Rising concerns over benzodiazepine prescriptions in older stroke survivors

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. 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."

Julianne Brooks, M.P.H., study co-author, data analytics manager at the Center for Value-based Healthcare and Sciences at Massachusetts General Brigham, Boston

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.