Elderly patients becoming chronic users of sleeping pills following hospitalization

A new ICES study shows that about half of elderly patients who are prescribed benzodiazepines, a type of sleeping pill, to treat short-term insomnia following hospital discharge are still chronic users of these drugs six months later.

“The use of benzodiazepines has been linked to serious adverse events such as residual daytime sedation, cognitive impairment, fall-related injuries including hip fractures, and motor vehicle collisions, particularly when combined with other drugs or alcohol. As well, an important but often overlooked issue is that long-term use of benzodiazepines can lead to dependence,” said Dr. Chaim Bell, Institute for Clinical and Evaluative Studies (ICES) adjunct scientist.

“Many patients are first introduced to benzodiazepines during hospitalization, and although the intent may have been to manage insomnia during the short period of time the patient was in hospital, there are concerns that their use in hospital may result in chronic use after discharge, together with the accompanying risks.”

To examine this issue further, investigators tracked community-dwelling seniors 66 years of age and older who had not been prescribed benzodiazepine drugs in the year before hospitalization, for the period between April 1992 and March 2005. They studied the effect of hospitalization on new chronic benzodiazepine users (defined as initiation of benzodiazepines within seven days after hospital discharge and an additional prescription within eight days to six months).

Of the over 405,000 hospitalizations during the study period, benzodiazepines were prescribed to 12,484 (3.1%) patients within seven days of being discharged from the hospital. A total of 6,136 (1.5%) patients were defined as new chronic benzodiazepine users.

The results also showed that women, patients admitted to the intensive care unit or non-surgical wards, those with longer hospital stays, more additional illnesses, a prior diagnosis of alcoholism, and those prescribed more medications had significantly greater odds of becoming a new chronic benzodiazepine user. Older individuals had a lower risk of this outcome.

“Initiatives such as the development of electronic medical records and more formal medication lists, or models of care that facilitate communication and coordination between hospital and community-based physicians, may help to further reduce the risk of new, chronic benzodiazepine prescriptions, particularly when targeted to the higher-risk patients identified in our study,” said Dr. Bell.

“Effective alternatives to treat insomnia should be considered first. Discussions about reasons for a prescription and associated risks, as with any new medication, should occur with patients before starting them on benzodiazepines. Also, a concerted, multidisciplinary effort at all levels of care will be needed to address this issue.”

The study “Initiation of benzodiazepines in the elderly after hospitalization” is in the July 2007 issue of the Journal of General Internal Medicine.

Author affiliations: ICES (Drs. Bell, Fischer, Gill, Wodchis, Bronskill, Anderson, and Rochon, Mr. Zagorski and Ms. Sykora); Department of Medicine, St. Michael’s Hospital (Dr. Bell); Department of Medicine (Drs. Bell and Rochon), Department of Health Policy, Management and Evaluation (Drs. Bell, Wodchis, Bronskill, Anderson, and Rochon), and Department of Psychiatry (Dr. Herrmann), University of Toronto; Department of Medicine, Queen’s University (Dr. Gill); Toronto Rehabilitation Institute (Dr. Wodchis); Department of Medicine, University of British Columbia (Dr. Lee); Baycrest Geriatric Healthcare System (Dr. Rochon).

ICES is an independent, non-profit organization that uses population-based health information to produce knowledge on a broad range of healthcare issues. Our unbiased evidence provides measures of health system performance, a clearer understanding of the shifting healthcare needs of Ontarians, and a stimulus for discussion of practical solutions to optimize scarce resources. ICES knowledge is highly regarded in Canada and abroad, and is widely used by government, hospitals, planners, and practitioners to make decisions about care delivery and to develop policy.

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