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Original Investigation |

Nonbenzodiazepine Sleep Medication Use and Hip Fractures in Nursing Home Residents

Sarah D. Berry, MD, MPH; Yoojin Lee, MS, MPH; Shubing Cai, PhD; David D. Dore, PharmD, PhD
JAMA Intern Med. 2013;173(9):754-761. doi:10.1001/jamainternmed.2013.3795.
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Importance It is important to understand the relationship between sleep medication use and injurious falls in nursing home residents.

Objective To conduct a case-crossover study to estimate the association between nonbenzodiazepine hypnotic drug use (zolpidem tartrate, eszopiclone, or zaleplon) and the risk for hip fracture among a nationwide sample of long-stay nursing home residents, overall and stratified by individual and facility-level characteristics.

Design and Setting Case-crossover study performed in an academic research setting.

Participants The study participants included 15 528 long-stay US nursing home residents 50 years or older with a hip fracture documented in Medicare Part A and Part D fee-for-service claims between July 1, 2007, and December 31, 2008.

Main Outcome Measures Odds ratios (ORs) of hip fracture were estimated using conditional logistic regression models by comparing the exposure to nonbenzodiazepine hypnotic drugs during the 0 to 29 days before the hip fracture (hazard period) with the exposure during the 60 to 89 and 120 to 149 days before the hip fracture (control periods). Analyses were stratified by individual and facility-level characteristics.

Results Among the study participants, 1715 (11.0%) were dispensed a nonbenzodiazepine hypnotic drug before the hip fracture, with 927 exposure-discordant pairs included in the analyses. The mean (SD) age of participants was 81.0 (9.7) years, and 77.6% were female. The risk for hip fracture was elevated among users of a nonbenzodiazepine hypnotic drug (OR, 1.66; 95% CI, 1.45-1.90). The association between nonbenzodiazepine hypnotic drug use and hip fracture was somes greater in new users (OR, 2.20; 95% CI, 1.76-2.74) and in residents with mild vs moderate to severe impairment in cognition (OR, 1.86 vs 1.43; P = .06), with moderate vs total or severe functional impairment (OR, 1.71 vs 1.16; P = .11), with limited vs full assistance required with transfers (OR, 2.02 vs 1.43; P = .02), or in a facility with fewer Medicaid beds (OR, 1.90 vs 1.46; P = .05).

Conclusions and Relevance The risk for hip fracture is elevated among nursing home residents using a nonbenzodiazepine hypnotic drug. New users and residents having mild to moderate cognitive impairment or requiring limited assistance with transfers may be most vulnerable to the use of these drugs. Caution should be exercised when prescribing sleep medications to nursing home residents.

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Figure 1. Selection process for participants in a case-crossover study of nonbenzodiazepine hypnotic drug use and hip fracture. ICD-9 indicates International Classification of Diseases, Ninth Revision; MDS, Minimum Data Set; and NH, nursing home.

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Figure 2. Case-crossover study design. We compared the exposure to nonbenzodiazepine hypnotic drugs during the 0 to 29 days before the hip fracture (hazard period) with the exposure during the 60 to 89 and 120 to 149 days before the hip fracture (control periods).

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Figure 3. Density and daily prevalence of dispensings of nonbenzodiazepine hypnotic drugs. A, In the 180 days before the hip fracture for the case series. B, In the 180 days before a density-sampled index date for 10 000 noncases.

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