Deprescribing benzodiazepine receptor agonists for insomnia in older adults

The Series paper on insomnia by Michael Perlis and colleagues1Perlis ML Posner D Riemann D Bastien CH Teel J Thase M Insomnia.Lancet. 2022; 400: 1047-1060Summary Full Text Full Text PDF PubMed Scopus (54) Google Scholar summarises evidence on the diagnosis and management of insomnia, but overlooks important considerations on the management of insomnia in older adults. Although the authors highlight that evidence on the efficacy of pharmacological approaches in older people, including benzodiazepine receptor agonists (BZRAs), is of low quality, they also emphasise that BZRAs are an appropriate option when cognitive behavioural therapy for insomnia is not effective or available. This statement should be reconsidered when it comes to older adults. First, the use of BZRAs is associated with major risks not mentioned by the authors, such as falls, fractures, delirium, impaired functioning, hospitalisations, and mortality,2Chatterjee D Iliffe S Kharicha K et al.Health risk appraisal in older people 7: long-acting benzodiazepine use in community-dwelling older adults in London: is it related to physical or psychological factors?.Prim Health Care Res Dev. 2017; 18: 253-260Crossref Scopus (6) Google Scholar burdening both patients and society.3Panneman MJ Goettsch WG Kramarz P Herings RM The costs of benzodiazepine-associated hospital-treated fall injuries in the EU: a Pharmo study.Drugs Aging. 2003; 20: 833-839Crossref PubMed Scopus (71) Google Scholar Second, international groups have made strong recommendations against the use of BZRAs in older adults, or recommendations to use them only short term (typically up to 4 weeks for the treatment of insomnia). Yet, BZRA overuse is one of the most prevalent and harmful overuse practices in older adults.4OECDHealth at a Glance 2019: OECD Indicators. OECD Publishers, Paris2019Crossref Google Scholar Deprescribing guidelines recommend to consider deprescribing in older adults taking a BZRA for insomnia.5Pottie K Thompson W Davies S et al.Deprescribing benzodiazepine receptor agonists: evidence-based clinical practice guideline.Can Fam Physician. 2018; 64: 339-351PubMed Google Scholar Such recommendations should ideally be integrated into the guidelines on the management of insomnia. Better addressing patients’ and health-care professionals’ barriers to BZRA deprescribing is also essential.6Evrard P Petein C Beuscart JB Spinewine A Barriers and enablers for deprescribing benzodiazepine receptor agonists in older adults: a systematic review of qualitative and quantitative studies using the theoretical domains framework.Implement Sci. 2022; 17: 41Crossref Scopus (16) Google Scholar Beyond the authors’ call for further research on new therapeutic approaches, we need further research on the effectiveness of theory-driven implementation approaches and a cultural change that promotes de-implementing potentially harmful strategies into the routine management of insomnia for older people. We declare no competing interests. The authors of this Correspondence are all partners of the Implementing a patient-centred and evidence-based intervention to reduce BEnzodiazepine and sedative-hypnotic use to improve patient SAFEty and quality of care (BE-SAFE) project, funded by the EU (Horizon Europe research and innovation programme, grant agreement 101057123) and by the Swiss State Secretariat for Education, Research and Innovation (SERI; contract number 22.00116). Views and opinions expressed are, however, those of the authors only and do not necessarily reflect those of the EU or SERI. Neither the EU nor SERI can be held responsible for them. The funders of the study had no role in writing this Correspondence. InsomniaInsomnia is highly prevalent in clinical practice, occurring in up to 50% of primary care patients. Insomnia can present independently or alongside other medical conditions or mental health disorders and is a risk factor for the development and exacerbation of these other disorders if not treated. In 2016, the American College of Physicians recommended that insomnia be specifically targeted for treatment. The recommended first-line treatment for insomnia, whether the underlying cause has been identified or not, is cognitive behavioural therapy for insomnia (CBT-I). Full-Text PDF