Department of Pharmacy, Mayo Clinic-Rochester, Rochester, MN, USA.
Department of Pharmacy, Mayo Clinic-Rochester, Rochester, MN, USA.
Am J Emerg Med. 2023 May;67:156-162. doi: 10.1016/j.ajem.2023.02.032. Epub 2023 Mar 1.
To examine the safety and effectiveness of benzodiazepines (BZD) as compared to antipsychotics for the management of acute agitation in older adults in the emergency department (ED).
Retrospective observational cohort study of 21 EDs across four states in the US, including adults ≥60 years old who received either BZD or antipsychotics for acute agitation in the ED and subsequently were admitted to the hospital. Safety was measured as presence of adverse events: respiratory depression, cardiovascular effects, extrapyramidal side effects, or a fall during hospitalization. Effectiveness was measured as indicators of treatment failure: need for additional medication, one-to-one observation, or physical restraints following initial medication administration. Proportions and odds ratios with 95% confidence intervals (CI) were calculated. Univariable and multivariable logistic regression were used to assess the association between potential risk factors and for efficacy and safety endpoints.
A total of 684 patients were included (63.9% received a BZD and 36.1% an antipsychotic). There was no difference in the incidence of adverse events between groups (20.6% vs 14.6%, difference 6.0%, 95% CI -0.2% to 11.8%), but there was a higher intubation rate in the BZD group (2.7% vs 0.4%, difference 2.3%). There were more treatment failures in the antipsychotic group for the composite primary efficacy endpoint (94.3% vs 87.6%, difference 6.7%, 95% CI 2.5% to 10.9%). This appears to have been driven by the need for 1:1 observation; sensitivity analysis excluding 1:1 observation in the composite outcome demonstrated no significant difference with a failure rate of 38.5% in the antipsychotic group and 35.2% in the benzodiazepine group.
Overall there are high rates of treatment failure among agitated older adults receiving pharmacological treatment for agitation in the emergency department. The optimal selection of pharmacological treatment for agitation in older adults should be made considering patient-specific factors that could increase the risk of adverse effects or treatment failure.
研究苯二氮䓬类药物（BZD）与抗精神病药相比，在急诊科（ED）治疗老年患者急性激越的安全性和有效性。
这是一项在美国四个州的 21 个急诊科进行的回顾性观察性队列研究，纳入年龄≥60 岁、在急诊科接受 BZD 或抗精神病药治疗急性激越且随后住院的成年人。安全性通过不良反应的发生情况来衡量：呼吸抑制、心血管效应、锥体外系副作用或住院期间跌倒。有效性通过治疗失败的指标来衡量：初始药物治疗后需要额外药物、一对一观察或身体约束。计算了比例和 95%置信区间（CI）的比值比。采用单变量和多变量逻辑回归评估潜在风险因素与疗效和安全性终点的相关性。
共纳入 684 例患者（63.9%接受 BZD，36.1%接受抗精神病药）。两组不良反应发生率无差异（20.6%比 14.6%，差异 6.0%，95%CI-0.2%至 11.8%），但 BZD 组插管率较高（2.7%比 0.4%，差异 2.3%）。抗精神病药组主要复合疗效终点的治疗失败率更高（94.3%比 87.6%，差异 6.7%，95%CI2.5%至 10.9%）。这似乎是由于需要一对一观察；排除复合结局中的一对一观察的敏感性分析显示，抗精神病药组的失败率为 38.5%，BZD 组的失败率为 35.2%，差异无统计学意义。
急诊科接受药物治疗的激越老年患者总体治疗失败率较高。在选择治疗老年激越的药物时，应考虑到可能增加不良反应或治疗失败风险的患者特定因素。
