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Using melatonin to reset the clock of hospitalized older patients
Helping hospitalized geriatric patients maintain an appropriate sleep-wake cycle can be a challenge. Older patients’ circadian rhythm may be affected by several factors—eg, obstructive sleep apnea and restless leg syndrome—that contribute to disrupted sleep and daytime fatigue. Some patients may have dementing illnesses that could dysregulate sleep. Many older patients experience delirium during hospitalization, of which sleep-wake cycle disturbances are a hallmark. Finally, geriatric patients’ natural sleep pattern often does not mimic a hospital’s typical schedule.
Sleep medication side effects
Medications used to promote sleep can cause side effects in geriatric patients. Benzodiazepine use by older adults is discouraged because these medications could cause falls or contribute to delirium. Non-benzodiazepine hypnotics such as zolpidem, zaleplon, and eszopiclone pose a similar risk. Medications containing diphenhydramine predispose patients to deliriogenic effects via their anticholinergic properties. Tricyclic antidepressants carry risks, such as delirium secondary to anticholinergic effects, orthostatic hypotension, falls from α-1 blockade, and cardiac arrythmias.
Atypical antipsychotics sometimes are used off-label to help initiate sleep, but they carry a “black-box” warning regarding sudden death from cardiovascular events in geriatric patients with dementia. Hydroxyzine and trazodone also are associated with side effects such as orthostatic hypotension and daytime sedation, and are not always effective.
Melatonin is a hormone secreted by the pineal gland in response to darkness, under the control of the suprachiasmatic nucleus (SCN), and is thought to promote sleep via synchronizing effects on the SCN.1 Melatonin is available as an over-the-counter dietary supplement and via prescription in dosages of 1 or 3 mg. The typical effective dose is 3 to 9 mg.1 Patients should take melatonin in the mid-evening, ideally between 7 pm and 8 pm, and effects become evident after a few days. Side effects are rare; the most common are headache and nausea. Daytime sedation and vivid dreams also have been reported. Melatonin can be used safely in conjunction with other sleep aids and its major drug-drug interactions involve enhancing the effects of other sedatives.2
We have found melatonin to be effective for treating sleep disturbances in older hospitalized patients. Its effectiveness may stem from the high incidence of dysregulated or calcified pineal glands in geriatric patients, which leads to a marked reduction in melatonin secretion.3 Recent evidence also suggests melatonin may reduce the incidence of delirium in older adults, and it has been proposed as a delirium treatment in post-operative and intensive care unit settings.4
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
1. de Jonghe A, Korevaar JC, van Munster BC, et al. Effectiveness of melatonin treatment on circadian rhythm disturbances in dementia. Are there implications for delirium? A systematic review. Int J Geriatr Psychiatry. 2010;25(12):1201-1208.
2. Werneke U, Turner T, Priebe S. Complementary medicines in psychiatry: review of effectiveness and safety. Br J Psychiatry. 2006;188:109-121.
3. Schmid HA. Decreased melatonin biosynthesis calcium flux, pineal gland calcification and aging: a hypothetical framework. Gerontology. 1993;39(4):189-199.
4. Al-Aama T, Brymer C, Gutmanis I, et al. Melatonin decreases delirium in elderly patients: a randomized, placebo-controlled trial. Int J Geriatr Psychiatry. 2011;26(7):687-694.
Helping hospitalized geriatric patients maintain an appropriate sleep-wake cycle can be a challenge. Older patients’ circadian rhythm may be affected by several factors—eg, obstructive sleep apnea and restless leg syndrome—that contribute to disrupted sleep and daytime fatigue. Some patients may have dementing illnesses that could dysregulate sleep. Many older patients experience delirium during hospitalization, of which sleep-wake cycle disturbances are a hallmark. Finally, geriatric patients’ natural sleep pattern often does not mimic a hospital’s typical schedule.
Sleep medication side effects
Medications used to promote sleep can cause side effects in geriatric patients. Benzodiazepine use by older adults is discouraged because these medications could cause falls or contribute to delirium. Non-benzodiazepine hypnotics such as zolpidem, zaleplon, and eszopiclone pose a similar risk. Medications containing diphenhydramine predispose patients to deliriogenic effects via their anticholinergic properties. Tricyclic antidepressants carry risks, such as delirium secondary to anticholinergic effects, orthostatic hypotension, falls from α-1 blockade, and cardiac arrythmias.
Atypical antipsychotics sometimes are used off-label to help initiate sleep, but they carry a “black-box” warning regarding sudden death from cardiovascular events in geriatric patients with dementia. Hydroxyzine and trazodone also are associated with side effects such as orthostatic hypotension and daytime sedation, and are not always effective.
Melatonin is a hormone secreted by the pineal gland in response to darkness, under the control of the suprachiasmatic nucleus (SCN), and is thought to promote sleep via synchronizing effects on the SCN.1 Melatonin is available as an over-the-counter dietary supplement and via prescription in dosages of 1 or 3 mg. The typical effective dose is 3 to 9 mg.1 Patients should take melatonin in the mid-evening, ideally between 7 pm and 8 pm, and effects become evident after a few days. Side effects are rare; the most common are headache and nausea. Daytime sedation and vivid dreams also have been reported. Melatonin can be used safely in conjunction with other sleep aids and its major drug-drug interactions involve enhancing the effects of other sedatives.2
We have found melatonin to be effective for treating sleep disturbances in older hospitalized patients. Its effectiveness may stem from the high incidence of dysregulated or calcified pineal glands in geriatric patients, which leads to a marked reduction in melatonin secretion.3 Recent evidence also suggests melatonin may reduce the incidence of delirium in older adults, and it has been proposed as a delirium treatment in post-operative and intensive care unit settings.4
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Helping hospitalized geriatric patients maintain an appropriate sleep-wake cycle can be a challenge. Older patients’ circadian rhythm may be affected by several factors—eg, obstructive sleep apnea and restless leg syndrome—that contribute to disrupted sleep and daytime fatigue. Some patients may have dementing illnesses that could dysregulate sleep. Many older patients experience delirium during hospitalization, of which sleep-wake cycle disturbances are a hallmark. Finally, geriatric patients’ natural sleep pattern often does not mimic a hospital’s typical schedule.
Sleep medication side effects
Medications used to promote sleep can cause side effects in geriatric patients. Benzodiazepine use by older adults is discouraged because these medications could cause falls or contribute to delirium. Non-benzodiazepine hypnotics such as zolpidem, zaleplon, and eszopiclone pose a similar risk. Medications containing diphenhydramine predispose patients to deliriogenic effects via their anticholinergic properties. Tricyclic antidepressants carry risks, such as delirium secondary to anticholinergic effects, orthostatic hypotension, falls from α-1 blockade, and cardiac arrythmias.
Atypical antipsychotics sometimes are used off-label to help initiate sleep, but they carry a “black-box” warning regarding sudden death from cardiovascular events in geriatric patients with dementia. Hydroxyzine and trazodone also are associated with side effects such as orthostatic hypotension and daytime sedation, and are not always effective.
Melatonin is a hormone secreted by the pineal gland in response to darkness, under the control of the suprachiasmatic nucleus (SCN), and is thought to promote sleep via synchronizing effects on the SCN.1 Melatonin is available as an over-the-counter dietary supplement and via prescription in dosages of 1 or 3 mg. The typical effective dose is 3 to 9 mg.1 Patients should take melatonin in the mid-evening, ideally between 7 pm and 8 pm, and effects become evident after a few days. Side effects are rare; the most common are headache and nausea. Daytime sedation and vivid dreams also have been reported. Melatonin can be used safely in conjunction with other sleep aids and its major drug-drug interactions involve enhancing the effects of other sedatives.2
We have found melatonin to be effective for treating sleep disturbances in older hospitalized patients. Its effectiveness may stem from the high incidence of dysregulated or calcified pineal glands in geriatric patients, which leads to a marked reduction in melatonin secretion.3 Recent evidence also suggests melatonin may reduce the incidence of delirium in older adults, and it has been proposed as a delirium treatment in post-operative and intensive care unit settings.4
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
1. de Jonghe A, Korevaar JC, van Munster BC, et al. Effectiveness of melatonin treatment on circadian rhythm disturbances in dementia. Are there implications for delirium? A systematic review. Int J Geriatr Psychiatry. 2010;25(12):1201-1208.
2. Werneke U, Turner T, Priebe S. Complementary medicines in psychiatry: review of effectiveness and safety. Br J Psychiatry. 2006;188:109-121.
3. Schmid HA. Decreased melatonin biosynthesis calcium flux, pineal gland calcification and aging: a hypothetical framework. Gerontology. 1993;39(4):189-199.
4. Al-Aama T, Brymer C, Gutmanis I, et al. Melatonin decreases delirium in elderly patients: a randomized, placebo-controlled trial. Int J Geriatr Psychiatry. 2011;26(7):687-694.
1. de Jonghe A, Korevaar JC, van Munster BC, et al. Effectiveness of melatonin treatment on circadian rhythm disturbances in dementia. Are there implications for delirium? A systematic review. Int J Geriatr Psychiatry. 2010;25(12):1201-1208.
2. Werneke U, Turner T, Priebe S. Complementary medicines in psychiatry: review of effectiveness and safety. Br J Psychiatry. 2006;188:109-121.
3. Schmid HA. Decreased melatonin biosynthesis calcium flux, pineal gland calcification and aging: a hypothetical framework. Gerontology. 1993;39(4):189-199.
4. Al-Aama T, Brymer C, Gutmanis I, et al. Melatonin decreases delirium in elderly patients: a randomized, placebo-controlled trial. Int J Geriatr Psychiatry. 2011;26(7):687-694.
Evaluating medication outcomes: 3 key questions
Post hoc ergo propter hoc—”after this, therefore because of this”—suggests that 2 distinct events linked temporally are related causally. Clinicians often apply this dictum when monitoring effects of psychotropics. Because of stigma associated with psychiatric medications, and the readiness with which many practitioners blame them for unexpected results, it is important to develop a rational approach to evaluating outcomes—particularly adverse ones—after administering psychotropic agents.
Consider a geriatric patient admitted to the hospital for a urinary tract infection. He becomes verbally aggressive and is given IV haloperidol. Five minutes later he strikes a nurse and receives lorazepam. Twenty minutes later, he is lying calmly in his bed. The nursing staff and primary team conclude that the patient’s agitation worsened because of the antipsychotic and responded to the benzodiazepine; the physician documents in the patient’s chart that he had an adverse reaction to haloperidol.
In light of what we know about psychotropic medications’ mechanism of action, a more plausible explanation is that whatever caused the patient to become agitated (delirium) resulted in physical aggression. Haloperidol simply did not have enough time to exert its effect before the patient hit the nurse. It also would be wrong to automatically conclude that the last intervention (a benzodiazepine) produced the beneficial outcome. Was it the lorazepam, the haloperidol finally “kicking in,” or a combination of both? Perhaps it was none of the above but rather a worsening infection or irregular waxing and waning of delirium that was the culprit.
To avoid incorrectly attributing negative outcomes to medications, we suggest asking yourself 3 questions:
1. Is the negative outcome a potential consequence of the underlying condition?
Consider the possibility that the medication did not cause the adverse event but merely failed to adequately treat the underlying problem. A teenager who attempts suicide 2 weeks after starting an antidepressant may be exhibiting symptoms related to depression rather than behavior caused by the medication.
2. Are other medical conditions or medications responsible for the negative outcome?
Weigh the relative likelihood that these factors are contributing to your patient’s presentation. In a surgical patient who is overly somnolent after receiving an anxiolytic, consider the possibility that a narcotic or worsening hypoxia are contributing to her somnolence.
3. Is the negative outcome likely to have occurred spontaneously?
Consider the possibility of coincidence. Lithium might not be causing declining renal function in an older patient. A dosing adjustment based on the patient’s current renal function may be a better harm-reduction strategy than discontinuing a potentially useful medication.
Careful evaluation of these potential confounding factors will greatly reduce the likelihood of falsely identifying psychotropic medications as responsible for negative outcomes. After this, but not always because of this.
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Post hoc ergo propter hoc—”after this, therefore because of this”—suggests that 2 distinct events linked temporally are related causally. Clinicians often apply this dictum when monitoring effects of psychotropics. Because of stigma associated with psychiatric medications, and the readiness with which many practitioners blame them for unexpected results, it is important to develop a rational approach to evaluating outcomes—particularly adverse ones—after administering psychotropic agents.
Consider a geriatric patient admitted to the hospital for a urinary tract infection. He becomes verbally aggressive and is given IV haloperidol. Five minutes later he strikes a nurse and receives lorazepam. Twenty minutes later, he is lying calmly in his bed. The nursing staff and primary team conclude that the patient’s agitation worsened because of the antipsychotic and responded to the benzodiazepine; the physician documents in the patient’s chart that he had an adverse reaction to haloperidol.
In light of what we know about psychotropic medications’ mechanism of action, a more plausible explanation is that whatever caused the patient to become agitated (delirium) resulted in physical aggression. Haloperidol simply did not have enough time to exert its effect before the patient hit the nurse. It also would be wrong to automatically conclude that the last intervention (a benzodiazepine) produced the beneficial outcome. Was it the lorazepam, the haloperidol finally “kicking in,” or a combination of both? Perhaps it was none of the above but rather a worsening infection or irregular waxing and waning of delirium that was the culprit.
To avoid incorrectly attributing negative outcomes to medications, we suggest asking yourself 3 questions:
1. Is the negative outcome a potential consequence of the underlying condition?
Consider the possibility that the medication did not cause the adverse event but merely failed to adequately treat the underlying problem. A teenager who attempts suicide 2 weeks after starting an antidepressant may be exhibiting symptoms related to depression rather than behavior caused by the medication.
2. Are other medical conditions or medications responsible for the negative outcome?
Weigh the relative likelihood that these factors are contributing to your patient’s presentation. In a surgical patient who is overly somnolent after receiving an anxiolytic, consider the possibility that a narcotic or worsening hypoxia are contributing to her somnolence.
3. Is the negative outcome likely to have occurred spontaneously?
Consider the possibility of coincidence. Lithium might not be causing declining renal function in an older patient. A dosing adjustment based on the patient’s current renal function may be a better harm-reduction strategy than discontinuing a potentially useful medication.
Careful evaluation of these potential confounding factors will greatly reduce the likelihood of falsely identifying psychotropic medications as responsible for negative outcomes. After this, but not always because of this.
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Post hoc ergo propter hoc—”after this, therefore because of this”—suggests that 2 distinct events linked temporally are related causally. Clinicians often apply this dictum when monitoring effects of psychotropics. Because of stigma associated with psychiatric medications, and the readiness with which many practitioners blame them for unexpected results, it is important to develop a rational approach to evaluating outcomes—particularly adverse ones—after administering psychotropic agents.
Consider a geriatric patient admitted to the hospital for a urinary tract infection. He becomes verbally aggressive and is given IV haloperidol. Five minutes later he strikes a nurse and receives lorazepam. Twenty minutes later, he is lying calmly in his bed. The nursing staff and primary team conclude that the patient’s agitation worsened because of the antipsychotic and responded to the benzodiazepine; the physician documents in the patient’s chart that he had an adverse reaction to haloperidol.
In light of what we know about psychotropic medications’ mechanism of action, a more plausible explanation is that whatever caused the patient to become agitated (delirium) resulted in physical aggression. Haloperidol simply did not have enough time to exert its effect before the patient hit the nurse. It also would be wrong to automatically conclude that the last intervention (a benzodiazepine) produced the beneficial outcome. Was it the lorazepam, the haloperidol finally “kicking in,” or a combination of both? Perhaps it was none of the above but rather a worsening infection or irregular waxing and waning of delirium that was the culprit.
To avoid incorrectly attributing negative outcomes to medications, we suggest asking yourself 3 questions:
1. Is the negative outcome a potential consequence of the underlying condition?
Consider the possibility that the medication did not cause the adverse event but merely failed to adequately treat the underlying problem. A teenager who attempts suicide 2 weeks after starting an antidepressant may be exhibiting symptoms related to depression rather than behavior caused by the medication.
2. Are other medical conditions or medications responsible for the negative outcome?
Weigh the relative likelihood that these factors are contributing to your patient’s presentation. In a surgical patient who is overly somnolent after receiving an anxiolytic, consider the possibility that a narcotic or worsening hypoxia are contributing to her somnolence.
3. Is the negative outcome likely to have occurred spontaneously?
Consider the possibility of coincidence. Lithium might not be causing declining renal function in an older patient. A dosing adjustment based on the patient’s current renal function may be a better harm-reduction strategy than discontinuing a potentially useful medication.
Careful evaluation of these potential confounding factors will greatly reduce the likelihood of falsely identifying psychotropic medications as responsible for negative outcomes. After this, but not always because of this.
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.