New and Persistent Sedative Prescriptions Among Older Adults Following a Critical Illness: A Population-Based Cohort Study

Abstract

ICU survivors often have complex care needs and can experience insufficient medication reconciliation and polypharmacy. It is unknown which ICU survivors are at risk of new sedative use posthospitalization. For sedative-naive, older adult ICU survivors, how common is receipt of new and persistent sedative prescriptions, and what factors are associated with receipt? This population-based cohort study included ICU survivors aged≥ 66 years who had not filled sedative prescriptions within≤ 6months before hospitalization (sedative-naive) in Ontario, Canada (2003-2019). Using multilevel logistic regression, demographic, clinical, and hospital characteristics and their association with new sedative prescription within≤ 7days of discharge are described. Variation between hospitals was quantified by using the adjusted median OR. Factors associated with persistent prescriptions (≤ 6months) were examined with a multivariable proportional hazards model. A total of 250,428 patients were included (mean age, 76 years; 61%male). A total of 15,277 (6.1%) filled a new sedative prescription, with variation noted across hospitals (2%[95%CI, 1-3] to 44%[95%CI, 3-57]); 8,458 (3.4%) filled persistent sedative prescriptions. Adjusted factors associated with a new sedative included: discharge to long-term care facility (adjusted OR [aOR], 4.00; 95%CI, 3.72-4.31), receipt of inpatient geriatric (aOR, 1.95; 95%CI, 1.80-2.10) or psychiatry (aOR, 2.76; 95%CI, 2.62-2.91) consultation, invasive ventilation (aOR, 1.59; 95%CI, 1.53-1.66), and ICU length of stay≥ 7days (aOR, 1.50; 95%CI, 1.42-1.58). The residual heterogeneity between hospitals (adjusted median OR, 1.43; 95%CI, 1.35-1.49) had a stronger association with new sedative prescriptions than the Charlson Comorbidity Index score or sepsis. Factors associated with persistent sedative use were similar with the addition of female subjects (subdistribution hazard ratio, 1.07; 95%CI, 1.02-1.13) and pre-existing polypharmacy (subdistribution hazard ratio, 0.88; 95%CI, 0.80-0.93). One in 15 sedative-naive, older adult ICU survivors filled a new sedative within≤ 7days of discharge; more than one-half of these survivors filled persistent prescriptions. New prescriptions at discharge varied widely across hospitals and represent the potential value of modifying prescription practices, including medication review and reconciliation.