-graphics, hypnotic use, drugs influencing sleep, sleep dis-turbing factors, and sleep scale scores were undertakenusing SPSS version 10.0.Due to the correlated nature of the repeated VSH SleepScale observations in each participant, generalized esti-mating equations (GEE) using the identity link were uti-lized to model the scores on each of the scales (dependentvariable) and possible predictors. The selection of predic-tors began with a univariate analysis of all variables thatwere identified a priori as being potential predictive factorsfor each dependent variable. Those variables with a p-value ≤ 0.10 were retained for inclusion in the finalmodel. Regression co-efficients (β) and standard errors(SE) are reported for each association. Model fit wasassessed by the closeness to 1.0 of the deviance statisticPage 3 of 10(page number not for citation purposes)awakening, subjective quality of sleep, sleep sufficiencyevaluation, total sleep time, and total sleep period. A vis-divided by its degrees of freedom. We used SAS version8.0 (SAS Institute, Inc., Cary, North Carolina), for allHealth and Quality of Life Outcomes 2004, 2 http://www.hqlo.com/content/2/1/17inferential statistical analyses. All p-values were derivedfrom two-sided hypothesis tests and were unadjusted formultiple comparisons. Plots of the residuals were exam-ined to determine if the assumptions of regression wereviolated.To assess differences in quality of sleep between our studyparticipants and other populations, mean sleep scoreresults for study days 1 and 3 were compared to normativedata published by Verran and Snyder-Halpern [22] for102 healthy adults (65% female, mean age 39.5 years (SD10.4)) and adults with insomnia (73% female, 45.5 years(SD16.1)) in their usual sleep environment in the UnitedStates.ResultsDuring the study period, health records were screened for295 consecutively admitted patients to determine poten-tial study eligibility. Of these patients, 193 were excludeddue to severity of illness or language barriers that wereconsidered by the investigators to seriously impede thepatient's ability to provide informed consent and com-plete the sleep questionnaires. Of the 102 patientsenrolled into the study, two patients were unable to com-plete any sleep questionnaires. The remaining 100patients completed at least one questionnaire. These par-ticipants were typically enrolled in the study within thefirst few days of admission (median 3 days (range 0–27)),while enrollment was occasionally delayed for those whowere transferred from another service.Patient demographics, pre-admission sleep characteristicsand sedative drug use are shown in Table 1. There was arelatively even distribution of males versus females, andpatients were typically in their 8th decade of life, retiredand diagnosed with multiple documented chronic dis-eases. The five most commonly recorded chronic diseaseswere hypertension (18% of patients), depression (14%),CVA (12%), COPD (10%) and CHF (9%). The five mostcommonly recorded chief complaints resulting in hospi-talization were GI bleed/ulcer (15%), CHF (9%), pneu-monia (8%), atrial fibrillation (3%) and angina (3%).The median self-reported pre-admission sleep durationfor participants was 8 hours and less than 30% of patientsclaimed to use sedating drugs on or around bedtime priorto admission.Sleep disturbance, effectiveness and supplementationThree hundred and thirty-two sleep disturbance, 308sleep effectiveness scores, and 332 sleep supplementationwere completed by the participants during the studyperiod. Sleep disturbance scores across all study days402, while sleep supplementation scores ranged between0 – 358.When mean quality of sleep scores for Day 1 (100patients) and Day 3 (52 patients) were compared withnormative published data for healthy and insomniacadults in their usual sleep environment, our patientstended to have worse sleep scores as compared to healthynon-hospitalized US adults in all three scales (Figure 1).Conversely, when compared to US non-hospitalizedadults with insomnia, our patients demonstrated sleepdisturbance and supplementation scores that were similaron Day 1, but lower (i.e. improved) on Day 3, while sleepeffectiveness were higher (i.e. better) on both days.The results of the GEE regression analysis are presented inTable 2. There was an association between sleep distur-bance scores and the number of chronic diseases, the pres-ence of pain, the use of bedtime tricyclic antidepressants,and the number of chronic diseases without pain. Therewas an association between sleep effectiveness scores andthe length of hospitalization, the in hospital use of bed-time sedatives and the presence of pain. Finally, there wasan association between sleep supplementation scores andthe in hospital use of bedtime sedatives (tricyclic antide-pressants and loxapine), and age. There was no associa-tion between sleep scores and the other variablesinvestigated.Drug use assessmentTwenty-nine (29%) patients reported using a sedatingTable 1: Patient demographicsParameter (N = 100) ValueGender (%)Male 41Female 59Ward (%)General Medicine Ward 42Family Practice Ward 58Mean age, yrs (range) 75 (35 – 97)Median number of chronic diseases (range) 3.0 (0 – 7)Median duration of sleep at home, hrs (range) 8 (1 – 14)Employment status (%)Retired 79Unemployed 8Part-time employment 4Full-time employment 9Sedative use at home (%)Yes 29No 71Page 4 of 10(page number not for citation purposes)ranged 16 – 681, sleep effectiveness scores ranged 54 – drug at or around bedtime while at home. According toour review of PharmaNetR profiles for these patients, 35Health and Quality of Life Outcomes 2004, 2 http://www.hqlo.com/content/2/1/17(35%) patients had actually received a dispensed prescrip-tion for a hypnotic or antidepressant drug in the 3-monthperiod prior to the current admission. Benzodiazepineswere the most common class of sedating drug prescribed(Figure 2). A PharmaNetR profile was not available forfour (4%) patients.Hypnotic agentsThirty-six (36%) patients did not have a hypnotic pre-scribed prior to or during hospitalization. Thirty-one(31%) patients had a continuation of their pre-admissionhypnotic prescription while in hospital, whereas anotherfour (4%) patients had their pre-admission hypnotic dis-continued while in hospital. Finally, 29 (29%) patientshad a hypnotic prescription initiated in hospital, with noevidence of pre-admission hypnotic use.Overall, 60 (60%) patients were prescribed zopiclone or abenzodiazepine for bedtime hypnotic use while in hospi-tal (Figure 3). Lorazepam was the most popular hypnoticprescribed followed by zopiclone, oxazepam, clon-azepam, alprazolam, temazepam, or a combination ofagents.Other drugs with sedating propertiesPatients were also prescribed a variety of other sedatingdrugs at bedtime during their hospitalization. Figure 4depicts the classes of drugs used as a percentage of thetotal patient observations recorded. Of those whoreceived a hypnotic the night prior to filling out a ques-tionnaire, 68 (20%) of observations revealed the admin-istration of a benzodiazepine while 37 (11%) revealed theadministration of zopiclone. Other notable drugs withsedating properties that were used at bedtime includedantidepressants, antipsychotics, antinauseants and nar-cotic analgesics.DiscussionThis study was designed to provide an objective measureof the quality of sleep and its predictive factors for hospi-talized adult patients at our institution. Our results showthat these inpatients have significant impairment in allsleep scales, and a quality of sleep that is inferior to non-institutionalized healthy adults and almost as impaired asinsomniacs. Although predictors varied across scales, bed-time sedative use was consistently associated (either posi-tively or negatively, depending on the agent) with sleepoutcomes. Sixty percent of our patients received a pre-Comparison of VSH Sleep Dimensions1Figure 1Comparison of VSH Sleep Dimensions (data represents mean VSH scores for each sleep dimension).Page 5 of 10(page number not for citation purposes)scription for a bedtime hypnotic. Thus, it would appearthat despite widespread sedative drug use in the hospital,Health and Quality of Life Outcomes 2004, 2 http://www.hqlo.com/content/2/1/17patients still experience sleep impairment. Zopiclone wasfound to be beneficial for sleep disturbance, butdetrimental for sleep effectiveness and supplementationrelative to other sedative drugs includingbenzodiazepines.Previous investigations have revealed that the most com-mon factors affecting sleep in hospitalized patientsinclude the effects of illness, environmental sleep disrup-tion, additional medication, anxiety, and depressiondecreased pain tolerance. [3] We found that sleep distur-bance was explained by the number of chronic diseases,presence of pain, bedtime sedative use and an interactionterm between pain and number of chronic diseases. Ofinterest, we had expected that as the number of chronicdiseases increased, the sleep disturbance score would alsoincrease. However, we found the opposite and are unableto explain this observation. This is further complicated bythe interaction term that found that chronic diseases withpain are associated with a decrease in sleep disturbance.Table 2: Relationship between sleep subscales and predictive factors95% CIFactor β coefficient Lower Upper p-valueSleep disturbance subscale*Sleep loss/disruption due to illnessYes 48 -7.83 105.01 0.092No (reference) 0 0 0# of chronic diseases -30.33 -46.78 -13.88 0.0003PainYes (reference) 0 0 0No -135 -218.31 -51.71 0.0015Bedtime sedative <0.0001None 57.33 -13.48 128.15 0.11Benzodiazepines 60.75 -12.87 134.4 0.11Tricyclic antidepressants 250.73 189.25 312.22 <0.0001Loxapine 16.24 -94.09 126.57 0.77Zopiclone (reference) 0 0 0# of chronic disease without pain 27.16 3.51 50.81 0.024# of chronic disease with pain (reference) 0 0 0Sleep supplementation subscaleAge (by year) -1.88 -3.07 -0.7 0.0018Bedtime sedative <0.0001None -18.12 -54.66 18.41 0.33Benzodiazepines -39.55 -83.68 4.58 0.079Tricyclic antidepressants -57.82 -92.51 -23.13 0.0011Loxapine 2.92 -112.48 118.33 0.96Zopiclone (reference) 0 0 0Sleep effectiveness subscaleDay of hospitalization -2.65 -4.88 -0.43 0.02Bedtime sedative 0.0031None 33.8 16.24 51.36 0.0002Benzodiazepines 32.82 13.87 51.78 0.007Tricyclic antidepressants 29.74 13.47 46.02 0.0003Loxapine 20.18 4.35 36.01 0.013Zopiclone (reference) 0 0 0PainYes (reference) 0 0 0No -15.76 -30.04 -1.47 0.031* Scaled deviance value divided by its degrees of freedom = 1.03 $ Scaled deviance value divided by its degrees of freedom = 1.02 # Scaled deviance value divided by its degrees of freedom = 1.02Page 6 of 10(page number not for citation purposes)[3,6,7]. Insomnia in the hospitalized patient leads toincreased fatigue, irritability and aggressiveness as well asPotentially, this could be confounded by the use of nar-cotic agents (i.e. narcotics would be expected to alleviateHealth and Quality of Life Outcomes 2004, 2 http://www.hqlo.com/content/2/1/17pain and may induce sleep) within the hospital. Furtherinvestigation into these results is warranted. For the sleepsupplementation scale, increasing age was associated withless supplementation. This may be because older peoplegenerally require less sleep. For sleep effectiveness, lengthof hospitalization resulted in lower scores. Thus, forpatients with prolonged duration of hospital stay, specialattention should be paid to their sleep patterns. Pain wasassociated with a better sleep effectiveness score (oppositeto its impact on sleep disturbance). Again, this resultcould be confounded by the use of narcotic agents in thehospital.Tranmer et al [21] recently assessed the sleep experience ofmedical and surgical patients during their stay in a Cana-dian teaching hospital using the Verran and Snyder –Halpern sleep scale. When scores for the 54 medicalpatients in this study were adjusted for visual analoguescale differences, it is apparent that our study patients gen-erally had reported more sleep disturbance, greater sleepeffectiveness and similar sleep supplementation needs.This was likely related to differences in the patient popu-lations (e.g. patients in this recent study tended to beyounger, predominantly male and from a limitedselection of diagnostic groups) as well as differences in thePre-admission hypnotic and antidepressant use1Figure 2Pre-admission hypnotic and antidepressant use (35 patients (35%) were prescribed a hypnotic or antidepressant during the 3-month period prior to admission according to our review of PharmaNetR records).Benzo63%Antidepressant14%Benzo combo3%Zopiclone9%Unknown11%Page 7 of 10(page number not for citation purposes)physical environments between the two study settings.Similar to Tranmer et al, we found an association betweenHealth and Quality of Life Outcomes 2004, 2 http://www.hqlo.com/content/2/1/17sleep quality and a number of internal and external fac-tors. In both studies, patients with longer hospital staystended to report better sleep, likely reflecting an increasedfamiliarity with the new surroundings. Older patients andthose with pain had a poorer quality of sleep.According to our analysis, approximately one-third ofinsomnia. This observation was not surprising consider-ing the prevalence of insomnia (~25%) in the generalpopulation [2]. Sixty percent of patients received a pre-scription for a hypnotic while in hospital and about one-half of these appear to have been hypnotic-naïve patients.This finding is consistent with observations published ina 2002 report by Ramesh and Roberts [20]. These investi-Distribution of hypnotic drugs prescribed during hospitalization1Figure 3Distribution of hypnotic drugs prescribed during hospitalization (N = 60 patients including 31 (31%) patients had a continuation of their pre-admission hypnotic prescription while in hospital and 29 (29%) patients had a hypnotic prescription initiated in hos-pital with no evidence of pre-admission hypnotic use).Lorazepam & Zopiclone2%Lorazepam35%Temazepam2%Oxazepam & Lorazepam6%Alprazolam4%Oxazepam16%Clonazepam6%Zopiclone29%Page 8 of 10(page number not for citation purposes)patients used a hypnotic prior to admission and contin-ued therapy during hospitalization for the treatment ofgators assessed inpatient and discharge prescribing of ben-zodiazepines used for sleep induction in two IndianHealth and Quality of Life Outcomes 2004, 2 http://www.hqlo.com/content/2/1/17medical wards over a 3-month period and found that 57%of those patients prescribed benzodiazepines in hospitalwere not taking a benzodiazepine at home prior to admis-sion. Approximately one in three inpatients in our studyreceived a benzodiazepine during admission and thisfinding is also similar to that reported in 2001 by Elliottet al [19]. Accordingly, it appears that hypnotic agentscontinue to be widely used in our hospitalized medicalpatient population and benzodiazepines remains themost commonly prescribed hypnotic drug class for thispurpose.participants. As such, it is possible, by applying our inclu-sion/exclusion criteria, that we selected people with lessserious sleep deficits. This could potentially bias ourresults and affect the generalizability of our findings.However, we believe that this is a conservative bias in thatwe still found a significant proportion and degree of sleepdeficits in our sample. While most patients were enrolledwithin a few days of hospitalization, enrollment wasdelayed for others and this may have influenced theirquality of sleep scores. No attempt was made to directlyassess this potential relationship. We relied on patient rec-ollection of sedating drug use prior to admission. Hyp-Drugs with sedating properties prescribed for bedtime administration during hospitallization1Figure 4Drugs with sedating properties prescribed for bedtime administration during hospitalization (percentage based upon 339 observations).No36%Benzo20%Other combo18%Antinauseant1%Benzo + Zopiclone2%Benzo combo1%Narcotic2%Antipsychotic4%Antidepressant5%Zopiclone11%Page 9 of 10(page number not for citation purposes)There are several limitations associated with this study.Foremost, we screened 295 patients in order to recruit 100notic use prior to hospitalization was confirmed by aPharmaNetR review; however, over-the-counter andPublish with BioMed Central   and  every scientist can read your work free of charge"BioMed Central will be the most significant development for disseminating the results of biomedical research in our lifetime."Sir Paul Nurse, Cancer Research UKYour research papers will be:available free of charge to the entire biomedical communitypeer reviewed and published immediately upon acceptancecited in PubMed and archived on PubMed Central Health and Quality of Life Outcomes 2004, 2 http://www.hqlo.com/content/2/1/17herbal hypnotic agents purchased without a prescriptionare not captured by this database. For the purposes ofquality of sleep comparisons with non-hospitalizedpatients, we relied on quality of sleep scores reported fora younger, predominantly female sample group. [22]Accordingly, it is not possible to conclude with any cer-tainty that institutionalization alone accounted for a dif-ferent in sleep quality between these two groups. Finally,this study involved patients in the general medicine andfamily practice areas of this hospital only; thus, we cannotextrapolate our results to the general hospital population.The results of this study reveal that quality of sleep is aproblem that affects hospitalized adult medical servicepatients and a relatively high percentage of these patientsare being prescribed a hypnotic prior to and duringhospitalization.Authors' contributionsLF, CM and PJ conceived of the study. LF, CM, SB, KW, TN,PJ collaborated in the design of the study and the draftingof the proposal, literature search and final manuscript. SB,KW, TN participated in the collection of the data. LF, CM,PJ performed the statistical analysis. PJ functioned as thecoordinating investigator with support from LF and CM.All authors read and approved the final manuscript.AcknowledgementsWe thank the patients who participated in this study, as well as the health care professionals that supported its conduct.References1. Asplund R: Sleep disorders in the elderly. Drugs Aging 1999,14:91-103.2. Holbrook AM, Crowther R, Lotter A, Cheng C, King D: The diag-nosis and management of insomnia in clinical practice: apractical evidence-based approach. CMAJ 2000, 162:216-220.3. Snyder-Halpern R, Verran JA: Instrumentation to describe sub-jective sleep characteristics in healthy subjects. Res NursHealth 1987, 10:155-163.4. Walsleben J: Sleep disorders. Am J Nurs 1982, 82:936-940.5. Dement WC: The proper use of sleeping pills in the primarycare setting. J Clin Psychiarty 1992, 53 Suppl(12):57-60. Review6. Kaempfer SH: Comfort: Sleep. 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Taylor S, McCracken CF, Wilson KC, Copeland JR: Extent andappropriateness of benzodiazepine use. Results from an eld-erly urban community. British J Psychiatry 1998, 173:433-438.15. Gales BJ, Menard SM: Relationship between the administrationof selected medications and falls in hospitalized elderlypatients. Ann Pharmacother 1995, 29:354-358.16. Grad RM: Benzodiazepines for insomnia in community-dwell-ing elderly: a review of benefit and risk. J Fam Pract 1995,41:473-481.17. Anonymous: Hypnotic drugs. The Medical Letter on Drugs andTherapeutics 2000, 42:71-72.18. Tu K, Mamdani MM, Hux JE, Tu JB: Progressive trends in theprevalence of benzodiazepine prescribing in older people inOntario, Canada. J Am Geriatr Soc 2001, 49:1341-1345.19. Elliott RA, Woodward MC, Oborne CA: Improving benzodi-azepine prescribing for elderly hospital inpatients using auditand multidisciplinary feedback. Intern Med J 2001, 31:529-535.20. Ramesh M, Roberts G: Use of night-time benzodiazepines in anelderly inpatient population. J Clin Pharm Ther 2002, 27:93-97.21. Tranmer JE, Minard J, Fox LA, Rebelo L: The sleep experience ofmedical and surgical patients. Clin Nurs Res 2003, 12:159-173.22. Verran JA, Snyder-Halpern R: Visual Analog Sleep (VAS) Scales.Tucson:University of Arizona; 1990:1-7,11. yours — you keep the copyrightSubmit your manuscript here:http://www.biomedcentral.com/info/publishing_adv.aspBioMedcentralPage 10 of 10(page number not for citation purposes)prevalence of benzodiazepine use in the older population ofNova Scotia: A cause for concern? Can J Clin Pharmacol 1999,6:149-156.


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