Sleep Medication in Older Adults: History
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Subjects: Health Care Sciences & Services
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Bertrand Décaudin

Pharmacy students and supervising community pharmacists are well placed to identify problems related to patients’ sleep disorders. Special attention should be given to the patient’s lifestyle.  A discussion with patients about their sleep patterns, nycturia and fluid intake. Another key point concerns the reassessment of hypnotic medications, particularly upon discharge from hospital; medications were rarely reassessed, and the medication use often failed to comply with the summary of product characteristics. Community pharmacists could collaborate with family physicians to facilitate the discontinuation of hypnotic medications and increase the patient’s commitment to change. Greater awareness of the ADRs associated with hypnotics might help to motivate the patients in this respect.

  • sleep disorders
  • benzodiazepines
  • sedative-hypnotics
  • community pharmacy
  • older adults
  • sleep patterns

1. Introduction

Physiological sleep processes change as people age. Older adults have a longer sleep onset latency and more nocturnal awakenings. Overall, sleep in older adults is characterized by an earlier sleep phase, a reduction in the proportion of deep sleep, and the appearance of a short mid-afternoon nap [1]. Furthermore, the prevalence of sleep disorders (restless legs syndrome, parasomnia, sleep apnea, etc.) [2] and comorbid conditions that reduce sleep quality and quality of life increase with age; these difficulties are due (as least in part) to changes in circadian rhythms and lower melatonin levels [3][4].
Benzodiazepines and benzodiazepine derivatives (“Z-drugs”) target GABA receptors/pathways and are the most frequently prescribed psychotropic medications for sleep disorders [4]. The prevalence of benzodiazepine and sedative-hypnotic (BSH) use increases with the patient’s age [5]. In cases of insomnia, treatment with a BSH can reduce the sleep onset latency by a few minutes and increase the sleep period by an hour [6]. However, the broad prescription of BSHs is usually inappropriate: the prescription duration is too long, and patients may overdose by taking medication several times during the night [7]. BSHs have harmful long-term effects, such as deregulation of the sleep architecture and thus a further increase in sleep disorders. This is why BSH prescriptions are limited to 4 weeks: beyond that time, the harm outweighs the benefits [8]. Moreover, BSHs can have other harmful effects: daytime drowsiness, memory problems [9], and a nearly two-fold increase in the risk of falls [10]. Moreover, the polypharmacy often observed in older adults [11] increases the likelihood of drug interactions, adverse drug reactions (ADRs) [12][13][14], unplanned hospitalization, and death [15][16]. Z-drugs have been linked to an increased risk of falls and certain central nervous system (confusion, dizziness, daytime sleepiness, etc.) [10][17].
Given the high prevalence of inappropriate BSH prescriptions and the unfavorable associated risk-benefit ratio, prompt discontinuation of these sleep medications should be a health priority for older adults [18]. Discontinuation can be encouraged and facilitated by various interventions, including patient education, dose reduction, medication replacement, and psychological support [18][19]. The recent literature data suggest that pharmacist involvement can boost the deprescription of inappropriate medications [20][21][22][23].
However, psychological and pharmacological dependency on BSHs means that complete discontinuation is particularly challenging. Knowledge of the patient’s bedtime and sleep patterns, medications taken for sleep disorders and behavioral information can also facilitate discontinuation [24]. However, there are very few literature data on the patient’s bedtime and sleep patterns in older patients.
At the Lille Faculty of Pharmacy (Lille, France), the final-year internship always includes work related to patient care pathways [25][26]. In 2016, this work concerned sleep disorders in older adults.

2. Current Inisights

The present study described older adults’ patterns and habits with regard to sleep and hypnotic medications. The study was based on 960 interviews. More than half reported having difficulty falling asleep, despite taking hypnotic medication. However, three quarters of the patients reported falling asleep within an hour. Our study also highlighted the elevated prevalence of poor habits and patterns before going to sleep. The vast majority of patients had tested only one hypnotic medication. At the end of the interview with the pharmacy student, nearly one-third of the patients (n = 330, 35%) stated that they had been willing to potentially discontinue medication at some point in the past, 245 (26%) of the 330 were willing to potentially discontinue medication at the time of the study, but only 94 agreed that the family physician could be contacted about possible deprescribing.
In older adults, sleep is characterized by frequent nocturnal awakenings, a reduction in the amount of deep sleep, early sleep onset, and early awakening [2]. The circadian mechanism becomes less efficient, and the overnight sleep period is often less than 6.0 to 7.5 h. In our study, however, the stated sleep period was higher; the mean ± SD value was 8.5 ± 2.1. Nearly 25% of the interviewees reported that they took more than 1 h to fall asleep. This fairly long time might be due (at least in part) to lifestyle patterns that do not promote sleep.
Indeed, many interviewees did not comply with good bedtime habits known to have a significant benefit for sleep (i.e., not using a screen in the bedroom, having a bedroom temperature below 19 °C (66.2 F°), etc.) [27][28]. Our results showed that about 75% of the patients had at least one poor sleep habit. A few reminders from the pharmacist about a healthy lifestyle might improve older adults’ sleep. A US study showed that telephone counseling on nutrition, physical activity, and sleep by a pharmacist can improve short-term physical and mental scores in the Duke Health Profile [29]. Moreover, the vast majority of our interviewees woke up during the night—mainly due to nycturia. Even though about half of interviewees woke up at night because of nycturia, only one in ten of the interviewees reported urinary disorders. This point could be addressed by the pharmacist through counselling on habits that might reduce the number of awakenings and nycturia (e.g., limiting late fluid intake, changing the administration time for diuretics and other medications that can cause nycturia, etc.) [30].
Although the patients were dissatisfied with their sleep, they appeared to be very committed to the medication they were taking: 8 in 10 of the patients had only tested a single hypnotic. The median time since the first prescription was 120 months, which is excessive and did not comply with current guidelines. In order to limit the side effects of hypnotics, the prescription period in France is limited to 28 days for zolpidem, nitrazepam, lormetazepam, zopiclone, estrazolam and loprazolam and to 12 weeks for hydroxyzine. Zolpidem was the most commonly used hypnotic. However, zolpidem has been classified as a narcotic since 2016; in order to limit the risk of abuse and misuse, the drug is subject to a controlled prescribing procedure [31]. This change led to a decrease in zolpidem prescriptions and a corresponding increase in zopiclone prescriptions. In France, it has been established that the two medications do not have the same effect: zolpidem is used to induce sleep, whereas zopiclone is used to maintain it [32]. The long-observed time since treatment initiation and the low number of patients with a recent dose change (126 of out 947, 13%) also reflects a lack of reassessment of a medication with many side effects. Half of the patients in our study were considered to be benzodiazepine-dependent, according to the ECAB score [33].
Melatonin and doxylamine are not related to benzodiazepines and so the prescription durations are not limited. Nevertheless, the two drugs should be used for short periods only. Sleep quality can be improved by changes in habits and patterns and not necessarily by medications. Doxylamine is present in many sleep medications but is classified as potentially inappropriate for older adults [18]. Although this medication is available over the counter, its use must be supervised by pharmacists [34].
One of our study’s most important findings was that about 15% of the hypnotic medications had been initiated during a hospital stay. Hospitalization can disturb sleep in older adults, due to environmental stimuli (such as noise or light exposure) and health problems [35]. However, the prescription for hypnotic medication was typically renewed after discharge from hospital, with no reassessment. This finding emphasizes the importance of re-evaluating medications on discharge for patients who were not previously being treated with hypnotics.
Another notable study finding concerned the patient’s willingness to discontinue the hypnotic medication. This is sometimes difficult for patients to envisage: only one third reported having already considered discontinuing their medication, and less than 25% patients felt ready to discontinue. Support and education are essential for successful discontinuation [23][36]. Martin et al. [23] showed that over-65 patients being followed up with an educational intervention were significantly more likely to discontinue benzodiazepine use than those without this follow-up. Cooperation between the family physician and the pharmacist is therefore essential for helping patients to discontinue BSHs [37]. Several studies have shown that a structured, personalized intervention helps to discontinue long-term benzodiazepine use [38][39]. However, only a small proportion of our interviewees authorized the community pharmacist to contact the family physician; this highlighting the moderate level of commitment to discontinuing sleep medications. It would be interesting to perform an interventional study assessing the number of patients who actually discontinued their medication following the interview with the pharmacist. Lastly, our results support the development of pharmacist interventions based on patient-centered inter-branch approaches. These approaches must take into account the patient’s behaviors and representations and must evolve from traditional “counselling” into actual motivational interventions [37]. Indeed, motivating patients is known to be an important aspect of deprescription strategies [40]. These strategies involve discussions about deprescription among members of the healthcare team; this team must include pharmacists and physicians because BSHs are prescription-only, controlled medications.

This entry is adapted from the peer-reviewed paper 10.3390/healthcare10010147

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