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Jan/22:Necessary evil or systemic failure of care?Use of benzo/antipsychotic...


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The full title of this editorial in the Journal of the American Geriatric Society is "Necessary evil or systemic failure of care? Use of benzodiazepine and antipsychotic medications in older people seeking emergency department care".






In this issue of the Journal of the American Geriatric Society, the article by Kennedy et al., entitled “Use of antipsychotic and sedative medications in older patients in the emergency department,” addresses an important challenge faced daily in the emergency department (ED)—how to respond to behaviors that potentially put older people at risk for harm as well as the people caring for them?1 As the intentionally provocative title of this editorial suggests, the use of sedatives and antipsychotics in this setting can be viewed as a necessary evil that ED care providers unfortunately cannot avoid, or a systemic failure of care.


So which is it? Unfortunately, there is a dearth of data on this topic. As noted by Kennedy et al., a systematic review of the use of sedatives for agitation in the ED found no articles that focused on use in older people. Thus, this paper provides important fundamental information. They found that over 2.3 million (3.2%) older people received sedatives or antipsychotics agents in the ED. The fact that this fundamental knowledge was lacking to this point speaks to our current limited evidence base on this critically important topic.


The current study has several important strengths. First, it is based on the National Hospital Ambulatory Medical Care Survey-Emergency Department (NHAMCS-ED), which uses trained abstractor that collect data on ED visits. The sampling frame collects data that is geographically representative, as well as representative of hospitals and ED's within each geographic region.


Next, the authors excluded visits for those requiring intubation, with an underlying psychiatric or substance-use diagnosis and those admitted to a mental health or detoxification unit. Why is this a strength? Excluding those with a primary indication for benzodiazepine or antipsychotic use essentially leaves any older person visiting an ED in the United States, where the use of antipsychotics or benzodiazepines is not expected.


How is this information useful? Primarily, the nationally representative nature of these data is the first step to establishing normative standards. If the use of antipsychotic and sedative agents in a specific ED or region is much higher or lower than the national “average” data presented here, further inquiry is warranted.


Next, the study identifies associations which will help inform future prospective research. For example, the authors identified that benzodiazepines were used more than seven times as often as antipsychotics. They expected the opposite, based on the potential for increased falls and delirium associated with benzodiazepine use in older people. Some comfort can be drawn from the finding that increasing age decreased the likelihood of receiving benzodiazepines, but the frequent use of benzodiazepines in older people during ED care is concerning, and suggests further education on the risks of benzodiazepine use in this population is needed.


Women and those in a more urban ED settings were more likely to receive a benzodiazepine. Vulnerable and marginalized groups often receive suboptimal care. As the authors clearly state, future research is needed to determine the degree to which sedatives use is increased because of different disease processes associated with biological sex, or the degree to which this is related to gender stereotypes of prescribers. Exploring whether urbanity was a proxy measure for income or race should also be explored.


There was a stark contrast in predictors of antipsychotic use, where those residing in a nursing home were more likely to receive an antipsychotic (odds ratio [OR] 2.7). Those with dementia and delirium were much more likely to receive antipsychotics (OR 5.62 and 7.33, respectively). Considering the frequent overlap between nursing home residence, dementia, and delirium, this study identifies a subpopulation where the risk of antipsychotic use is significantly increased.


The authors comment that increased antipsychotics use among those with delirium may indicate compliance with evidence-based guidelines such as the Assess, Diagnose, Evaluate, Prevent, and Treat (ADEPT) tool and the American Geriatric Society.2, 3 However, they also found more than a five-fold increase in the odds of receiving antipsychotic for those with dementia, despite ADEPT tool recommendations and an FDA black-box warning.1


Whether there is any difference in the first- or second-generation antipsychotic use remains an important unanswered question. Further prospective research should explore what informs ED clinicians choices of medication in older people with agitation. Specifically, what are the barriers to adoption of current guidelines? Do current guidelines have sufficient face validity to convince ED clinicians to use them? Is more high-quality outcome research needed?


This paper also provides early evidence of the association between sedative and antipsychotic use and higher hospitalization rates. Data on longer ED length of stays were less conclusive, but 12% of ED stays in the current study were longer than 10 h compared to only 4% among those who did not receive a sedative or antipsychotic. The authors are to be commended for clearly identifying that they cannot determine the directionality of this association, that is, were the sedatives causative of prolonged length of stay, or vice versa.


An important limitation of the current study is the extremely low rate of delirium—only 0.4%. Prospective observational research show delirium prevalence of 7%–11% in the ED.4, 5 Marcantonio noted at least three reasons delirium rates can be under-reported in administrative databases.6 First, clinicians may not recognize delirium, and our recent work suggests that delirium recognition rates in the ED continue to be less than 50%.4, 7 Next, even if recognized, delirium may not be documented in the clinical chart.7, 8 Finally, diagnostic codes may not capture all cases of delirium. For example, Redelmeier et al. found their method to be 98% specific, but only 35% sensitive compared to a chart review to identify delirium.9 It is likely that a significant minority of those included in the current study had unrecognized delirium.


How this impacts interpretation of their data is difficult to predict without knowing more about how representative the included cases of delirium are of the general population. For example, recognition rates of delirium have been shown to be increased in those with more severe delirium.4, 7 Thus, there is potential for selection bias, that is, antipsychotics may only be more frequently administered to those with severe delirium. It is also unclear how this low delirium identification rate might impact their findings regarding antipsychotic use in delirium. Future research to validate the method used to identify delirium in the current study against chart reviews or prospectively assessed delirium would assist in the interpretation of their findings.


Almost one third of older people in the current study received diagnostic imaging, and this was a risk factor for exposure to sedatives. The value of computed tomography head imaging in patients with delirium who lack any sign of trauma nor any focal neurological signs has been questioned.10 The current papers thus adds potentially “inappropriate” sedation to the “risks” column when considering the utility of neuroimaging.


But when is sedation “inappropriate”? Unfortunately, administrative data cannot answer this question. But it does prompt an important thought experiment.


Is chemical restraint of an older person presenting with delirium or behavioral symptoms of dementia ever indicated? Of course. There are circumstances where there is an imminent danger to the older person or staff in the ED. What constitutes a true threat to safety, as opposed to reactive angry behavior that can be de-escalated by non-pharmacological means, is by no means standardized.


Is every use of chemical restraints appropriate? Of course not. Kennedy et al. clearly identified the importance of future research and education on optimum use of non-pharmacological approaches, sedatives, and antipsychotics in the ED. The authors have identified the Geriatric Emergency Care Applied Research Network as an excellent means to facilitate such research.11


Researchers like myself have a tendency to stress the need for more research. But it is also important to identify urgent care gaps that require action. The impact of COVID-19 across North America identified major weaknesses in the care provided to older adults. There are undoubtedly instances when a lack of resources means that non-pharmacological interventions to address agitation or behavioral symptoms of dementia in the ED were not feasible, and sedatives were used instead. What resources are needed? While education is important, trained personal support workers (PSWs) dedicated to caring for older people are critical.


From my own experience of training and working in 10 hospitals in four provinces in Canada over 30 years, I cannot think of single ED where sufficient PSWs were available even most of the time. Now imagine that chemical restraints were frequently used in the pediatric setting due to a lack of resources. What would be the public response?


We urgently need to rethink how we care for older people in the ED and provide sufficient PSWs to provide non-pharmacological interventions, if we want to reduce and eventually avoid inappropriate use of sedatives and antipsychotics in older people. Readers are urged to share their creative solutions and advocate for such resources, even as we undertake necessary research. But we must not wait for definitive proof—tonight it could be your parent who is unnecessarily chemically restrained. One such inappropriate use is one too many.




The author has no conflicts of interest to declare.



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Thank you for this good editorial Lapis.  This is such an important topic for getting better care for our elders.  I follow a very good website called betterhealthwhileaging.net by geriatrician, Dr Leslie Kernisan.  She just had a very good article on this topic titled "5 Types of Medication Used to Treat Difficult Dementia Behaviors".  In it, she discusses the effects and risks of commonly used drugs including benzos.  She promotes trying non-drug approaches first.
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You're welcome, BurnedOut. I thought it was an excellent piece as well. Thanks for taking the time to read it.


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