THE RISK OF POLYPHARMACY IN TREATING INSOMNIA S. Golboo, T. Gurvich, L. Gibbs, S. Sehgal. Family Medicine, University of California, Irvine, Orange, CA, United States.
Definition Case Non Pharmacological Pharmacological
The use of unnecessary medications which is A 71-year-old male came to a Geriatric Medicine clinic to Create a stable sleep pattern Benzodiazepines (Beers list) independent of the number of medications being establish care and discuss ongoing issues with sleep difficulty. Non-disruptive sleep environment Z Drugs (Beers list) taken. He reported insomnia, present for at least 5 years, for which he Reduce pre-sleep tension Melatonin (1mg-10mg ) had seen multiple providers of various specialties. Dietary and Lifestyle Modification: Antidepressants: Background and Significance Avoid alcohol Trazadone ( 25mg-150mg ) On presentation to clinic, patient was taking the following Avoid or minimize caffeine Mirtazapine ( 7.5mg ) medications all used to induce and maintain sleep: ramelteon, • Polypharmacy is a growing concern for older temazepam, amitriptyline, quetiapine, hydrocortisone, Americans. Evidence of Polypharmacy Sleep changes in elderly anastrozole, progesterone, tryptophan, melatonin (30mg), and Stage I: Takes longer to fall asleep DHEA. He also reported seeing a naturopathic provider who •No apparent indication • Polypharmacy impacts almost 50% of older adults. was prescribing additional supplements- the active ingredients •Duplicative medications Stage 2: Impaired, easily awakened of which were unknown. In addition, he would consume large • Stage 3 and 4: Shorter Americans spend $3 billion annually on prescription quantities of alcohol nightly to aid with sleep. •Use of interacting drugs medications. •Contraindicated drugs REM: Shorter After evaluation by a geriatrician and clinical geriatric • Most take an average of 3-5 RX and 3-4 OTC pharmacist consultant the patient was advised to taper off and •Inappropriate doses medications. discontinue ramelteon, temazepam, amitriptyline, melatonin •Adverse drug reactions and quetiapine. An endocrine evaluation was completed and •Prescribing cascade • Specific interventions designed to reduce numbers of found no hormonal abnormality. He as advised to discontinue prescribed and over the counter medications have hydrocortisone, anastrozole, testosterone, progesterone and been shown to improve and prevent negative DHEA. Patient was counselled extensively on sleep hygiene Conclusion consequences in all care settings. practices. •Inappropriate and unnecessary use of medications with potentially adverse effects to treat insomnia. At a subsequent primary care visit the patient was taking only •Medications without FDA approval for the treatment of insomnia. •This case highlights the use of multiple medications to quetiapine. He reported insomnia had significantly improved. treat insomnia and the potential for adverse health Alcohol use had diminished, but was still an issue. He was •Most cases of insomnia can be improved by discussing sleep hygiene. outcomes advised to follow up with a psychiatrist for evaluation of •Treatment should be targeted with minimum numbers of medicines at quetiapine and resources were given for alcohol cessation. the lowest effective doses to prevent adverse effects.
Medication Related Problems Contributing Factors References • Multiple disease states • Time constraints during a visit •Glass J, et al. BMJ. 2005;331(7526):1169. •Journal of American Geriatric Society, 2012 Archives of • Multiple chronic conditions • Multiple providers Internal Medicine. • Altered response to medications • Lack of communication among providers •Nabil S. Kamel, MD, Julie K. Gammack MD, Insomnia in the Elderly: Cause, Approach, and Treatment, The American • Drug-drug interactions • Use of nonprescription medications and herbs Journal of Medicine, (2006) 119, 463-469. • Adverse drug reactions • Patient driven prescribing