In the third of a six-part series, we expand on the PSA Choosing Wisely recommendations, taking a closer look at the use of sedatives.
Insomnia, agitation and delirium in older adults can cause significant distress to both the older adult and their caregivers. Sedative and hypnotic medications such as antipsychotics, benzodiazepines and Z-drugs are used to manage these symptoms. Sedative load is associated with impaired activities of daily living1 and reduced physical function.2 Many sedative medicines also have anticholinergic side effects, which add to the risk of typical anticholinergic effects of dry mouth, urinary retention, constipation and blurred vision, and less acknowledged effects on memory and cognition.3 The highest rates of sedatives are in the older population even though they are most at risk of harm from adverse effects, such as falls and cognitive impairment.3
Insomnia includes difficulty getting to sleep and maintaining sleep, as well as unrefreshing sleep.4 It can have profound impact on wellbeing and health, so improving daytime functioning, sleep quality and quantity is the main treatment goal. Non-pharmacological treatments form the mainstay of treatment options. Management of underlying problems and medications that can cause or exacerbate sleep disturbances is the first-line approach. Sleep hygiene education, and psychological and behavioural interventions such as relaxation therapies and cognitive therapies, are considered first-line treatment options.
Pharmacological treatment should be limited to short-term use and only where non-pharmacological treatments are ineffective. The Therapeutic Guidelines limit treatment options to short-acting benzodiazepines, Z-drugs, and melatonin.5 Tolerance can develop rapidly to the medication which means it is unlikely to be effective long-term and can lead to escalating doses.6 Dependence also can develop over a short timeframe, which can lead to withdrawal effects when stopping the medication.6
Other pharmacological treatments are not preferable alternatives to benzodiazepines or Z-drugs. While sedation can be caused by the use of sedating antihistamines, sedating antidepressants and antipsychotics, these are not recommended due to the limited evidence or adverse effect profile with these medications. Complementary medicines are not a more viable alternative with a systematic review finding that there was no evidence to suggest herbal medicines were significantly different to placebo for insomnia.7 Further, valerian had a similar safety profile to benzodiazepines.7
People living with dementia
For people living with dementia, neuropsychiatric symptoms can present as one or more of agitation, aggression, anxiety, delusions, disinhibition, hallucinations, repeated vocalisations and others. These symptoms can often be transient. Non-pharmacological treatments are first-line therapy, but where these have been unsuccessful, short-term use of other medications such as antipsychotics can be used for severe symptoms.8 The use of antipsychotics can result in symptomatic improvement for some patients, however these medications can worsen symptoms for others and the side effects can be severe.9 These medications are not effective for all people.10 Studies range from showing that the number needed to treat is between five and 14, meaning that at least five people will need to be treated for one person to benefit.10 For about one in seven people the agitation may worsen, possibly because of the akathisia. There is an increase in premature mortality of 1.5%.9,10 Other factors include an increased risk of stroke, urinary tract infections and movement disorders.9
BOX 1: The recommendation
Do not continue benzodiazepines, other sedative hypnotics or antipsychotics in older adults for insomnia, agitation or delirium for more than three months without review.
The use of benzodiazepines, other sedative hypnotics or antipsychotics in older adults for insomnia, agitation or delirium is associated with a range of adverse effects including falls and impaired cognition. Non-pharmacological interventions can be an effective substitute and use of these medicines should be for the shortest duration possible. Reductions in the use of these medicines can be achieved following pharmacist review, interdisciplinary input, staff education and feedback from audits.
BOX 2: Resources
|Tasmanian Primary Health Network||www.primaryhealthtas.com.au/for-health-professionals/resources/?keyword=&cat=medicines|
|Canadian Deprescribing Network||www.deprescribing.org|
|Appropriateness Tool for Comorbid Health conditions in Dementia (MATCH‐D)||www.Match-d.com.au|
Experts in the field agree that non-pharmacological strategies should be used in preference to medications for the management of behavioural and psychological symptoms of dementia.11 Benzodiazepines should be avoided, though they can be useful for managing acute agitation where use is closely monitored. Similarly, antipsychotics at low doses for limited periods can be considered for distressing behavioural symptoms that have not responded to non-pharmacological management strategies. When sedatives are given, strategies are needed to be implemented to improve the safety for these patients, e.g. increased monitoring and assistance with mobility and toileting.
The pharmacist’s role in optimising medicines
A meta-analysis of deprescribing interventions found that interventions to withdraw antipsychotics and benzodiazepines made a significant difference in the usage of these medicines.12 Pharmacists can take a leading role in these interventions. The EMPOWER study looked at pharmacists providing consumer education in the community pharmacy with the aim to reduce benzodiazepine use.13 It found that one in four people ceased benzodiazepine use because of the pharmacists’ intervention.13
Residential Medication Management Reviews (RMMRs) by pharmacists in aged care facilities and Home Medication Reviews (HMRs) have both been shown to reduce the overall use of sedative and anticholinergic medications.14,15
A multi-faceted, multi-disciplinary intervention in Australian aged care facilities showed a reduction of 81.7% in long-term regular antipsychotic use after 12 months.16 Another Australian study in aged care facilities involving pharmacists providing education and undertaking reviews showed that 40% of residents had either been withdrawn from or reduced the dose of long-term antipsychotic use after six months.17
Pharmacists play an important role in reviewing and reducing the use of inappropriate sedatives and antipsychotics in older adults. The long-term use of these medications is frequently inappropriate with the potential for harm. Interdisciplinary and pharmacist-led interventions can contribute to reducing the use of these medications.
- Gnjidic, D., et al., Sedative load and functional outcomes in community-dwelling older Australian men: The CHAMP study. Fundamental and Clinical Pharmacology, 2014. 28(1): p. 10–19. At: https://www.ncbi.nlm.nih.gov/pubmed/22849300
- Cao, Y.J., et al., Physical and cognitive performance and burden of anticholinergics, sedatives, and ACE inhibitors in older women. Clinical Pharmacology & Therapeutics, 2008. 83(3): p. 422–9. At: https://www.ncbi.nlm.nih.gov/pubmed/17713474
- Parkinson, L., et al., Anticholinergic burden in older women: Not seeing the wood for the trees? Medical Journal of Australia, 2015. 202(2): p. 92–5. At: https://www.mja.com.au/journal/2015/202/2/anticholinergic-burden-older-women-not-seeing-wood-trees
- Alessi, C. and M.V. Vitiello, Insomnia (primary) in older people: non-drug treatments. BMJ clinical evidence, 2015. At: https://www.ncbi.nlm.nih.gov/pubmed/25968443
- Therapeutic Guidelines, Insomnia, in Psychotropic Therapeutic Guidelines. 2013, Therapeutic Guidelines: Melbourne, Victoria. At: https://tgldcdp.tg.org.au/
- Brett, J. and B. Murnion, Management of benzodiazepine misuse and dependence. Australian prescriber, 2015. 38(5): p. 152. At: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4657308/
- Leach, M. and A. Page, Herbal medicine for insomnia: a systematic review and meta-analysis. Sleep Medicine Reviews, 2015. At: https://www.ncbi.nlm.nih.gov/pubmed/25644982
- Therapeutic Guidelines, Dementia, in Psychotropic Therapeutic Guidelines. 2013, Therapeutic Guidelines: Melbourne, Victoria. At: https://tgldcdp.tg.org.au/
- Ma, H., et al., The efficacy and safety of atypical antipsychotics for the treatment of dementia: a meta-analysis of randomized placebo-controlled trials. Journal of Alzheimer’s Disease, 2014. 42(3): p. 915–37. At: https://www.ncbi.nlm.nih.gov/pubmed/25024323
- Banerjee, S., The use of antipsychotic medication for people with dementia: time for action. 2009. At: https://www.jcpmh.info/wp-content/uploads/time-for-action.pdf
- Page, A., et al., Medication appropriateness tool for co‐morbid health conditions in dementia: consensus recommendations from a multidisciplinary expert panel. Internal medicine journal, 2016. 46(10): p. 1189–97. At: https://www.ncbi.nlm.nih.gov/pubmed/27527376
- Page, A.T., et al., The feasibility and effect of deprescribing in older adults on mortality and health: a systematic review and meta-analysis. British Journal of Clinical Pharmacology, 2016: p. 583–623. At: https://www.ncbi.nlm.nih.gov/pubmed/27077231
- Tannenbaum, C., et al., Reduction of inappropriate benzodiazepine prescriptions among older adults through direct patient education: the EMPOWER cluster randomized trial. JAMA internal medicine, 2014. 174(6): p. 890–8. At: https://www.ncbi.nlm.nih.gov/pubmed/24733354
- Nishtala, P.S., et al., Impact of residential medication management reviews on drug burden index in aged-care homes: A retrospective analysis. Drugs and Aging, 2009. 26(8): p. 677–86. At: https://www.ncbi.nlm.nih.gov/pubmed/19685933
- Castelino, R.L., et al., Drug burden index and potentially inappropriate medications in community-dwelling older people: The impact of home medicines review. Drugs and Aging, 2010. 27(2): p. 135–48. At: https://www.ncbi.nlm.nih.gov/pubmed/20104939
- Brodaty, H., et al., Antipsychotic Deprescription for Older Adults in Longterm Care: The HALT Study. Journal of the American Medical Directors Association, 2018. 19(7): p. 592–600.e7. At: https://www.ncbi.nlm.nih.gov/pubmed/29941156
- Westbury, J.L., et al., RedUSe: reducing antipsychotic and benzodiazepine prescribing in residential aged care facilities. Medical Journal of Australia, 2018. 208(9): p. 398–403. At: https://www.mja.com.au/journal/2018/208/9/reduse-reducing-antipsychotic-and-benzodiazepine-prescribing-residential-aged
See PSA’s six recommendations to the Choosing Wisely initiative at: www.psa.org.au/choosing-wisely/
BY PSA CHOOSING WISELY WORKING PARTY: CHRIS CAMPBELL, DR AMY PAGE, SUE EDWARDS, A/PROF REBEKAH MOLES, DR KENNETH LEE, ALYSSA PISANO, DR SHANE JACKSON & DR CHRIS FREEMAN