- Within 90 days after having an ischemic (clot-caused) stroke, about
5% of stroke survivors ages 65 and older were prescribed (depressants that relieve anxiety, muscle spasms,
produce sedation and reduce seizures) for the first time.
- More than half of the new prescriptions of benzodiazepines were
written for a supply of 15 to 30 days, rather than the smaller number of
pills for short-term, as-needed use.
- The study also found that women were more likely than men to
receive an initial prescription for benzodiazepines after having a
stroke.
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DALLAS, Oct. 17, 2024 — Although there has been a slight downward
trend in the prescription of benzodiazepines (depressants that relieve
anxiety, muscle spasms, produce sedation and reduce seizures) among
older adults over the last decade, the rate of first-time prescriptions
for these medications after an ischemic (clot-caused) stroke is still sizable, according to research published today in Stroke, the peer-reviewed scientific journal of the American Stroke Association, a division of the American Heart Association.
After a stroke, benzodiazepines may be used to calm anxiety and
improve sleep. However, when prescribed to older adults, these
medications may increase the risk of falls and broken bones, as well as
memory problems, confusion and other harmful effects. The U.S. Drug
Enforcement Agency lists benzodiazepines as a schedule IV-controlled
substance and have the potential for abuse, addiction, withdrawal and
illegal distribution.
Researchers reviewed data from Medicare claims in the U.S. and
analyzed 10 years of first-time prescriptions for benzodiazepines among
more than 120,000 people, ages 65 and older, who were hospitalized for
ischemic stroke. The rate of benzodiazepine prescriptions during the
first three months after stroke were examined, and data were adjusted
for race, sex and ethnicity. Then year-to-year prescription patterns
were reviewed to identify the number of potentially excessive new
benzodiazepine prescriptions given to stroke survivors.
“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,”
said study co-author Julianne Brooks, M.P.H., a data analytics manager
at the Center for Value-based Healthcare and Sciences at Massachusetts
General Brigham in Boston. “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.”
The study found:
- Within 90 days of stroke, 6,127 (4.9%) people were started on a benzodiazepine for the first time.
- Lorazepam (40%) and alprazolam (33%) were the most-prescribed benzodiazepine medications.
- Three-quarters of the first-time benzodiazepine prescriptions were
for a supply of over seven days, and more than half of the prescriptions
were for a supply between 15 to 30 days.
- Prescription rates were higher among women (5.5%) than men (3.8%).
- Prescription fill rates were also higher in Hispanic adults (5.8%),
though this group was limited by the small number of participants -
1.9% of the overall sample.
- Overall, prescription rates were highest in the Southeast (5.1%)
and lowest in the Midwest (4%) of the U.S. “The Southeast region is the
stroke belt with a higher rate of strokes, so that could explain some
differences in care in that region,” Brooks said.
- There was an overall modest nationwide decline of initial prescriptions from 2013 to 2021 of 1.6%.
“We found a pattern of potential oversupply with these initial
benzodiazepine prescriptions, which would be enough for patients to
become long-term users or possibly addicted. The benzodiazepine
prescriptions given under these circumstances may lead to dependence,”
Brooks said. “Increased awareness and improved recommendations about the
risks of these medications for older stroke survivors are needed.
“Although the overall prescription rate decreased slightly over 10
years, this prescription pattern is still a problem. It’s concerning
because older adults are vulnerable to overprescribing and adverse
outcomes. We know from previous studies that vulnerable and marginalized
populations experience worse outcomes after stroke, so we want to
understand the factors that may play a role so we can provide better
care,” Brooks said.
The 2019 American Geriatrics Society Beers Criteria maintains a list
of medications that health care professionals can reference to safely
prescribe medications for adults older than 65. Beers criteria
recommends avoiding benzodiazepines in all older adults due to the risk
of cognitive impairment, delirium, falls, fractures and motor vehicle
crashes.
“Other guidelines also suggest behavioral interventions such as
cognitive behavior therapy for insomnia, antidepressant medications for
anxiety disorders and trying non-pharmaceutical interventions first,”
Brooks said.
Researchers said more studies are needed to understand if there is a
safe level for prescribing benzodiazepines that may be most appropriate
for older adults. The main limitation was that this study used a large,
national dataset that did not include information about why
benzodiazepines were prescribed.
According to the American Heart Association’s Heart Disease and Stroke Statistics 2024 Update,
stroke is a leading cause of serious long-term disability in the U.S.
and accounted for approximately 1 of every 21 deaths in the United
States in 2021.
Study details, background and design:
- The analysis included the records of 126,050 adults from U.S.
Medicare claims for all adults ages 65 and older discharged from the
hospital for ischemic stroke between 2013 and 2021.
- Their average age was 78; 54% were self-identified as female, and 82% were self-identified as white adults.
- The analysis examined new prescriptions of benzodiazepines within
90 days of discharge after ischemic stroke. The study only included
people who had no previous benzodiazepine prescriptions.
Co-authors, disclosures and funding sources are listed in the manuscript.
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