Bhanu Prakash Kolla

Zolpidem is independently associated with increased risk of inpatient falls.

BACKGROUND Inpatient falls are associated with significant morbidity and increased healthcare costs. Zolpidem has been reported to decrease balance and is associated with falls. Yet, it is a commonly used hypnotic agent in the inpatient setting. Zolpidem use in hospitalized patients may be a significant and potentially modifiable risk factor for falling. OBJECTIVE To determine whether inpatients administered zolpidem are at greater risk of falling. DESIGN Retrospective cohort study. SETTING Adult non-intensive care unit (non-ICU) inpatients at a tertiary care center. METHODS Adult inpatients who were prescribed zolpidem were identified. Electronic medical records were reviewed to capture demographics and other risk factors for falls. The fall rate was compared in those administered zolpidem versus those only prescribed zolpidem. Multivariate analyses were performed to determine whether zolpidem was independently associated with falls. RESULTS The fall rate among patients who were prescribed and received zolpidem (n = 4962) was significantly greater than among patients who were prescribed but did not receive zolpidem (n = 11,358) (3.04% vs 0.71%; P < 0.001). Zolpidem use continued to remain significantly associated with increased fall risk after accounting for age, gender, insomnia, delirium status, dose of zolpidem, Charlson comorbidity index, Hendrichs fall risk score, length of hospital stay, presence of visual impairment, gait abnormalities, and dementia/cognitive impairment (adjusted odds ratio [OR] 4.37, 95% confidence interval [CI] = 3.34-5.76; P < 0.001). Additionally, patients taking zolpidem who experienced a fall did not differ from other hospitalized adult patients who fell in terms of age, opioids, antidepressants, sedative-antidepressants, antipsychotics, benzodiazepine, or antihistamine use. CONCLUSION Zolpidem use was a strong, independent, and potentially modifiable risk factor for inpatient falls.

Sleep Deprivation in Resident Physicians, Work Hour Limitations, and Related Outcomes: A Systematic Review of the Literature

Abstract Extended work hours, interrupted sleep, and shift work are integral parts of medical training among all specialties. The need for 24-hour patient care coverage and economic factors have resulted in prolonged work hours for resident physicians. This has traditionally been thought to enhance medical educational experience. These long and erratic work hours lead to acute and chronic sleep deprivation and poor sleep quality, resulting in numerous adverse consequences. Impairments may occur in several domains, including attention, cognition, motor skills, and mood. Resident performance, professionalism, safety, and well–being are affected by sleep deprivation, causing potentially adverse implications for patient care. Studies have shown adverse health consequences, motor vehicle accidents, increased alcohol and medication use, and serious medical errors to occur in association with both sleep deprivation and shift work. Resident work hour limitations have been mandated by the Accreditation Council for Graduate Medical Education in response to patient safety concerns. Studies evaluating the impact of these regulations on resident physicians have generated conflicting reports on patient outcomes, demonstrating only a modest increase in sleep duration for resident physicians, along with negative perceptions regarding their education. This literature review summarizes research on the effects of sleep deprivation and shift work, and examines current literature on the impact of recent work hour limitations on resident physicians and patient–related outcomes.

Jet lag and shift work sleep disorders: How to help reset the internal clock

Jet lag sleep disorder and shift work sleep disorder are the result of dyssynchrony between the internal clock and the external light-dark cycle, brought on by rapid travel across time zones or by working a nonstandard schedule. Symptoms can be minimized by optimizing the sleep environment, by strategic avoidance of and exposure to light, and also with drug and behavioral therapies. Some relief is possible for the grogginess and disorientation that often ensue from travelling long distances or working the night shift.

Valproate-induced hyperammonemic encephalopathy: an update on risk factors, clinical correlates and management

INTRODUCTION Valproate (VPA)-induced hyperammonemic encephalopathy (VHE) is a serious drug-related adverse effect characterized by lethargy, vomiting, cognitive slowing, focal neurological deficits and decreased levels of consciousness ranging from drowsiness to coma. METHODS We present a case series (n=5) and also review previous cases of VHE (n=30) in psychiatric patients to provide an update on risk factors, clinical correlates and management of VHE. RESULTS To our knowledge, there are 30 (16 female, 14 male) previously reported VHE cases in psychiatric patients. Risk factors for VHE include VPA-drug interactions, mental retardation, carnitine deficiency and presence of urea cycle disorders. Length of VPA treatment, VPA dosage, serum VPA levels and serum ammonia levels do not appear to correlate with onset or severity of VHE.VPA discontinuation is the primary treatment of VHE, although, l-carnitine, lactulose and neomycin have been used adjunctively in some patients. CONCLUSION Clinicians should consider VHE in patients taking VPA who present with lethargy, gastrointestinal symptoms, confusion and decreased levels of drowsiness. VPA discontinuation is currently the mainstay of treatment for VHE, although more research is warranted to delineate the underlying risk factors for VHE and consolidate treatment modalities for this potentially life-threatening drug adverse effect.

Worse Outcome after Stroke in Patients with Obstructive Sleep Apnea: An Observational Cohort Study

To evaluate the risk and presence of obstructive sleep apnea (OSA) in patients presenting with acute ischemic stroke, and examine the correlation of OSA with age, sex, ischemic stroke subtype, disability, and death, a prospective cohort study was conducted in all consecutive patients presenting with acute ischemic stroke between June 2007 and March 2008. Exclusion criteria were age < 18 years, refusal of consent for the study, and incomplete questionnaire. The Berlin Sleep Questionnaire was used to identify patients at high risk for OSA. A total of 174 patients with acute ischemic stroke were included; 130 (74.7%) had a modified Rankin Scale (mRS) score ≥ 3 at dismissal, and 11 patients (6.3%) died within 1 month. The Berlin Sleep Questionnaire identified 105 patients (60.4%) at high risk for OSA, along with 7 patients (4%) with a previous diagnosis of OSA. Those with a previous diagnosis of OSA were more likely to die within the first month after stroke (relative risk, 5.3; 95% confidence interval, 1.4-20.1) compared with those without OSA. Patients at high risk for OSA did not demonstrate increased mortality at 30 days (P = 1.0). In multivariate analysis, after adjusting for age and National Institutes of Health Stroke Scale score, previous diagnosis of OSA was an independent predictor of worse functional outcome, that is, worse mRS score at hospital discharge (P = .004). The mRS score was 1.2 points higher (adjusted R², 40%) in those with OSA. Our findings suggest that patients considered at high risk for ischemic stroke should be screened for OSA, the prevalence of which may be as high as 60%. Those with definitive diagnosis of OSA before stroke are at increased risk of death within the first month after an acute ischemic stroke.

The association between atrial fibrillation and stroke in patients with obstructive sleep apnea: a population-based case-control study.

BACKGROUND Obstructive sleep apnea (OSA) has been shown to be an independent risk factor for ischemic stroke and may increase the risk of atrial fibrillation (AF) by up to fourfold. Given these relationships, it is possible that OSA may provide a link between stroke and AF. A case-control study was conducted to examine the association between AF and stroke in patients with OSA. METHODS Olmsted County, MN, USA, residents with a new diagnosis of OSA based on polysomnography (PSG) between 2005 and 2010 (N = 2980) who suffered a first-time ischemic stroke during the same period were identified as cases. Controls with no history of stroke were randomly chosen from the same database. Univariate and multiple logistic regression analyses were performed with age, gender, body mass index (BMI), smoking, hypertension, hyperlipidemia, diabetes mellitus, apnea-hypopnea index (AHI) and coronary artery disease (CAD) as co-variates, with the diagnosis of AF as the variable of interest. RESULTS A total of 108 subjects were studied. Mean age of cases (n = 34) was 73 ± 12 years and 53% were men. Among controls (n = 74), mean age was 61 ± 16 years and 55% were male. On univariate analyses, AF was significantly more common in the cases than among controls (50.0% vs 10.8%, p < 0.01). On multivariate regression analyses, the association between AF and stroke was significant after controlling for age, BMI, coronary artery disease, hypertension, diabetes mellitus, hyperlipidemia and smoking status (corrected odds ratio (OR): 5.34; 95% confidence interval (CI): 1.79-17.29). CONCLUSIONS Patients with OSA who had a stroke had higher rates of AF even after accounting for potential confounders.

Consumer sleep tracking devices: a review of mechanisms, validity and utility

ABSTRACT Consumer sleep tracking devices such as fitness trackers and smartphone apps have become increasingly popular. These devices claim to measure the sleep duration of their users and in some cases purport to measure sleep quality and awaken users from light sleep, potentially improving overall sleep. Most of these devices appear to utilize data generated from in-built accelerometers to determine sleep parameters but the exact mechanisms and algorithms are proprietary. The growing literature comparing these devices against polysomnography/actigraphy shows that they tend to underestimate sleep disruptions and overestimate total sleep times and sleep efficiency in normal subjects. In this review, we evaluate the current literature comparing the accuracy of consumer sleep tracking devices against more conventional methods used to measure sleep duration and quality. We discuss the current technology that these devices utilize as well as summarize the value of these devices in clinical evaluations and their potential limitations.

Pharmacological treatment of insomnia in alcohol recovery: a systematic review.

AIMS To conduct a systematic review of pharmacological agents used to treat sleep problems in alcohol recovery. METHODS In accordance with the Quorum statement, we searched PubMed, EMBASE, Psych Info and Medline databases using the terms alcohol, insomnia/sleep and treatment/management with no year/language restrictions. RESULTS The search revealed 1239 articles and 20 met inclusion criteria. Trazodone was compared against placebo and found to be superior in two trials. Trazodone and gabapentin improved sleep measures with gabapentin performing significantly better in an open-label study. The data regarding gabapentin are equivocal with few studies showing a clear benefit. In one randomized trial, topiramate resulted in improved subjective sleep measures and a reduction in the percentage of heavy drinking days. Two randomized control trials of carbamazepine revealed improvement in subjective sleep measures. A randomized study showed lormetazepam was better than zopiclone on some measures. In a small placebo-controlled trial, acamprosate was found to result in improvements on some sleep measures. In single, small, mostly open-label studies, quetiapine, triazolam, ritanserin, bright light and magnesium have shown efficacy, while chlormethiazole, scopolamine and melperone showed no difference or worsening. CONCLUSION Trazodone has the most data suggesting efficacy. This finding is tempered by a study suggesting its association with a return to heavy drinking in some patients. Data regarding the efficacy of gabapentin are unclear at this point.

Impact of Dopamine Agonists on Compulsive Behaviors: A Case Series of Pramipexole-Induced Pathological Gambling

Background Dopamine agonists (DAs), long used in treating Parkinsons disease and effective in relieving symptoms of restless legs syndrome, have frequently been reported to induce problematic compulsive behaviors (e.g., obsessive gambling, hypersexuality) in individuals who had never had difficulties with such behaviors before. Objective The authors report two cases that add to a small-but-growing literature suggesting that these drugs be dispensed with appropriate caution. Method The authors describe two patients seen in a psychiatric setting—one, after a suicide attempt, and one with depression—both resulting from intractable compulsive gambling. Results In both instances, control of gambling was achieved: in one, when pramipexole was discontinued, and in the other, after substitution of ropinirole and addition of spiritual and support-group approaches. Discussion DAs stimulate pathways that govern reward behavior, including pleasure and addiction. Other reward behaviors, such as eating and sexual activity, may also be affected by DAs. These cases demonstrate a clear temporal relationship between initiation and behavioral change; patients and their caregivers should be alerted to the possibility of such changes.

The Course of Sleep Disturbances in Early Alcohol Recovery: An Observational Cohort Study

INTRODUCTION Understanding the course and determinants of sleep disturbances in alcoholic patients may help identify patients at high risk of persistent sleep problems, relapse and guide treatment interventions. METHODS We prospectively administered the Pittsburgh Sleep Quality Index (PSQI) to all patients (N = 196) admitted to a 1-month residential treatment program. Our analysis excluded patients with active drug abuse/dependence. Demographic data, psychiatric diagnoses, Patient Health Questionnaire-9 (PHQ-9), Alcohol Use Disorders Identification Test (AUDIT) and Inventory of Drug Taking Situations (IDTS) scores were obtained. Univariate and logistic regression analyses were performed using sex, age, hazardous alcohol use, PHQ-9 scores, hypnotic use, and use of alcohol as a hypnotic as correlates to admission PSQI scores and improvement in PSQI scores. RESULTS A total of 119 alcoholic patients met inclusion criteria (mean age 50.6 ± 13.2 years). The rates of sleep disturbances at admission and discharge were 69.3% and 49.1%, respectively. Self report of using alcohol to fall asleep and use of hypnotics were associated with elevated PSQI scores. Total PSQI scores improved over 4 weeks (p < .001). Change in PSQI scores was not effected by gender, use of hypnotics, hazardous alcohol use, use of alcohol as a hypnotic or co-morbid psychiatric diagnosis. Older age predicted improvement in PSQI scores in patients with sleep disturbances (p = .004). CONCLUSION While a large proportion of alcoholics had sleep disturbances upon admission and at discharge from a residential treatment program, only older age was associated with improvements in sleep disturbances during early alcohol recovery.