“And mostly they have a need for sleeping pills”: Physicians' views on treatment of sleep disorders with drugs in nursing homes
Highlights
► The interviewed physicians often showed a sweeping attitude towards hypnotics. ► Nursing home physicians believe hypnotics are the appropriate treatment. ► Risks and chances of sleep medication are seldom sophisticatedly balanced. ► Addiction to medication is considered an insignificant risk. ► Alternatives to drugs for sleep disorders are considered only exceptionally.
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.
Section snippets
Sleep disorders in long-term care facilities: structural framing
Old people and residents in long-term care facilities frequently exhibit a characteristic specific sleep–wake pattern: they sleep repeatedly for short periods in daytime, and they wake up time again and time again at night, having problems falling and staying asleep. Night-time sleep interruptions and frequent daytime sleep are related (Martin & Ancoli-Israel, 2008). Although sleep disorders can be caused by a variety of factors like physical or mental diseases, medication or particular
Doctor–patient relations and the multi-functionality of prescriptions
Medical doctors and nurses are the health professionals to whom German nursing home residents relate most, despite the fact that medical care and treatment are extremely fragmentary, if not inadequate (Hallauer, Bienstein, Lehr, & Rönsch, 2005). The impact of a trusting doctor–patient relationship must be interpreted as a way to satisfy patients' psycho-social needs. This meaning has been discussed in numerous publications, particularly in connection with the possibility of improving older
Physicians' views on treating sleep disorders in nursing homes
Studies addressing the specifics of sleeping disorders of nursing home residents (see Martin and Ancoli-Israel, 2008, Neikrug and Ancoli-Israel, 2010) are available as well as studies focusing on the functionality of medication beyond strict medical indications (see Cohen et al., 2001, Weiss and Fitzpatrick, 1997). Hardly any studies, however, have addressed the multilayered meaning of drug prescription in terms of the relationship between physicians and nursing home residents suffering from
Sampling procedure and interviews
The study focused on physicians who are formally responsible for care of residents in nursing homes (NHs) on the basis of a special agreement between regional healthcare funding bodies and a consortium of nursing home providers. We interviewed two groups of physicians: doctors who were directly employed by nursing home providers and thus part of the regular staff of the NHs (1), and general practitioners, who were “private entrepreneurs” and contracted by particular nursing homes for standby
Collection and analysis of the data
Data were collected in episodic interviews (Flick, 2009). Episodic interviews were based on an interview schedule and usually addressed two different forms of knowledge. (1) Semantic knowledge includes abstract and generalized concepts and their relations. To address this kind of knowledge, episodic interviews included targeted questions (e.g. about the need to treat sleep disorders). (2) Episodic knowledge refers to concrete situations and events and thus is closer to experiences. It was
Physicians' interpretative patterns regarding medical treatment of sleep disorders
In what follows, we will present the attitudes of the doctors1 we interviewed about the medical treatment of sleep disorders, and consider in particular how they perceive the risk of addiction to hypnotics and the consequences they identify? Three interpretative patterns could be identified as follows.
Links and distinctions between the interpretative patterns: a continuum on three levels
Analysis of our interviews allowed us to identify three interpretative patterns:
- 1.
By request
- 2.
Ambivalence
- 3.
Reflected prescription
These interpretive patterns represent a continuum on three levels:
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what justifications are given for prescribing hypnotics?
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how far are the costs and benefits of sleep medication balanced against each other in a sophisticated way?
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what consequences result from this balancing?
Patterns 1 and 3 are in maximal contrast, whereas pattern 2 is in the middle of the two poles but has
Discussion
Our article deals with attitudes and opinions of nursing home physicians and GPs who are responsible for the treatment of nursing home residents with and without sleeping disorders. The picture drawn is based on attitudes and opinions but does not reflect the actual practices of physicians when prescribing hypnotic and sedative medication. Rather, a weighting of pros and cons creates the structure of “patterns” in which either the pro or the con prevails. The actual prescribing behavior was
Conclusion
The use of hypnotics and sedative medication in the context of treatment of nursing home residents suffering from sleep disorders fulfills a variety of functions. The relief of symptoms and discomfort is one, but not always the most important, factor influencing doctors' decision-making with regard to drug treatment. When we analyzed the opinions and attitudes of nursing home physicians and of GPs in attendance, we identified three different interpretative patterns. The first and the most
Competing interests
None declared.
Acknowledgment
We want to thank the doctors who participated in this study for their candor and interest. The project was funded by the German Federal Ministry of Education and Research, grant #01 ET 0707.
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