Louise Organista is an Advanced Clinical Pharmacist in the Frail Elderly Assessment team at the University Hospitals of Derby and Burton NHS Foundation Trust. She is a co-chair of the BGS Pharmacy Professionals Group, an Honorary Associate Professor at the University of Nottingham and a Trustee of the British Society of Pharmacy Sleep Services (BSPSS). Louise posts on X via @Louise1401.
Earlier this year, "Ending Overprescribing for Insomnia: A Summit for Change" was held at the House of Commons. The meeting discussed the issue of overprescribing medicines for the management of insomnia, the potential harms to patients (including older people) of continued prescribing and how these matters can be overcome.
The topic has since gained media traction, with The Telegraph sharing the powerful story of Lynne, a patient with lived experience of insomnia. Her narrative clearly illustrates the overprescribing issue at hand: hypnotics prescribing actually increased last year with more than 8 million prescriptions written for more than 1 million unique individuals.
Meanwhile, the 10 Year Health Plan for health in England includes a potentially significant change about funding for non-drug treatments recommended by NICE: "Just like the NHS provides access to the best, most cost-effective medicines, it will provide universal access to the best digital tools and health apps, free at the point of need". This could include a digital CBT for insomnia (CBTi) app to provide non-drug management for insomnia: what NICE recommends as first-line treatment.
I am pleased to share the recently published report from the Summit, which provides clear recommendations for key stakeholders in Government and the NHS to take forward.
Here, I have summarised key points and provided some key tips that may be helpful for those providing care for older people who struggle with sleep.
Understanding the problem
- Insomnia affects 6–10% of adults (4–6 million people in the UK), disproportionately older people and women. It significantly raises the risk of depression, anxiety, cardiovascular disease, diabetes, and falls.
- Overprescribing is widespread: over 8 million prescriptions for hypnotics are issued every year. Of these, 5 million are for z-drugs like zopiclone despite clear risks and guidelines warning against long-term use.
- There is a high risk of harm in older adults: hypnotics increase the likelihood of falls (and ensuing fractures), cognitive impairment and confusion, dependence and withdrawal effects on discontinuation as well as possible adverse psychiatric and neurological effects.
- NICE recommends hypnotics for no longer than 7 days, yet about 50% of patients stay on them for over a year.
- Older adults are more likely to be prescribed off-label insomnia treatments (e.g., amitriptyline, promethazine) which add to the anticholinergic burden and increase the risk of harm.
- Cognitive Behavioural Therapy for Insomnia (CBTi) is the first-line treatment recommended by NICE: it is the most effective and safest option, yet access is severely limited in England.
Systemic and educational improvements needed
Sleep education
Most medical and nursing curricula offer less than 90 minutes of sleep-related education. More interdisciplinary training on insomnia management is needed. Could this be something you develop in your area within your MDT?
Clinical guidelines
We need access to clear toolkits for safe prescribing and deprescribing, especially regarding older people and off-label use. Have a look at your local guidelines - are they appropriate and up to date? Could OpenPrescribing datasets be used to give more granularity on prescribing in at-risk patient demographics, to enable targeted approaches to improve care quality?
Awareness raising
You can help to raise awareness about the benefits of digital CBTi, advocate for the NHS to adopt NICE-approved digital treatments that deliver CBTi and support the call for national funding of such therapies. Please join us at the BGS Autumn Meeting in Nottingham to hear more about innovative technology and about the management of insomnia in the older patient.
Practical steps for managing insomnia in older patients
Medication review
Is your patient taking any drugs which promote wakefulness or disrupt sleep in the evening? These could be medications such as SSRIs (e.g. sertraline), oral steroids, decongestants, diuretics or beta-blockers. Is your patient on sedating drugs during the day which are causing excessive napping and therefore reducing their homeostatic sleep drive?
It is important to evaluate all medicines in the context of frailty, falls risk, and comorbidities. Consider the cumulative effect of polypharmacy and anticholinergic burden (ACB). Ask about over the counter (OTC) meds too - often people try to self-medicate which sedating antihistamines which have a high ACB.
Is there anything else which is affecting sleep?
Screen for sleep apnoea and restless legs syndrome, low mood or anxiety, manage unmet pain requirements (can timings of analgesia be amended to support quality nightly rest?) and address incontinence.
Non-drug management
Sleep hygiene advice should always be provided. Ask the patient about their daily routine - it will provide key insights to help tailor advice e.g. increasing morning daylight exposure, leaving the bedroom during the day (and keeping the bed for sleep and intimacy only), reducing caffeine and alcohol intake (or cut out if possible), increasing movement and social stimuli. The Sleep Charity can provide information to patients and HCPs. It has a free National Sleep Helpline for patients to seek advice from a trained sleep advisor. Sleep diaries can be useful to review and help implement principles of CBT for insomnia.
Discuss deprescribing early
If hypnotics are needed to manage sleep due to a short-term stressor, include a clear plan for review and cessation at the point of initiation. Shared decision-making and regular reviews are important to prevent ongoing prescribing and potential tolerance and dependence on medicines.
