Hypnosedative use and predictors of successful withdrawal in new patients attending a falls clinic: a retrospective, cohort study.
BACKGROUND
Many older individuals suffer from difficulty initiating and maintaining sleep, and consequently use hypnosedative medication. The use of sleeping tablets, usually benzodiazepines (BZs) and the newer Z drugs such as zolpidem, is largely unnecessary and problematic since their efficacy is not maintained over an extended period of time and they increase the risk of falls. Withdrawing these medications is challenging because of their propensity for causing dependence and rebound insomnia.


OBJECTIVE
To describe the use of anxiolytic and hypnosedative medications by patients attending a falls clinic, determine the success of recommendations to cease or reduce use of these medications, and evaluate patient characteristics influencing the success of these recommendations.


METHODS
Patients with a first appointment at an Australian falls clinic between January 2006 and December 2008 were identified from letters written by the geriatrician or rehabilitation physician who ran the clinic. Patients who were taking a BZ/Z drug, had attended a follow-up appointment at least 2 months after their index appointment and had received a documented recommendation to alter their BZ/Z drug use at the index appointment were included in this study. The associations between compliance with the specialist physician's recommendation to alter the BZ/Z drug and BZ/Z drug dose, frequency and duration, patient's age, sex, residence, co-morbidities and number of regular medications were assessed. Inter-clinician variation in the proportion of patients receiving a follow-up appointment, recording of BZ/Z drug use and the proportion of patients given a recommendation to alter BZ/Z drug use were also analysed in the broader population of all patients receiving a first appointment at the falls clinic in the study period.


RESULTS
Data from 302 patient records revealed that 21.5% of patients were using a BZ/Z drug and 27.8% were using any drug for its hypnosedative properties. Over the 3-year study period there was a reduction in BZ use, which was countered by an increase in the use of zolpidem, so that the overall use of BZ/Z drugs did not change. Of those patients taking a BZ/Z drug, 48% (31/65) were followed up and had a documented recommendation to alter their BZ/Z drug use. At least 68% (21/31) of these patients were compliant at follow-up. Patients who were assessed by a geriatrician were more likely to be advised to alter their BZ use than those assessed by a rehabilitation specialist (p = 0.002). Patients were more likely to be compliant if they were given a recommendation to cease their BZ/Z drug compared with advice to reduce the dose or to gradually reduce the dose with the aim of cessation (p = 0.019). There were no sex- or age-specific differences in compliance. Patients who were successful in ceasing or reducing BZ/Z drug use showed nonsignificant trends toward having a reduced number of co-morbidities and regular medications, and lower frequency of use of BZ/Z drugs.


CONCLUSIONS
We observed a constant proportion of falls clinic patients taking BZs or Z drugs between 2006 and 2008. Specialist recommendation to cease or reduce dosage of these medications was associated with a high success rate.
Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia.
Jenna
J
Joester
Constance M
CM
Vogler
Kevin
K
Chang
Sarah N
SN
Hilmer
D000058:Accidental Falls; D000368:Aged; D000369:Aged, 80 and over; D014151:Anti-Anxiety Agents / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use; D001569:Benzodiazepines / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use; D015331:Cohort Studies; D005260:Female; D006801:Humans; D006993:Hypnotics and Sedatives / Q000008:administration & dosage* / Q000009:adverse effects / Q000627:therapeutic use*; D008297:Male; D008499:Medical Records; D055118:Medication Adherence; D010044:Outpatient Clinics, Hospital; D010353:Patient Education as Topic; D010818:Practice Patterns, Physicians'; D011725:Pyridines / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use; D012189:Retrospective Studies; D007319:Sleep Initiation and Maintenance Disorders / Q000188:drug therapy* / Q000517:prevention & control; D019966:Substance-Related Disorders / Q000517:prevention & control; D000077334:Zolpidem
D014151:Anti-Anxiety Agents; D006993:Hypnotics and Sedatives; D011725:Pyridines; D001569:Benzodiazepines; D000077334:Zolpidem