International Comparison of Benzodiazepine Prescription for Older Adults in Acute Care Hospitals

Benzodiazepines (BZD) are harmful to older adults. They are associated with increased mortality [1], and increased hospitalization-associated complications (HAC), such as delirium [2] and falls [3]. Despite these known adverse events, BZD use remains prevalent in older adults and represents a potentially modifiable risk factor for adverse outcomes. Although acute care hospitals are at particularly high risk for HAC from BZD usage, there has been little systematic research into the prescribing practices of BZD. The purpose of this study was to investigate the current status of BZD prescriptions, including Z-drugs (ZD), in acute care hospitals in the United States and Japan, where guidelines recommend reducing and discontinuing BZD [4, 5], and to conduct an international comparison. We conducted a retrospective, observational, cross-sectional study. Data collection was conducted at two high-acute care university hospitals: The University of North Carolina at Chapel Hill School of Medicine (UNC) in Chapel Hill, NC, USA and Nagoya University Hospital (NUH) in Nagoya, Aichi, Japan. Inclusion criteria were patients aged 65 years or older who were admitted to an internal medicine ward, including geriatrics, at UNC or NUH, between January 1, 2023, and December 31, 2024. Patients admitted to the oncology or intensive care units were excluded. Medical information on medications administered during hospital admission and age was collected and analyzed. Prescription rates of BZD and ZD were compared using the Chi-square test. UNC enrolled 61 790 and NUH enrolled 4953 patients. The comparison of BZD prescription is shown in Table 1. During the study period, 2291 patients were admitted to the geriatrics at UNC, of which 501 were prescribed BZD and 17 were prescribed ZD (prescription rates: BZD 21.9%, ZD 0.7%). On the other hand, 59 499 were admitted to internal medicine wards without geriatrics, of which 17 934 were prescribed BZD and 896 were prescribed ZD (prescription rates: BZD 30.1%, ZD 1.5%). Prescription rates for both BZD and ZD were significantly lower in the geriatrics than in other internal medicine wards. At NUH, 278 patients were admitted to geriatrics, of which 22 were prescribed BZD and 10 were prescribed ZD (prescription rates: BZD 7.9%, ZD 3.6%). Meanwhile, 4675 patients were admitted to internal medicine wards without geriatrics, of which 364 were prescribed BZD and 248 were prescribed ZD (prescription rates: BZD 7.8%, ZD 5.3%). There was no statistically significant difference in the prescription rates of either BZD or ZD between the geriatrics and other internal medicine wards. This survey revealed that BZD or ZD were prescribed to 31.3% of all older adults hospitalized at UNC and 13.0% at NUH. The rate of BZD use among older people is reported to vary between 10% and 42% depending on the research field [2], and our results fell within this range. In the United States, the rate of BZD use increases with age, and is reported to be 8.7% among those aged 65 to 80, The long-term use rate among that age group is 31.4% [6]. The UNC cohort likely includes many long-term users of BZD. In Japan, the use of BZD in patients aged 65 years or older was 14.5% [7], it is similar to the result of NUH. Acute geriatric wards are known for improving prescription rates by providing a patient-centered approach and a multidisciplinary team [8]. In this study, prescription rates for BZD's were significantly lower in the geriatrics at UNC compared to the general wards. However, at NUH, there was no difference. This may be because even for patients admitted to geriatrics in Japan, many patients are usually prescribed medication by their local general practitioners, so geriatric considerations for BZD reduction are not always taken into account. BZD remain a potential modifier of adverse events in acute care hospitals. However, BZD reduction efforts remain limited due to the lack of evidence-based tapering methods and concerns about withdrawal symptoms, both of which discourage physicians from reducing BZD. A multidisciplinary approach involving not only doctors but also other professionals is one effective approach to overcome the barriers associated with reducing BZD. It has been reported that intervention by a multidisciplinary team, including pharmacists, during hospitalization can reduce the amount of psychotropic medication [9]. The strengths of this study are that prescription rates were investigated using accurate data collected from electronic medical records. Limitations of this study include a sample size of only two institutions and limited data collection over a short period of time. Current study revealed the prescription of BZD in acute care hospitals remains prevalent. This new evidence supports the need for protocols for BZD prescription reduction in the acute care setting. These protocols will need to be developed and implemented in multidisciplinary collaboration. The study followed the principles of the Declaration of Helsinki. The study was approved by the ethical committee of the Nagoya University Graduate School of Medicine (2024-0293). The authors declare no conflicts of interest. The data that support the findings of this study are available from the corresponding author upon reasonable request.