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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? 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 (NHAMCSED), 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 substanceuse 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. However, they also found more than a five-fold increase in the odds of receiving See related article by Kennedy et al. in this issue. Received: 16 December 2021 Accepted: 24 December 2021