5% of older adults start benzodiazepine after acute stroke, despite link to cognitive risk
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Key takeaways:
- One in 20 older adults discharged after acute stroke initiate benzodiazepine within 90 days and were often prescribed them for more than 7 days.
- Benzodiazepine use was proportionately higher among women.
Nearly 5% of older adults initiate benzodiazepine after discharge for acute ischemic stroke, half of which receive up to a 30-day supply, despite known risks for cognitive decline, researchers reported in Stroke.
The U.S. Drug Enforcement Administration defines benzodiazepines as depressants used for sedation, hypnosis, anxiety relief, muscle spasm relief and to reduce seizures.
According to a study published in Frontiers in Psychiatry, the prevalence of benzodiazepine misuse — defined as prescription drug use in any way not directed by a physician — was approximately 5.2% among those prescribed.
Moreover, a review published in Scientific Reports predicted that reducing chronic intake of benzodiazepine could significantly reduce the burden of dementia in older adults.
“In the United States, the use of benzodiazepine in Medicare Part D (prescription drug coverage) beneficiaries was 17.5% to 25.6% annually from 2013 to 2019. Benzodiazepine use in older adults is particularly concerning due to deleterious effects such as dementia, falls, and potentially more severe stroke. Additionally, benzodiazepine has the potential to be misused,” Victor Lomachinsky Torres, MD, research fellow in neurology at Massachusetts General Hospital and Harvard Medical School, and colleagues wrote in Stroke. “The use of benzodiazepine before stroke may be associated with increased stroke severity and mortality. There is, however, little to no data about which stroke survivors are more at risk for receiving new, likely inappropriate benzodiazepine prescription.”
For the present study, Torres and colleagues evaluated the demographics, comorbidities, first prescription days’ supply and benzodiazepine first prescription fills within 90 days after discharge for stroke among 126,050 Medicare beneficiaries (mean age, 78 years; 54% women; 82% white).
The analysis represented 20% of U.S. Medicare claims from April 2013 to September 2021; included beneficiaries aged 65 years or older discharged alive after stroke with traditional Medicare coverage and 6 months’ enrollment in Part A, B or D; and excluded those with prior benzodiazepine prescriptions, self-discharges or discharge to skilled nursing facilities, the researchers wrote.
“We reviewed stroke survivors at 90 days after a stroke because that window of time is critical for rehabilitation of motor, speech and cognitive function, as well as mental health. It’s often a very difficult time for patients who experience loss of mobility and independence. Benzodiazepines may inhibit recovery and rehabilitation,” Julianne Brooks, MPH, data analytics manager at the Center for Value-Based Health Care and Sciences at Massachusetts General Brigham, said in a press release. “For this older age group, guidelines recommend that benzodiazepine prescriptions should be avoided if possible. However, there may be cases where benzodiazepines are prescribed to be used as needed. For example, to treat breakthrough anxiety, a provider may prescribe a few pills and counsel the patient that the medication should only be used as needed. The increased risks of dependence, falls and other harmful effects should be discussed with the patient.”
Benzodiazepine initiation after stroke discharge
Within 90 days of stroke discharge, 4.9% of patients initiated a benzodiazepine prescription, the most common being lorazepam (40%) and alprazolam (33%).
Overall, 76% of first fills had a supply of more than 7 days and 55% had between 15 and 30 days of benzodiazepine, according to the study.
New benzodiazepine initiation occurred in 5.5% of women and 3.8% of men.
In addition, 98% of patients who initiated a benzodiazepine after discharge for stroke had at least one comorbidity documented in the 12 months before stroke hospitalization (mean Charlson comorbidity score, 1.38).
New benzodiazepine initiation was also highest in the Southeast (5.1%; 95% CI, 4.8-5.3) and lowest in the Midwest (4%; 95% CI, 3.8-4.3), and researchers observed a modest nationwide decline in initiation from 2013 to 2021 (cumulative incidence difference, 1.6%).
Moreover, 61% of patients who initiated a benzodiazepine also had other psychotropic prescription claims in the 90 days after stroke discharge, compared with 35% of patients who did not initiate a benzodiazepine. The most common psychotropic prescription claims were gabapentin, sertraline, donepezil, escitalopram and trazodone.
“We found that 4.7% of [acute ischemic stroke] survivors receive new benzodiazepine prescriptions within the 90-day postdischarge window. Benzodiazepines can be used in acute stroke care for a variety of purposes, which range from periprocedural sedation to managing short-term complications such as insomnia, depression and anxiety,” the researchers wrote. “However, there are multiple other pharmacological and nonpharmacological options, such as antipsychotics, which could be considered concerning patient-specific factors directly related to the odds of adverse events and treatment success.
“There is, furthermore, strong evidence that longer than necessary benzodiazepine use in older adults is associated with dependence. A need remains for adequate studies on benzodiazepine safety and effectiveness among older adults, that can inform health care policy and guideline,” the researchers wrote. “In addition, a large number of beneficiaries in our sample received prescriptions for other psychotropic medications (antidepressants, antianxiety medications, antipsychotics, and stimulants), which could add to the increased risk of balance impairment and falls.”
Access to poststroke mental health services ‘limited’
In a related editorial, Justin J. MacKenzie, PhD, psychologist at Southern Utah Psychological Consultants, and Veronica Moreno-Gomez, MD, neurologist at the University of Utah School of Medicine, discussed the importance of anxiety screening in this patient population.
“These findings highlight a concerning pattern of possible benzodiazepine overprescription in vulnerable adults following ischemic stroke,” the authors wrote. “In addition to the number of risks regarding benzodiazepine use already noted, prolonged use of benzodiazepines for certain anxiety disorders (ie, posttraumatic stress disorder) and insomnia are not recommended. With these factors in mind, accurate diagnosis and treatment options for poststroke anxiety in older patients are needed.
“Unfortunately, access to mental health services after stroke can be limited and not all hospitals or clinics will have these types of resources available,” they wrote. “These limitations require stroke physicians to often become the first line of treatment for poststroke anxiety and sometimes are the only option available. However, utilizing a comprehensive approach to poststroke anxiety in older adults, including screening and appropriate pharmacological interventions, can support the optimal recovery of this vulnerable population.”
References:
- Initial prescriptions of sedatives among older stroke survivors may include too many pills. https://newsroom.heart.org/news/initial-prescriptions-of-sedatives-among-older-stroke-survivors-may-include-too-many-pills. Published Oct. 17, 2024. Accessed Oct. 17, 2024.
- Jacqmin-Gadda H, et al. Sci Rep. 2020;doi:10.1038/s41598-020-71482-0.
- MacKenzie JJ, et al. Stroke. 2024;doi:10.1161/STROKEAHA.124.048771.
- McHugh RK, et al. Front Psychiatry. 2023;doi:10.3389/fpsyt.2023.1129447.
- U.S. Drug Enforcement Administration. Benzodiazepines. https://www.dea.gov/factsheets/benzodiazepines. Accessed Oct. 17, 2024.
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