Hypnosedatives are used extensively in older people, although their usage has fallen since the early 1970s, Increasing consumer concerns now risk underuse of these drugs, even in appropriate situations. High quality prescribing of hypnosedatives requires consideration of the pharmacokinetics and pharmacodynamics of these drugs, an understanding of their adverse effects, efficacy and clinical situations in which they may be of use, and an appreciation of the role of nonpharmacological therapy. If these issues are adequately addressed, hypnosedatives can be used effectively to treat insomnia and some anxiety disorders. Hypnosedative prescribing can be improved through regular audits, and the development of a local prescribing policy and educational programmes. Benzodiazepines are the most commonly used hypnosedatives, They are used for the treatment of both insomnia and anxiety disorders, but can be associated with a number of adverse effects in older individuals including confusion, falls and fractures (particularly agents that have a long elimination half-life) and injurious car crashes. Increased mortality has also been reported in older individuals taking these drugs. Tolerance and dependency are concerns with poor prescribing of all benzodiazepines and withdrawal effects can be extreme when there is inappropriate clinical management of the cessation of very short half-life agents. Zopiclone and zolpidem are nonbenzodiazepine agents but they bind to the same receptors as benzodiazepines. They are used for the treatment of insomnia, and may be better tolerated than benzodiazepines in some older people. Other hypnosedatives, such as melatonin, chloral hydrate and chlormethiazole, are less suitable for the treatment of insomnia in older patients, but may be considered. Buspirone and antidepressants are specifically indicated in some anxiety disorders, but are generally not first-line hypnosedatives. Antipsychotics should not be used as hypnosedatives. Individual drug choice is affected by consideration of speed of onset, withdrawal effects, half-life and hangover effects, efficacy data and cost. Initial dosages should be low, and increases made slowly. Duration of therapy should generally be limited to 2 weeks in the first instance. It is often appropriate to withdraw hypnosedatives in long term users and this may be assisted by substituting short half-life agents with those that have a longer half-life.
