- Design
- Nationwide cross-sectional study of a convenience sample of 911 EMS encounters
- Population
- 1,468,697 EMS encounters for behavioural health emergencies managed by advanced life support units in the United States during 2023; 238,754 (16.3%) in adults aged 65+
- Primary outcome
- Use of physical restraint or chemical sedation, stratified by age group
- Effect
- Sedation in 69.2% of older versus 61.3% of younger adults; restraint 39.7% versus 52.7%; benzodiazepines 52.8% versus 45.3%; antipsychotics 15.4% versus 14.9%; ketamine 5.5% versus 6.6%
Acute agitation in an older person reaching an ambulance crew is one of the highest-risk encounters in prehospital care, and the protocols crews work from are largely written for younger patients. This is the first nationwide description of what actually happens.
A cross-sectional evaluation of a nationwide convenience sample of 911 EMS encounters during 2023 identified 1,468,697 encounters for behavioural health emergencies managed by advanced life support units, of which 238,754 (16.3%) involved someone aged 65 or over. Chemical sedation or physical restraint was used in 65,088 encounters, including 5,915 older adults (9.1% of the older-adult encounters).
Older adults were more likely to be chemically sedated than younger adults (69.2% versus 61.3%) and less likely to be physically restrained (39.7% versus 52.7%). Among those sedated or restrained, benzodiazepines were used more often in older adults (52.8% versus 45.3%), antipsychotics at similar rates (15.4% versus 14.9%) and ketamine slightly less often (5.5% versus 6.6%).
The benzodiazepine figure is the one to sit with. It is the drug class most consistently identified as inappropriate in older adults, it is on every deprescribing list, and it is the one most often reached for in exactly the group where delirium, falls and respiratory depression are the predictable consequences. And the agitation prompting it is frequently delirium from a cause that sedation will obscure.
- Ask what was given prehospital before attributing ongoing drowsiness to the presenting illness
- Agitation in an older adult is delirium until proven otherwise — look for the cause
- Benzodiazepine exposure begins before the emergency department in many of these patients
- This is a convenience sample of EMS records, not a complete national census
- Prehospital protocols for agitation are a target for geriatric input in your own system
Why it matters
The drug class geriatricians work hardest to remove is the one most often given before the patient reaches hospital.
Don't overread it
A convenience sample of EMS records without adjustment for presentation severity or cause of agitation.
The statistics, in plain English
These are descriptive proportions from a convenience sample, so they show what was recorded rather than what happened across the whole country, and no adjustment was made for how sick or agitated the patients were. The comparison between age groups is also confounded by cause — older adults presenting with agitation are more often delirious and less often intoxicated, which changes both the appropriate response and what a crew is likely to reach for.
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