Recent data (pdf) shows that nearly one-third of Americans have insomnia, and about one-third of those may be self-medicating to treat the condition. New research finds the price they pay for a good night's sleep might be very high.
The study followed approximately 3,000 older white and black adults without dementia over an average duration of nine years, to find that white participants who frequently used sleep medications had a 79 percent increased risk of developing dementia compared to those who rarely used them.
During the study, 20 percent of participants developed dementia, and researchers discovered that whites were three times as likely as blacks to take sleep medications often.
Whites were also much more likely to use sleep aids like benzodiazepines, trazodone, and "Z-drugs," which include zopiclone, eszopiclone, zaleplon, and zolpidem (Ambien).
"We've known for a while that certain sleep medications like benzodiazepines are associated with an increased risk of dementia," Percy Griffin, who holds a doctorate in molecular cell biology and is the Alzheimer's Association director of scientific engagement, told The Epoch Times.
"Benzodiazepines have been found to have anticholinergic activity, which increases the risk for dementia," he said.
Anticholinergics are terrible for both sleep and brain function.
"Acetylcholine signaling is already deficient in people with Alzheimer's, and further blocking these receptors has caused delirium in patients I have seen and may increase dementia risk as well," said Dr. Alex Dimitriu, who is double board-certified in psychiatry and sleep medicine and the founder of Menlo Park Psychiatry & Sleep Medicine.
"For everyone else, short-term use is okay, but ideally avoided," he continued. "Anticholinergic medications can alter sleep architecture, and reduce REM sleep."
Research shows that patients with dementia who were prescribed higher-dose Z-drugs were also more likely to be hospitalized, visit their primary care doctor, and be prescribed antipsychotics, antidepressants, and even antibiotics.
Among black participants, whose sleep-aid use was much lower, frequent users had a similar likelihood of developing dementia to those who didn't-or rarely used-the medications.
According to the study's first author, Yue Leng, who holds a doctorate in epidemiology and is faculty at the University of California, San Fransisco, Department of Psychiatry and Behavioral Sciences and the Weill Institute for Neurosciences, these differences may be attributed to socioeconomic status.
"Black participants who have access to sleep medications might be a select group with high socioeconomic status and, thus, greater cognitive reserve, making them less susceptible to dementia," she said. "It's also possible that some sleep medications were associated with a higher risk of dementia than others."
Previous studies have shown that blacks were less likely than whites to report their use of prescription and nonprescription sleep medications. This may have exerted a protective effect on this population.
Sleep meds such as Ambien can certainly help sleep. "The question is: at what cost?" said Dimitriu. "As a sleep doctor and a psychiatrist, I treat a fair amount of insomnia, and regularly come back to this question."
But at the same time, lack of sleep alone can cause cognitive issues. A 2018 study looked at over 50,000 participants to find an almost doubled risk of dementia in both adults and younger patients with a diagnosis of primary insomnia.
Insomnia is also a well-known symptom in those who have dementia.
But any study that tries to connect insomnia and dementia potentially has a fatal flaw at the very onset: deciding whether self-reported insomniacs actually have undiagnosed early dementia, said Dr. Bibhuti Mishra, chief of neurology at Long Island Jewish Forest Hills, part of Northwell Health in New York.
"Studies that seek to investigate anticholinergics' effect on cognition also suffer from the same inescapable flaw," he added, noting an important limitation of Leng's study: It didn't include a well-known risk factor for dementia at the time of recruitment, the APOE4 gene.
However, there has also been research, such as a large 2020 study, that concluded these drugs may even have a protective effect, via improved sleep.
Regarding sleep aids with anticholinergic effects, Dimitriu suggested that "short-term use is okay, but ideally avoided."
"The question of whether to use sleep aids or not and what type of sleep aids to use, is best directed to your physician," advised Mishra.
Besides benzodiazepines and Z-drugs, melatonin is also used by physicians to treat sleep disorders. It is a common, over-the-counter sleep aid, which so far hasn't been associated with cognitive decline. However, it also hasn't shown any benefits for people living with cognitive issues.
A large review paper in 2015 found that while melatonin did aid with insomnia in people with dementia, the improvement in sleep didn't result in an improvement in cognition. However, there were also no severe side effects or evidence of worsening cognition from using melatonin.
Melatonin has also been shown to be beneficial for sundowning, which is the confusion that often arises in people with dementia during later hours.
"In my experience, and per research trials, melatonin works best taken in doses below the typical 3-milligram dose found in most pharmacies," said Dimitriu. Doses of 0.3 mg up to 1 or 2 mg are often effective, "especially for some in the elderly population with sleep trouble, shift workers, and people with jet lag."
There are nonmedical ways to improve sleep, and many cases of insomnia are caused by factors that include stress and poor sleep habits.
"I tell all my patients to 'turn tech off at 10,' get back to reading books, and try to be asleep before midnight," said Dimitriu. "Winding down and reading before bed, without screens, works miraculously well."
He also recommended sticking to regular sleep and wake times, as the "body and sleep love rhythm.
"Reducing stress and treating anxiety if present also can markedly improve sleep quality," he continued. "Exercise and meditation are also quite helpful."
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