“And mostly they have a need for sleeping pills”: Physicians' views on treatment of sleep disorders with drugs in nursing homes

Abstract

The percentage of nursing home residents treated with hypnotic medications is high, as many authors report, despite the fact that such medications are almost always associated with undesirable effects for old people. This article takes a closer look at nursing home physicians' views of prescriptions when treating sleep disorders of nursing home residents. How do physicians characterize the treatment strategy for residents suffering from sleep disorders? How do they balance the benefits and risks of the hypnotic medication? Under what circumstances do they accept negative consequences? To answer these questions, N = 20 physicians (aged 36 to 68 years) in 16 nursing homes in a German city were interviewed. The physicians were either employed by nursing homes or worked on a contract basis. Comparative categorization of the data produced a typology across cases. Three interpretative patterns concerning the use of drugs for treating sleep disorders were identified — “by request,” “ambivalence,” and “reflected prescription.” Differences between them were determined by the significance of residents' wishes, neglect of risks, particularly that of addiction, and the attempt to balance benefits and disadvantages. The study showed deficits in professional management of sleep disorders in nursing homes.

Introduction

Sleep–wake disorders of any kind are very common in the aged population. They are especially prevalent in those in long-term care facilities (Makhlouf et al., 2007, Garms-Homolová et al., 2010). Sleep–wake disorders reduce the residents' quality of life and are believed to be a risk to health and to contribute to different diseases (e.g. depression or cardiovascular diseases). Many health problems and morbidities are accompanied by sleep–wake disorders (Krishnan & Hawranik, 2008).

Despite their negative influence on health, sleep disorders are often not sufficiently diagnosed and prematurely treated with hypnotics in clinical practice (Schwarz, Fröhlich, & Deuschle, 2010). Hypnotics – above all benzodiazepine and other sedatives – are among the drugs frequently prescribed for residents of nursing homes (Schwarz et al., 2010, p. 916). According to a study of nine European countries, 70% of the 1972 geriatric patients under study received psychotropic medication for different reasons (Petrovic, Spatharakis, Conroy, Van Maeles, & Moulias, 2006).

Regular consumption of sleeping pills and sedatives can lead to specific health risks in old age, such as locomotion and stability problems, falls, confusion, or depression. Furthermore, habitual consumption of psychotropic drugs increases the risk of addiction (Anthierens et al., 2007, Glass et al., 2005).

A meta-analysis (Glass et al., 2005) showed the limited benefits of psychoactive drugs for the aged as compared with younger people. Given the specific risks and the limited effect of sleeping medication, the question arises as to what makes doctors nevertheless prescribe hypnotics for the elderly? What do physicians expect and how do they evaluate the relevance of hypnotics in the context of everyday treatment of old people in long-term care settings? How do physicians evaluate the risk associated with hypnotic medication? These questions were pursued in a project which will be discussed later in this article. First, we will briefly review the literature about selected aspects of institutional routines in nursing homes which may account for residents' sleeping problems and provide the frame for their treatment. We will also discuss the relevance of the doctor–patient relation in old age and for the prescription of medication. In this context, we also raise the question of the various functionalities which the prescription of medication can have.