Older adults in behavioural emergencies are sedated more often, mostly with benzodiazepines

Design

Nationwide cross-sectional study of EMS encounters

Population

1,468,697 US ambulance encounters for behavioural emergencies in 2023

Primary outcome

Use of chemical sedation and physical restraint by age

Effect

Sedation 69.2% vs 61.3%; benzodiazepines 52.8% vs 45.3% in older vs younger adults

This US cross-sectional study examined 1,468,697 advanced life support ambulance encounters for behavioural health emergencies in 2023; 16.3% involved adults aged 65 or over.

Among encounters needing sedation or restraint, older adults were more often sedated (69.2% vs 61.3%) and less often restrained (39.7% vs 52.7%) than younger adults. Benzodiazepines were used more often in older adults (52.8% vs 45.3%), antipsychotics at similar rates (15.4% vs 14.9%) and ketamine slightly less (5.5% vs 6.6%).

Agitation in an older person is often delirium, and benzodiazepines can worsen delirium and cause respiratory depression and falls. Prehospital protocols are mostly written for younger adults. The study is descriptive and cannot say whether sedation was appropriate in individual cases, but it points to a gap in protocols and training for older patients.

• Consider delirium first when an older adult presents with acute agitation, and look for a cause.
• Avoid benzodiazepines for agitation in older adults except for alcohol or benzodiazepine withdrawal or seizures.
• Use de-escalation and the lowest effective dose of any sedative, with monitoring.
• Work with local emergency services on age-specific agitation protocols.

Why it matters

Benzodiazepines were the commonest sedative for older adults despite worsening delirium.

Don't overread it

Descriptive data from a convenience sample; it does not show harm in individual cases.

The statistics, in plain English

These are simple proportions from a very large sample, so small differences are precise but not necessarily clinically important. The key figure is that more than half of sedated older adults received a benzodiazepine.

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