GPs' reflections on prescribing addictive hypnotics to older people: a qualitative study

Background: The European guideline for the diagnosis and treatment of insomnia recommends, for all age groups, only restrictive, short-term, and periodic use of potentially addictive hypnotics. As in other European countries, in Norway, actual practice involving older patients differs substantially from this recommendation, as shown by the persistent high frequency of regular prescriptions of addictive hypnotics. Aim: To explore experienced Norwegian GPs' views of the regular prescription of addictive hypnotics to patients aged >70 years living at home. Design & setting: In-depth individual interviews of a purposive sample of experienced specialists in family medicine at GP offices in Southern Norway. Method: The interviews used a semi-structured interview guide and were performed between June 2022 and January 2023. Reflexive thematic cross-case analysis was used to analyse the data. Results: Most of the 11 GPs interviewed had more than 10 older patients who were prescribed hypnotics for daily use and the same number for intermittent prescription. Almost all prescriptions were of z-hypnotics. The GPs knew this was contrary to the guideline. Many were at ease with this fact. They emphasised the need to avoid creating new dependencies. The GPs considered these patients a selected minority within this age group with serious sleep problems, for whom few realistic alternatives were available and whose tolerance over time was better than expected. This logic of pragmatic practice reflected a patient-centred approach and respect for the patient's view in a shared decision-making process, combined with challenges of limited alternatives and resources. Conclusion: A 'zero vision' on the prescription of addictive hypnotics to older people may neither be prudent nor realistic in the context of general practice.