Oral Papers: Delirium & Agitation
Background: Benzodiazepines are commonly administered to hospitalized inpatients, potentially for inappropriate indications (Pek, 2017). Delirium is an often-discussed yet controversial side effect of benzodiazepines (Zaal, 2015). Our study sought to assess prevalence of benzodiazepine prescriptions at a large academic medical center as part of an implementation study of a hospital-wide delirium screening tool.
Methods: All inpatient patient encounters from July 2014 to September 2018 were queried from the medical record to investigate the impact of a delirium screening protocol. In addition to demographic information, data obtained included the results of the Brief Confusion Assessment Method (bCAM), all medications prescribed while inpatient, all diagnoses, and outcome markers such as length of stay and disposition. Patient encounters were then compared for presence of benzodiazepines prescribed or non-prescribed as well as bCAM positive or negative.
Results: Benzodiazepines were prescribed to 45,449 hospitalized patients since 2014, representing 24% of all patients. A delirium screening protocol with the bCAM was implemented in 2017 on non-ICU units, screening a total of 36,700 patients with 6,998 (19%) screening positive. Of patients screened for delirium, 13,817 (38%) were prescribed benzodiazepines during hospitalization. Twenty-eight percent (3,931) of benzodiazepine-prescribed patients screened positive for delirium, compared with 13% (3,067) of non-benzodiazepine patients (RR 2.12, 95% CI 2.03-2.21).
Discussion: This study provides one of the largest populations for a benzodiazepine-delirium correlative assessment and demonstrates a preserved increased delirium risk in non-ICU settings. Benzodiazepines were frequently prescribed at our institution, at rates consistent with previous literature (Pek, 2017; Zhang X, 2017). While the authors expected benzodiazepines to be associated with increased risk of delirium, these results demonstrate a markedly stronger correlation than previously demonstrated (Pisani, 2009). Benzodiazepine-prescribed patients comprised just over one-third of the study population, yet more than half of all bCAM positive results.
Conclusion: Benzodiazepines remain highly prevalent among non-ICU inpatients and are strongly correlated with increased rate of delirium. Further research regarding delirium in all inpatient settings should include significant consideration of benzodiazepines.
Pek E, Remfry A, Pendrith C, Fan-Lun C, Bhatia R, Soong C: High prevalence of inappropriate benzodiazepine and sedative hypnotic prescriptions among hospitalized older adults. J. Hosp. Med 2017; 5:310-316.
Pisani M, Murphy T, Araujo K, Slattum P, Van Ness P, Inouye S: Benzodiazepine and opioid use and the duration of intensive care unit delirium in an older population. Crit Care Med 2009; 37(1):177-83.
Zaal, I.J., Devlin, J.W., Hazelbag, M. et al: Benzodiazepine-associated delirium in critically ill adults. Intensive Care Med 2015; 41: 2130-2137.
Zhang X, Zhou S, Pan K, et al. Potentially inappropriate medications in hospitalized older patients: a cross-sectional study using the Beers 2015 criteria versus the 2012 criteria. Clin Interv Aging 2017; 12:1697-1703.