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Initiation of Benzodiazepines in the Elderly After Hospitalization

  • Hospital Medicine
  • Published:
Journal of General Internal Medicine Aims and scope Submit manuscript

Abstract

Objective

To estimate the rate of new chronic benzodiazepine use after hospitalization in older adults not previously prescribed with benzodiazepines.

Design

Retrospective cohort study using linked, population-based administrative data.

Setting

Ontario, Canada between April 1, 1992 and March 31, 2005.

Participants

Community-dwelling seniors who had not been prescribed benzodiazepine drugs in the year before hospitalization were selected from all 1.4 million Ontario residents aged 66 years and older.

Main Outcome Measures

New chronic benzodiazepine users, defined as initiation of benzodiazepines within 7 days after hospital discharge and an additional claim within 8 days to 6 months. We used multivariate logistic regression to examine for the effect of hospitalization on the primary outcome after adjusting for confounders.

Results

There were 405,128 patient hospitalizations included in the cohort. Benzodiazepines were prescribed to 12,484 (3.1%) patients within 7 days of being discharged from hospital. A total of 6,136 (1.5%) patients were identified as new chronic benzodiazepine users. The rate of new chronic benzodiazepine users decreased over the study period from 1.8% in the first year to 1.2% in the final year (P < .001). Multivariate logistic regression found that women, patients admitted to the intensive care unit or nonsurgical wards, those with longer hospital stays, higher overall comorbidity, a prior diagnosis of alcoholism, and those prescribed more medications had significantly elevated adjusted odds ratios for new chronic benzodiazepine users. Older individuals had a lower risk for the primary outcome.

Conclusion

New benzodiazepine prescription after hospitalization occurs frequently in older adults and may result in chronic use. A systemic effort to address this risky practice should be considered.

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References

  1. Tu K, Mamdani MM, Hux JE, Tu JB. Progressive trends in the prevalence of benzodiazepine prescribing in older people in Ontario, Canada. J Am Geriatr Soc. 2001;49(10):1341–5.

    PubMed  CAS  Google Scholar 

  2. Bartlett G, Abrahamowicz M, Tamblyn R, Grad R, Capek R, du BR. Longitudinal patterns of new benzodiazepine use in the elderly. Pharmacoepidemiol Drug Saf. 2004;13(10):669–82.

    PubMed  Google Scholar 

  3. Lagnaoui R, Depont F, Fourrier A, et al. Patterns and correlates of benzodiazepine use in the French general population. Eur J Clin Pharmacol. 2004;60(7):523–29.

    PubMed  CAS  Google Scholar 

  4. Barbone F, McMahon AD, Davey PG, et al. Association of road-traffic accidents with benzodiazepine use. Lancet. 1998;352(9137):1331–6.

    PubMed  CAS  Google Scholar 

  5. Hemmelgarn B, Suissa S, Huang A, Boivin JF, Pinard G. Benzodiazepine use and the risk of motor vehicle crash in the elderly. JAMA. 1997;278(1):27–31.

    PubMed  CAS  Google Scholar 

  6. Cummings SR, Nevitt MC, Browner WS, et al. Risk factors for hip fracture in white women. Study of Osteoporotic Fractures Research Group. N Engl J Med. 1995;332(12):767–73.

    PubMed  CAS  Google Scholar 

  7. Ray WA, Griffin MR, Downey W. Benzodiazepines of long and short elimination half-life and the risk of hip fracture. JAMA. 1989;262(23):3303–7.

    PubMed  CAS  Google Scholar 

  8. Foy A, O’Connell D, Henry D, Kelly J, Cocking S, Halliday J. Benzodiazepine use as a cause of cognitive impairment in elderly hospital inpatients. J Gerontol A Biol Sci Med Sci. 1995;50(2):M99–106.

    PubMed  CAS  Google Scholar 

  9. Marriott S, Tyrer P. Benzodiazepine dependence. Avoidance and withdrawal. Drug Saf. 1993;9(2):93–103.

    PubMed  CAS  Google Scholar 

  10. Murphy SM, Tyrer P. A double-blind comparison of the effects of gradual withdrawal of lorazepam, diazepam and bromazepam in benzodiazepine dependence. Br J Psychiatry. 1991;158:511–6.

    Article  PubMed  CAS  Google Scholar 

  11. Paton C, Lelliott P. The use of prescribing indicators to measure the quality of care in psychiatric inpatients. Qual Saf Health Care. 2004;13(1):40–5.

    PubMed  CAS  Google Scholar 

  12. Department of Health. Quality and Performance in the NHS: NHS Performance Indicators. London, UK: Department of Health; 2000.

    Google Scholar 

  13. Katz A, DeCoster C, Bogdanovic B, Soodeen RA, Chateau D. Using Administrative Data to Develop Indicators of Quality in Family Practice. Winnipeg, Manitoba: Manitoba Centre for Health Policy, University of Manitoba; 2004.

  14. Gorgels WJ, Oude Voshaar RC, Mol AJ, et al. Discontinuation of long-term benzodiazepine use by sending a letter to users in family practice: a prospective controlled intervention study. Drug Alcohol Depend. 2005;78(1):49–56.

    PubMed  Google Scholar 

  15. Voshaar RC, Gorgels WJ, Mol AJ, et al. Tapering off long-term benzodiazepine use with or without group cognitive-behavioural therapy: three-condition, randomised controlled trial. Br J Psychiatry. 2003;182:498–504.

    PubMed  Google Scholar 

  16. Wagner AK, Soumerai SB, Zhang F, et al. Effects of state surveillance on new post-hospitalization benzodiazepine use. Int J Qual Health Care. 2003;15(5):423–31.

    PubMed  Google Scholar 

  17. Grad R, Tamblyn R, Holbrook AM, Hurley J, Feightner J, Gayton D. Risk of a new benzodiazepine prescription in relation to recent hospitalization. J Am Geriatr Soc. 1999;47(2):184–88.

    PubMed  CAS  Google Scholar 

  18. Stuffken R, van Hulten RP, Heerdink ER, Movig KL, Egberts AC. The impact of hospitalisation on the initiation and long-term use of benzodiazepines. Eur J Clin Pharmacol. 2005;61(4):291–5.

    PubMed  Google Scholar 

  19. Surendrakumar D, Dunn M, Roberts CJ. Hospital admission and the start of benzodiazepine use. BMJ. 1992;304(6831):881.

    PubMed  CAS  Google Scholar 

  20. Millar HL, Clunie FS, McGilchrist MM, McMahon AD, MacDonald TM. The impact on community benzodiazepine prescribing of hospitalization. J Psychosom Res. 1997;42(1):61–9.

    PubMed  CAS  Google Scholar 

  21. Shan K, Nolan JA, Turner P, Jackson SH. Prescription of benzodiazepines in a London teaching hospital. J R Soc Med 1990;83(5):306–7.

    PubMed  CAS  Google Scholar 

  22. Howes JB, Ryan J, Fairbrother G, O’Neill K, Howes LG. Benzodiazepine prescribing in a Sydney teaching hospital. Med J Aust. 1996;165(6):305–8.

    PubMed  CAS  Google Scholar 

  23. Lagnaoui R, Moore N, Longy-Boursier M, Baumevieille M, Begaud B. Benzodiazepine use in patients hospitalized in a department of internal medicine: frequency and clinical correlates. Pharmacoepidemiol Drug Saf. 2001;10(6):531–5.

    PubMed  CAS  Google Scholar 

  24. Zisselman MH, Rovner BW, Yuen EJ, Sholevar D. Physician rationale for benzodiazepine prescriptions to elderly hospitalized patients. Am J Geriatr Psychiatry. 1997;5(2):167–71.

    PubMed  CAS  Google Scholar 

  25. Williams JI, Young W. A summary of studies on the quality of health care administrative databases in Canada. In: Goel V, Williams JI, Anderson GM, Blacksterin-Hirsch P, Fooks C, Naylor CD, eds. Patterns of Health Care in Ontario. The ICES Practice Atlas. Ottawa: Canadian Medical Association; 1996:339–45.

    Google Scholar 

  26. Naylor CD, Anderson GM, Goel V. Patterns of Health Care in Ontario. Toronto: Institute for Clinical Evaluative Sciences; 1994.

  27. Zeger SL, Liang KY. Longitudinal data analysis for discrete and continuous outcomes. Biometrics, 1986;42(1):121–30.

    PubMed  CAS  Google Scholar 

  28. Christiansen CL, Wang F, Barton MB, et al. Predicting the cumulative risk of false-positive mammograms. J Natl Cancer Inst. 2000;92(20):1657–66.

    PubMed  CAS  Google Scholar 

  29. Greenblatt DJ, Harmatz JS, Shapiro L, Engelhardt N, Gouthro TA, Shader RI. Sensitivity to triazolam in the elderly. N Engl J Med. 1991;324(24):1691–8.

    Article  PubMed  CAS  Google Scholar 

  30. Tamblyn R, Abrahamowicz M, du BR, McLeod P, Bartlett G. A 5-year prospective assessment of the risk associated with individual benzodiazepines and doses in new elderly users. J Am Geriatr Soc. 2005;53(2):233–41.

    PubMed  Google Scholar 

  31. Wagner AK, Zhang F, Soumerai SB, et al. Benzodiazepine use and hip fractures in the elderly: who is at greatest risk? Arch Intern Med. 2004;164(14):1567–72.

    PubMed  Google Scholar 

  32. Wang PS, Bohn RL, Glynn RJ, Mogun H, Avorn J. Hazardous benzodiazepine regimens in the elderly: effects of half-life, dosage, and duration on risk of hip fracture. Am J Psychiatry. 2001;158(6):892–8.

    PubMed  CAS  Google Scholar 

  33. Mahoney JE, Palta M, Johnson J, et al. Temporal association between hospitalization and rate of falls after discharge. Arch Intern Med. 2000;160(18):2788–95.

    PubMed  CAS  Google Scholar 

  34. Gill SS, Rochon PA, Herrmann N, et al. Atypical antipsychotic drugs and risk of ischaemic stroke: population based retrospective cohort study. BMJ. 2005;330(7489):445.

    PubMed  Google Scholar 

  35. Whittington J, Cohen H. OSF healthcare’s journey in patient safety. Qual Manag Health Care. 2004;13(1):53–59.

    PubMed  Google Scholar 

  36. Branger PJ, van der Wouden JC, Schudel BR, et al. Electronic communication between providers of primary and secondary care. BMJ. 1992;305(6861):1068–70.

    PubMed  CAS  Google Scholar 

  37. Kaushal R, Barker KN, Bates DW. How can information technology improve patient safety and reduce medication errors in children’s health care? Arch Pediatr Adolesc Med. 2001;155(9):1002–7.

    PubMed  CAS  Google Scholar 

  38. van Walraven C, Laupacis A, Seth R, Wells G. Dictated versus database-generated discharge summaries: a randomized clinical trial. CMAJ. 1999;160(3):319–26.

    PubMed  Google Scholar 

  39. Weintraub M, Singh S, Byrne L, Maharaj K, Guttmacher L. Consequences of the 1989 New York State triplicate benzodiazepine prescription regulations. JAMA. 1991;266(17):2392–7.

    PubMed  CAS  Google Scholar 

  40. Wagner AK, Ross-Degnan D, Gurwitz JH, et al. Effect of New York State regulatory action on benzodiazepine prescribing and hip fracture rates. Ann Intern Med. 2007;146:96–103.

    PubMed  Google Scholar 

  41. Sivertsen B, Omvik S, Pallesen S, et al. Cognitive behavioral therapy vs zopiclone for treatment of chronic primary insomnia in older adults: a randomized controlled trial. JAMA. 2006;295(24):2851–8.

    PubMed  Google Scholar 

  42. Scales DC, Guan J, Martin CM, Redelmeier DA. Administrative data accurately identified intensive care unit admissions in Ontario. J Clin Epidemiol. 2006;59:802–7

    PubMed  Google Scholar 

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Acknowledgements

This study was supported by a Canadian Institutes of Health Research (CIHR) Chronic Disease New Emerging Team (NET) program grant (NET 54010). The NET program receives joint sponsorship from the Canadian Diabetes Association, the Kidney Foundation of Canada, the Heart and Stroke Foundation of Canada, and the CIHR Institutes of Nutrition, Metabolism and Diabetes and Circulatory and Respiratory Health. Dr. Bell, Dr. Bronskill, and Dr. Wodchis were supported by New Investigator Awards from the CIHR. Dr. Gill was supported by an Ontario Ministry of Health and Long-term Care Career Scientist Award. Dr. Anderson was supported by a Chair in Health Management Strategies from the University of Toronto. Dr. Rochon was supported by a CIHR Investigator Award and through a Premiers Research Excellence Award. Sponsor Role: The funding agencies had no role in the design and conduct of the study; collection, management, analysis, or interpretation of the data; or preparation, review, or approval of the manuscript.

Conflicts of Interest/Financial Disclosures

Dr. Lee’s fellowship was sponsored in part by a grant from Eli Lilly Canada. Dr. Lee has received honoraria from Janssen, Novartis, and Pfizer. Dr. Herrmann has received research support and speaker’s honoraria from Bristol-Myers Squibb, Eli Lilly, Janssen, Novartis, and Pfizer. Dr. Fischer was employed by Bayer Canada until 2004.

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Authors and Affiliations

  1. Department of Medicine, St. Michael’s Hospital, 30 Bond Street, Toronto, Ontario, Canada, M5B 1W8

    Chaim M. Bell MD, PhD

  2. Institute for Clinical Evaluative Sciences, Toronto, Canada

    Chaim M. Bell MD, PhD, Hadas D. Fischer MD, Sudeep S. Gill MD MSc, Brandon Zagorski MS, Kathy Sykora MSc, Walter P. Wodchis PhD, Susan E. Bronskill PhD, Geoff M. Anderson MD, PhD & Paula A. Rochon MD, MPH

  3. Department of Medicine, University of Toronto, Toronto, Canada

    Chaim M. Bell MD, PhD & Paula A. Rochon MD, MPH

  4. Department of Health Policy Management and Evaluation, University of Toronto, Toronto, Canada

    Chaim M. Bell MD, PhD, Walter P. Wodchis PhD, Susan E. Bronskill PhD, Geoff M. Anderson MD, PhD & Paula A. Rochon MD, MPH

  5. Department of Medicine, Queen’s University, Kingston, Canada

    Sudeep S. Gill MD MSc

  6. Toronto Rehabilitation Institute, Toronto, Canada

    Walter P. Wodchis PhD

  7. Department of Psychiatry, University of Toronto, Toronto, Canada

    Nathan Herrmann MD

  8. Department of Medicine, University of British Columbia, Vancouver, Canada

    Phil E. Lee MD

  9. Kunin-Lunenfeld Applied Research Unit, Baycrest, Toronto, Canada

    Paula A. Rochon MD, MPH

Authors
  1. Chaim M. Bell MD, PhD
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  2. Hadas D. Fischer MD
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Corresponding author

Correspondence to Chaim M. Bell MD, PhD.

Appendices

Appendix

Exclusion Codes

  1. 1.

    Psychiatry consult during the hospital stay (as described by one of the variables mdserv#1–8 = 64 before 2002 or prvserv1–8 = 00064 from 2002)

  2. 2.

    Exclude all subjects in palliative care (OHIP fee code A945, C945, C882, or C982, W872, W882, W972, or W982 or CIHI record with patserv = 58).

  3. 3.

    Long-term care residents were identified by an LTC flag in the ODB Database.

List of benzodiazepines included on ODB plan, which were included in the analysis

Table 4 Benzodiazepines Included in the Analysis
Full size table

ICU and Alcoholism Coding

  1. 1.

    ICU stay during index hospitalization (i.e., between admission and discharge dates, inclusive.). ICU stay was identified using OHIP ICU codes42:

    • Comprehensive care–intensive care area (covers all aspects of ICU care including mechanical ventilation): G557-day 1 only, G558-day 2–10 inclusive, G559-day 11 onward.

    • Critical care–intensive care area (covers all aspects of ICU excluding mechanical ventilation): G400-day 1 only, G401-days 2–10 inclusive, G402-Days 11 onward.

Ventilatory support–intensive care area (covers management of mechanical ventilation only): G405-day 1 only, G406-days 2–10 inclusive, G407-days 11 onward.

  1. 1.

    Alcoholism based on any (not only primary diagnosis) admission diagnosis within the past 3 years (including index hospitalization) (for ICD-9-any CIHI dxcode: V113, 2911, 2913–2919, 3030, 3050, 3575, 4255, 5353, 5710–5713, 7903, 9808, 9809. For ICD-10-F100-F109, G621, I426, K292, K700–K704, K709, R780, T518, T519, Y910–Y913, Y919, Z811) or OHIP visit within past 3 years (OHIP dxcode: 291, 303).

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Bell, C.M., Fischer, H.D., Gill, S.S. et al. Initiation of Benzodiazepines in the Elderly After Hospitalization. J GEN INTERN MED 22, 1024–1029 (2007). https://doi.org/10.1007/s11606-007-0194-4

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  • DOI: https://doi.org/10.1007/s11606-007-0194-4

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