Sleep disruption or insomnia is a debilitating problem for 30 per cent of the population. In hospitals, insomnia can seriously disrupt operations, which is why patients are being prescribed sedation medications to help them get a good night’s sleep. However, night medications can lead to falls, fractures, confusion, and delirium, and in many cases, it can lead to dependency and withdrawal symptoms within 2–4 weeks of use.
NSW Therapeutic Advisory Group’s Executive Officer, Dr Sasha Bennett, recently developed person-centred guidance around optimising sleep in hospitals. In her Giant Steps 22 presentation, Dr Bennett said hospital initiation was a powerful driver for the ongoing prescribing and use of night sedation medications.
“In combination with other respiratory depressants such as opioids, these night sedation medicines can increase the risk of overdose deaths, multiplied by ten. Ongoing sedative use can delay discharge, result in unplanned re-hospitalisations, lead to increase costs of care and ultimately death,” she said.
The older the user, the higher the dose, the longer the use. Taken in combination with other medicines prescribed for pre-existing conditions and mixed with alcohol, a patient is far more likely to suffer harmful effects, including heart failure.
Dr Bennett told the conference, that night sedatives don’t work very well either. She said, “Patients might go to sleep 8–20 minutes sooner and they might increase sleep duration slightly (35 minutes), but it is non-refreshing sleep." In fact, night sedation medicines such as benzodiazepines and Z-drugs improve sleep quality in one in 13 patients, while adverse effects occur in one in 6 patients.”
Dr Bennet canvassed other sedation medicines, including melatonin, and identified:
- poor evidence-base in hospitalised patients
- inappropriate formulations for inducing sleep
- minor short-lived side effects
- expensive with widespread use.
She also discussed antipsychotics, antidepressants and antihistamines and found:
- lack high-quality evidence for effectiveness
- high risk of adverse effects
- off-label use.
Dr Bennett said, “It’s better to target the causes of insomnia, whenever possible, in consultation with patients and their families. Medical teams should discuss sleep hygiene principles with patients and their carers at every opportunity and communicate the limited effect and significant harm of night sedation medicines. If a clinician wants to prescribe a sedative, they ought to obtain informed consent first and prescribe only for an agreed limited period.”
Listing long-term challenges, Dr Bennett says there are no national or state policies or guidance, especially for in-hospital use. She said there are no existing hospital programs addressing sleep in treatment-naïve or non-naïve patients. Junior medical officers are the most frequent prescribers of sedation medication, often after hours to unknown patients. Medication review processes are immature and no written information is available for patients and their families before or at admission.
Poor transition of care processes are another longstanding challenge but there are solutions. Dr Bennett said targeting prevention of sleep disturbance as part of a hospital’s duty of care and safety culture is essential.
- Build an environment and workflow conducive to sleep at night.
- Enlist executive support to make optimisation of patients’ sleep in hospital a priority and fund the resourcing required for implementation and maintenance.
- Apply evidence-based practical resources.
- Enlist clinical champions for sleep and initiate local/multisite quality improvement studies.
- Proactively inform patients and family whenever possible and provide tips for sleeping in hospital, e.g. pre-admission clinics, ensure information is provided at admission and shared decision making is practiced.
- Monitoring patient reported sleep experience and outcome measures.
The NSW Therapeutic Advisory Group has developed a Patient Information Booklet that is freely available as well as other helpful resources and implementation tools, including a poster and sleep checklist.
“Health services need a vision,” Dr Bennett said. “A hospital environment and culture that promotes patients’ sleep at night and causes no harm from use of inappropriate sleep medicines.” She said the priority project will need strong leadership and the involvement of colleagues at multiple levels. Communication is key and teams need to identify barriers and enablers. Proper resourcing is required including a project officer, training programs, environment and workflow redesign, and extra equipment. Dr Bennett recommends considering local logistics such as a pilot ward with a roll out to other wards.
Dr Bennett concluded her presentation with a call to action to make hospital environments more conducive to sleep at night, reduce the use of inappropriate potentially harmful night sedation medicines in hospital, and implement non-drug strategies for optimising sleep.