Reducing risk of harm from sedative–hypnotic medications in older people

In this issue of the Journal, Amy Reynolds and Robert Adams summarise the literature on pharmacological management of sleep disturbance in older people.1 They highlight that medications used to treat insomnia have limited effectiveness and are associated with significant side effects in older people, including falls and cognitive decline.1 Despite the risks, sedative–hypnotic medications are commonly prescribed.2 Unfortunately, there is no highly effective and safe option for the pharmacological management of insomnia in older people. Commonly used sedative–hypnotic medications are all listed by the American Geriatrics Society's Beers Criteria as medications that should usually be avoided in older people.3 Melatonin has become a popular alternative because it is thought to be safe, but its effectiveness is limited1 and it has been linked to increased fracture risk.4 It is not surprising that older people often seek help for sleep complaints, because sleep quality and duration decline with age and some of the chronic diseases that commonly affect older people can cause or worsen insomnia.1 It is important that sleep disorders are managed because they can contribute to adverse health outcomes and reduced quality of life.1 In hospitals and aged care facilities, sleep disturbance may be caused or worsened by environmental factors such as noise, light and overnight or early morning nursing care, including medication administration. In hospitalised patients, sleep deprivation has been linked to poorer recovery and increased risk of delirium.5 Sedative–hypnotic medications are frequently prescribed in hospitals despite limited evidence for effectiveness in this setting, and contraindications such as high falls risk or cognitive impairment.6, 7 Aside from the immediate risks, commencing sedative–hypnotic medications in hospital may also lead to longer-term use in the community. So, what can be done to reduce the risk of harm from sedative–hypnotic medications in older people? First and foremost, before introducing a medication for insomnia it is important to address underlying medical conditions (e.g. depression, pain) and remove medications that may cause or worsen sleep disturbance (e.g. stimulants, beta-blockers), where possible.1 At the same time, non-pharmacological sleep management approaches should be introduced, including ensuring an optimal sleep environment, sleep hygiene and relaxation training. Educating the person, and their family or nursing/care staff, where appropriate, about sleep hygiene and environmental modification is vital. Explaining the limited effectiveness of sedative–hypnotic medications and the risks associated with their use (before they are started) may help with motivating the person to try non-pharmacological approaches. Cognitive behavioural treatment for insomnia (CBT-I), to address beliefs and behaviours that may hinder sleep, is a proven strategy for the treatment of chronic insomnia in older people.1 CBT-I produces similar or greater benefits compared with sedative–hypnotic medications, with fewer side effects and more sustained benefits.1 Unfortunately, non-pharmacological approaches are not routinely offered to people who present with sleep problems.2 Non-pharmacological approaches should also be used in hospital and aged care settings. These include bright light exposure during the daytime, relaxation techniques, sleep hygiene and minimising noise and disruptions overnight.5 Pharmacists can assist with minimising overnight disruptions by ensuring medications are not unnecessarily scheduled to be administered during the night or early in the morning. In older people, there is evidence that a multicomponent intervention that includes a non-pharmacological sleep protocol promoting relaxation and less overnight disruption can reduce the prescription of sedative–hypnotic medications and the risk of delirium.8 For patients already using sedative–hypnotic medications, reducing the risk of harm involves carefully deprescribing these medications when it is safe to do so. In long-term users, gradual dose reduction is important to reduce the risk of withdrawal symptoms and rebound insomnia. Although deprescribing sedative–hypnotics can be challenging, there are resources available to assist and support clinicians and patients.9 Deprescribing can be achieved in all settings, and three recent studies highlight the contribution pharmacists can make towards this important goal. A randomised controlled trial in Canada demonstrated that when community pharmacists provided information to patients about the risks associated with long-term sedative–hypnotic use and guidance for withdrawing from them, as well as deprescribing recommendations to their primary care physician, 43% of patients discontinued the medication compared with 9% of control patients.10 In a deprescribing study at three New Zealand nursing homes, a pharmacist performed medication reviews focusing on sedative and anticholinergic medications, and 72% of deprescribing recommendations were agreed to by patients and implemented by physicians.11 In a pharmacist-led interdisciplinary deprescribing study at an Australian hospital, benzodiazepines were one of the most common deprescribing opportunities identified, and were successfully deprescribed in 50% of cases prior to discharge.12 There is clear evidence that sedative–hypnotic medications have an unfavourable risk:benefit ratio in older people, yet they continue to be commonly prescribed. Non-pharmacological approaches are equally, if not more, effective and safer. Clinicians in all settings should encourage non-pharmacological management for sleep disturbances and minimise the use of sedative–hypnotic medications. Pharmacist-led interdisciplinary interventions can help patients withdraw from established sedative–hypnotic use. The author declares that he has no conflicts of interest.

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