By PAULA SPAN
July 2, 2014 2:11 pmJuly 2, 2014
“Deprescribe.” It’s a word I hadn’t encountered before, but Dr. Cara Tannenbaum, who holds an endowed chair in geriatric pharmacy at the University of Montreal, told me that “it’s been popping up with exponential frequency” in medical journals and conversations among geriatricians.
Along with campaigns to dissuade older patients from having so many screening tests (like mammograms, Pap smears and colonoscopies) and potentially harmful procedures, researchers now are trying to help them kick certain prescription drugs.
Specifically, Dr. Tannenbaum and her colleagues want older people to wean themselves from benzodiazepines, widely used for insomnia and anxiety. The brand names are familiar: Ativan, Ambien, Halcion, Klonopin, Lunesta, Sonata, Valium and Xanax. (Some, like Ambien and Lunesta, actually belong to a class of sister drugs but have the same effects on the brain.)
How widely are they used? “It varies between 8 and 35 percent of the population over 65, worldwide,” Dr. Tannenbaum said. One study found that after the introduction of Medicare Part D, which doesn’t cover benzodiazepines (nor do some state Medicaid programs), use in nursing homes dropped sharply in the United States, but 17 percent of residents still took them. A third of older adults in Quebec take sleeping pills, too, Dr. Tannenbaum added. Dependency is not just an American problem.
But it is a problem — especially given older users’ changing metabolisms and the likelihood that they’re taking many other drugs. “People taking sleeping pills are five times more likely to report problems with concentration and memory,” Dr. Tannenbaum said. “Twice as likely to have a hip fracture. Twice as likely to have a car accident the next day if they’re driving.” They also experience more incontinence.
If the risks of sedative-hypnotics are well established, why do so many older people keep taking them? “They’re psychologically addictive,” Dr. Tannenbaum said. “People believe they can’t function without them.”
They may have unrealistic ideas about how much sleep older adults actually need — most 80-year-olds will do fine with six hours a night — or how much sedatives can help. “Unfortunately, it’s normal for older people to wake up a couple of times a night,” Dr. Tannenbaum said. “But they don’t like it.”
She has worked in an emergency room and seen older patients come in with fractures from nighttime falls. “That’s a bad time to say, ‘Maybe you shouldn’t be taking a sleeping pill,’” she said.
Instead, she and her colleagues devised, in “medspeak,” a “deprescribing patient empowerment intervention” – a brochure – to help older users detox.
Through a pharmacy chain in metropolitan Montreal, the researchers identified 303 long-term users, aged 65 to 95, who agreed to be contacted and to share their health records. Half received the eight-page brochure in the mail; the other half didn’t see it until after the study ended, six months later. All took at least five prescription drugs, so neither pharmacists nor patients knew sleeping pills were the focus.
The brochure, customized to refer to the actual drug a patient was taking, was cannily designed to employ many of the same strategies used in direct-to-consumer advertising. It begins, for instance, with a true/false quiz. (Sample question: “Ambien is a mild tranquilizer that is safe when taken for long periods of time.”)
“It’s intended to elicit cognitive dissonance,” Dr. Tannenbaum said. “If you turn the page and see that no, you’re wrong, it creates a kind of anxiety: What do I do about this situation?” (For the record, benzodiazepines are recommended for insomnia in older patients only in very rare cases.)
The booklet also includes a narrative from a 65-year-old woman — actually a composite of several of Dr. Tannenbaum’s patients — and alternative ways to improve sleep or handle anxiety. A chart shows how to gradually stop using the drug.
“You have to be weaned off the pills over 12 to 20 weeks, so your blood levels go down slowly,” she said. “We tell patients, you’ll have a few nights where you have trouble sleeping, so just plan your activities accordingly. Eventually, your body will catch up.”
How did these older patients fare? Among those who received the brochure, 27 percent had discontinued the drug by the six-month follow-up, pharmacy records showed, compared to 5 percent of the control group. Another 11 percent of brochure recipients had reduced their doses.
“Just from reading a brochure, one in four patients got off a medication they’d been taking for, in some cases, 10 to 30 years,” Dr. Tannenbaum said.
If older relatives are taking sleeping pills — and sometimes people don’t realize they are — reading about the risks and following the day-by-day reduction plan might help them quit. You can download the brochure here.
“I’m amazed at how receptive older people are when you explain the evidence,” Dr. Tannenbaum said. “They’re thirsty for this information.”
Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”