Published in the March 2015 issue of Today’s Hospitalist
WITH HOSPITALS still one of the worst places to get any serious shut-eye, many desperate patients trying to tune out all the nighttime noise, lights and interruptions are asking for drugs to help.
A recent study at Boston’s Brigham and Women’s Hospital suggests that physicians are responding to such requests “or anticipating patients’ sleep problems “by widely prescribing pharmacological sleep aids, despite those agents’ known risks in certain populations. The study, which was published in the October 2014 Journal of Hospital Medicine, found that 26.2% of the patients studied over two months received a sleep medication, and that two-thirds of those patients (68.5%) had no known history of either insomnia or prior sleep-aid use. Further, 34.3% of patients with no previous history of use who were prescribed an agent in the hospital were discharged with a new prescription for one.
Researchers found that 13 different medications were being prescribed, drugs that ran the gamut from antidepressants and atypical antipsychotics to antihistamines and a handful of benzodiazepines. Trazodone was the most frequently prescribed (30.4%), followed by lorazepam (24.4%) and zolpidem (17.9%). Seventy-one percent of patients stayed on the prescribed sleep aid until discharge.
Sleep disorders specialist Robert Owens, MD, one of the study authors, has since moved to University of California, San Diego’s division of pulmonary, critical care and sleep medicine. Dr. Owens spoke to Today’s Hospitalist about the study findings.
What surprised you the most?
The biggest surprise was the magnitude of the problem. We had done an earlier survey asking physicians what they knew about prescribing sleep aids. The general response was, “Sleep medications are bad, especially for elderly patients, and I wouldn’t prescribe them.”
But data in this subsequent study didn’t show that. For example, we found that the use of sleep aids was not dramatically lower in patients over age 65 than in those 64 and younger (41.7% vs. 58.3%), even though increasing evidence has documented the risks of inpatient sleep medications including delirium and falls in this population. And recent studies have shown that nonpharmacological interventions are effective: altering noise and light levels, and minimizing nurse interactions or clinician interruptions as much as possible. So I was surprised to find that prescribing numbers were still so high.
I was also surprised to see antipsychotics on the list and by how many patients went home with a new prescription for a sleep medication. That might be a consequence of the speed with which we discharge patients and how easy it is to carry over an inpatient medicine to discharge with a click of a button. Interestingly, computer order entry may make this problem worse.
How many patients either requested or came in on these medications?
We did look at the type of order, whether it was a standing order, an X1 order or a PRN-type medication. Most standing orders would likely have been people coming in on a sleep medication. We found that about 40% of the time, it was an X1 or PRN order.
You also found considerable variation in both the use of agents and when they were administered. What were those key issues?
I don’t think we know what the most appropriate agents are, but we have some suggestions about what are inappropriate. Both benzodiazepines and Ambien have been linked to fall risk and delirium, and very few of the medications we saw prescribed have an FDA indication for sleep.
As to why people use so many different medications: I think the word is out on benzodiazepines. People want to find something sedating, such as the antidepressants we saw, that’s not a benzodiazepine. But other kinds of medications might have as many side effects, which just aren’t as well-studied.
And on the timing of doses, we found that the majority of these medications were given in the appropriate range between 9 p.m. and midnight. But 35% were outside that range, either earlier or later. That suggests that some patients who received medications early might be awake at 4 a.m., and those who got them late could still have been asleep when clinicians came in to assess them.
What do guidelines recommend?
Guidelines recommend first trying all of the nonpharmacologic things to reduce sleep disruption before moving to medications. Those include improving the sleep environment and avoiding sleep-disrupting medications at night, such as furosemide.
The ideal medication might vary among specific patients, their age and comorbidities. Having said that, there are few rigorous studies to guide clinicians, and guidelines are based mostly on expert opinion.
The safest medication is likely to be melatonin, which is not FDA-approved, so some hospitals might not have it on formulary, or ramelteon (Rozerem), a melatonin-receptor agonist that is FDA-approved. But that’s still on patent so it’s very expensive, and a lot of hospitals might not spring for it.
Did the study lead to putting new interventions in place?
In terms of the high number of patients leaving with a new prescription for a sleep aid, many Brigham and Women’s units now have a discharge pharmacist who goes through discharge medications to remove sleep medications and other things that patients end up on like antacids and proton pump inhibitors. Before, pharmacists assisted only with more complex patients, such as those on oncology wards. But based on our study, we recommended that the hospital expand that program.
The best thing for sleep is to use nonpharmacological interventions, with many of our units implementing “quiet times” and other changes to promote sleep. We also try to better understand why patients are having trouble sleeping. If they’re having pain or are uncomfortable for other reasons, giving a sleep aid is probably not the ideal way to treat them.
There are broader changes to consider for the future: Hospitalists could change orders to avoid testing at night and to limit interactions and disruptions, based on vital signs. If you can avoid a 2 a.m. CT scan, move it to later in the day.
And most clinicians don’t ask about sleep in the hospital. By just asking patients in the morning and being aware of sleep problems, physicians could come up with a few things that would be useful, like making sure clinicians aren’t chattering in the hall in the middle of the night.
Ultimately, education will be important. In our earlier survey, we found that many physicians receive little training on sleep or its importance. We should provide more education on sleep and on nonpharmacological strategies.
Bonnie Darves is a freelance health care writer based in Seattle.