Deprescribing Benzodiazepines in Older Adults: An Anesthesiology Quality Initiative

Benzodiazepines are used routinely for sedation prior to general anesthesia. The most common medication is intravenous midazolam, at a median dose of 2 mg, administered after completion of informed consent and presurgical discussion but before transport to the operating room. Many patients appreciate the anxiolysis and periprocedural amnesia which this confers, and hemodynamic or respiratory complications at this dose are extremely uncommon.

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Of greater concern in the era of brain health is the impact of midazolam on postoperative neurocognitive recovery, especially in older patients. Chronic benzodiazepine use is associated with an increased risk for postoperative delirium and long-term changes in memory and attentiveness. Minimizing unnecessary benzodiazepine use has become an important principle for patients and anesthesiologists hoping to have the clearest, quickest emergence from anesthesia, with the lowest risk for delirium or any other cognitive dysfunction.

Numerous studies have shown that non-pharmacologic anxiolysis—clear preop instructions and good communications—can be just as effective as medication for many patients. Patient satisfaction studies have demonstrated equivalent or higher satisfaction when midazolam is omitted, based on a faster wake-up with less brain fog after the procedure.

Although many anesthesia clinicians have already examined their own practice and reduced the use of midazolam, especially in older patients, many others have not yet made this change. Reasons for this include a perception that most patients desire anxiolysis, comfort with a standard dose of midazolam as part of the overall anesthetic plan, and a lack of recognition of downstream consequences for their patients. This last point is a common concern in anesthesia quality improvement because most clinicians receive little feedback about patient outcomes past the time of PACU care.

A novel collaboration between the University of Pennsylvania and US Anesthesia Partners is working to drive evidence-based change in benzodiazepine use. Under the guidance of principal investigator Mark D. Neuman, MD, MSc, and with research funding from the Donaghue Foundation, USAP is conducting a pragmatic quality improvement initiative to reduce the unnecessary use of preoperative midazolam in patients 65 years of age or older scheduled for general anesthesia.

The DROP-Benzo trial (De-adopting Routine Preoperative Benzodiazepines for Older Surgical Patients) consists of a year-long sequence of educational efforts followed by block-randomized deployment of 2 behavioral nudges designed to increase mindfulness about the risks and benefits of benzodiazepine administration. Over the course of the year, the investigators will track midazolam use while one, the other, and then both interventions are deployed across 24 USAP Divisions nationwide, eventually reaching more than 4500 anesthesia clinicians at hundreds of hospitals and surgery centers nationwide.

One of the deployed interventions is directed at patients in the course of preoperative education. USAP has developed and routinely delivers “Preparing for Your Procedure,” a 20-page, easy-to-read, guide to anesthesia care: online.flippingbook.com/view/728110703/.

Through direct patient contact and collaboration with hospital pre-admission assessment centers, this guide reaches hundreds of thousands of patients in the days prior to their scheduled anesthetic. For the DROP-Benzo initiative, a page was added that specifically encourages the patient to ask about the anesthetic plan.

The other intervention was the delivery of individual monthly feedback to USAP anesthesiologists, showing their use of midazolam compared to peer performance across the practice. As with the patient-facing intervention, this feedback was started in each division at a different time. The goal of DROP-Benzo is not just to reduce the use of preoperative midazolam from the baseline rate of 30%, but also to study the efficacy of each intervention at driving a change in practice.

DROP-Benzo is scheduled to complete data capture at the end of May 2023. Study interventions have already proven feasible in a busy anesthesia private practice, and feedback from both patients and clinicians indicates the interventions are being taken seriously.

Among other likely outcomes from the trial will be a better understanding of when midazolam is clinically indicated—for example when a regional anesthetic block is being performed before induction of general anesthesia—and when it can be safely omitted. USAP, uniquely among large anesthesia practices, maintains a robust system for soliciting data on patient satisfaction in the week following the anesthetic. These data, and individual comments received, will provide important secondary information on the value—or not—of midazolam use for reducing perioperative anxiety in older patients.

DROP-Benzo is likely to be a model for future change management initiatives in anesthesia, representing as it does a unique combination of academic expertise from the University of Pennsylvania and the broad reach of a large and well-organized private practice.

About the Author

Richard P. Dutton, MD, MBA, is chief quality officer, US Anesthesia Partners.