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Comment on ‘The relationship between the severity of insomnia and falls in the elderly’

Dear Editor, We have read with great interest the article titled ‘The relationship between the severity of insomnia and falls in the elderly’ published by _Ibrahim _Ileri et al. The authors investigated whether there is a relationship between the severity of insomnia and falls, and they found insomnia was more common in patients who fell than in patients who did not fall within the past year. These results make a valuable contribution to the literature, but some issues should be considered when evaluating the effect of insomnia on the development of falls in older adults. Especially in cross-sectional studies, when examining the relationship between two conditions, it is very important to look at the effects of factors that affect both conditions (confounding factors) simultaneously. From this point of view, the fact that many factors affecting both insomnia and falling in the elderly were examined simultaneously by Ibrahim et al. increases the power of the study. For example, the authors realised that the insomnia severity index score was highly correlated with mild, moderate, and severe insomnia, and the Mini Nutritional Assessment-Short Form score was highly correlated with malnutrition or malnutrition risk, and therefore these scores were not included in the regression analysis. As we have shown in one of our previous studies, there is indeed a strong association between insomnia and malnutrition in the elderly, and malnutrition is a significant cause of falling, so it should be excluded from the analysis. However, just like malnutrition, excessive daytime sleepiness (EDS) is associated with both insomnia and falling. For example, in a study investigating the prevalence of EDS in those with insomnia, the rate was found to be 45.61%. According to the results of a study conducted by our group, EDS is associated with increased frequency of falling and sarcopenia (another strong risk factor for falling) in the elderly. Thus, in the study of Ibrahim et al., it seems difficult to understand whether falling is really due to insomnia or caused by EDS. Another issue is that drugs used to treat insomnia can also cause falls and injuries. It was reported that drugs were recorded in Ibrahim et al.’s study, but no difference was found in terms of polypharmacy when they compared those who fell and those who did not. However, if patients using drugs such as trazodone, mirtazapine, benzodiazepine receptor agonists that can cause falls could be excluded from the study, or if these drugs were used with the same frequency in patients with and without falls, the results could have been more clearly revealed. In conclusion, the study contributes valuable data to the medical literature, but rather than ignore the above-mentioned issues in studies evaluating insomnia, especially in the elderly, they should be taken into account as they may affect the results of the study.