(136) Regional Variations Between Drug Treatment Recommendations for Insomnia in Older People in Sweden

Background: Insomnia is a common problem among older individuals. In Sweden, regional recommendations for drug treatment of insomnia provide healthcare professionals with evidence-based information on how to manage this condition.

Objectives: To analyse the extent to which regional drug treatment recommendations for insomnia in older people differ among three Swedish regions.

Methods: Descriptive analysis of content in three regional sets of recommendations, “Kloka listan” (Stockholm), “REKlistan” (Västra Götaland), and “Skånelistan” (Skåne), focusing on individuals aged ≥75 years. The populations in these regions correspond to approximately 52% of the total Swedish population of 10 million people. Information on first-line drug therapy, second-line drug therapy and drugs to avoid was extracted from each set of recommendations. If available, the rationale for each recommendation was recorded. Discordances were analysed and discussed among three specialist physicians (two clinical pharmacologists (one also a GP) and one GP/trainee in clinical pharmacology).

Results: All sets were published in 2024. Two sets included an appendix describing drug treatment recommendations in older people, whereas one set presented some advice for older people within the general recommendations. Two sets included only one first-line drug line therapy and one set included two options. The first-line recommendations were consistent in two sets and included zopiclone. One set included short-acting and long-acting melatonin as first-line therapy. Two sets included more than one option for second-line drug therapy, while one set included only one option. Mirtazapine and melatonin were consistent second-line therapy options in two sets of recommendations. Other drugs included as second-line therapy were zopiclone and oxazepam, in one set each. Drugs to avoid in insomnia were listed in three recommendation sets, all including benzodiazepines and propiomazine. Sedative antihistamines were mentioned in two sets, in one set specified as those with anticholinergic effects, e.g., hydroxyzine and promethazine. Zolpidem and clomethiazole were both mentioned in one set.

Conclusions: Evidence-based drug treatment recommendations for insomnia in older people vary substantially. The underlying reasons for this variation should be investigated through systematic analysis of the methodology employed in evidence synthesis and guideline formation.