Edited by Adam Da Costa Gomes
More than 50% of adult and elderly hospitalized patients report sleep problems. In response, hospital physicians are quick to prescribe benzodiazepines and other sedatives/hypnotics (BSHs) for patients due to their quick onset and simple prescriptive process. These medicines are also frequently prescribed first-line, without taking non-pharmacological strategies into consideration. Classical examples of BSHs include temazepam, zopiclone, and zolpidem. Several studies have reported that approximately 1 in 3 hospitalized patients have taken a BSH within the first 24 hours of their stay, and of these patients, 1 in 3 were continued on this medication while in the hospital.
BSHs are not without their risks, of course, and include side effects of physical dependence, falls, memory disorders (including dementia), daytime sedation, and motor vehicle accidents. On top of this, BSHs can worsen side effects of other medications such as opioids, particularly prevalent when administered to the elderly and to those with renal disorders. Because of these risks, it is beneficial to both patients and the healthcare system to consider deprescribing sedative hypnotics and benzodiazepines wherever possible. In this effort, there are a number of techniques that the modern healthcare system can use to achieve this goal of improving patient safety.
The current guidelines, including those published by the Canadian Geriatrics Society, Canadian Psychiatric Association, and the Canadian Society of Hospital Pharmacists, recommend against the use of BSHs as first-line treatments for insomnia except where long-term use may be indicated, such as alcohol withdrawal or when co-morbid conditions occur. Furthermore, both the Canadian Psychiatric Association and Canadian Pharmacists Association (CPhA) recommend that when BSHs are prescribed for insomnia, a tapering plan and/or discontinuation strategy should be included in the patient’s treatment plan. When it comes to reducing the inappropriate use of these medications, The Choosing Wisely Canada toolkits outline four main areas where healthcare professionals can be involved:
1. Establish an interprofessional team
Insomnia and sleep disturbances are often multi-disciplinary, meaning there is a role for all healthcare professionals to address the underlying cause of the insomnia and triage the signs and symptoms. For example, a psychologist can administer cognitive behavioural therapy (CBT), a pharmacist can manage medications that may cause or alleviate insomnia, and nursing staff can be involved with inpatient management of factors affecting sleep (See #3 below).
2. Create a consensus as to what constitutes an appropriate indication for BSHs
As it stands, only three benzodiazepines and three Z-drugs are indicated for insomnia. Many others (including diazepam and lorazepam) are used off-label. This means that it is up to the individual prescriber to determine which BSH they wish to administer. Reaching a consensus among staff members within a hospital system will help ensure patients are being given the most appropriate medication for their specific circumstances if medication is determined to be appropriate.
3. Trial non-pharmacologic measures to improve sleep
There are a number of ways by which healthcare workers can improve patients’ sleep and help reduce the anxiety surrounding insomnia.
a) Minimize interruptions
In hospital, this can include reducing the frequency of vital checks, medications, and/or blood draws, ideally leaving a 6- to 8-hour window in which patients are not woken up.
b) Promote sleep
This includes strategies like blackout curtains, establishing nighttime routines, eye masks and ear plus, warm blankets, and perhaps most importantly, allowing patients to mimic their home sleeping environment as much as possible.
c) Respond to patients’ needs
Routines and protocols should be individualized for each patient. Room temperature, hunger, and medications are just a few patient-specific factors that can affect a person’s sleep. It is paramount that a one-size-fits-all approach is not adopted, as everyone sleeps differently, and different triggers can either help or prevent a patient’s sleep.
4. Restrict the initiation of BSHs
There are a number of methods that can be used to discourage the use of BSHs among healthcare professionals. Education is the foremost method in which BSH use can be discouraged. Many of the non-pharmacologic strategies listed above are very easy to implement! Educating staff on these topics and encouraging non-pharmacological prioritization over BSHs can help dispel the myth that administering a BSH is a quicker and easier alternative. Patients can also benefit from education on the dangers of these medications to help dispel the belief that they are “safe” sedatives. Beyond education, hospital pharmacies can make the effort to remove BSHs from order sets, or at the very least, remove the option of making them available as needed. Additionally, pharmacists can take a closer look at discharge medication reconciliations to ensure patients are not being sent home on BSHs without an appropriate indication or include a pop-up alert on the patient’s electronic medical record to prompt the discussion around deprescribing.
Benzodiazepines and other sedative hypnotic drugs are commonly used to help patients fall asleep and are often used for months, or even years without first trying non-pharmacologic measures. It is important for all members of the healthcare team to be aware of the long-term benefits of non-pharmacologic sleep aids as well as the dangers associated with long-term BSH use. In order to do this, there are a number of strategies that can be implemented such as establishing an interprofessional team, defining appropriate indications for BSHs, implementing non-pharmacologic measures in advance of BSHs, and restricting the initiation of BSHs in hospital and primary care.
More information on managing insomnia can be found in the Choosing Wisely Canada toolkits "Drowsy Without Feeling Lousy" and "Less Sedatives for Your Older Relatives", Sleepwell, and the Compendium of Therapeutic Choices chapter on Insomnia. Most of these resources also contain recommended deprescribing algorithms and tapering schedules that can be given to patients.
The next time you see a prescription for a BSH, think twice!
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