Hypnotics prescription in a population of hospitalised patients in four psychogeriatric units in Switzerland 

Benzodiazepines and z-drugs, hypnotic medications also known as benzodiazepine-receptor agonists (BZRA), are widely prescribed among older people as a treatment for insomnia symptoms, despite recommendations advising against their use for this indication, especially among older adults. Older people have a higher risk of adverse effects from BZRA (falls, fractures, addiction, cognitive impairment and overall mortality). Moreover, people suffering from dementia are at highest risk of these adverse effects. For all these reasons, inappropriate prescription of BZRA in the general population, and especially among the elderly, can be considered a public health threat.  

The first-line treatment for insomnia disorder is cognitive behavioural therapy for insomnia (CBT-I), but specific guidelines on how to manage acute insomnia symptoms do not exist. Furthermore, cognitive and behavioural strategies are generally not implemented in psychiatric facilities.  

 Few studies focus on prescribing patterns of BZRA among hospitalised patients, although new prescriptions during and after the hospitalisations are very frequent, and often lead to chronic use of these medications. Insomnia symptoms are very common in the general population, but this prevalence is even higher among hospitalised patients, and about 40% of Swiss inpatients receive at least one sleep-inducing drug during their hospitalisation. The use of these drugs among patients with psychiatric comorbidities is much higher than that of the general population, and about 90% of psychiatric inpatients report insomnia symptoms during hospitalisations. To the best of our knowledge, there were no studies describing the patterns of BZRA prescription among older patients hospitalised in psychiatry, even though because of their age and their psychiatric comorbidities (including dementia), they are more likely to receive these drugs and to suffer from their adverse effects.  

 For this reason, we conducted a retrospective study including patients aged 65 or more hospitalised in four psychogeriatric units in Switzerland. Our study showed a high prevalence of BZRA prescription at admission, which decreased at discharge both in absolute (from 33.4% to 22.5%) and in relative terms (78% relative reduction in standardised dose of BZRA), with longer hospitalisations being associated with a higher reduction of BZRA prescription. A diagnosis of substance abuse was found to be a risk factor for BZRA prescription at admission, while age and being hospitalised in the dementology unit were found to be protective factors.  

 Prescription of BZRA in our population was high, and probably not in line with current guidelines recommending CBT-I as a first-line treatment for insomnia disorder. Non-pharmacological strategies, including behavioural treatment, should be further developed in this specific population for patients, their carers and the health teams.