(P19) Revisiting Benzodiazepine Use for Dental Procedures in Nursing Home Residents

Introduction: Benzodiazepines (BDZ) are included in the Beer’s list as a potentially inappropriate drug class for the elderly due to risk of confusion, falls, cognitive decline and dependance. Nonetheless, it is common dental practice to prescribe this class of medications prior to dental procedures to reduce periprocedural anxiety. We present a case of a nursing home resident who received a pre-procedure dose of BDZ and developed sudden change in mental status post procedure.

Case Description: An 81-year-old female long term care resident, with a medical history of Aortic Stenosis was transferred to the hospital from the long term care facility for evaluation of change in mental status. Patient had undergone an elective dental extraction the day prior in preparation for a Transcatheter Aortic Valve Replacement. Post procedure she was noted to be agitated and confused and was initially observed at the facility, she was eventually transferred to the hospital as the behavior continued to escalate . At the hospital, all workup for infectious, cardiac and neurologic etiologies for the change in mental status was unremarkable. She was incidentally found to have a clean chronic left lower extremity wound with no signs of cellulitis but she was started on empiric antibiotics. During the first day of hospitalization she continued to remain severely agitated requiring physical restraints, and three doses of Olanzapine and one dose of Lorazepam. A careful review of the LTC records indicated that she had received Alprazolam 1 mg prior to the dental extraction per the recommendations of the her dental practitioner. Patient had no prior history of BDZ use. BDZ cessation was recommended given concern that the change in mental status was related to paradoxical agitation from the use of this class of drugs. Patient improved clinically on the following days and was orientable and returned to baseline mental status. Empiric antibiotics were stopped and she was discharged to back to her LTC facility .

Discussion: Long term care patients are at particular risk for medication related side effects given their overall frailty, multimorbidity and limited physiological reserve. In this case a high dose of a BDZ was prescribed to an elderly LTC resident with no prior history of BDZ use and this caused an adverse reaction that resulted in a hospitalization. Given the rise in the complexity of patients in the long term care arena it is important that the dental practitioners caring for these patients incorporate geriatric prescribing principles for the perioperative management of this patient population.