Choosing insomnia treatments wisely

Geriatrics recommendation 2

Do not use benzodiazepines or other sedative-hypnotics in older adults as first-choice treatment for insomnia, agitation, or delirium.

Recall and describe a clinical encounter in which you were called on to choose wisely

In my family medicine practice, I work with many geriatric patients who are prescribed benzodiazepines or other z drugs, such as zopiclone, for insomnia by other physicians. Now, knowing the harms associated with these medications, I have made an effort to help my patients find safer ways to manage their insomnia. I try to educate them on the harms of these medications, and when they are ready to discontinue the medications, I try to empower them.

At one time, these medications were marketed as safe and were standard of practice. I often share this information with patients so they do not feel as though previous physicians were prescribing incorrectly.

In your exchange with the patient, how did you raise the need to choose wisely?

Education. Usually, I pull up a resource or handout when discussing the potential harms of these medications. Then, I take out my highlighter and highlight some of the specific harms that generally concern my patients.

Falls. My patients are typically concerned with falls, given that they can lead to potentially devastating fractures. Often, the first question I ask is, “How often do you get up at night to go to the bathroom?” Most of my elderly patients are not going all night without using the bathroom. I will use this as an opportunity to discuss fall risks with them. I tell them that they have taken something to help them sleep and stay asleep and that the medication affects their balance. By waking up to go to the bathroom, they are at risk of falling.

Memory and cognition. Most of my elderly patients do not want to take anything that adversely affects their memory or cognition. I tell them that even if they do not feel like their memory is being affected, studies have shown that over time these medications will have adverse effects on their memory or cognition.

Addiction and dependence. Interestingly, I have found that patients seem less interested in the addictive potential of these medications. I have learned over time that this is less important to my patients, so while I mention it, I do not focus on it.

Sleep. Aside from harms, I also educate patients on misconceptions regarding sleep. I have a handout with the top 10 sleep myths. Many of my elderly patients are concerned that they are not getting 8 to 10 hours of sleep and I let them know that perhaps their body does not need that much sleep at this point in their lives.

Challenging the status quo. Many patients are hesitant to discontinue these medications owing to previous bad experiences trying alternative strategies such as avoiding electronic screens before bed, avoiding alcohol before bed, and using room-darkening aids. For those who say that these strategies did not work, I challenge them to describe their whole sleep routine, and we often will find multiple things to try.

What are the key elements of the communication that made it a success?

I think the most successful cases are ones in which the patient feels in control of tapering his or her medications, such that he or she is the one making the decisions. I go as fast or slow as they want to go. This is challenging work and is not a single-visit issue. I also want my patients to know that I care about their sleep and that I want to support better sleep for them. This is a long journey and I congratulate them for making any attempt, as every time we manage a decrease in their benzodiazepine dose, we are lowering the risk of harm.