Abstract
Background
Unintentional falls are the leading cause of injury among adults 65 years and older. It’s believed that adverse benzodiazepine side effects increase the risk and frequency of falls. We hypothesize that geriatric patients taking benzodiazepines prior to admission experience worse clinical outcomes compared to those without preadmission use.
Methods
Using our level 1 trauma database, patients 65 years or older admitted following a ground level fall were divided into 2 groups, benzodiazepines positive on admission urine drug screen (+Benzo) and negative (−Benzo). Primary outcomes included in-hospital complications with additional outcomes including ICU admission rates, ICU LOS, overall hospital LOS, injury pattern data, and Injury Severity Score (ISS).
Results
11 133 patients were included with 764 in the +Benzo group. There was no difference in Injury Severity Score between the two groups (6.1 vs 5.7, P = .140). The + Benzo group had a higher percentage of TBI (39.7% vs 29.8%, P < .001), rib fractures (12.7% vs 9.1%, P = .001), and extremity fractures (49.9% vs 43.2%, <.001) with no difference in ISS (6.1 vs 5.7, P = .140). The + Benzo group had higher ICU admission rates (25.8% vs 17.7%, P < .001) and experienced more cardiac arrests (2.2% vs 1.0%, P = .004), pulmonary embolus (4.6% vs 3.1%, P = .032), and pneumonia/VAP (0.65% vs 0.15%, P = .008). On multivariable analysis, benzodiazepines prior to admission were an independent predictor of in-hospital complications (OR: 1.60, CI: 1.18-2.17, P = .003).
Discussion
Our study identifies pre-hospital benzodiazepine use and its association with worse in-hospital outcomes. Our findings can be used to identify high-risk fall patients on admission to mobilize additional resources to reduce the risk of adverse in-hospital outcomes.
Keywords
• Pre-hospital benzodiazepine use detected on admission urine drug screens following a ground level fall has been shown to be associated with increased burden of TBIs, spinal, pelvic and extremity fractures as well as contribute to worse in-hospital outcomes compared to those without pre-hospital use. • Benzodiazepine-positive patients were found to have increased ICU admission rates and ICU length of stay in additional to experienced more in-hospital complications including cardiac arrests, pneumonias, and pulmonary embolus. • Admitted geriatric trauma patients with pre-hospital benzodiazepine use detected on admission urine drug screen were more likely to be discharged to skilled nursing facilities and less likely to return to their home following admission, resulting in a loss of independence.Key Takeaways
Introduction
In the United States, unintentional falls are the leading cause of injury among adults aged 65 years and older, with those who survive experiencing significant disability and possible loss of independence.1,2 As the aging population continues to expand, understanding modifiable risk factors for falls becomes increasingly critical. Within the United States, the proportion of the population 65 years and older is projected to increase from 18% to 23% by 2054. 3 Falls in older adults account for nearly 3 million emergency department visits annually, resulting in over 800 000 hospitalizations and an estimated 38 742 deaths in the year 2021.1,4 The financial burden associated with hip fractures due to falls is estimated at approximately $5.96 billion in direct medical costs annually. 5
Risk factors associated with falls within this population include malnutrition, smoking, alcohol use, hypertension, diabetes, and polypharmacy. 6 Polypharmacy is highly prevalent among those 65 years and older, with one study looking at over 2 billion office visits for patients within this age group demonstrating at least some degree of polypharmacy in 65% of visits, with over 36% of individuals reporting more than 5 medications. 7 Benzodiazepines commonly prescribed for anxiety, insomnia, and related disorders frequently contribute to polypharmacy regimens in older adults. Additionally, one study showed approximately one-third of new benzodiazepine prescription lengths to be longer than 120 days. 8 Geriatric patients are particularly vulnerable to adverse benzodiazepine effects because of age-related pharmacokinetic and pharmacodynamic changes, leading to prolonged drug action and increased sensitivity. Benzodiazepine use in elderly individuals has been associated with several adverse outcomes including falls, fractures, motor vehicle collisions, and cognitive impairment, with some studies even suggesting a link to an increased risk of dementia. 9 Recognizing this heightened risk, the American Geriatrics Society created the Beers Criteria, which outlines guidelines aimed at improving medication safety in older adults. These guidelines aim to identify medications, such as benzodiazepines, that pose considerable health risks to geriatric individuals. A recent update has now listed all benzodiazepines as inappropriate for use in older adults due to their high-risk side effect profile within this population. 10
Understanding the relationship between benzodiazepine use and fall-related outcomes becomes crucial given the anticipated growth of this population over the next decade. Side effects such as decreased reaction time, disrupted balance, disrupted gait, sedation, and impaired vision are all believed to contribute to the increased risk and frequency of falls within this population. 8 Clarifying this relationship will allow health care providers to better manage medication prescriptions, enhance patient safety protocols, and improve overall care. With this in mind, our study hypothesizes that geriatric patients taking benzodiazepines prior to admission experience worse clinical outcomes after falls compared to those without preadmission use of benzodiazepines.
Methods
We utilized the trauma registry database at our level 1 trauma center for this study. As a de-identified database, this study was deemed exempt by our institutional review board and a waiver of consent was granted. The database was queried from January 2018 through December 2024 for geriatric trauma patients aged 65 years and older that were evaluated after a fall mechanism. Patients were divided into 2 groups. The first group consisted of patients with benzodiazepines on urine drug screen (+Benzo) at the time of admission. The second group consisted of all remaining geriatric fall patients with a urine drug screen negative for benzodiazepines (−Benzo) at the time of admission. The primary outcome was in-hospital complication rates, which included pneumonia, acute respiratory distress syndrome (ARDS), cardiac arrest, cerebrovascular accident (CVA), deep venous thrombosis, pulmonary embolism, myocardial infarction, and acute kidney injury.
Demographic data points that were collected included age, sex, and comorbidities including congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), myocardial infarction (MI), and chronic kidney disease. The injury data collected included traumatic brain injury, thoracic injury, solid organ and hollow viscus injuries, as well as extremity and spine fractures, and the Injury Severity Score (ISS). Additional outcomes evaluated were intensive care unit (ICU) admission, ICU length of stay (LOS), and hospital LOS.
All bivariate analyses were performed with IBM SPSS Statistics for Windows (Version 29, IBM Corp., Armonk, NY). A Mann-Whitney-U test was used to compare continuous variables, and a chi-square was used to compare categorical variables in the bivariate analysis. Categorical data was presented as percentages while continuous data was presented as a mean with standard deviation. We then performed a multivariable logistic regression analysis to determine the risk of complications after ground level fall for patients on benzodiazepines compared to those not on benzodiazepines. We adjusted for potential confounders, which were selected based on discussion among coauthors, review of the literature, and identifying univariate statistically significant differences between proposed confounding variables. These included age, ISS, ICU admission, and comorbidities. P-values were defined as statistically significant if < 0.05.
Results
Demographics and Comorbidities of Geriatric Fall Patients on Benzodiazepines Compared to Those not on Benzodiazepines
SD, standard deviation; ISS, Injury Severity Score; COPD, chronic obstructive pulmonary disease.
Injury Patterns for Geriatric Fall Patients on Benzodiazepines compared to Those not on Benzodiazepines
Clinical Outcomes in Geriatric Fall Patients on Benzodiazepines Compared to Those not on Benzodiazepines
LOS, length of stay; SD, standard deviation; ICU, intensive care unit; AIS, Abbreviated Injury Scale; GCS, Glasgow Coma Scale; CVA, cerebrovascular accident; VAP, ventilator-associated pneumonia.
Multivariable Logistic Regression Analysis for Risk of In-Hospital Complication After Fall in Geriatric Patients
ICU, intensive care unit.
Discussion
While the adverse outcomes associated with benzodiazepine use within the geriatric population are well documented by prior studies, our study highlights the risk associated with preadmission benzodiazepine use within geriatric fall patients. Geriatric fall patients who were benzodiazepine positive on trauma admission urine drug screen were more likely to be admitted to the ICU with longer ICU length of stay and overall hospital length of stay. Those individuals were also found to have a higher incidence of TBI, spinal fractures, rib fractures, and extremity fractures when compared to their benzodiazepine-negative counterparts. Once admitted, these individuals experienced a higher burden of complications including cardiac arrest, pneumonia, and pulmonary embolism. Lastly, our study shows that the +Benzo group patients were less likely to be discharged back home compared to their −Benzo counterpart and more likely to require Skilled Nursing Facility (SNF) placement.
Our study demonstrated that geriatric patients presenting as benzodiazepine-positive were more likely to be admitted to the ICU compared to their benzodiazepine-negative counterparts, despite having no overall difference in ISS. While there was no increase in injury severity, there was an overall higher incidence of certain injury patterns that are typically monitored in ICU settings in geriatric patients. One study evaluating benzodiazepine use showed this medication class is associated with reduced levels of serum vitamin D as well as decreased osteoblast differentiation through benzodiazepine-like receptors on bone. 11 These adverse medication effects are believed to play a role in decreased bone mineral density, placing geriatric individuals who use this medication long term at an increased risk for traumatic fractures following a fall. These injury patterns might require ICU level of care prompting admission for overnight respiratory or neurologic monitoring. In another study, pre-injury controlled substance use (including benzodiazepines) among older fall patients was associated with significantly increased ICU days and greater need for mechanical ventilation. Though that study did not separate benzodiazepine users from opioid users, their combined cohort still exhibited increased ICU and ventilation demands, suggesting sedative exposure is related to ICU LOS. 12
Our study demonstrated an increased incidence of in-hospital complications seen within our + Benzo group compared to our −Benzo group. One explanation is that benzodiazepines can decrease mental alertness, resulting in aspiration, potential respiratory arrest, and ultimately cardiac arrest. However, this could also be due to the higher incidence of certain comorbidities seen in the +Benzo group placing these individuals at an increased risk for such complications. Aligned with current literature, those with pre-existing heart failure are at an increased risk for in-hospital cardiac arrest with worse outcomes in these patients than those without underlying heart failure. 13 Additionally, the interplay between CHF, CKD, and benzodiazepine use could be the reason for increased cardiac arrest. In one study, benzodiazepine use in older patients with chronic CHF was independently associated with a 36% increase in all-cause mortality in patients with concurrent underlying CKD. 14 This suggests that benzodiazepines may exacerbate underlying heart failure and renal dysfunction, driving the worse in-hospital outcomes we observed in our study. However, our study did find benzodiazepine use in the pre-hospital setting to independently predict in-hospital complications after fall, even after controlling for comorbidities. With this information, increased awareness of this finding could help reduce benzodiazepine prescriptions in the outpatient setting or prompt closer prescription monitoring by primary care providers prescribing this medication class.
In addition to in-hospital differences observed among our two groups, we also observed significant differences in the disposition of these patients once their acute injuries were addressed. Those within our + Benzo group were more likely to be discharged to an SNF compared to the −Benzo group, who were more likely to be discharged home. This has been echoed by other studies with geriatric fall patients who were more likely to be discharged to an acute or long-term care facility vs back home. 15 Loss of independence following a fall-related admission is a well-known concern among patients, with many patients reporting a decline in ADLs from preadmission baseline after discharge which is likely attributed to in-hospital deconditioning and complications. 16 One study even highlighted that controlled substance users were more often discharged to long-term care facilities, aligning with our observation of fewer discharges to home. 12
While the results of our study echo that of existing literature, there are some limitations to our research. First is the retrospective nature of our study which places reliance on pre-existing records for data collection. This can pose challenges if aspects being evaluated are inaccurately reported or documentation is incomplete. While benzodiazepine administration in the pre-hospital EMS course for geriatric trauma falls outside of our usual practice patterns within our county, this data was not captured by the data obtained for this study. We do not administer benzodiazepines for geriatric trauma within our trauma evaluation and if given during hospitalization, would have been administrated after admission urine drug screen, likely in the setting of alcohol withdrawal during the course of the hospitalization. Additionally, during our study we failed to identify the reason for benzodiazepine prescription as well as the length of treatment received in the prehospital setting, which could have modulated our results. Long-term use (>3 months) of benzodiazepines has been associated with poor outcomes in the geriatric population, and subgroup analysis evaluating outcomes after fall in long-term users compared to short-term users would be useful.
The adverse risks of benzodiazepine use within the geriatric population are well documented with practice guidelines such as the Beers criteria highlighting this risk to providers and deterring the use within this population. Geriatric individuals often experience the negative side effects of polypharmacy, possibly exacerbating the negative side effects of benzodiazepine and increasing the risk of falls due to possible sedation, impaired gait, and balance. While many studies evaluate the outcomes associated with benzodiazepine use in the inpatient setting, few look at pre-hospital benzodiazepine use and its effect on in-hospital outcomes. Our study identifies pre-hospital benzodiazepine use as an indicator for worse in-hospital outcomes, which can be used on admission to mobilize additional resources within this patient population. While more research on this topic is necessary to fully understand the long-term impacts on pre-hospital benzodiazepine use within geriatric fall patients, our study is an important step in promptly identifying high-risk patients at the time of trauma admission to hopefully reduce the incidence of in-hospital complications.
Footnotes
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.