New sedative prescription at hospital discharge linked to higher risk of falls, health-care utilization and death

Published in the Canadian Medical Association Journal, the study found that older adults who leave hospital with a new prescription for sedative medications have a 20 percent higher risk of falls, visits to the emergency department (ED) and readmission to hospital, and 80 percent increased risk of dying within a month of discharge. 

Led by Dr. Lisa Burry, clinician scientist at Mount Sinai Hospital, Sinai Health, it is the first investigation of the outcomes linked to prescribing sedatives for older adults at hospital discharge. 

“In the hospital, we often prescribe these medications as they are an important component of acute care. But as patients get better and they leave the hospital, these medications are often no longer needed. We wanted to understand if these medications are continued post-discharge and whether they are associated with harm given that they are considered to be risky medications for most older adults," said Dr. Burry, who is also an associate professor at the Leslie Dan Faculty of Pharmacy at the University of Toronto. 

The study brought together an interdisciplinary team from Sinai Health, Sunnybrook Health Sciences Centre, the University of Toronto, the University of Montreal, King’s College London and Weill Cornell Medicine in the U.S.

To find out, the research team turned to administrative and prescription data from the ICES, Ontario’s hub for population-level health data. Drawing on the records of more than 1.86 million people aged 66 and older between 2003 and 2023, they tracked which medications patients had been taking before hospital admission, and which new prescriptions were filled within a week of hospital discharge. 

Of the total, 13 per cent, or 246,440 patients, filled at least one sedative prescription within a week of discharge and about one-third, or 76,335 patients, had not filled a prescription for a sedative in the past and were considered new to the medications. The sedative medications examined included benzodiazepines, sedating antidepressants like mirtazapine and trazodone, and antipsychotics all of which are frequently prescribed in hospital for sleep and delirium.

The contrast with patients who were already taking sedatives before admission was striking. Their risk of falling, ED visits or readmissions were not significantly increased. The finding underscores how much context matters when introducing new drugs for older adults upon discharge, said Dr. Burry.

The timing of the adverse events, Dr. Burry also notes, tells us important information for follow-up care. “We found the adverse events we examined occurred early after hospital discharge - within 2 weeks,” she says. “Most people fill their prescriptions the day they are discharged, but when are they seeing their health team for follow-up and medication review after discharge? Probably in a month. By then, the adverse events have already happened for more than half of the patients.”

Because the study draws on real-world data such as health records, it points to a strong association rather than proof that these medications alone cause the harm. Dr. Burry stresses that this caveat must be considered in the interpretation of the data, since sicker patients may be more likely to be prescribed these medications.

Toward safer prescribing practices

For Dr. Burry, the findings highlight clinical teams must carefully consider which medications patients need to continue after discharge, weigh the potential risks and benefits of new medications in the acute period post-discharge, and advise what follow-up monitoring may be required. Where possible, doses should be reduced or medications stopped before discharge. When new prescriptions are determined to be necessary, they should be limited to a set time period and this information should be communicated to the receiving team for continued assessment and plan, Dr. Burry said.

Dr. Burry and her team plan to present their findings to the Ministry of Health to help inform policy around safer prescribing practices for older adults leaving acute care. “The harms we identified,” she says, “are impactful for patients and their families. Given the high volumes of hospital admissions among older adults and the aging population, our findings suggest the need for detailed medication review with risk assessment before hospital discharge in Canada.” 

This research was funded by the Canadian Institutes of Health Research and supported by ICES.