AMDA – The Society for Post-Acute and Long-Term Care Medicine

View all recommendations from this society

November 20, 2020, Updated July 1, 2021

Don’t routinely prescribe or continue sedative hypnotics such as Restoril or Ambien, diphenhydramine (Benadryl), benzodiazepines, or Serotonin Modulators (Trazadone) for long-term treatment of sleep disorders in geriatric populations. Consider the use of nonpharmacological interventions (e.g., physical activity, a regular schedule or cognitive behavioral therapy.)

Use of diphenhydramine (or other first generation antihistamines), benzodiazepines or sedative hypnotics with anticholinergic side effects should be avoided as the data suggests these drugs may cause confusion and delirium in the short term, and some have been associated with an increased risk of dementia with long-term use. These drugs are associated with a five-fold increase in adverse cognitive events, an increase in adverse psychomotor events and are associated with an increased risk of falls. The 2019 updated Beers criteria for potentially inappropriate medications for use in older adults recognized these medications as problematic.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

How The List Was Created

1–5: AMDA – The Society for Post -Acute and Long-Term Care Medicine convened a work group made up of members from the Clinical Practice Steering Committee (CPSC). Members of the CPSC include board certified geriatricians, certified medical directors, multi-facility medical directors, attending practitioners, physicians practicing in both office-based and nursing facility practice, physicians in rural, suburban and academic settings, those with university appointments, and more. It was important to AMDA that the workgroup chosen represent the core base of the AMDA membership. Ideas for the “five things” were solicited from the workgroup. Suggested elements were considered for appropriateness, relevance to the core of the specialty and opportunities to improve patient care. They were further refined to maximize impact and eliminate overlap, and then ranked in order of potential importance both for the specialty and for the public. A literature search was conducted to provide supporting evidence or refute the activities. The list was modified and a second round of selection of the refined list was sent to the workgroup for paring down to the final “top five” list. Finally, the work group chose its top five recommendations before submitting a final draft to the AMDA Executive Committee, which were then approved.

6–10: The AMDA Choosing Wisely® endeavor utilized a similar procedure as published in JAMA Intern Med. 2014;174(4):509-515 – A Top 5 List for Emergency Medicine for our five items.

The AMDA Clinical Practice Committee acted as the Technical Expert Panel (TEP).

Phase 1 – The Clinical Practice Steering Committee (CPSC) along with the Infection Advisory Committee clinicians brainstormed an initial list of low-value clinical decisions that are under control of PA/LTC physicians that were thought to have a potential for cost savings.

Phase 2 – Each member of the CPSC selected five low-value tests considering the perceived contribution to cost (how commonly the item is ordered and the individual expense of the test/treatment/action), benefit of the item (scientific evidence to support use of the item in the literature or in guidelines); and highly actionable (use decided by PA/LTC clinicians only).

Phase 3 – A survey was sent to all AMDA members. Statements were phrased as specific overuse statements by using the word “don’t,” thereby reflecting the action necessary to improve the value of care.

Phase 4 – CPSC members reviewed survey results and chose the five items.

The AMDA Choosing Wisely project utilized procedures similar to previous workgroups.
In Phase 1 – The Clinical Practice Steering Committee (CPSC) solicited recommendations from members of the Society’s five subcommittees.

In Phase 2 – Each member of the CPSC reviewed the submitted recommendations (with the goal to selecting the best five recommendations) considering the
perceived contribution to cost, benefit of the item and scientific evidence to support use of the item in the literature or in guidelines. Based on the feedback of the CPSC, the recommendations were narrowed to five, revised, and supporting evidence was added.

Phase 3 – The revised five recommendations and sources were reviewed by the CPSC for final approval, and then approved by the Board of Directors.

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Jacobs GD, Pace-Schott EF, Stickgold R, Otto MW. Cognitive behavior therapy and pharmacotherapy for insomnia: A randomized controlled trial and direct comparison. Arch Intern Med 2004;164:1888-1896.

McMillan JM, Aitken E, Holroyd-Leduc JM. Management of insomnia and long-term use of sedative-hypnotic drugs in older patients. CMAJ. 2013;185(17):1499–1505. doi:10.1503/cmaj.130025

Mysliwiec, V, Martin, J, Ulmer, C, Chowdhuri, S, Brock, M, Spevak, C, Sall, J. The management of chronic insomnia disorder and obstructive sleep apnea. Annals of Internal Medicine. 2020;172(5).

Randall T. Espinoza, Clarifying the Relationship Between Benzodiazepines and Dementia, Journal of the American Medical Directors Association, 10.1016/j.jamda.2019.12.006, 21, 2, (143-145), (2020).

Khusbu Patel, High-Risk Prescriptions for Aging Patients, Geriatric Practice, 10.1007/978-3-030-19625-7_14, (177-184), (2019).

Claire K. Ankuda and Olusegun Apoeso, Diagnosis and Management of Delirium, Geriatric Practice, 10.1007/978-3-030-19625-7_19, (237-246), (2019).

Kelly Cummings and Helen Fernandez, Driving, Geriatric Practice, 10.1007/978-3-030-19625-7_27, (335-344), (2019).

“American Geriatrics Society Updated Beers Criteria®.”, American Geriatrics Society. January 31, 2019.

Dore, D. D., Zullo, A. R., Mor, V., Lee, Y., & Berry, S. D. (2018). Age, Sex, and Dose Effects of Nonbenzodiazepine Hypnotics on Hip Fracture in Nursing Home Residents. Journal of the American Medical Directors Association, 19(4), 328–332.e2.