New research identifies the dangers of Z-drugs for dementia patients

Strong sleeping pills known as ‘Z-drugs’ (zopiclone, zaleplon, and zolpidem) are often prescribed to people with dementia for sleep disturbance. But a new study highlighting the dangers of Z-drugs for dementia patients reveals that stronger doses of these drugs are linked with an increased risk of adverse effects including falls, fractures, and stroke.

Around 60% of people living with dementia are affected by sleep disturbance including insomnia, fragmented night-time sleep, night-time wandering, or excessive day sleep all of which affect the quality of life of the patient and their informal carers. These problems can often accelerate the need for care home admission.

The study, which was led by the University of East Anglia (UEA) in collaboration with researchers from The Quadram Institute, Aston University, University College London, and the University of Exeter, used data from 27,090 patients diagnosed with dementia between January 2000 and March 2016.

STUDY CONCLUSIONS

Higher dose Z-drug use in dementia is associated with increased fracture and stroke risks, similar or greater to that for higher dose benzodiazepines. Higher dose Z-drugs should be avoided, if possible, in people living with dementia, and non-pharmacological alternatives preferentially considered. Prescriptions for higher dose Z-drugs in dementia should be regularly reviewed.

The team say that patients already taking higher doses of Z-drugs should not stop taking their medication suddenly, however they should seek a review with their GP.

Prof Chris Fox, from UEA’s Norwich Medical School, said:

“We studied a range of adverse outcomes including fractures, falls, deep vein thrombosis, stroke and death – over two years. And we were particularly interested to see whether higher doses led to worse outcomes.

For patients prescribed Z-drugs, 17 per cent were given higher doses. And we found that these patients on higher doses were more at risk of falls and fractures, particularly hip fractures, and stroke – compared with patients who were not taking any medication for sleep disturbance.”

Higher dose Z-drugs and benzodiazepines were defined as prescriptions equivalent to ≥7.5mg zopiclone or >5mg diazepam daily. Those on lower doses, however (≤3.75mg zopiclone or equivalent) were not found to have an increased risk of adverse outcomes.

And there were no differences in adverse events for Z-drugs compared to benzodiazepines, except lower mortality rates with Z-drugs.

Prof Clive Ballard, of the University of Exeter Medical School, who collaborated on the study, said:

 “Our findings serve an important caution regarding the harms of sleeping tablets in people with dementia.

This research is a very timely and unfortunately necessary reminder that sedative medications are not a helpful way to manage social isolation during Covid-19.

Our study also highlights the importance of research to develop non-drug approaches to help people with dementia to sleep – whether they are at home or in residential care.”

Dr Ian Maidment, Reader in Clinical Pharmacy at Aston University, and lead pharmacist on the study said:

 “Z-drugs are widely used to treat insomnia in people living with dementia, but are only recommended as a short-term treatment for the maximum of four weeks. Our work shows the importance of clinicians including GPs and pharmacists reviewing patients on long-term Z-drugs.”

The full report is published in BMC Medicine

Editor’s comments: yet another instance of the over-prescribing of drugs in the NHS

Evidencing the dangers of Z-drugs for dementia patients is a very important piece of research.  We certainly hope steps are taken as soon as possible to ensure that GPs are advised to carefully consider what drugs and at what dosage they prescribe for dementia patients with sleep issues.

However, sadly, this is just another instance of the NHS over-prescribing drugs that cause more harmful side effects than benefits; just another instance of the NHS failing to investigate non-pharmacological alternatives that may be far more suitable for numerous patients with varying health issues; just another instance of huge sums of money being spent inappropriately on medications.

Let’s look at just a few examples

Antibiotics

For many years, there has been global awareness that the overuse of antibiotics creates two major issues:

1. Overuse which is creating resistance
2. Overuse which is destroying good bacteria and compromising our immune systems

In February 2018, Public Health England (PHE) announced ambitious targets to cut GP antibiotic prescribing dramatically by 2020. Research at that point indicated that one in five GP antibiotic prescriptions is inappropriate.

I wonder how successful that campaign has been to date?

STOMP

STOMP is a medication-related project launched by NHS England in December 2018 for people with a learning disability and/or autism. STOMP stands for: Stopping Over-medication of people with a learning disability, autism or both and it aims to improve people’s quality of life through appropriate use of medication and other ways of supporting vulnerable people.

In the past, doctors have used powerful medication to “manage” behavioural issues despite there being little evidence to show that they work. Some of these medicines are used for serious mental illness and can cause a huge range of side effects such as sedation, weight gain, dizziness, and stiff limbs.

STOMP also aims to improve awareness of non-drug therapies and practical ways of supporting people whose behaviour is seen as challenging.

ANTIDEPRESSANTS

In the UK, warnings were issued to GPs in 2004 against using certain antidepressants in children because of increased risks of suicidal tendencies and increased aggressive behaviour, but studies continue to show that antidepressants are still routinely prescribed for young people.

But the problem does not just relate to young people. In 2019, research also published by the UEA showed that antidepressant prescriptions have doubled for the over 65s in the last twenty years even though the number who identify as depressed has remained static

THE OPIOID CRISIS

This year, NICE (National Institute for Health and Clinical Excellence) published a draft guideline for consultation for the assessment and management of chronic pain in the over 16s in an attempt to overt the growing opioid crisis in the UK.

The guideline is emphatic in its recommendation that certain pharmaceuticals should not be prescribed to managed chronic primary, with opioids at the top of the list.

The report has been particularly welcomed by drug addiction treatment experts such as UKAT. Managing Director, Eytan Alexander says:

“Finally, it is written in black and white the dangers and addictive nature that prescribing opioids and other ‘pain relief’ drugs can have on patients”

“Prescription drug addiction is as real as a Heroin addiction, but in this case, the addict gets their drugs from their GP rather than a dealer, to ‘treat’ their pain.

OUR NHS Illness Service

Much has happened since we published our article in October 2018: NHS – The National Illness Service including, of course, the COVID-19 pandemic where the NHS has admirably stepped up to the challenge. However, there are many problems still to be addressed.

Matt Hancock, Secretary of State for Health and Social Care, triggered a row in late 2018 by calling for people to take more responsibility for their health and wellbeing by making healthier lifestyle choices. And, when discussing how an additional £20bn windfall would be spent by the NHS, said:

“In the UK, we are spending £97bn of public money on treating disease and only £8bn preventing it across the UK. You don’t have to be an economist to see those numbers don’t stack up.”

Since then, we are delighted to see that social prescribing link workers are now attached to most GP surgeries to help signpost patients to beneficial non-medical interventions. Similarly, there are now Clinical Pharmacists attached to most GP practices. Clinical Pharmacists will be able to help patients with complex needs get the best from their medication by reducing, when possible, the different types of medications prescribed: research shows that patients taking five or more different medications have a 50% chance of an adverse drug interaction. This will also reduce waste and therefore NHS costs.

But as we have stressed in previous articles:

Most doctors take the Hippocratic Oath when they graduate, although there are varying forms. The most popular is the Lasagna version which, in the third and fourth sentences says:

“I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism. *

I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.”

[*Therapeutic nihilism is a contention that it is impossible to cure people or societies of their ills through treatment. In medicine, it was connected to the idea that many “cures” do more harm than good, and that one should instead encourage the body to heal itself.]

Let’s hope that an increasing number of health professionals remember that there is art to medicine; remember to stop over-prescribing medications; and acknowledge the benefits of non-medical interventions that encourage the body to heal itself.

Image by viniciusemc2 from Pixabay