Deprescribing and Sleep Therapy for Seniors:
Deprescribing and Sleep Therapy for Seniors:
Report on a presentation at the CURAC Conference in Halifax, May 2018
(modified from a report by Harold Atwood on the conference presentation of Dr. David Gardner)
Deprescribing: It’s no dream. Sleep well without sleeping pills.
Speaker: Dr. David Gardner (Professor of Psychiatry and Pharmacy, Dalhousie University)
David Gardner’s presentation addressed two major issues that confront seniors very frequently: the need for medications, and their specific roles in treatment of problems with sleep. While medications have proven benefits for health and longevity, they can easily lead to adverse health consequences if over-used or combined — and the risk increases in an aging population, since more medications are used on average as aging progresses. Adverse side effects leading to hospitalization can be countered by reducing or eliminating medications that are not essential — a procedure termed “deprescribing”. The use of medications to promote sleep illustrates strongly the need for deprescribing. Getting a good night’s sleep is of special interest for many seniors, but some of the sleep-inducing drugs carry a substantial risk of adverse side effects. Careful assessment of the need for such drugs should be undertaken, and deprescribing employed when detrimental effects on health are apparent or likely. Taking fewer drugs often leads to better health overall.
Medications with high risk for harm, especially in older adults, are “potentially inappropriate medications”, and should be avoided if possible by looking for safer management alternatives. Examples include: chronic use of anti-inflammatory medications (such as ibuprofen); antipsychotic medications and sleeping pills when used to induce or promote sleep; some drugs used for treatment of Type 2 diabetes; and others. Older adults are more likely to take at least one potentially inappropriate medication, and are at greater risk due to physiological changes that occur normally with aging. The need for deprescribing thus increases for older adults.
In older adults, difficulty getting to sleep often leads to use of potentially inappropriate medications including anti-anxiety and sleep medications. Data from studies in the U.S.A. indicate that combined use of opioids and sleeping pills often leads to death among the elderly. Use of sleeping pills is linked to greater risk for several adverse consequences, including falls (broken bones, especially hip fractures), pneumonia, driving accidents, social withdrawal, memory and cognitive impairments, and the cycle of drug dependence and withdrawal symptoms. These alarming outcomes make a strong case for safer alternatives (choosing treatment options wisely). Alternatives for insomnia include cognitive behavioural therapy (CBTi) as a first choice, rather than sedative-hypnotic medications. Patient-directed alternatives were put forward by David Gardner in the form of booklets (“You May Be At Risk”) and the Sleepwell program ( mysleepwell.ca) which emphasizes 5 major components: sleep hygiene, cognitive therapy, relaxation therapy, stimulus control, and sleep restriction. Several books and internet resources are recommended in the Sleepwell program. Thus, the non-medication alternatives are well worth the effort of engagement, since many detrimental consequences of the “quick and easy” sleeping pill alternative can be minimized —- including the problem of trying to stop sleep medications after dependence and health problems have developed.
A few useful details of the components of CBTi will serve to illustrate its general approach, and aid those who stand to benefit. (i) Sleep hygiene: before bedtime, avoid stimulants (caffeine, nicotine, texting) and sleep disruptors (e.g. alcohol); exercise wisely by day, not right before bedtime; eat wisely, avoid going to bed hungry or over-full; seek a comfortable temperature and comfortable bed. (ii) Relaxation therapy: meditations, relaxing sounds (described in the website mysleepwell.ca and in printed material recommended there). (iii) Cognitive therapy: manage thoughts that cause stress and worry in advance of getting to bed rather than in bed; relaxation therapy could help with this. (iv) Stimulus control: break the cycle of being frustrated trying to go to sleep in bed: if awake after 15 minutes, leave the bedroom, return when feeling sleepy; leave again if still not asleep in 15 minutes; aim to avoid the association between being in bed and not getting to sleep. (v) Sleep drive control: a more difficult procedure: begin with reducing time in bed to promote sleepiness, then gradually increase sleep time, aiming for an optimal duration. These procedures, and others, are covered in detail in several recommended books: e.g. “End the Insomnia Struggle: A step by step guide to help you get to sleep and stay asleep” (C. Ehrnstrom, 2016).