LAUSR

Dear Editor, We are writing to highlight the link between the use of zolpidem to treat sleep problems and an increased risk of falls in older adults. Falls are one of the major public health concerns in this population and are among the top seven causes of the number of years lived with disability, according to the Global Burden of Disease Study (2010). The costs of treating these patients is extremely high for the health systems. It is estimated that around 30% of older adults suffer falls each year and, although about 30% to 50% of these falls only result in minor injuries and lacerations, 5% to 10% may culminate in serious damage, such as fractures, head injuries, and long-lasting impairment. Sleep disorders are a well-known risk factor associated with agerelated functional impairment. Insomnia is defined by the American Academy of Sleep Disorders as difficulty in starting or maintaining sleep and early awakening, and is one of the main sleep disorders affecting older adults. A recent systematic review showed that about 35% to 60% of this population report difficulty in initiating sleep; 50% to 70% present trouble in maintaining sleep; and 20% to 25% complain about nonrestorative sleep. EPISONO study has shown that 19.6% of older participants complaint about insomnia. Currently, the gold standard treatment for insomnia is the socalled z-drugs. The most commonly prescribed is zolpidem, a fast acting nonbenzodiazepine hypnotic drug of the imidazopyridine group with a short half-life, that acts as a benzodiazepine receptor agonist on the c-aminobutyric acid receptor (GABA) complex-A. Results from a retrospective cohort study showed that zolpidem administration increased the risk of falls in adults and elderly. In older populations, which usually present some degree of functional impairment, the fall risk is even greater. According to a recent systematic review and meta-analysis, which included more than 830 877 participants, administration of zolpidem doubles the chances of falls, and also contributes to future injury in older adults. Moreover, it is possible to state that the relationship between zdrugs and falls in older people is not well understood. A possible hypothesis is the adverse pharmacodynamic effect on cognition, gait, and balance that may contribute to falls. Thus, z-drug administration may negatively impact postural stability and balance, causing further falls in this population. We would like to highlight the fact that the use of drugs for insomnia, especially z-drugs, may increase the risk of falls in the older population and contribute to a greater risk of morbidities. Falls usually result from an interaction between environmental challenges and the numerous deficits related to cognitive, neuromuscular, or cardiovascular functions. Therefore, doctors and clinicians in general should consider nondrug clinical strategies, such as exercise therapy, that can bring benefits to balance, sleep quality, and help to reduce insomnia without presenting deleterious effects on the health of the elderly.