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Sedative use in older people is often highlighted as a problem. Some days
I feel that I have discussed this topic with everyone and done it to death
through several projects over the past 15+ years.
Yet the fact that it requires ongoing
input, discussion and review should not
be a surprise to any of us given that:
• many medicines have sedative
effects (e.g. opioids, neuropathic
pain medication, antihistamines,
antidepressants as well as
benzodiazepines and antipsychotics)
• many older people have
comorbidities and thus more likely to
take these medicines
• older people often have sleeping
problems and request a 'sleeping tablet'.
When undertaking medicine reviews
in either the home or aged care setting
I am often asked, 'What is the best
Patients who are taking sedatives e.g.
temazepam, will tell me they are, 'taking
a small dose of a mild sleeping tablet'
and then ask, 'is there anything better?'
Evidence tells us that sedatives do not
improve the quality of sleep but they do
cause falls. In addition benzodiazepines
have been associated with an increased
risk of developing dementia. Yet as a
society there is a general belief that
medicines have benefits and a sedative
will assist sleep. That they can cause falls
(or even harm) in usual doses can be
confronting and cognitive dissonance can
lead to resistance from patients who may
say: 'But I have taken it for years with no
problems'. I reply that the medicine hasn't
changed but as you age your memory
reserves, and resilience and ability to
recover balance, reduces. The risk of
disability from a fracture also increases.
Sleeping in aged care homes has the
added complexity of a communal living
environment which is not necessarily
conducive to sleep. It is not quite as
bad as a hospital environment but
sometimes worse than a roadside motel
room. In general, aged care homes have
minimal staffing overnight and evening
staff try to get residents to bed and
settled -- this can be quite early, starting
between 7--8 pm.
If residents go to sleep then, it is not
surprising that they may be complaining
of inability to sleep by 2--3 am as they
have already had seven hours sleep.
Sedative use in aged care homes is high.
The federally funded Reducing Use of
Sedatives (RedUSe) project audited
27 aged care homes across three states
and found more than 25% of residents
regularly take benzodiazepines.
Residents in aged care homes have
less contact with pharmacists and
thus less potential for education as
they no longer collect scripts from
ACCREDITED PHARMACIST SPECIAL
BY SUE EDWARDS
a community pharmacy. In addition,
the RMMR pharmacist is unlikely to talk
with a resident more than once a year
(often much less, if at all, with changes
to the business rules). The Team Aged
care project was undertaken in 10 aged
care homes across South Australia and
Victoria. During resident discussions
90% of residents said that they learnt
something new about sedatives from
the education sessions provided.
It is curious to me that patients and carers
do not seem to be aware of the potential
risks associated with sedative medication.
Is it that the CMI is not at the right level of
health literacy? Or is it simply self-denial?
As pharmacists, do we provide
information effectively about the
medicines at the right level in a manner
that fosters optimal health outcomes?
Or do we give too much irrelevant
information and focus too much on 'sleep
I use two excellent consumer resources
to discuss sedatives and their potential
harms with patients. These are:
• A sleep medication fact sheet
available by searching for Insomnia
Management Kit at www.sahealth.
• Benzodiazepines: Information for
residents, relatives and carers at:
These resources can also be of use when
discussing medicines with aged care
staff. The majority of staff in aged care
homes are 'care staff' -- not registered or
enrolled nurses and may have very little
knowledge about medicine effects even
if they are credentialed to administer
sedatives to residents.
Sometimes the answer to the 'What is
the safest sleeping tablet?' question for a
patient who really wants to take a medicine
at night to help sleep might be: 'Take
paracetamol at night which may help with
comfort and foster ability to sleep.'
Sue Edwards is an accredited pharmacist working with
Southern Adelaide Fleurieu and KI Medicare Local. She
is a Project Pharmacist for the RedUSE Project in South
Australia and DATIS Project manager TEAM Aged care.
She is also President of PSA South Australia.
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