Evidence base: Elderly people have increased sensitivity to side effects from sedation, thus increasing the risk of falls and fractures.
The latest National Institute for Clinical Excellence (NICE) guidance for management of delirium no longer advocates a role for benzodiazepines as first line pharmacological treatment.
There are guidelines regarding different aspects of sedative prescription in various clinical contexts e.g. Alzheimer's Disease (AD), Lewy Body Dementia (DLB); but no guideline that combines these into a single protocol.
Change strategies: 476 sets of patient notes and drug charts were analysed using a proforma. Data was collected across all wards at Newham university hospital (NUH) (excluding paediatrics, intensive care and maternity). This was conducted on 2 days in May 2012 and 2 days in December 2013. We compared prescribing practise with the latest British Geriatrics Society (2006) and NICE (2010) guidelines.
Intervention consisted of departmental meeting presentations and development of a local protocol. This incorporated prescribing in delirium on a background of AD and DLB.
Change effects: 2012 data:32/476 (14%) patients were prescribed a new sedative. 22/32 (69%) had documented delirium, 12/32 (38%) dementia (some in addition to delirium) and 2/32 (6%) alcohol excess.
23/32 (72%) had a medication review and 30/32 (94%) a documented reason for sedation.
A variety of medications were used. 9/32 (28%) prescriptions were for end of life agitation, 10/32 (31%) were for delirium and 13/32 (41%) for insomnia. 4/32 (13%) prescriptions were inappropriate (trazadone, quetiapine, diazepam and temazepam).
2013 data: Overall sedative prescriptions were similar but new benzodiazepine prescriptions fell to 15 (6%) with improvements in documentation, medication reviews and documented side effects.
Conclusions: This audit shows low levels of sedative prescribing in the >75yrs. The majority of prescribing is appropriate.
The implementation of a Bart's Health trust-wide new clinical guideline should increase compliance further.