Sleeping Pill Use Linked to Later Increase in BP Meds

April 09, 2019

The use of sleeping tablets by older hypertensive patients was linked to a subsequent increase in use of antihypertensive medications in a new study.

"Previous studies have generally found associations of sleep characteristics with blood pressure and hypertension in middle-aged adults. However, these associations were absent or inconsistent among older subjects," senior author José Banegas, MD, Universidad Autónoma de Madrid, Spain, explained to Medscape Medical News.

"Our findings may be useful in practice, given that 1 in 5 older people in the present study increased their antihypertensive treatments during the follow-up, and it is known that the greater the number of medications patients take, the higher the risk of inappropriate medications, adverse reactions, and lower treatment adherence," he added.

The prospective cohort study was published online on March 25 in Geriatrics and Gerontology International.

The study involved 752 patients aged ≥60 years (average, 69 years; 49% men) participating in a seniors cohort. The patients were undergoing treatment for hypertension and were followed from 2008-2010 through 2012-2013.

Self‐reported sleep duration, sleep quality (usually having difficulty falling asleep or staying asleep), and sleeping pill use (the type of hypnotic used was not specified) were ascertained at baseline, and the change in the number of antihypertensive drugs prescribed by the end of follow-up was calculated.

Analyses were carried out with logistic regression and were adjusted for demographics, lifestyle, comorbidity, baseline number of antihypertensive drugs used, and hypertension control.

Results showed that the mean sleep duration was 6.9 hours per night. Poor sleep quality was reported by 37%, and 16.5% reported that they usually took sleeping pills. The mean number of antihypertensive drugs used was 1.8.

During the follow‐up period, 156 patients (20.7%) increased the number of antihypertensive drugs they were taking. No association was found between sleep duration or quality and the change in antihypertensive drug use.

However, usual sleeping pill consumption was associated with a higher risk of increasing the number of antihypertensive drugs (odds ratio, 1.85; P = .02). The association was seen regardless of sleep duration and quality, body mass index, diet, physical activity, and hypertension control.

The researchers suggest several possible explanations for this observation.

They point out that some hypnotic agents may induce atropine-related parasympathetic inhibition and tachycardia, as well as hypertension, and others may increase sleep-disordered breathing, which may be associated with hypertension and, in particular, with nocturnal hypertension in older patients.

Other potential reasons of the association include underlying sleep disturbances that were not examined in the study (eg, anxiety) and reduced physical activity because of sedation, Banegas added.

"The importance of this study from a clinical viewpoint is the association reported may indicate future need of antihypertensive drugs in usual consumers of sleep pills; and sleeping pill use could be used as a warning indicator to investigate the underlying sleep disorders or unhealthy lifestyles," he concluded.

"However, further studies are needed to confirm this association and elucidate underlying mechanisms," he added. "Among other things, these studies should consider long-term patterns of sleep characteristics and covariates, as some changes over time are possible."

Commenting on the study for Medscape Medical News, David A. Calhoun, MD, Vascular Biology and Hypertension Program and Sleep/Wake Disorders Center, University of Alabama at Birmingham, said: "The findings are provocative. Being an observational study, causality or lack thereof cannot be assumed, but it is concerning that habitual use of sleeping aids made be associated with more difficult to treat hypertension."

He noted that the effect could be the result of unfavorable effects of hypnotic agents on underlying sleep disorders, such as obstructive sleep apnea, or from interactions with antihypertensive agents that diminish their effectiveness.

"The association might also be related to a greater likelihood of underlying causes of sleep disruption among adults taking sleep aids, such as insomnia, obstructive sleep apnea, or restless leg syndromes, which have been shown to the increase risk of developing and/or worsen the severity of hypertension.

"Prospective assessments of hypnotic medications are needed to establish or exclude a causative role directly attributable to hypnotic agents. Until then, these findings highlight the importance of close monitoring of blood pressure in older subjects, and particularly in subjects requiring regular use of sleep aids," Calhoun added.

Also commenting for Medscape Medical News, Ariel B. Neikrug, PhD, director, Behavioral Sleep Medicine Program, University of California, Irvine, said the current study aligns with prior epidemiologic studies that show a consistent link between hypertension and symptoms of sleep disturbances.

"Obstructive sleep apnea, a major sleep disorder, has been linked to increased risk for hypertension, and the sleep apnea treatment CPAP [continuous positive airway pressure] has been shown to improve hypertension," he noted.

Neikrug said the lack of a statistically significant association between self-reported total sleep time or quality in this study was of "little significance" because "increasing the use of sleeping pills itself indicated increased perception of poor sleep or sleep difficulties that were sufficient to prompt seeking additional medical care.

"This study raises the importance of adequate assessment and management of sleep disorders. Sleep is a major biobehavioral process that is vital to our health. Therefore, sleep disorders should be appropriately assessed and treated with cognitive-behavioral therapy for insomnia as the first line of treatment. I hope this research is used to further stress the importance of sleep to our overall health," he added.

The study was supported by grants from Fondo de Investigación Sanitaria and Catedra UAM de Epidemiología. The authors have disclosed no relevant financial relationships.

Geriatr Gerontol Int. Published online March 25, 2019. Abstract

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