We thank Dr. James for his comments1 on our paper, Clinical Practice Guideline for Pharmacologic Treatment of Chronic Insomnia in Adults.2 Although there is uncertainty regarding increased risk of dementia associated with use of benzodiazepines (BZD) and BZD receptor agonists (see Imfeld et al.),3 Dr. James is correct in asserting that clinicians must consider this, as well as numerous other potential adverse consequences of hypnotic medication, particularly in the elderly.
The adverse effects described in our systematic review were drawn only from the efficacy studies that met overall inclusion criteria. We note in our publication that “the data (from studies included in this analysis) are scant and inconsistent, suggesting that caution should be applied in the assessment of relative risks associated with use of hypnotic medications.” We also note that there are many additional observational studies that address these and other potential adverse effects; “Other reported adverse effects include—but are not limited to—dependency/withdrawal, cognitive impairment, falls/fractures, parasomnias, and driving impairment and motor vehicle accidents. Epidemiological studies have also suggested a possible link between hypnotic use and infection, depression and overall mortality risk. These complications are observed most frequently in older populations, who are among the most frequent users of these drugs.” Per Dr. James' comment, dementia could be listed among the conditions related to BZD hypnotic use in epidemiological studies. Although these observational studies are beyond the scope of our investigation, they are by all means important considerations for clinicians who are prescribing these drugs.
The authors approve the manuscript. Dr. Buysse has been a consultant for Cereve, Inc, Emmi Solutions, Philips Respironics, and BeHealth; he has received research support from the NIH; and he owns intellectual property rights in the Pittsburgh Sleep Quality Index (PSQI). Dr. Krystal serves on a scientific advisory board for Merck; he has received research support from the NIH, TEVA, and Sunovion; and he has been a consultant for Flamel, Atentiv, Ostuka, Neurocrine, Lundbeck, Pernix, Janssen, Jazz, and Merck. Dr. Neubauer is a member of the Board of Directors for the National Sleep Foundation; and he has been a consultant for Purdue Pharama. Dr. Sateia has indicated no conflicts of interest.
Sateia MJ, Buysse DJ, Krystal AD, Neubauer DN. Adverse effects of hypnotic medications. J Clin Sleep Med. 2017;13(6):839.
James W. Hypnotics and the risks of dementia. J Clin Sleep Med. 2017;13(6):837
Sateia M, Buysse D, Krystal A, et al. Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: an American Academy of Sleep Medicine Clinical Practice Guideline. J Clin Sleep Med. 2017;13(2):307–349. [PubMed]
Imfeld P, Bodmer M, Jick SS, Meier CR. Benzodiazepine use and risk of developing Alzheimer's disease or vascular dementia: a case-control analysis. Drug Saf. 2015;38(10):909–919. [PubMed]