Use of Sedative/Hypnotic Medications

Overview | Resident Evaluation | Care Planning | Quality Improvement | Additional Resources | Bibliography | Reviewers | Feedback

Overview

The DADS Quality Assurance and Improvement vision for the use of hypnotic medications in LTC is

Improving sleep hygiene in order to reduce the misuse of hypnotic medications.

Definitions and Scope

The term sedative/hypnotic medication, as used in the Quality Indicator profile and this framework, refers to agents intended to induce sleep. The simpler term hypnotic is used in this framework to refer to such agents regardless of their pharmacological class.

Sleep disturbances are common in nursing home residents with up to 75% of residents reporting some type of sleep disturbance.[1,2] Residents who experience interruptions of nighttime sleep also experience daytime fatigue, impaired daily functioning, and nocturnal insomnia. Sleep disturbances in nursing homes are often caused by poor sleep hygiene as a result of individual bedtime habits as well as environmental factors such as noise and light.[3] This QMWeb framework focuses on sleep disruptions caused by poor sleep hygiene. Medical causes of sleep disturbances such as sleep disordered breathing, periodic limb movements, and restless leg syndrome require treatment other than hypnotic medications.

Pharmacological therapy is commonly used to address sleep disturbances among nursing home residents. In some studies up to 34% of residents have been found to take a hypnotic medication.[4] Giving residents a medication to help them asleep seems an easy solution. However, the effectiveness of benzodiazepines for insomnia is limited to about 14 days.[12,31]  After that time, drug tolerance leads to loss of effectiveness. In addition, hypnotics, especially benzodiazepines, produce side effects (e.g., risk of fall, confusion) that can worsen ADL dependence and increase care needs. In 2003, 8.5% of Texas nursing facility residents aged 65 or older were taking hypnotic medications, and 58% of hypnotics were ordered for routine rather than as needed use.[29,30] This prevalence is three times higher than the national average (2.8%).[29]

Best practice in treating sleep disturbances is to improve sleep hygiene in order to reduce the use of hypnotic medications.

Considerations for Reducing Hypnotic Drug Use

The goal of hypnotic drug therapy is to maximize resident comfort and quality of life. Therefore, the use of these medications, must address the hazards of their use and the benefits of reducing or discontinuing them.

Falls

Nursing home residents taking benzodiazepines experience falls at a rate of 44% greater than those not taking these drugs.[5] The risk of hip fracture is 47% greater for those using benzodiazepines.[6] Risk of falling increases with increasing benzodiazepine dose. While falls are more likely to occur at the onset of benzodiazepine use, increased fall risk is persistent for individuals on chronic benzodiazepine therapy.[5,6] Falls are more frequently associated with long-acting benzodiazepines.[5] However, short-acting agents are associated with a two-fold increased risk of nighttime falling. Thus, the reduction or discontinuation of hypnotic drugs is a crucial step in managing the risk of falls in your facility.

Lack of benefit in sleep disorders

Nursing home residents taking benzodiazepines medications appear just as likely to complain of sleep disturbances as residents not taking these medications.[7] There is no proven relationship between decreased use of hypnotics and worsening sleep quality, nor between increased hypnotic use and improved sleep quality in this population. When benzodiazepines are withdrawn after chronic use, residents can experience rebound insomnia due to withdrawal.[7] This phenomenon can can create the impression for both the resident and physician that the benzodiazepine was a necessary and useful treatment. Meta-analysis of pooled trials of benzodiazepine use for insomnia shows that this class of medications has few, if any, benefits while posing unacceptable risks of serious side effects - regardless of patient age.[33]

Improved functioning after discontinuation

The elderly are more susceptible to prolonged effects of benzodiazepines. Increased drowsiness and ataxia (loss of coordinated muscle movement typically manifest as loss of balance), as well as impaired cognition and memory have been associated with benzodiazepine use in this population.[8,9] Discontinuation of benzodiazepine therapy in nursing home residents can lead to improvements in memory and daily functioning. Discontinuation of chronic benzodiazepine therapy should be acoomplished by gradual dose reduction rather than by abrupt withdrawal in order to avoid withdrawal symptoms.[10,11]  

Resident Evaluation

Clear Identification and Understanding of the Clinical Problems, Goals, and Risks

Residents with Sleep Disturbances

Residents with complaints of sleep disturbances, observed nighttime awakenings and daytime sleepiness should undergo an evaluation to determine the root cause of the problem. Start by taking a sleep history from the resident, as well as from nighttime staff.[12] Answering these questions is the beginning to identifying the sleep problem.

• What was the resident's sleep pattern before admission?
• How much does the resident sleep during the night and during the day?
• Is the problem getting to sleep, awakening during sleep, or waking up too early?
• How long has the problem occurred and how often?
• Describe the sleep environment. Is it quiet and undisturbed?
• Does the resident snore or gasp during sleep?
• Does the resident have pain?
• Does the resident make frequent leg jerks while asleep?
• Has the resident experienced a recent significant life change, loss or other stress?
• Does the resident have signs  and symptoms of anxiety or depression?
• What prescription and non-prescription medications does the resident take?
• When and how much caffeine (coffee and soda pop), tobacco or alcohol is the resident using?

If likely causes for the sleep problem are not identified from the sleep history, use a two-week sleep diary for further evaluation. Document bed and wake times, number of awakenings during the night, time spent awake and what preceded the awakening, as well as daytime sleeping episodes and their duration.

Look for underlying medical problems such as sleep disordered breathing, restless leg syndrome as well as symptoms such as orthopnea, nocturia, and pain that can disrupt sleep. If a specific medical condition is not the cause of the sleep disturbance, perform a physical examination with special attention to cardiopulmonary, upper airway and neurologic findings. Evaluate the resident for pain, anxiety, and depression.

Candidates for Hypnotic Drug Reduction or Discontinuation

Residents are candidates for hypnotic reduction or discontinuation when they are taking more than one psychotropic drug, experiencing side effects from a hypnotic drug (e.g., daytime sedation), having no sleep problems for several days, having sleep disturbances caused by underlying medical disorders, or having been treated with hypnotics continuously for more than ten days.

• Why were hypnotic drugs prescribed?
• Was a specific clinical condition diagnosed and documented in the clinical record?
• Were appropriate non-pharmacological methods initiated to manage the condition?
• Is there evidence that supports the use of hypnotic medications (for this duration) for this condition?
• Has informed consent been obtained from the resident and/or family?
• Does the informed consent document contain the following required information?
  • Specific condition to be treated;
  • Beneficial effects on that condition expected from the hypnotic medication?
  • Probable clinically significant side effects (common side effects/adverse reactions) and risks associated with the hypnotic medication, as reported in widely available pharmacy databases or the manufacturer's package insert; and
  • Proposed course of the hypnotic medication.
• What are the measurable goals of the prescribed therapy?
• Is the hypnotic medication producing the desired benefit regarding the treatment goals?
• Is there active monitoring for side effects?

Structured Resident Assessment and Care Planning

When possible, develop and implement a care plan that addresses the cause of the sleep disturbance rather than solely its symptoms. When the sleep disturbance is caused by an underlying condition (e.g., pain, anxiety, depression, sleep disordered breathing, periodic limb movements and restless leg syndrome), treat the cause. The initial care plan for residents with sleep disturbances should include proper sleep hygiene measures, hypnotic therapy only when sleep hygiene is not enough to restore normal sleep, and a specific plan for discontinuing hypnotic medications.

Sleep Hygiene Measures and Other Non-Pharmacological Therapies

Non-pharmacological interventions are considered primary therapy for sleep disturbances.[13] Begin by ensuring a peaceful environment for sleep. Many sleep disturbances can be eliminated by simply creating an environment conducive to sleep. Proper sleep hygiene has been shown to improve sleep quality and duration of sleep among nursing home residents.[14,15] The following describes the behavioral interventions and environmental modifications that have been shown to help residents sleep better.[12,14,16,17,18,19,20,21] Have staff assist residents in implementing these measures.

Bedtime Behaviors

• Establish a regular bedtime and wake time. Stay consistent, even on the weekends.
• Avoid stressful activities before bed - promote relaxing activities.
• Avoid fluids before bedtime to reduce the need for nighttime toileting.
• Establish a consistent bedtime routine.
• Avoid watching television in bed.

Daytime Behaviors

• Avoid excessive time in bed during the day.
• Increase residents' daytime light exposure.
• Reduce or eliminate daytime naps.
• Promote daytime activity.
• Refrain from caffeine, tobacco and alcohol, especially during the afternoon.

Environmental Instructions for Medical and Direct Care Staff

• Abate nighttime noise and lighting.
  • Post signs reminding staff of nighttime quiet.
  • Use hushed voices.
  • Close residents' doors at night in order to improve quiet and provide privacy.
  • Turn off all devices (e.g., televisions, radios, audio players) that have no audience.
  • Turn off non-essential lighting.
• Provide residents with earplugs if desired.
• Revise medication schedules in order to eliminate giving medications while residents are asleep.
• When entering the room of a sleeping resident:
  • Keep the overhead light turned off. Use small flashlights to enter the room if light is necessary.
  • Avoid sleep disruptions (e.g., changing pads or repositioning residents) that are not absolutely essential.
• Do not force a facility sleep schedule for convenience (e.g., do not put residents to bed before they are sleepy). Individualize nighttime care.

Insomnia that does not improve with good sleep hygiene may respond to non-pharmacological therapies such as the following.[4,12,21,22,23,24,25]

• Bright Light Therapy
• Stimulus-Control Therapy
• Sleep Restriction Therapy
• Cognitive Therapy (See Treatment Overview - Behavior therapy)

Appropriate Pharmacological Therapy

In uncomplicated insomnia, hypnotics serve as an adjunct short-term therapy to non-pharmacological interventions.[13,19] In residents experiencing disturbed sleep despite good sleep hygiene, treatment with hypnotic medications may be considered. Hypnotic therapy should be initiated at the lowest effective dose, prescribed for short duration (less than ten days) and prescribed for use as needed rather than given routinely. Monitor residents on hypnotic medications for the emergence of delirium. During the course of treatment, continuously reassess the resident's sleep pattern so that the hypnotic can be reduced and ultimately discontinued.  Refer to the Dosing table for specific information on the usual geriatric dosing and side effects for each sedative and hypnotic drug in each of the drug classes discussed above.

Non-benzodiazepine hypnotics

Non-benzodiazepine hypnotics (zolpidem and zaleplon) are short acting and are as effective as benzodiazepines.[4] They are associated with fewer side effects and less withdrawal problems.[13] They appear to have a lower risk of falls, daytime sedation, tolerance, rebound, and respiratory depression than has been observed with benzodiazepine hypnotics. Limit the use of these medications to 7 - 10 days. Re-evaluate any resident who is treated with these medications for more than two weeks.[26]

Benzodiazepines

These agents are typically prescribed for no more than ten days.[13] When a benzodiazepine has been used continuously for six weeks or longer, taper it gradually over two to 12 weeks observing closely for withdrawal symptoms.[19]

Antihistamines

Antihistamines are effective medications, but they are not generally recommended in elderly persons due to their side effects, especially anticholinergic side effects such as dry mouth, urinary retention and delirium.[27] Side effects occur even at low doses.[13]

Trazodone

Low-dose trazodone (i.e., 25 to 150 mg per day) is an antidepressant commonly used to induce nighttime sleep. It has an advantage over benzodiazepines in that it does not cause respiratory depression.[13,27] Trazodone does not cause anticholinergic effects.

Hypnotic Medication Reduction and Discontinuation

For residents who are candidates, institute good sleep hygiene measures before beginning drug reduction or discontinuation. Hypnotic dosage reduction can be attempted three times in six months unless this proves clearly harmful.[13] In long-term users, doses should be reduced gradually. When switching from a benzodiazepine to a non-benzodiazepine hypnotic, the non-benzodiazepine may be started during benzodiazepine reduction.[28]

Practical Guide to Quality Improvement

The structural and process components of the practice guide to quality improvement are the same for all psychotropic drugs.

Key Components for Successful Hypnotic Drug Reduction Programs

Part I. Education [14,16]

1. Use DADS Joint Training, and QMWeb resources to provide staff and family education on sleep hygiene and appropriate hypnotic drug use and reduction. Emphasize the importance of uninterrupted sleep for all residents.
2. Assess the factors that contribute to sleep disorders in your facility.
3. Develop a plan for providing a peaceful nighttime environment for residents and for encouraging good sleep hygiene behaviors.
4. Provide periodic retraining in good sleep hygiene strategies.
5. Develop a facility plan for reducing and discontinuing the use of hypnotic medications and present it to staff, family and resident council.
6. Work with DADS Pharmacy Quality Monitors to pilot, evaluate and refine your hypnotic drug reduction program.

Part II. Discontinue Unnecessary Hypnotic Medications

The decision to discontinue unnecessary hypnotic medications requires a formal review process that includes the following steps and involves the medical director, consultant pharmacist, and DON as well as the support of the attending physician staff.[32] This may be as simple as discontinuation of an infrequently used PRN order or may require gradual tapering of an agent that has been used frequently over a long period of time.

1. Begin with your facility's Quality Indicator profile to identify residents who are taking hypnotic medications (QI-20).
2. Review all medication administration records in order to identify residents on hypnotics not yet reported in MDS assessments.
3. Implement good sleep hygiene measures in your facility before beginning hypnotic drug reduction.
4. For residents who are candidates for hypnotic drug reduction, develop and implement a hypnotic drug reduction plan.
   1. Involve the resident's family in the design of the plan.
   2. Provide family education on the risks of hypnotic drug use, the side effects of prolonged hypnotic drug use, and the benefits of reduction or discontinuation.
   3. Have the consultant pharmacist inform both the attending physician and director of nursing (DON) of orders for hypnotic drugs that should be reduced or discontinued.
   4. Require that the attending physician respond to the pharmacist's recommendations by either revising the order for hypnotics or providing a valid medical justification for its continuation.
   5. Require that the medical director intervene if attending staff does not respond appropriately to recommendations from the consultant pharmacist .
   6. Closely monitor the resident for adverse effects of dose reduction.
   7. Adjust the pace of dose tapering to minimize adverse effects.
   8. Carefully document the changes in the symptoms of residents in whom hypnotic drug reduction or discontinuation is not successful.
5. Schedule periodic hypnotic drug use reevaluation for every resident who continues on hypnotic treatment.

Part III. Prevent the Unnecessary Initiation of Hypnotic Medications

1. Implement good sleep hygiene techniques.
2. Require the use of structured assessment and non-pharmacologic interventions before hypnotic medications can be ordered.
3. Use a formal review process to develop care plan alternatives when structured assessment shows that hypnotic drug use is not necessary.
4. When hypnotic drug use is appropriate:
   1. Provide proper sleep hygiene measures.
   2. Initiate treatment at the lowest effective dose for no more than ten days and only as needed.
   3. Monitor for side effects.
   4. Continuously reassess the need for continued hypnotic drug use.

Part IV. Monitor Therapy for Benefits and Side Effects

Use a process of on-going structured assessment to ensure all of the following:

1. That there is monitoring for hypnotic medication side effects.
2. That there is monitoring of the medication's effects regarding sleeping pattern.
3. That the hypnotic is considered as a possible cause of unexpected adverse events.
4. That the family and prescribing physician are notified of significant changes in the resident's condition that may be related to the hypnotic medication.
5. That the physician responds to notifications concerning adverse events potentially related to the hypnotic medication.

Additional Resources (including online resources)

The resources listed below are provided solely as a convenience to our users. These may include publications from government, professional, for-profit, and non-profit sources. Some of these sources may have financial ties to industry. DADS does not control the content of these resources, and the opinions and recommendations provided there are those of the authors and do not necessarily reflect the position of QAI or DADS.

Online

How is Insomnia Diagnosed? (University of California Davis Medical Center)

AGS Position Statement Psychotherapeutic Medications in the Nursing Home

In Print

Maletta G, Mattox KM, Dysken M. Guidelines for prescribing psychoactive drugs. Geriatrics 2000;55(3):65-79.

Bibliography

[1] Gentili A, Weiner DK, Kuchibhatil M, Edinger JD. Factors that disturb sleep in nursing home residents. Aging: Clinical and Experimental Research 1997;9(3):207-13.

[2] Middelkoop HA, Kerkhof GA, Smilde-van den Doel DA et al. Sleep and ageing: the effect of institutionalization on subjective and objective characteristics of sleep. Age and Ageing 1994;23(5):411-17.

[3] Ersser S, Wiles A, Taylor H et al. The sleep of older people in hospital and nursing homes. Journal of Clinical Nursing 1999;8(4):360-68.

[4] Petit L, Azad N, Byszewski A et al. Non-pharmacological management of primary and secondary insomnia among older people: review of assessment tools and treatments. Age and Ageing 2003;32(1):19-25.

[5] Ray WA, Thapa PB, Gideon P. Benzodiazepines and the risk of falls in nursing home residents. Journal of the American Geriatrics Society 2000;48(6):682-85.

[6] Wang PS, Bohn RL, Glynn RJ et al. Hazardous benzodiazepine regimens in the elderly: Effects of half-life, dosage, and duration on risk of hip fracture. American Journal of Psychiatry 2001;158(6):892-98.

[7] Monane M, Glynn RJ, Avorn J. The impact of sedative-hypnotic use on sleep symptoms in elderly nursing home residents. Clinical Pharmacology and Therapeutics 1996;59(1):83-92.

[8] Shorr RI, Robin DW. Rational use of benzodiazepines in the elderly. Drugs and Aging 1994;4(1):9- 20.

[9] Opedal K, Schjott J, Eide E. Use of hypnotics among patients in geriatric institutions. International Journal of Geriatric Psychiatry 1998;13:846-51.

[10] Salzman C, Fisher J, Nobel K et al. Cognitive improvement following benzodiazepine discontinuation in elderly nursing home residents. International Journal of Geriatric Psychiatry 1992;7:89-93.

[11] Habraken H, Soenen K, Blondeel L et al. Gradual withdrawal from benzodiazepines in residents of homes for the elderly: experience and suggestions for future research. European Journal of Clinical Pharmacology 1997;51(5):355-58.

[12] Martin J, Shochat T, Ancoli-Israel S. Assessment and treatment of sleep disturbances in older adults. Clinical Psychology Review 2000;20(6):783-805.

[13] Gurvich T, Cunningham JA. Appropriate use of psychotropic drugs in nursing homes (federal guidelines). American Family Physician 2000;61(5):1437-46.

[14] Alessi CA, Yoon EJ, Schnelle JF et al. A randomized trial of a combined physical activity and environmental intervention in nursing home residents: do sleep and agitation improve? Journal of the American Geriatrics Society 1999;47(7):784-91.

[15] O'Rourke DJ, Klaasen KS, Sloan JA. Redesigning nighttime care for personal care residents. Journal of Gerontological Nursing 2001;27(7):30-37.

[16] Cruise PA, Schnelle JF, Alessi CA et al. The nighttime environment and incontinence care practices in nursing homes. Journal of the American Geriatrics Society 1998;46(2):181-86.

[17] Schnelle JF, Alessi CA, Al Samarrai NR, Fricker RD, Jr., Ouslander JG. The nursing home at night: effects of an intervention on noise, light, and sleep. Journal of the American Geriatrics Society 1999;47(4):430-38.

[18] Schnelle JF, Cruise PA, Alessi CA, Al Samarrai N, Ouslander JG. Individualizing nighttime incontinence care in nursing home residents. Nursing Research 1998;47(4):197-204.

[19] Shorr RI, Robin DW. Rational use of benzodiazepines in the elderly. Drugs and Aging 1994;4(1):9- 20.

[20] Schnelle JF, Ouslander JG, Simmons SF et al. Nighttime sleep and bed mobility among incontinent nursing home residents. Journal of the American Geriatrics Society 1993;41(9):903-09.

[21] Morin CM, Mimeault V, Gagne A. Nonpharmacological treatment of late-life insomnia. Journal of Psychosomatic Research 1999;46(2):103-16.

[22] Bliwise DL. Sleep in normal aging and dementia. Sleep 1993;16(1):40-81. [23] Ancoli-Israel S, Martin JL, Kripke DF et al. Effect of light treatment on sleep and circadian rhythms in demented nursing home patients. Journal of the American Geriatrics Society 2002;50(2):282-89.

[24] Koyama E, Matsubara H, Nakano T. Bright light treatment for sleep-wake disturbances in aged individuals with dementia. Psychiatry and Clinical Neurosciences 1999;53(2):227-29.

[25] Lyketsos CG, Lindell VL, Baker A, Steele C. A randomized, controlled trial of bright light therapy for agitated behaviors in dementia patients residing in long-term care. International Journal of Geriatric Psychiatry 1999;14(7):520-25.

[26] Drug Facts and Comparisons, 56th Edition. Facts and Comparisons: St. Louis, Missouri. 2002.

[27] Rajput V, Bromley SM. Chronic insomnia: a practical review. American Family Physician 1999;60:1431-42.

[28] Estivill E, Bov A, Garca-Borreguero D et al. Consensus on drug treatment, definition and diagnosis for insomnia. Clinical Drug Investigation 2003;23(6):351-85.

[29] Cortés L, Monroe D, Morrow, K. A statewide assessment of quality of care, quality of life and consumer satisfaction in Texas Medicaid nursing facilities 2003.

[30] Cortés L, Monroe D, [Ed.]. Medication Use Among Geriatric Residents of Texas Certified Nursing Facilities (2000-2003).

[31] Alessi CA.  Chapter 47 - Sleep Disorders.  The Merck Manual of Geriatrics.  Accessed May 15, 2003.

[32] MacLean DS.  Drug regimen review: bane or boon?  Caring for the Ages 2002;3(10);1-5.  Accessed July 13, 2004.

[33] Holbrook AM, Crowther R, et al. Meta-analysis of benzodiazepine use in the treatment of insomnia. JAMC 25 JANV. 2000; 162 (2). Accessed July 24, 2004.

Literature Review Evidence Table

Reviewers

Peer Reviewer: David A. Smith, MD, CMD
Review Date: May 28, 2004

Dr. Smith practices Long Term Care Geriatrics in Brownwood, Texas. He is a Professor in Family Medicine at the Texas A&M School of Medicine and is Vice President of the American Medical Directors Association.

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