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Jivalagian P, Gettel CJ, Smith CM, Robinson L, Brinker M, Shah D, Kumar A, Faustino IV, Nath B, Chang-Sing E, Taylor RA, Kennedy M, Hwang U, Wong AH. Racial, Ethnic, and Age-Related Disparities in Sedation and Restraint Use for Older Adults in the Emergency Department. Am J Geriatr Psychiatry 2024:S1064-7481(24)00398-1. [PMID: 39054237 DOI: 10.1016/j.jagp.2024.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2024] [Revised: 07/01/2024] [Accepted: 07/03/2024] [Indexed: 07/27/2024]
Abstract
OBJECTIVES Older adults may present to the emergency department (ED) with agitation, a symptom often resulting in chemical sedation and physical restraint use which carry significant risks and side effects for the geriatric population. To date, limited literature describes the patterns of differential restraint use in this population. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS This retrospective cross-sectional study used electronic health records data from ED visits by older adults (age ≥65 years) ranging 2015-2022 across nine hospital sites in a regional hospital network. Logistic regression models were estimated to determine the association between patient-level characteristics and the primary outcomes of chemical sedation and physical restraint. RESULTS Among 872,587 ED visits during the study period, 11,875 (1.4%) and 32,658 (3.7%) encounters involved the use of chemical sedation and physical restraints respectively. The populations aged 75-84, 85-94, 95+ years had increasingly higher odds of chemical sedation [adjusted odds ratios (AORs) 1.35 (95% CI 1.29-1.42); 1.82 (1.73-1.91); 2.35 (2.15-2.57) respectively] as well as physical restraint compared to the 65-74 group [AOR 1.31 (1.27-1.34); 1.55 (1.50-1.60); 1.69 (1.59-1.79)]. Compared to the White Non-Hispanic group, the Black Non-Hispanic and Hispanic/Latinx groups had significantly higher odds of chemical sedation [AOR 1.26 (1.18-1.35); AOR 1.22 (1.15-1.29)] and physical restraint [AOR 1.12 (95% CI 1.07-1.16); 1.22 (1.18-1.26)]. CONCLUSION Approximately one in 20 ED visits among older adults resulted in chemical sedation or physical restraint use. Minoritized group status was associated with increasing use of chemical sedation and physical restraint, particularly among the oldest old. These results may indicate the need for further research in agitation management for historically marginalized populations in older adults.
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Affiliation(s)
- Patelle Jivalagian
- Department of Emergency Medicine (PJ, CJG, LR, DS, AK, IVF, BN, ECS, RAT, AHW), Yale School of Medicine, New Haven, CT
| | - Cameron J Gettel
- Department of Emergency Medicine (PJ, CJG, LR, DS, AK, IVF, BN, ECS, RAT, AHW), Yale School of Medicine, New Haven, CT
| | - Colin M Smith
- Hubert-Yeargan Center for Global Health (CMS), Duke University, Durham, NC
| | - Leah Robinson
- Department of Emergency Medicine (PJ, CJG, LR, DS, AK, IVF, BN, ECS, RAT, AHW), Yale School of Medicine, New Haven, CT
| | - Morgan Brinker
- Department of Emergency Medicine, Yale School of Medicine (MB), New Haven, CT
| | - Dhruvil Shah
- Department of Emergency Medicine (PJ, CJG, LR, DS, AK, IVF, BN, ECS, RAT, AHW), Yale School of Medicine, New Haven, CT
| | - Anusha Kumar
- Department of Emergency Medicine (PJ, CJG, LR, DS, AK, IVF, BN, ECS, RAT, AHW), Yale School of Medicine, New Haven, CT
| | - Isaac V Faustino
- Department of Emergency Medicine (PJ, CJG, LR, DS, AK, IVF, BN, ECS, RAT, AHW), Yale School of Medicine, New Haven, CT
| | - Bidisha Nath
- Department of Emergency Medicine (PJ, CJG, LR, DS, AK, IVF, BN, ECS, RAT, AHW), Yale School of Medicine, New Haven, CT
| | - Erika Chang-Sing
- Department of Emergency Medicine (PJ, CJG, LR, DS, AK, IVF, BN, ECS, RAT, AHW), Yale School of Medicine, New Haven, CT
| | - R Andrew Taylor
- Department of Emergency Medicine (PJ, CJG, LR, DS, AK, IVF, BN, ECS, RAT, AHW), Yale School of Medicine, New Haven, CT; Department of Biomedical Informatics and Data Science (RAT), Yale School of Medicine, New Haven, CT
| | - Maura Kennedy
- Department of Emergency Medicine (MK), Massachusetts General Hospital, Boston, MA; Department of Emergency Medicine (MK), Harvard Medical School, Boston, MA
| | - Ula Hwang
- Department of Emergency Medicine (UH), New York University Grossman School of Medicine, New York, NY; Geriatric Research Education and Clinical Center (UH), James J. Peters VAMC, Bronx, NY
| | - Ambrose H Wong
- Department of Emergency Medicine (PJ, CJG, LR, DS, AK, IVF, BN, ECS, RAT, AHW), Yale School of Medicine, New Haven, CT.
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Sun S, Lomachinsky V, Smith LH, Newhouse JP, Westover MB, Blacker D, Schwamm L, Haneuse S, Moura LMVR. Benzodiazepine Initiation and the Risk of Falls or Fall-Related Injuries in Older Adults Following Acute Ischemic Stroke. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.02.06.24302430. [PMID: 38370813 PMCID: PMC10871457 DOI: 10.1101/2024.02.06.24302430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/20/2024]
Abstract
Background Benzodiazepine use in older adults following acute ischemic stroke (AIS) is common, yet short-term safety concerning falls or fall-related injuries remains unexplored. Methods We emulated a hypothetical randomized trial of benzodiazepine use during the acute post stroke recovery period to assess incidence of falls or fall related injuries in older adults. Using linked data from the Get With the Guidelines Registry and Mass General Brigham's electronic health records, we selected patients aged 65 and older admitted for Acute Ischemic Stroke (AIS) between 2014 and 2021 with no documented prior stroke and no benzodiazepine prescriptions in the previous 3 months. Potential for immortal-time and confounding biases was addressed via separate inverse-probability weighting strategies. Results The study included 495 patients who initiated inpatient benzodiazepines within three days of admission and 2,564 who did not. After standardization, the estimated 10-day risk of falls or fall-related injuries was 694 events per 1000 (95% confidence interval CI: 676-709) for the benzodiazepine initiation strategy and 584 events per 1000 (95% CI: 575-595) for the non-initiation strategy. Subgroup analyses showed risk differences of 142 events per 1000 (95% CI: 111-165) and 85 events per 1000 (95% CI: 64-107) for patients aged 65 to 74 years and for those aged 75 years or older, respectively. Risk differences were 187 events per 1000 (95% CI: 159-206) for patients with minor (NIHSS≤ 4) AIS and 32 events per 1000 (95% CI: 10-58) for those with moderate-to-severe AIS. Conclusions Initiating inpatient benzodiazepines within three days of AIS is associated with an elevated 10-day risk of falls or fall-related injuries, particularly for patients aged 65 to 74 years and for those with minor strokes. This underscores the need for caution with benzodiazepines, especially among individuals likely to be ambulatory during the acute and sub-acute post-stroke period.
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