High prevalence of inappropriate benzodiazepine and sedative hypnotic prescriptions among hospitalized older adults
BACKGROUND
Benzodiazepines and sedative hypnotics are commonly used to treat insomnia and agitation in older adults despite significant risk. A clear understanding of the extent of the problem and its contributors is required to implement effective interventions.
OBJECTIVE
To determine the proportion of hospitalized older adults who are inappropriately prescribed benzodiazepines or sedative hypnotics, and to identify patient and prescriber factors associated with increased prescriptions.
DESIGN
Single-center retrospective observational study.
SETTING
Urban academic medical center.
PARTICIPANTS
Medical-surgical inpatients aged 65 or older who were newly prescribed a benzodiazepine or zopiclone.
MEASUREMENTS
Our primary outcome was the proportion of patients who were prescribed a potentially inappropriate benzodiazepine or sedative hypnotic. Potentially inappropriate indications included new prescriptions for insomnia or agitation/anxiety. We used a multivariable random-intercept logistic regression model to identify patient- and prescriber-level variables that were associated with potentially inappropriate prescriptions.
RESULTS
Of 1308 patients, 208 (15.9%) received a potentially inappropriate prescription. The majority of prescriptions, 254 (77.4%), were potentially inappropriate. Of these, most were prescribed for insomnia (222; 87.4%) and during overnight hours (159; 62.3%). Admission to a surgical or specialty service was associated with significantly increased odds of potentially inappropriate prescription compared to the general internal medicine service (odds ratio [OR], 6.61; 95% confidence interval [CI], 2.70-16.17). Prescription by an attending physician or fellow was associated with significantly fewer prescriptions compared to first-year trainees (OR, 0.28; 95% CI, 0.08-0.93). Nighttime prescriptions did not reach significance in initial bivariate analyses but were associated with increased odds of potentially inappropriate prescription in our regression model (OR, 4.48; 95% CI, 2.21-9.06).
CONCLUSIONS
The majority of newly prescribed benzodiazepines and sedative hypnotics were potentially inappropriate and were primarily prescribed as sleep aids. Future interventions should focus on the development of safe sleep protocols and education targeted at first-year trainees. Journal of Hospital Medicine 2017;12:310-316. © 2017 Society of Hospital Medicine
© 2017 Society of Hospital Medicine
Older adults commonly experience insomnia and agitation during hospitalization. Unfortunately, the use of benzodiazepines and sedative hypnotics (BSH) to treat these conditions can be ineffective and expose patients to significant adverse effects.1,2 Choosing Wisely® is a campaign that promotes dialogue to reduce unnecessary medical tests, procedures, or treatments. This international campaign has highlighted BSHs as potentially harmful and has recommended against their use as first-line treatment of insomnia and agitation.3-5 Examples of harm with benzodiazepine use include cognitive impairment, impaired postural stability, and an increased incidence of falls and hip fractures in both community and acute care settings.6-8 In addition, prescriptions initiated in hospital appear to be associated with a higher risk of falls and unplanned readmission.9,10 The newer nonbenzodiazepine sedative hypnotics, commonly referred to as “z-drugs”, were initially marketed as a safer alternative in older adults due to their more favorable pharmacokinetics. Evidence has emerged that they carry similar risks.6,11,12 A study comparing benzodiazepines and zolpidem found relatively greater risk of fractures requiring hospitalization with the use of zolpidem compared to lorazepam.13
The use of benzodiazepines in the acute care setting has been evaluated in a number of studies and ranges from 20% to 45%.14-16 Few studies focus on the initiation of these medications in BSH-naïve hospitalized patients; however, reports range from 18% to 29%.17,18 Factors found to be associated with potentially inappropriate prescriptions (PIP) include Hispanic ethnicity, residing in an assisted care setting, and a greater number of BSH prescriptions prior to admission.16,19 Additionally, Cumbler et al.15 found that the presence of dementia was associated with fewer prescriptions for sleep aids in hospital. To our knowledge, there are no published studies that have investigated prescriber factors associated with the use of BSH.
The purpose of our study was to determine the frequency of PIPs of BSH in our academic hospital. Additionally, we aimed to identify patient and prescriber factors that were associated with increased likelihood of prescriptions to help guide future quality improvement initiatives.
