Prehospital Sedation and Physical Restraint of Older Adults Presenting With Behavioral Health Emergencies: A...

Management of behavioral health emergencies (BHE) such as acute agitation by emergency medical services (EMS) is associated with significant patient safety risks, particularly among older adults. However, the unique considerations for BHE among older adults may not be adequately addressed in prehospital BHE protocols and training. We aimed to provide the first nationwide description of EMS use of physical restraint and sedation for older adults with BHE in the United States.

We conducted a cross-sectional evaluation of a nationwide convenience sample of 9-1-1 EMS encounters during 2023. We included EMS encounters for BHE that were managed by advanced life support (ALS) units. Outcomes of interest included physical restraint or administration of chemical sedation. Descriptive statistics were computed and stratified by patient age group. Differences in proportions with 95% confidence intervals were used to compare older (age ≥ 65 years) versus younger adults (age 18-64 years).

A total of 1,468,697 EMS encounters for BHE were included, of which 238,754 (16.3%) involved an older adult. Among 65,088 BHE encounters in which chemical sedation and/or physical restraint was used (older adults: n = 5915, 9.1%), older adults were more likely than younger adults to be sedated (69.2% vs. 61.3%) and less likely to be restrained (39.7% vs. 52.7%). Among those requiring sedation and/or restraint, benzodiazepines were more often used in older adults compared to younger adults (52.8% vs. 45.3%), antipsychotic agents were used at similar rates (15.4% vs. 14.9%), and ketamine was used slightly less often in older adults (5.5% vs. 6.6%).

Thousands of older adults presenting with BHE are restrained and/or sedated by EMS each year in the United States. Further work to improve evidence-based recommendations, protocols, and training specific to older adults is needed to help support EMS in these high-risk encounters.