Skip to main content

Antipsychotics for Sleep: When Did This Become a Thing?



by: Eric Widera (@ewidera)

Sleep.   It’s sometimes hard enough to get enough at home with all the distractions of daily life.   It’s only made more difficult in the hospital setting.

We’ve seen a lot of interventions to help with this that generally consist of pills, because as compared to changing the environment or culture of the hospital, as it’s an easy intervention.  However, most of these have little to no evidence that they work.

The latest one that I just saw in the hospital was prescriptions for quetiapine, an antipsychotic, for sleep.   I thought to myself, well that’s odd.   Hopefully this won’t become a thing.   I’m sad to say, just like Pok√©mon Go, it has.

A study came out last week in JAMA IM titled “Off-label Use of Quetiapine in Medical Inpatients and Postdischarge.”   The authors prospectively enrolled all inpatients 60 years or older between December of 2013 and April of 2015 from a teaching hospital in Quebec, Canada.

One of the authors then looked at all of the medical records for quetiapine prescriptions, dosing, and indication.    If they didn't have a comorbid psychiatric condition (eg, schizophrenia, major depressive, or bipolar affective disorder) or evidence of delirium it was assumed that they were receiving night time dosing of quetiapine for sleep.

What they found was shocking.   One out of every ten patients (13.0%) received quetiapine during hospitalization, 64.0% of which received the medication at bedtime for sleep.  That’s 8% of hospitalized patients getting quetiapine for sleep.   Most of these individuals were newly initiated on this antipsychotic in the hospital.   Sadly, 1 in 7 patients who first received quetiapine for sleep in the hospital was discharged home with at least a 1-month prescription.

Seriously.  Antipsychotics for sleep.  Really, is this the best we can do to help with sleep in the hospital?  If you want to read a good case of why this is just bad practice, take a look at the Teachable Moment case from that same JAMA IM issue.

Is this a thing at your hospital too?








Comments

Jordan Fallis said…
It's ridiculous that these are being prescribed for sleep. They deplete critical nutrients too, yet no one ever discusses it: http://www.optimallivingdynamics.com/blog/7-important-nutrients-depleted-by-psychiatric-drugs-antidepressants-antipsychotics-stimulants-benzodiazepines-induced-guide-vitamins-medications
Helen Chen, MD said…
In post-acute, skilled nursing settings, we are required to consent patients/healthcare proxies whenever we prescribe psychoactive medications and specifically antipsychotics. We have also noticed a small rise in patients being discharged to us on antipsychotics for insomnia, often without their clear understanding or consent. For so many reasons, not a good practice. As attendings and geriatrics consultants we should be taking a stand and educating trainees about the dangers of this approach.
Rodney KSiegel said…
I agree with @Fallis: "It's ridiculous that these are being prescribed for sleep"
Laurie said…
I don't think it's ridiculous. Just take more time for it.

Popular posts from this blog

The Dangers of Fleet Enemas

The dangers of oral sodium phosphate preparations are fairly well known in the medical community. In 2006 the FDA issued it’s first warning that patients taking oral sodium phosphate preparations are at risk for potential for acute kidney injury. Two years later, over-the-counter preparations of these drugs were voluntarily withdrawn by the manufacturers.  Those agents still available by prescription were given black box warnings mainly due to acute phosphate nephropathy that can result in renal failure, especially in older adults. Despite all this talk of oral preparations, little was mentioned about a sodium phosphate preparation that is still available over-the-counter – the Fleet enema.

Why Oral Sodium Phosphate Preparations Are Dangerous 

Before we go into the risks of Fleet enemas, lets spend just a couple sentences on why oral sodium phosphate preparations carry significant risks. First, oral sodium phosphate preparations can cause significant fluid shifts within the colon …

Opening the Black Box of LTACs: Podcast with Anil Makam

What happens in Long Term Acute Care Hospitals, or LTACs (pronounced L-tacs)?  I've never been in one.  I've sent patients to them - usually patients with long ICU stays, chronically critically ill, with a gastric feeding tube and a trach for ventilator support.  For those patients, the goals (usually as articulated by the family) are based on a hope for recovery of function and a return home.

And yet we learn some surprising things from Anil Makam, Assistant Professor of Medicine at UCSF.  In his JAGS study of about 14,000 patients admitted to LTACHs, the average patient spent two thirds of his or her remaining life in an institutional settings (including hospitals, LTACs and skilled nursing facilities).  One third died in an LTAC, never returning home.

So you would think with this population of older people with serious illness and a shorter prognosis than many cancers, we would have robust geriatrics and palliative care in LTACs?  Right? Wrong.

3% were seen by a geriatrici…

Length of Stay in Nursing Homes at the End of Life

One out of every four of us will die while residing in a nursing home. For most of us, that stay in a nursing home will be brief, although this may depend upon social and demographic variables like our gender, net worth, and marital status. These are the conclusions of an important new study published in JAGS by Kelly and colleagues (many of whom are geripal contributors, including Alex Smith and Ken Covinsky).

The study authors used data from the Health and Retirement Study (HRS) to describe the lengths of stay of older adults who resided in nursing homes at the end of life. What they found was that out of the 8,433 study participants who died between 1992 and 2006, 27.3% of resided in a nursing home prior to their death. Most of these patients (70%) actually died in the nursing home without being transferred to another setting like a hospital.

 The length of stay data were striking:

the median length of stay in a nursing home before death was 5 months the average length of stay was l…