Sleep medications and older adults

Published by Padmaja Genesh in the Red Deer Advocate 

June 14, 2018
Original article here

Betty is a 70-year-old lady living alone in an apartment. She has been generally healthy, except for arthritis of the knee, mild depression, and sleeplessness, for which she has been taking medications. However, in the last few months, she has had multiple falls, and her family has noticed her increasing confusion, daytime sleepiness, and forgetfulness.

Following a serious fall, she was brought to the hospital and a review of her medication list showed that she was on Lorazepam and Clonazepam – sleep medications belonging to the class of Benzodiazepines – the culprits responsible for Betty’s symptoms.

Benzodiazepines are among the most widely prescribed medication for older adults. In Alberta, in 2013 alone, there were over 560,000 prescriptions for benzodiazepines and a third of these were for individuals aged 60 or over. It is estimated that 5%-32% of older adults in the community use these medications. Benzodiazepines account for 20-25% of inappropriate prescriptions in older adults.

While Benzodiazepines may be effective and indicated in some situations in the short-term, their long-term use has very little proven benefit and poses serious risks to older adults. In general, older adults have increased sensitivity to Benzodiazepines and ‘z drugs’ such as Zopiclone, and these medications stay longer in their bodies.

Long-term use of Benzodiazepines in older adults has been associated with falls, dementia, depression, mobility issues, motor vehicle accidents, alcohol dependence, and physical addiction. It has also been linked to frequent visits to doctors, increased emergency room visits, hospitalization, and increased risk of death.

The interesting situation here is physicians are aware of the risks associated with the use of Benzodiazepines, but 50% of them continue to prescribe these medications, either because patients say it works for them or patients do not want to stop taking them. Additionally, the majority of long-term Benzodiazepine users, 65 years of age and older, report not being concerned about their side effects, mainly because they have never been alerted to the risks.

The Canadian initiative, Choosing Wisely Canada, advises physicians not to use Benzodiazepines and other sedative-hypnotics as a first choice drug for older adults with sleeplessness, agitation or delirium, and to use safer alternatives instead.

Since continued use of Benzodiazepines can lead to tolerance and dependence, even if used at therapeutic dose for a few weeks, their sudden discontinuation can cause withdrawal symptoms.

Withdrawal symptoms may be minor such as anxiety, irritability, sleeplessness, tremors, dizziness, vision distortion, nausea, and vomiting or could be major including agitation, delirium, seizures, loss of identity, and changes in vital signs.

The current protocol is not to prescribe Benzodiazepines to older adults. If an older adult has been on these medications for up to four weeks or more, then the dose has to be slowly tapered by 10% every 1-2 weeks until the dose becomes 20% of the original, and then to decrease the dose by 5% for 2-4 weeks.

For older adults with insomnia, alternatives include enforcing strict sleep hygiene, avoiding caffeinated drinks after 3 pm, exercising daily, decreasing fluid intake at night, meditating, and using Cognitive Behavioural Therapy (CBT). If these interventions fail, taking melatonin to replenish the naturally decreasing melatonin levels in our body as we age, can help restore sleep.

Returning to Betty, her Benzodiazepine dose was slowly tapered over a couple of weeks; cognitive behavioural therapy was initiated, and sleep hygiene practice given. Consequently, Betty’s memory has improved, she is more active and alert during the day, and sleeps better at night.

So if you are on a sleep medication, please discuss with your physician about the side effects of the medication, and other treatment options. Be reassured that by eliminating these medications, you will have lower risk of falls, and improved alertness and energy during the day.