July 31, 2014
Author Paula Span has recently posted a series of articles to the New York Times.com blog commenting on the use of sleeping pills by American older adults. The most recent posting occurred July 30th. The ActualMeds clinical team posted an edited response on July 31st. Following is the complete version.
As Paula Span recently comments, many have been fretting for years about sedative-hypnotic use, especially in older adults. These medications have also been the target of geriatric-specialist pharmacists for many years in the nursing home setting and most recently since medication therapy management services have been required by Medicare for eligible patients covered by the Medicare Part D Prescription Drug Benefit.
We agree that for several reasons, the Z-drugs emerged as the ‘go to’ alternative to the benzodiazepines, but are they really the way to go? Ms. Span mentioned that in February 2013 the American Geriatric Society (AGS) put sedative hypnotics on their “Five Things Physicians and Patients Should Question,” and the FDA has required labelling changes to the Ambien dosage recommendations. The AGS had also included Ambien specifically in their 2012 American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults (J Am Geriatr Soc. 2012;60:616–631.).
The AGS Beers update also notes many other medications with similar side-effects for older adults that can make the effects of the sedative-hypnotics like Ambien even worse.
In February 2014, the AGS expanded their watch list to ‘Ten Things Physicians and Patients Should Question’. We note that #9 is “Don’t prescribe a medication without conducting a drug regimen review.” Drug Regimen Review (DRR) starts with determination of the patient’s current medication regimen (medication reconciliation), and works to identify high-risk medications and potentially inappropriate use of medications (like the sedative-hypnotics). In addition, capturing potentially harmful over-the-counter medications and supplements is an important part of the process. DRR has a host of other components and benefits (Gruber et al: The Consultant Pharmacist Nov 2010 VOL. 25. No. 11). In fact, an annual comprehensive medication review for older adults is a quality indicator set by CMS (the Centers for Medicare and Medicaid Services).
In reality, medication reconciliation and medication review have the most critical importance whenever the patient has a change in the setting of care. These ‘transitions of care’ are most often the time when medications can ‘fall through the cracks’. If we can better characterize an older adult’s medication use at home, at the doctor’s office and when they change care settings, we may be able to put a dent in those ‘one in five E.R. visits’ mentioned by Ms. Span. http://newoldage.blogs.nytimes.com/2014/07/30/more-on-sleeping-pills-and-the-elderly/?ref=health
Joseph Gruber, RPh, CGP, FASCP: Chief Clinical Officer, ActualMeds Corporation. Past President, American Society of Consultant Pharmacists. @jgactualmeds
PJ Neafsey, PhD (pharmacology): Co-founder and Principal Scientist, ActualMeds Corporation. Professor Emeritus, University of Connecticut School of Nursing. @PharmacoQueen