Sleeping pills and older adults

Call me nuts, but I want to talk more about sleeping pill use. Hold your fire for a few paragraphs, please.

Just a week after I posted about medical efforts to help wean older patients off sleeping pills — causing a flurry of comments, many taking exception to the whole idea as condescending or dismissive of the miseries of insomnia — researchers at the Centres for Disease Control and Prevention and Johns Hopkins published findings that reinforce concerns about these drugs.

I say ‘reinforce’ because geriatricians and other physicians have fretted for years about the use of sedative-hypnotic medications, including benzodiazepines (like Ativan, Klonopin, Xanax and Valium) and the related ‘Z-drugs’ (like Ambien) for treating insomnia.

“I’m not comfortable writing a prescription for these medications,” said Dr Cara Tannenbaum, the geriatrician at the University of Montreal who led the weaning study. “I haven’t prescribed a sedative-hypnotic in 15 years.” In 2013, the American Geriatrics Society put sedative-hypnotics on its first Choosing Wisely campaign list of “Five Things Physicians and Patients Should Question,” citing heightened fall and fracture risks and automobile accidents in older patients who took them.

Now the CDC has reported that a high number of emergency room visits are associated with psychiatric medications in general, and Ambien in particular. They’re implicated in 90,000 adult ER visits annually because of adverse reactions, the study found; more than 19 per cent of those visits result in hospital admissions. Among those taking sedatives and anxiety-reducing drugs, “a lot of visits were because people were too sleepy or hard to arouse, or confused,” said the lead author, Dr Lee Hampton, a medical officer at the CDC.

The CDC looked at visits by drug and by age. Older patients, it turns out, did not show up more often in emergency rooms because of adverse reactions to sedatives and antianxiety drugs. People ages 19 to 44 have the highest number of visits in proportion to prescriptions for those medicines.

About a third of those older than 65 (32 percent) who went to ERs with adverse responses to sedatives were hospitalized, compared with about 13 percent of those 19 to 44 .

The data also showed that Ambien, the use of which has soared in recent years, accounted for one in five ER visits among those older than 65, more than any other medication. “I didn’t expect a single drug to stand out that much,” Dr Hampton said. That may be because Medicare didn’t cover benzodiazepines but did cover zolpidem from the inception of Part D in 2003 until last year, when the policy changed.

Fatal falls

The Food and Drug Administration, concerned about “next-morning impairment” from Ambien, last year halved the recommended dose for women, to 5 milligrams from 10 milligrams, and to 6.25 milligrams from 12.5 milligrams for extended-release versions like Ambien CR.

The other particular concern for older people is falls, a leading cause of death and disability. A 2010 analysis of falls says 22 percent of “community dwelling” Medicare beneficiaries older than 65 fell in a year. The CDC estimates that a third of older adults fall annually.

“There’s a constellation of risks that contribute to falls, and medications are clearly part of it,” said Dr Jerry H Gurwitz, a geriatrician at the University of Massachusetts Medical School. “And high on the list of those medications related to falls and fall-related injuries are sedative-hypnotics.”

On to some other questions readers raised. First, for those who objected to collectively referring to benzo and non-benzo sedatives and “not honouring the differences” between them. The Z-drugs are approved only as sleep aids. Benzodiazepines have other uses, like treating panic disorders or seizures; some people may be taking them throughout the day, not only at bedtime.

Yet those remedies — changing sleep habits, seeking cognitive behavioural therapy — have been found to be effective against insomnia. The physicians I consulted urged patients to seek a comprehensive evaluation, and then try nonpharmacological remedies first, turning to sleeping pills only after exhausting the alternatives. JAMA published a patient guide to treating insomnia last year.

A final caveat: Yes, older people are different. A 65-year-old speedwalker has a different risk profile from an 85-year-old with poor vision or osteoporosis. But the physicians I consulted couldn’t countenance extended sedative use, even for the former.