Millions of older Americans suffering from insomnia regularly use prescription sleep medications, despite the risk of serious side effects—such as falls, broken bones, cognitive impairment and dependence—and warnings from leading medical societies against their use.
A new study from the USC Schaeffer Center for Health Policy & Economics finds that reducing prescriptions of sleep medication in older adults could provide substantial health and economic benefits.
Avoiding use of these medications among older adults would reduce lifetime incidence of falls by 8.5% and cognitive impairment by 2.1%, researchers found. It would also increase life expectancy by 1.3 months, which translates to 1.7 million life-years gained across the population—most of which would be spent in good health.
"Our results show reducing use of sleep medications could help older adults live healthier lives with fewer limitations," said lead author Hanke Heun-Johnson , a research scientist at the Schaeffer Center.
The study appears in the December issue of The Lancet Regional Health - Americas.
Improved Quality of Life
An estimated 15.3 million American adults ages 50 and older take prescribed sleep medications, including benzodiazepines and "Z-drugs" such as Ambien. Use of these medications tends to increase with age and is more common among women and white adults.
While medical guidelines discourage long-term use, doctors often prescribe these drugs long-term. For some patients, the primary benefit becomes the avoidance of withdrawal, which in a clinical setting is easily misconstrued as ongoing effectiveness.
Insomnia itself carries serious risks for older adults, including depression, heart disease and cognitive decline. But while many people take sleep medications hoping to improve their quality of life, long-term use appears to do more harm than good.
For the new study, researchers leveraged a dynamic microsimulation model developed at the Schaeffer Center, the Future Elderly Model , to project the impacts of sleep medication use in older adults. They compared current use of the drugs with a scenario in which no one uses them, examining various outcomes such as cognitive decline, fall risk, nursing home use, medical costs and lifetime earnings.
People ages 65 to 74 saw the largest potential benefit in cognitive function and physical health from avoiding these drugs, suggesting that efforts to reduce prescribing should focus on this age group.
In addition to the health benefits of avoiding these drugs, researchers found it would mean lifetime savings of $6,600 per person, or about $101 billion across the United States. Most of the savings come from improvements in quality of life.
Encouraging Safer Prescribing Practices
Professional organizations such as the American Academy of Sleep Medicine recommend cognitive behavioral therapy for insomnia (CBT-I), rather than sleep medication, as a first-line treatment. The treatment is structured to help people adopt better sleeping habits and can be delivered in-person, virtually or through an app (for example, the Department of Veterans Affairs' CBT-I Coach). CBT-I is just as effective as sleep medication in the short term and is more effective in the long run, without the side effects.
Previous Schaeffer Center research identified practical interventions to reduce inappropriate prescribing of antibiotics, opioids and other medications. Researchers said some of these methods could likely be used to reduce prescriptions of sleep medications and steer physicians toward recommending safer options.
For example, it's possible that electronic health record systems could prompt physicians to justify prescriptions for older patients and provide information about cognitive behavioral therapy. Physicians could also receive periodic reports comparing their prescribing patterns with those of their peers.
"Insomnia is a serious issue for many older adults, but regular use of sleep medication can pose real risks. Supporting physicians in reducing prescriptions and promoting safer, proven alternatives will ultimately benefit patients and society," said co-author Jason Doctor , a senior scholar at the Schaeffer Center and the Norman Topping Medical Enterprise Chair in Medicine at the USC Price School of Public Policy.
About the Study
Other co-authors are Johanna Thunell, Jonathan Cloughesy and Bryan Tysinger of the USC Schaeffer Center; Jeffrey Linder and Stephen Persell of Northwestern University; and Mark Sullivan of the University of Washington.
The authors received support from the National Heart, Lung & Blood Institute (R01HL167023), and the USC-Yale Roybal Center for Behavioral Interventions in Aging (P30AG024968). The funding sources had no role in the design and conduct of the study; the collection, management, analysis, and interpretation of the data; the preparation, review, or approval of the manuscript; and the decision to submit the manuscript for publication.
