I am currently leading in a research project in my facility (Care of the Older Person) in regard to use of Hypnotic and PRN Psychotropic Medication. While clinically significant insomnia averages around 10%, prescribing rates are around 36% - 49%,or higher globally for the over 65 year age group. Concerningly, it's use is shown by the evidence to exacerbate symptoms of dementia when used long term. There appears to be an issue with over prescribing for insomnia without first making the diagnosis that it's clinically requred. The medication is then not discontinued within the recommended 4 weeks. We have 40% of residents on this medication taking it a year or more. A wider study is in the plannning stage.
Dear Florence,
The attached review article entitled "Current Treatments for Sleep Disturbances in Individuals With Dementia " by Cynthia L. Deschenes and Susan M. McCurry published in Curr Psychiatry Rep. 2009 Feb; 11(1): 20–26 may contribute to the discussion on this important topic.
Herein the Conclusion Section of the above mentioned review article:
Conclusions
Sleep disturbances in older adults with dementia are common. Their etiology is complex, involving multiple factors, such as neurodegenerative changes in the brain, the patient's environment, medical or psychiatric morbidity, and medications used to treat chronic illnesses and dementia-related behavioral symptoms. An accurate diagnosis of the neurologic disorder and comprehensive review of current medications are important for understanding possible causes of patient sleep changes and for developing a plan of care to improve nighttime sleep and daytime wakefulness and reduce caregiver burden.
Because of the multifaceted nature of sleep disturbances and fragility of older adult patients with dementia, nonpharmacologic options should always be considered as first-line treatment. Pharmacologic options should be used judiciously, with potential side effects seriously considered before prescribing hypnotic and psychotropic agents. In light of the aging of the US population and subsequent probable increase in the prevalence of dementia, continued research to develop safe, effective medications and solid, evidence-based guidelines for sleep problems in this population is needed.
Hoping this will contribute to the discussion on this important issue,
Rafik
I agree generally with this:
Sleep disturbances in older adults with dementia are common. Their etiology is complex, involving multiple factors, such as neurodegenerative changes in the brain, the patient's environment, medical or psychiatric morbidity, and medications used to treat chronic illnesses and dementia-related behavioral symptoms. An accurate diagnosis of the neurologic disorder and comprehensive review of current medications are important for understanding possible causes of patient sleep changes and for developing a plan of care to improve nighttime sleep and daytime wakefulness and reduce caregiver burden.
Because of the multifaceted nature of sleep disturbances and fragility of older adult patients with dementia, nonpharmacologic options should always be considered as first-line treatment. Pharmacologic options should be used judiciously, with potential side effects seriously considered before prescribing hypnotic and psychotropic agents. In light of the aging of the US population and subsequent probable increase in the prevalence of dementia, continued research to develop safe, effective medications and solid, evidence-based guidelines for sleep problems in this population is needed.
Hypnotic Medication may exacerbate symptoms of dementia when used long term. Any advice on prevelence and duration of use? - ResearchGate. Available from: https://www.researchgate.net/post/Hypnotic_Medication_may_exacerbate_symptoms_of_dementia_when_used_long_term_Any_advice_on_prevelence_and_duration_of_use [accessed Oct 28, 2016].
Trying to understand the factors involved in any insomnia is critical. Circadian influences are often overlooked especially in this population. Further, the regimentation of persons in residential care facilities may not allow for individual variance in sleep patterns. I try to avoid hypnotics, especially in elderly and/or demented patients. This goes doubly for so-called psychotropic drugs.
You may wish to consider a device called Somniresonance which is FDA approved. Admits a very low level electromagnetic pulse which is self-limited for 22 minutes. Patients wear it over the mid clavicle region on the right. If they awaken and have difficulty returning to sleep all the need to his press the button again. It may be helpful for some of the patient's senior population.
P Terrence Moore M.D.
- Excellent references Rafik and Paul. Thank you. But the central issue remains. Why are there no guidelines for the prescribing of Hypnotic Medications ....or indeen PRN Psychotropics in this high risk age group ?.Here in Ireland we haven't even started to grasp the nettle - let alone deal with it. I am hoping we will start the ball rollling as thankfully our Medical Council are also now showing great interest in this topic.Insomnia should be the main issue - not trying to deal with the high prevelence of H.M.
My answer should have said 'emits' instead of 'admits'. I will check about AASM guidelines about hypnotics, but do recall literature associating increased rate hip fractures and psychotropics in the 'elderly'.
Regards,
P. Terrence Moore, MD
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