Mailed intervention cuts sedative use and improves sleep in the elderly

A simple, scalable, direct-to-patient intervention consisting of two booklets and a website substantially reduced benzodiazepine receptor agonist (BZRA) use and improved sleep outcomes in older adults, the randomized YAWNS NB trial has shown.

“The prevalence of insomnia increases with age, as does the use of sedatives and the burden of their adverse effects. Avoiding BZRA [eg, benzodiazepines and z-drugs] use in older adults is widely endorsed,” wrote the researchers. Cognitive behavioural therapy for insomnia (CBTI) as first-line treatment has demonstrated effectiveness in older adults and across delivery formats, but its uptake is limited. [JAMA Psychiatry 2024;doi:10.1001/jamapsychiatry.2024.2731]

YAWNS NB was a three-arm pragmatic, open-label, minimum-contact, randomized clinical trial conducted in 580 older adults living independently with long-term use of BZRAs (mean age, 72.1 years; female, 64.1 percent; mean BZRA use duration, 11.4 years) and current or past insomnia. The first arm, YAWNS-1, included a website and two booklets titled “How to Stop Sleeping Pills” and “How to Get Your Sleep Back” as intervention. The second arm, YAWNS-2, featured updated versions of the booklets “You May Be at Risk” and “How to Get a Good Night’s Sleep Without Medication” used in the prior EMPOWER study. The third arm was treatment as usual (TAU). [JAMA Intern Med 2014;174:890-898; JAMA Psychiatry 2024;doi:10.1001/jamapsychiatry.2024.2731]

“Both YAWNS-1 and YAWNS-2 packages encouraged participants to contact their healthcare professionals for guidance on BZRA reduction,” noted the researchers.

Results showed that YAWNS-1 was superior to YAWNS-2 (46.6 vs 34.8 percent; p=0.02) and TAU (46.6 vs 20.3 percent; p<0.001) for the combined outcome of BZRA discontinuations and dose reductions of ≥25 percent at 6 months. Of note, the number needed to mail to have one person discontinue long-term sedative use was 5.3 with YAWNS-1 and 7.8 with YAWNS-2.

“This study included sleep and related health outcomes that, to our knowledge, are unique compared with existing brief intervention studies targeting BZRA use,” pointed out the researchers.

YAWNS-1 was also associated with better uptake of CBTI techniques (3.05 vs 2.45; p=0.03) and sleep efficiency (mean difference, 4.1 vs -1.7 percent; p=0.001) vs YAWNS-2, as well as reduced insomnia severity (insomnia severity index difference, -2.0 vs 0.3; p<0.001) and daytime sleepiness (Epworth Sleepiness Scale difference, -0.8 vs 0.3; p=0.001) vs TAU.

The YAWNS-1 and YAWNS-2 interventions share several features, yet important differences exist. YAWNS-1 encouraged participants to learn about and use CBTI, while YAWNS-2 did not describe or emphasize CBTI as first-line therapy for insomnia. “Improvements in daytime sleepiness with YAWNS-1 could be attributed to reduced sedative use and better sleep outcomes. Each of YAWNS-1’s advantages may be, at least in part, due to its superior CBTI uptake,” commented the researchers.

“Transitioning insomnia care for older adults away from long-term sedative use and toward CBTI can be achieved using a mailed, direct-to-patient approach [ie, YAWNS -1],” highlighted the researchers. “The direct-to-patient approach makes its implementation scalable, sustainable, and equitable.”