Current Interventions Fail to Reduce Benzodiazepine Use in Older Adults

Mark D. Neuman, MD, MSc

Credit: Penn LDI

A new study revealed neither clinician peer comparison, patient informational mail, nor a combination of both interventions reduced benzodiazepine administration among older adults compared with usual care.¹

“While unadjusted benzodiazepine administration rates were lower in each of the 3 intervention groups than in usual care, these differences did not persist after adjusting for the overall reduction in administration over time,” wrote investigators, led by Mark D. Neuman, MD, MSc, from the department of anesthesiology and critical care at the University of Pennsylvania Perelman School of Medicine.

Benzodiazepine poses a danger for adults aged ≥ 65 years. A 2023 study reported that older adults who take benzodiazepines are unknowingly putting themselves at risk of car accidents due to the drug’s adverse effects of sedation, impaired motor coordination, and drowsiness.² Benzodiazepines also puts older adults at a greater risk of falls and fractures, confusion, and emergency room visits.³

Guidelines advise against giving older patients benzodiazepine, yet many still receive this as a part of anesthesia care.⁴ Clinician- and patient-facing interventions try to discourage benzodiazepine administration among this population, but the effectiveness of these efforts remains unclear.¹

Investigators sought to evaluate the effect of clinician peer comparison, patient information mail, or a combination of these combinations on the rate of perioperative benzodiazepine administration to older patients, compared with patients receiving usual care. The primary endpoints were the rate of benzodiazepine administration during anesthesia care and patient satisfaction with anesthesia care, measured by the 8-item Anesthesia Patient Satisfaction Questionnaire.

The team conducted a 2 x 2 factorial, stepped-wedge, cluster randomized clinical trial between August 8, 2022, and May 28, 2023, across 415 hospitals, surgery centers, and physician offices in 8 US states. Participants (n = 509,269) were aged ≥ 65 years (mean age: 74 years; 50.2% females) who underwent surgical or endoscopic procedure with general anesthesia. The patients were randomly assigned to 1 of the 4 groups: clinician peer comparison (16%), patient informational mail (19.3%), both interventions (33.3%), and usual care (no intervention) (31.4%).

Clinician peer comparison describes clinicians receiving feedback on their performance compared to other clinicians in the practice. Moreover, patient informational mail describes where patients received an informational letter encouraging them to discuss with their clinician what medication they select on the day of the surgery.

Among patients who received benzodiazepine during anesthesia care, 24.5% received usual care, 19.7% received clinician peer comparison, 20% received patient informational mail, and 19.7% received clinician peer comparison and patient informational mail. After adjusting for time, neither clinician peer comparison (odds ratio [OR], 1.02; 95% confidence interval [CI], 0.98 – 1.07; P = .35), patient informational mail (OR,1.01; 95% CI, 0.96 – 1.05; P = .81; OR, 1.11), or both interventions (OR, 1.11; 95% CI, 1.05 to 1.16; P < .001) were linked to lower odds of benzodiazepine administration compared with usual care.

Furthermore, satisfaction scores were high and similar for all groups. Among the 39,326 patients who answered ≥ 1 item on the postoperative satisfaction surgery, ≥ 90% gave a score of ≥ 4.

“Considered as a whole, trial findings suggest that clinician peer comparisons do not add a benefit to basic efforts to discourage routine benzodiazepine administration during anesthesia care, such as routine measurement of use and prioritization by practice leaders,” investigators wrote. “Similarly, simple patient informational mail may have limited impact on benzodiazepine administration; the potential for other patient-targeted interventions to improve anesthesia care should be explored in future work. Additionally, the lack of a change in patient satisfaction confirms evidence from prior trials that reducing benzodiazepine administration during anesthesia care does not adversely affect satisfaction.”

References

1. ^{Neuman MD, Feng R, Shukla AS, et al. Strategies to Limit Benzodiazepine Use in Anesthesia for Older Adults: A Randomized Clinical Trial. JAMA Netw Open. 2024;7(10):e2442207. Published 2024 Oct 1. doi:10.1001/jamanetworkopen.2024.42207}
2. ^{Derman, C. Older Age Does Not Cause Car Accidents—Medication with Adverse Effects Do. HCPLive. September 29, 2024. https://www.hcplive.com/view/older-age-car-accidents-medication-adverse-effects. Accessed October 31, 2024.}
3. ^{Gress T, Miller M, Meadows C 3rd, Neitch SM. Benzodiazepine Overuse in Elders: Defining the Problem and Potential Solutions. Cureus. 2020 Oct 19;12(10):e11042. doi: 10.7759/cureus.11042. PMID: 33214968; PMCID: PMC7673272.}
4. ^{Hughes CG, Boncyk CS, Culley DJ, et al; Perioperative Quality Initiative (POQI) 6 Workgroup. American Society for Enhanced Recovery and Perioperative Quality Initiative joint consensus statement on postoperative delirium prevention. Anesth Analg. 2020;130(6):1572-1590. doi:10.1213/ANE.0000000000004641}