How to do it ... Choosing sleep meds wisely

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There is a dizzying array of over-the-counter and prescription-strength medications designed to encourage sleep. What many providers don't fully realize, however, is these drugs are not meant as a long-term or permanent solution to conditions such as insomnia. Experts chime in on the risks, as well as proven alternatives.

1. Identify and be vigilant about the riskiest sleep medications. Virtually all medicines designed to induce sleep can produce side effects. Some substantially more than others, however.

Experts agree benzodiazepines are among the riskiest. That class of drugs increases the chance of cognitive and psychomotor impairment, falls, fractures, and motor vehicle accidents, says T.J. Griffin, RPh., chief pharmacy officer for PharMerica.

Kathleen Wise, consultant pharmacist with Boomer Solutions, a member of the Guardian Pharmacy Services family, says these and non-benzodiazepine receptor agonists are recommended only for short-term use due to additional risks such as “rebound insomnia, withdrawal and tolerance.”

Other high-risk sleep meds include antihistamines, which “have strong potential for anticholinergic side effects,” as well as antipsychotic and antidepressant medications, which “are not recommended for the treatment of insomnia.” These medications not only have the potential for adverse side effects but may interact with other medications, says Wise.

Barbiturates are another medication to avoid because they can cause overdose even at low levels, and are highly addictive, adds Griffin. “Chloral hydrate should also be avoided in older adults because of tolerance within just 10 days of treatment and risk of overdose,” he says.

2. Educate staff about the early warning signs of troublesome sleep medications. Additional monitoring and quick intervention throughout the day are needed for any residents on sleep medication.

Joe Kramer, vice president of sales and marketing for Geri-Care Pharmaceuticals Corp., refers to them as “complex sleep behaviors, which are episodes in which a patient has no control over his or her movements, behaviors or actions, with no remembrance, which is identical to sleepwalking. This tends to occur when a patient has built a high tolerance or has become dependent on the medication.”

Wise says insomnia meds are known to lead to “residual daytime sedation, increased confusion, rebound/withdrawal symptoms and physical dependence.”

3. Non-pharmacological approaches to insomnia are usually preferred.

Wise asserts that risks from over-the-counter sleep aids can be avoided by: resident and caregiver education; employing non-medication therapies; creating environments conducive to restful sleep; treating comorbid conditions such as depression, sleep apnea and chronic pain; assessing medications known to contribute to insomnia; and scheduling routine medications during waking hours when possible.

4. There are a host of alternatives to pills and many are shown to produce better outcomes.

William Vaughan, RN, BSN, vice president of education and clinical affairs for Remedi SeniorCare, says nonpharmacological approaches to insomnia include both behavioral and environmental interventions.

“Emphasis is placed on going to bed and waking up at the same time each day, getting out of bed while awake, avoiding caffeine, heavy meals, nicotine and alcohol before going to bed and limiting naps,” he adds. Daily exercise and regular exposure to sunlight also improve insomnia. The National Sleep Foundation also recommends a sleep environment that is cool, dark and quiet.

Kramer encourages caregivers to put their residents' smartphones on silent or vibrate mode before bed, and to consult with their physicians about “safer” herbal and dietary supplements such as MidNite or LUNA.

Wise asserts that cognitive behavioral therapy is the recommended initial intervention for insomnia in most residents. It consists of several modalities and addresses behaviors that are counterproductive to decent sleep.
—John Hall

Mistakes to avoid

1. Treating sleep medications as long-term solutions. Experts all agree drug therapy should be kept to a minimum.

2. Ignoring safer, non-pharmacological approaches.

3. Forgetting to carefully monitor residents on sleep medication therapy, and intervene if necessary. Things can get out of control quickly.