High prevalence of inappropriate benzodiazepine and sedative hypnotic prescriptions among hospitalized older adults

Our study showed that 15.9% of hospitalized older adults were newly prescribed a PIP during their admission. Of all new in hospital prescriptions, 77% were deemed potentially inappropriate. These numbers are similar to those reported by other centers; however, wide ranges exist.^16,19 This is likely the result of differences in appropriate use and inclusion criteria. Gillis et al.¹⁷ focused their investigation on sleep aids and showed that 26% of all admitted patients and 18% of BSH naïve patients received a prescription for insomnia. While this is similar to our findings, more than half of these patients were under the age of 65, and additional medications, such as trazodone, antihistamines, and antipsychotics were included.¹⁷ Other studies did not exclude patients who used a BSH regularly prior to admission. For example, 21% of veterans admitted to an acute care facility received a prescription for potentially inappropriate indications, but this included continuation of prior home medications.¹⁹ In contrast, we chose to focus on older adults in whom BSH pose a greater risk of harm. Exclusion of patients who regularly used a BSH prior to admission allowed us to better understand the circumstances surrounding the initiation of these medications in hospital. Furthermore, abrupt cessation of benzodiazepines can cause withdrawal and worsen confusion.²²

We found that 10% of patients newly prescribed a BSH in hospital were discharged with a prescription for a BSH. The accuracy of this is limited by the lack of availability of electronic discharge prescriptions on our surgical wards; however, it is likely an underrepresentation of the true effect given the high rates of PIPs on these wards. Our study highlights the concerning practice of continuing newly prescribed BSH following discharge from hospital.

Sleep disruption and poor quality sleep in hospital is a common issue that leads to significant use of BSH.¹⁵ Nonpharmacologic interventions in older adults can be effective in improving sleep quality and reducing the need for BSH; however, they can be time-consuming to implement.²³ With the exception of preventative strategies used on our Acute Care for Elders unit, formal nonpharmacologic interventions for sleep are not practiced in our hospital. We found that the majority of PIPs were prescribed as sleep aids in the overnight hours. This suggests that disruptions in sleep are leading patients and nursing staff to request pharmacologic treatments and highlights an area with significant room for improvement. Work is underway to implement and evaluate safe sleep protocols for older adults.

To our knowledge, we are the first to report an association between training level and PIP of BSH in older adults. The highest rates of PIPs were found among the first-year residents and, after controlling for patient and prescribing event characteristics, such as time of prescription, first-year residents were significantly more likely to prescribe a PIP. First-year residents are more likely to respond first to issues on the wards. There may be pressure on first-year trainees to prescribe sleep aids, as many patients and nurses may seek pharmacologic solutions for symptom management. Knowledge gaps may also be a contributing factor early in their training. A survey of physicians found that residents were more likely than attending physicians to list lack of formal education as a barrier to appropriate prescribing.²⁴

Similarities are seen in a study of antibiotic appropriateness, where residents demonstrated gaps in knowledge of treatment of asymptomatic bacteriuria that seemed to vary by specialty.²⁵ Interestingly, we found that patients admitted to general internal medicine were prescribed fewer PIPs. This service includes our Acute Care for Elders unit, which is staffed by trained geriatric nurses and other allied health professionals. Residents who rotated on internal medicine are also likely to have received informal teaching about medication safety in older adults. Educational interventions highlighting adverse effects of BSH and promoting nonpharmacologic solutions should be targeted at first-year residents. However, an interprofessional team approach to sleep disturbance in hospital, in combination with decision support for appropriate BSH use will achieve greater impact than education alone.

Several limitations of this study merit discussion. First, findings from a single academic center may lack generalizability. However, the demographics of our patient population and our rates of BSH use were similar to those reported in previous studies. Second, our study may be subject to observer bias, as the data collectors were not blinded. To minimize this, a strict template and clear appropriateness criteria were developed. Additionally, a second reviewer independently conducted data validation with 100% agreement among reviewers. Third, we studied prescribing patterns rather than medication administration and lacked data on filling of new BSH prescriptions in the postdischarge period. However, our primary goal is to determine risk of exposure to a BSH to minimize it. Fourth, although BSH are discouraged as “first choice for insomnia, anxiety or delirium,”⁴ they may be appropriate in limited situations where all nonpharmacologic strategies have failed and patient or staff safety is at risk. In our chart reviews, we were unable to determine whether all nonpharmacologic strategies were exhausted prior to prescription initiation. However, more than 20% of all PIP were routinely prescribed as part of an admission or postoperative order set, suggesting a reflexive rather than reflective approach to sedative use. Furthermore, the indications of anxiety and agitation were combined as they appear in the CPOE as a combination indication, thus leaving us unable to determine the true proportion for each indication. However, more than 87% of all PIPs were for insomnia, reflecting a clear opportunity to improve sleep management in hospital. Last, the lack of a power calculation may have resulted in the study being underpowered and thus affected the ability to detect a significant effect of covariates that have real differences on the likelihood of sedative prescriptions. For example, the low number of prescribing events by second-year residents and staff may have resulted in a type II error when comparing PIP rates with first-year residents.

We found that the majority of newly prescribed BSH among older adults in hospital were potentially inappropriate. They were most frequently prescribed by first-year residents overnight in response to insomnia. Our findings demonstrate BSH overuse remains prevalent and is associated with poor sleep in hospital. Future work will focus on implementing and evaluating safe sleep protocols and educational interventions aimed at first-year residents.