According to a report released by the Canadian Institute for Health Information, nearly two-thirds of seniors living in long-term care (LTC) facilities take 10 or more drugs. So why not stop – or de-prescribe – some of them? De-prescribing is a strategy recommended by Dr. Cara Tannenbaum, co-Director of the newly launched Canadian Deprescribing Network, who claims that both the word and its action are gaining international popularity.
Of course not all medicines are bad. Many are required to treat bothersome symptoms, alleviate pain or control disease progression. What is alarming to Dr. Tannenbaum is that nearly a quarter of seniors take drugs that are “potentially inappropriate” or unnecessary. Potentially inappropriate is a term that refers to medicines that have a greater risk of harm than benefit for many consumers. Sleeping pills and antipsychotic drugs fall under this category. A full list of the top ten drugs to avoid or use with caution in older adults is available at http://www.americangeriatrics.org/files/documents/beers/FHATipMEDS.pdf.
The use of sleeping pills elicits concern because sleeping pills increase the risk of an emergency room visit for confusion, falls, hip fractures and death for individuals who use these drugs on a chronic or even episodic basis. Even two sleeping pills per week can increase the risk of Alzheimer Disease.
Many older adults are unaware of these risks. Others do not know that sleeping pills are included in their pillbox. It is not always easy to recognize the little round yellow or oval white pills that masquerade as innocent sleep panaceas, hidden among the medley of other pills that need to be taken before bed.
With the help of consumer marketing techniques – which usually get people to want to start taking certain medications – and feedback from older adults themselves, Dr. Tannenbaum developed an educational brochure designed to help seniors want to stop taking sleeping pills. The brochure is available online and can be downloaded and printed free of charge from http://www.criugm.qc.ca/images/stories/les_chercheurs/risk_ct.pdf
Dr. Tannenbaum tested the deprescribing brochure among 303 seniors aged 65-95 who regularly used sleeping pills. After reading the brochure, two-thirds of participants decided to broach the subject of de-prescribing with their doctor or pharmacist. One-infour succeeded in safely tapering off their sleeping pills by 6-months, and another 11% were in the process of following the weaning protocol.
The study raises three important questions. First, should educational brochures be disseminated to all seniors and their family members for commonly consumed, but possibly unnecessary and potentially harmful medication? Second, if exposure to scientific information can catalyze seniors to bring about changes in prescribing patterns, then how can seniors be recruited to help drive other quality of care health improvement initiatives? Finally, the question begs to be asked if everyone knows what the word deprescribe means, and whether it warrants becoming part of the regular vernacular of healthcare in Canada.
Emerging statistics about the cost, quantity, and types of potentially inappropriate medications that are being prescribed in long-term care must be viewed as an opportunity for introspection, not as an excuse to point fingers. What is the reason so many sleeping pills are prescribed? The long-term care resident who has to wake up early and be wellrested to face a stressful day at the office is the rare exception. After retirement, shouldn’t individuals be allowed to embrace the luxury of going to bed and waking up whenever they want?
Yet all too often caregiver schedules dictate when seniors sleep. Nursing home culture and structure impose an artificial routine on natural biologic rhythms, creating the need for chemical coping. Going to bed at 7 or 8 p.m. at night and sleeping until 6 in the morning is an unrealistic expectation. Due to changes with age in sleep architecture patterns and the need for sleep, most seniors only require 6-7 hours of sleep per night. Less if they nap for 3 hours each afternoon. To stay on a regular sleep schedule, individuals must be exposed to bright sunlight during waking hours, plenty of physical activity and mental or sensory stimulation, and no caffeinated beverages after dinner. These criteria are infrequently met in long-term care, and for these reasons the overuse of sleeping pills is unsurprising.
A wake up call is ringing. The pendulum has swung too far. Major changes are needed for more humane care with minimal reliance on the over-prescription of drugs. Sleeping pills and antipsychotics represent the tip of the iceberg only. Geriatricians debate whether statin therapy for high cholesterol and strict control of blood sugar to prevent the longterm complications of diabetes truly embody the concept of rational resource allocation for seniors at the end of life. A more reasonable approach might be to shift healthcare spending away from unnecessary prescription drugs, and instead augment the availability of qualified personnel to deliver individualized care and ensure that human interactions take precedence over pharmaceutical ones. Over the long-term, de-prescribing, rather than prescribing, may be part of what is needed to help improve care for seniors in our current healthcare system.