This is a Practice Question published with the kind permission of the Royal College of Nursing
Falls are a frequent and frightening issue for patients and staff, and they have physical and psychological consequences for individuals and society. They are costly in human and financial terms (National Institute for Health and Clinical ExceIlence 2004).
The prevention and management of falls in older people is a government target in reducing morbidity and mortality. This was outlined in the National Service Framework for Older People (Department of Health 2001). Standard six covered falls and specifically aimed to: ‘Reduce the number of falls which result in serious injury and ensure effective treatment and rehabilitation for those who have fallen.’
Therefore, nurses need to do all they can to reduce the risk of falls. In addition to medical, environmental and mobility issues associated with falls prevention, polypharmacy increases risk. We need to consider the regular and occasional medication patients are taking. Patients’ medications should be reviewed frequently and we should engage with their prescribers and pharmacists to reduce associated risks. The Nursing and Midwifery Council (2010) states that registrants ‘must know the therapeutic uses of the medicine to be administered, its normal dosage, side effects, precautions and contra-indications’.
Night sedation
Use of benzodiazepines, also known as hypnotics, should be regularly reviewed. They are commonly used as night sedation and include temazepam, nitrazepam and lorazepam. Their use may increase falls as a result of side effects on the central nervous system and they may cause confusion in older people, which has implications for quality of life. Benzodiazepines may impair judgement and increase reaction time (MeReC 2005). They can also have paradoxical effects that may increase hostility and aggression.
The British National Formulary (BNF) (2011) reminds us that benzodiazepines may cause dependence and that tolerance occurs. It is particularly important to note that if given for periods longer than a few weeks, these drugs should not be stopped abruptly as severe withdrawal symptoms can occur. Short-acting hypnotics are preferable when prescribing for older patients with insomnia. However, hypnotics should be avoided in older people because they are at greater risk of becoming ataxic and confused, leading to falls and injury.
Benzodiazepines should be used to treat insomnia only when it is severe, disabling or causing the patient extreme distress (BNF 2011). Before suggesting medication for the management of insomnia, non-pharmacological interventions should be tried.
The management of insomnia is a skilled nursing intervention and many of the principles of sleep hygiene can be adopted in whatever setting care is being given (Box 1). The means to summon help quickly during the night and discussion to reduce fear or anxiety may also be beneficial.
When you next administer medication or support patients when they take it, make it an opportunity to identify how many people have been taking benzodiazepines for more than one week. Discuss with the prescriber whether or not this is appropriate and if any further action should be taken.