Epidemic Use of Benzodiazepines among Older Adults in Israel: Epidemiology and Leverage Points for Improvement

Abstract

Background: Benzodiazepines and benzodiazepine-receptor agonists (BDZRAs, often known as "Z-drugs") are commonly used in older adults despite well-documented harms.

Objective: To evaluate patterns of benzodiazepine and BDZRA use in Israel, focusing on potential leverage points where quality improvement initiatives might effectively curtail new use or the transition from intermittent to chronic use.

Design and participants: We used national electronic medical data to assess a 10% random sample of adults receiving care in Clalit Health Services, which serves half of Israel's population. The sample included 267,221 adults, of whom 56,808 (21%) were age 65 and older.

Main measures: Medication use from 2013 to 2015 was ascertained using pharmacy dispensing data.

Results: In 2014, 7% of adults age 21-64 and 32% of adults age 65 and older received at least one benzodiazepine/BDZRA, including 49% of adults age 85 and older (P < 0.001). The majority of older users (59%) were long-term users of the drugs, and 21% of older adults who were short-term users in 2014 transitioned to medium- or long-term use in 2015. Older Arab Israelis were much less likely to receive benzodiazepine/BDZRAs than older Jewish Israelis (adjusted OR 0.28, 95% 0.25-0.31), but within each community there was no major variation in prescribing rates across clinics. Depression diagnosis was associated with particularly high rates of benzodiazepine/BDZRA use: 17% of older adults with depression received a benzodiazepine/BDZRA but no antidepressant, and 42% received both. Recent hospitalization increased the risk of new benzodiazepine/BDZRA use (adjusted OR 1.41, 95% CI 1.01-1.96), but the absolute risk increase was only 3%.

Conclusions: Benzodiazepines/BDZRAs are used at exceptionally high rates by older Israeli adults, especially the oldest old. Important leverage points for quality improvement efforts include curtailing the transition from short-term to long-term use, reducing use in older adults with depression, and identifying reasons that explain large differences in benzodiazepine/BDZRA prescribing between different ethnic groups.

Keywords: aging; ambulatory care; health services research; pharmaceutical care; pharmacoepidemiology.

Figure 1

Use of benzodiazepine/BDZRAs during 2014, by age. The total height of each bar shows the percentage of people in that age group who received at least one dispensing of a benzodiazepine/BDZRA during 2014. In each age group, use is subdivided into people who received 1–2 dispensings during 2014 (“short-term users”), people who received 3–5 dispensings (“medium-term users”), and those who received 6 or more dispensings (“long-term users”).

Figure 2

Use of benzodiazepines/BDZRAs by older adults in 2015, stratified by extent of use in the preceding year. Each horizontal bar shows the number of benzodiazepine/BDZRA dispensings in 2015. These bars are stratified by the extent of use in the previous year. For example, among older adults receiving no benzodiazepine/BDZRA dispensings in 2014, 10% had at least one dispensing in 2015; most of these adults had only 1–2 dispensings in 2015.

Figure 3

Percentage of people age 65 and older who received a benzodiazepine/BDZRA in 2014, by clinic. Results are adjusted for the distribution of age, sex, and ACG score of patients age 65 years and older within each clinic. Dashed bar shows the prescribing rate for the clinic at the 50th percentile of prescribing (36%).