Prevalence of Benzodiazepine, Z‐Drug and Melatonin Use in Australian Residential Aged Care Facilities: A Systematic Review and Meta‐Analysis

Yuxing Joyce Liu; J Simon Bell; Annie M L Ea; Mingxuan Cui; Ho Chan; Faiza Hoda; Amanda J Cross

doi:10.1111/ajag.70210

. 2026 Jul 17;45(3):e70210. doi: 10.1111/ajag.70210

Prevalence of Benzodiazepine, Z‐Drug and Melatonin Use in Australian Residential Aged Care Facilities: A Systematic Review and Meta‐Analysis

Yuxing Joyce Liu ¹, J Simon Bell ¹, Annie M L Ea ¹, Mingxuan Cui ¹, Ho Chan ¹, Faiza Hoda ¹, Amanda J Cross ^1,^✉

PMCID: PMC13379513 PMID: 42469600

ABSTRACT

Objectives

To systematically examine the prevalence of, and factors associated with, benzodiazepine, Z‐drug and melatonin use in Australian residential aged care facilities (RACFs).

Methods

MEDLINE, Embase, CINAHL, PsycINFO, Scopus and International Pharmaceutical Abstracts were searched from January 2000 to February 2025 for studies reporting benzodiazepine, Z‐drug and/or melatonin prevalence in Australian RACFs. Overall, regular and pro re nata (PRN) medication use was considered. Screening, data extraction and quality assessment were performed independently by two authors. The primary outcome was overall prevalence (regular and PRN) of benzodiazepines, Z‐drugs and/or melatonin. Secondary outcomes included regular prevalence, PRN prevalence and medication class prevalence.

Results

Fifty‐two studies (n = 658,585 residents) were included. Overall prevalence of benzodiazepines and/or Z‐drugs was 33% (95% confidence interval [CI]: 30.4%–34.7%, 30 studies) when assessed over periods from point prevalence to one‐year prevalence. Prevalence was highest when assessed using prescribing (35%) rather than dispensing (32%) or administration (28%) data. Findings were similar when limited to studies published in the last 10 years (31%), studies of 100 or more residents (32%) and when excluding studies conducted in subsets of residents (33%). Benzodiazepine prevalence (35% [95% CI: 32.5%–36.9%], 24 studies) was higher than Z‐drug prevalence (0.4% [95% CI: 0.1%–1.1%], three studies). No published studies reported melatonin prevalence, and unpublished regular prevalence ranged 1%–9% (four studies).

Conclusions

One in three Australian residents in RACFs use benzodiazepines and/or Z‐drugs. Targeted interventions are needed to ensure their use is consistent with evidence‐based practice and residents' clinical needs.

Keywords: benzodiazepines, long‐term care, melatonin, nursing homes

1. Introduction

Benzodiazepines and Z‐drugs are widely used in residential aged care facilities (RACFs, also referred to as ‘nursing homes’ and ‘long‐term care facilities’), despite limited evidence of long‐term benefits and known risks of harms. A meta‐analysis of population‐based studies reported a pooled international prevalence of benzodiazepine use in RACFs of 36%, with regional estimates of 27% in Australia, 19% in North America and 45% in Europe [1]. A European study of 4023 residents across eight countries reported Z‐drugs were prescribed regularly to 8% of residents and pro re nata (PRN) to 2% [2].

Benzodiazepines are commonly prescribed for sleep disturbance in older adults, in addition to conditions such as anxiety disorder, acute seizure and palliative sedation [3]. Their widespread use is concerning given the association with high risk of harms, including a 1.52‐fold higher risk of hip fracture [4] and 1.42‐fold higher odds of falls compared to non‐exposure [5]. Z‐drugs are mainly used for managing sleep disturbance, and short‐term use of Z‐drugs, including zopiclone and zolpidem, has demonstrated efficacy for insomnia in older adults [6]. However, Z‐drugs have a similar safety profile to benzodiazepines, including falls, fractures and cognitive impairment [7]. The 2023 American Geriatrics Society's Beers Criteria listed benzodiazepines and Z‐drugs as potentially inappropriate for older adults due to their associated risks. Beers Criteria recommend avoiding benzodiazepines and Z‐drugs in older adults with the exception of benzodiazepines used for rapid eye movement sleep behaviour disorder [8]. To date, there has been no systematic review of Z‐drug prevalence in Australian RACFs.

Melatonin is increasingly being used to manage sleep disturbance in older adults [9] and sundowning in those with dementia [10]. Melatonin is generally considered well‐tolerated at doses of 0.15–12 mg/day [11]. The American Academy of Sleep Medicine (AASM) guidelines recommend against melatonin 2 mg for sleep onset or sleep maintenance in adults due to limited evidence of efficacy [12]. The British Association for Psychopharmacology (BAP) guidelines suggest melatonin may be useful in delayed sleep–wake phase disorder and jet lag, and recommend prolonged release melatonin should be the first‐line hypnotic treatment for individuals over 55 years if pharmacological intervention is required [13]. The prevalence of melatonin use in Australian RACFs is unknown.

Additionally, as methodological variation in medication definitions, exposure measurement and data source when reporting medication use may limit the direct comparison between individual studies, a comprehensive synthesis is required. Therefore, the aim of this study was to systematically review the prevalence of, and factors associated with, benzodiazepine, Z‐drug and melatonin use in Australian RACFs.

2. Methods

This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and meta‐analyses (PRISMA) guidelines [14] and was prospectively registered in PROSPERO (ID CRD42024553010).

2.1. Search Strategy

MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCOhost), PsycINFO (Ovid), Scopus (Elsevier) and International Pharmaceutical Abstract (ProQuest) were searched for studies published from January 2000 to February 2025. The year 2000 was selected to broadly align with the introduction of the Aged Care Act (1997) [15], residential medication management review (1997) [16] and approval of zolpidem in Australia (1999) [17]. The search strategy (Table S1) was developed in consultation with an information specialist, utilising subject headings and keywords related to region (Australia), exposure (benzodiazepines, Z‐drugs and/or melatonin) and setting (RACFs). Forward and backward citation tracking of included studies was completed by YJL using Web of Science.

2.2. Study Eligibility

This review included original, peer‐reviewed full‐text articles published in English. Eligible studies reported the prescribing, dispensing or administration of benzodiazepines, Z‐drugs and/or melatonin in Australian RACFs, as defined by the World Health Organization (WHO) Anatomical Therapeutic Chemical (ATC) code: benzodiazepines (N05BA; N05CD; N03AE01), Z‐drugs (N05CF) and melatonin (N05CH01), irrespective of indications. Studies of older people were defined as those with mean or median resident age 65 years or older. There were no restrictions on study design.

Studies were excluded if benzodiazepine, Z‐drug and/or melatonin prevalence could not be separated from the prevalence of other central nervous system medications (e.g., antipsychotics or antidepressants). Conference abstracts, opinion pieces, case studies, review articles, grey literature, letters, commentaries and research theses were excluded. When relevant conference abstracts were identified, attempts were made to identify potential full‐text articles. If information was unclear or unavailable in specific studies, the corresponding authors were emailed for clarification or additional data, which sometimes resulted in receiving additional unpublished data related to an included study.

2.3. Study Selection

The search results were imported into EndNote and duplicates were removed. Title and abstract screening were performed independently in Covidence [18] by two review authors (YJL, AJC), with discrepancies resolved by a third reviewer (AMLE). Full texts were independently reviewed by two authors (YJL and AMLE or AJC), and discrepancies were discussed until consensus was reached.

Data extraction was conducted independently by two authors (YJL and AMLE, MC, HC, FH or AJC). Extracted data included: author, year of publication, study design, geographical regions, setting and participant characteristics, size, length of RACF stay, medication exposure characteristics (e.g., year of data, study medications, medication source, exposure time window, conditions associated with medication use) and medication prevalence (overall, regular and pro re nata [PRN, or 'as‐needed'] prevalence of benzodiazepines, Z‐drugs and/or melatonin). Medication use was classified as ‘regular’ when studies explicitly documented the regimen as regular, or using equivalent descriptions (e.g., a drug administered at least once daily for four weeks [19]). Medications were classified as ‘PRN’ if studies defined the regimen as ‘pro re nata’, ‘when required’ or ‘as needed’, or equivalent descriptions (e.g., medications administered as the occasion arose but not regularly administered [20]). Prevalence was extracted from the earliest non‐intervention data regardless of the research designs. For longitudinal studies of greater than five‐years duration, prevalence data were extracted from the most recent time point, where available.

2.4. Quality Assessment

Two authors (YJL and AMLE or AJC) independently assessed the risk of bias using an adapted version of the Joanna Briggs Institute (JBI) critical appraisal checklist for studies reporting prevalence data [21]. The checklist was adapted to assess the quality of the identification, measurement, collection and reporting of medication‐related data in each study (i.e., not the overall quality of the studies). Potential biases were evaluated by assessing the sample frame, sampling method, sample size, description of study subjects and setting, data analysis, validity of the methodology, reliability of measurement approach and response rate. For studies where unpublished data were received, the quality appraisal was conducted on the parent study that contained the relevant methodological details. Further details on assessment of biases are included in Table S2. Any discrepancies were resolved through consensus discussion among the core research team (YJL, AMLE and AJC).

2.5. Outcomes

The primary outcome was overall prevalence (regular and PRN) of benzodiazepines, Z‐drugs and/or melatonin. Overall prevalence was defined as the total point/period prevalence of medication exposure, including both regular and PRN medication use. In studies that did not provide a clear definition of regular or PRN use, the reported prevalence was classified as overall medication use.

The secondary outcomes included:

regular prevalence of benzodiazepines, Z‐drugs and/or melatonin;
PRN prevalence of benzodiazepines, Z‐drugs and/or melatonin;
overall, regular and PRN prevalence of each medication class: (i) benzodiazepines, (ii) Z‐drugs, and (iii) melatonin; and
prevalence of individual benzodiazepines.

2.6. Statistical Analyses

Meta‐analyses of binomial data were performed in the R Statistical Software (version 4.4.2) within the Posit Cloud platform for R using the packages ‘meta’ and ‘metafor’. The ‘metaprop’ function, specifically developed for meta‐analysis of single proportions, was employed [22]. The DerSimonian and Laid random‐effects model [23] was applied to estimate the pooled prevalence if three or more studies were identified that reported data in a comparable format. Study weights were determined using the inverse of the total variance, which consisted of both within and between‐study variance [24]. A logit transformation was used to stabilise variance estimates where proportions were not close to 0 or 1. Heterogeneity was measured by the I ² statistic, where an I ² > 75% indicates substantial heterogeneity [25]. The 95% confidence intervals (CIs) for the reported prevalence were estimated using the Clopper–Pearson (exact binomial) method [26].

To avoid duplication, only one unique prevalence estimate per study was used for data analysis. Specifically, where multiple reports were from the same or overlapping cohort, estimates from the primary report or, when reports were published in the same year, the largest sample size were used. For longitudinal studies lasting more than 5 years, the most recent data were utilised. Studies reporting prevalence data exclusively for specific medications (e.g., long‐acting benzodiazepines) were excluded from the overall pooled analyses. For studies that reported prevalence of benzodiazepines, Z‐drugs and melatonin separately but not in combination, the benzodiazepine prevalence was included in the meta‐analysis as the primary outcome. This approach prevented double‐counting of residents using multiple hypnotic classes while acknowledging that benzodiazepines have historically been the dominant class reported in older adults.

The robustness of the primary outcome was evaluated through three sensitivity analyses: (a) limiting inclusion to studies published in the past 10 years, (b) limiting inclusion to studies of 100 or more residents and (c) excluding studies selective for specific resident demographics (e.g., female only), clinical characteristics (e.g., dementia only, anxiety disorder only, unplanned hospitalisations, regular antipsychotic users), interventions (e.g., recipients of residential medication management reviews or telehealth services) or healthcare entitlements (e.g., Veteran Gold Card holders, concession card holders). Subgroup analyses and univariable meta‐regression were conducted to explore associations between the primary outcome and following factors: (a) medication sources (prescribing, dispensing or administration records); (b) dementia status of residents (< 50% with dementia, 50% to < 100% with dementia, 100% with dementia, and unclear); (c) medication exposure time window (≤ 14 days, > 14 days to 3 months, > 3 months, and unclear); (d) geographical regions of studies (state or territory of Australia, mixed regions and unclear).

3. Results

The search identified 5520 articles, with 253 full text articles screened and 52 studies (described in 62 reports) included in the narrative review (Figure 1). Forty‐two studies were included in meta‐analyses, with 30 included in the primary outcome analysis. Eleven studies [19, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36] provided prevalence only for specific benzodiazepines, 10 reports [28, 32, 34, 37, 38, 39, 40, 41, 42, 43] had the same or overlapping cohorts, and one study [44] presented prevalence as a proportion of total prescriptions. These studies were excluded from the meta‐analyses.

PRISMA flow diagram for selection of studies in our analyses. IPA, International Pharmaceutical Abstracts; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta‐Analyses; RACF, Residential Aged Care Facility.

3.1. Study Characteristics

The 52 included studies collectively involved 658,585 residents (Table S3). The mean/median age of residents ranged from 77 to 91 years, and the proportion of female residents ranged from 39% to 100% (reported in 50 studies). Fifteen studies comprised cohorts with < 50% of residents with dementia, 11 studies involved cohorts with 50% to < 100% dementia prevalence, 11 studies had 100% of residents with dementia, and 19 studies did not report dementia prevalence. The highest number of single‐state studies were from New South Wales (NSW, 9 studies), followed by Victoria (VIC, 6 studies). Twelve studies reported data from mixed regions (i.e., multiple states or territories), including eight national studies [45, 46, 47, 48, 49, 50, 51, 52]. Five studies did not specify a geographical region.

3.2. Medication Exposure and Prevalence Measures

Of the 62 reports, 46 reported prevalence of benzodiazepines only and nine presented prevalence data for Z‐drugs. No published reports provided prevalence of melatonin or orexin receptor antagonists (ORAs), but unpublished regular prevalence data were collected via direct author contact related to four reports [42, 43, 53, 54]. Eleven reports provided combined prevalence (Table S4) [41, 42, 43, 44, 46, 54, 55, 56, 57, 58, 59]. Eight reports provided overall, regular and PRN prevalence estimates for medication use [20, 55, 57, 60, 61, 62, 63, 64], 10 reports specifically reported data on regular use [36, 37, 40, 42, 43, 53, 54, 65, 66, 67], and only one report exclusively focused on PRN prevalence [68].

Thirty‐two reports used ATC codes to categorise medication exposure, although only 14 reports listed the specific codes. Nearly half of the reports omitted definitions for regular medication use (28 reports) or PRN use (25 reports). Twenty reports provided point prevalence, and 28 reports estimated period prevalence, with exposure time windows varying from short timeframes of 3 days [69] or 1 week [70], to longer timeframes such as 1 year [68].

Concurrent use of psychotropic medications and benzodiazepines (Table S5) was described in 13 reports and ranged from 0% to 42% (excluding the study that only included regular antipsychotic users [71]. i.e., 100% concurrent use). Only one report provided the prevalence of diagnosed insomnia, finding a fourfold higher rate of insomnia among benzodiazepine users compared to non‐users [57].

3.3. Quality Assessment

Appraisal of the included reports (Table S2) identified that 38 reports had unclear sample frames, mainly due to lack of comparison of characteristics and demographics between the study population and target population. More than half the reports lacked a detailed description of study setting (32 reports), specifically the location of RACFs or type of RACFs (e.g., if they were public, private or not‐for‐profit). Twenty reports lacked detailed description of study participants, primarily the reporting of dementia prevalence. Twenty reports were assessed as unclear validity of the methodology for identification of the medication use, including 15 that did not clearly describe the exposure time window for medication use [20, 27, 32, 44, 48, 55, 60, 71, 72, 73, 74, 75, 76, 77, 78], and seven that had unclear medication data source [30, 60, 69, 74, 78, 79, 80].

3.4. Primary Outcome

3.4.1. Overall Prevalence (Regular and PRN) of Benzodiazepines, Z‐Drugs and/or Melatonin

The overall prevalence of benzodiazepine and/or Z‐drug use was 33% (95% CI: 30.4%–34.7%, I ² = 98.5%, 30 studies [20, 45, 46, 47, 48, 49, 50, 51, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 69, 73, 74, 75, 76, 79, 81, 82, 83, 84, 85, 86]) (Figure 2). Among these studies, 24 reported benzodiazepine prevalence, four provided combined estimates of benzodiazepines and Z‐drugs, and two aggregated benzodiazepines with benzodiazepine‐like medications. No studies reported a combined overall prevalence including benzodiazepines, Z‐drugs and melatonin (Table S4). Results remained consistent across sensitivity analyses (Figure S1) when limiting to studies published in last 10 years (31%, [95% CI: 28.4%–33.8%], 19 studies), those of 100 or more residents (32%, [95% CI: 29.9%–34.3%], 24 studies) and excluding studies that reported data for only subsets of residents (33%, [95% CI: 26.0%–40.0%], 12 studies). Subgroup and meta‐regression analyses for the primary outcome (Table 1, Figure 2) showed the highest prevalence in prescribing benzodiazepines and/or Z‐drugs data (35%, n =17 studies, range: 20%–59%), followed by dispensing data (32%, seven studies, range: 23%–40%), and administration data (28%, six studies, range: 16%–43%).

Overall prevalence of benzodiazepines and/or Z‐drugs stratified by medication sources.

TABLE 1.

Univariable meta‐regression of the associations between the overall benzodiazepine and/or Z‐drug use and factors considered.

Potential factors	Number of studies, n	Coefficient (95% CI)	p	R ²
Medication sources				0.00%
Administration	6	Ref.
Prescribing	17	0.34 (0.07, 0.60)	0.01
Dispensing	7	0.19 (−0.11, 0.49)	0.21
Dementia status				0.00%
< 50%	7	Ref.
50% to < 100%	6	−0.66 (−1.00, −0.33)	< 0.0001
100%	5	−0.47 (−0.85, −0.09)	0.02
Unclear	12	−0.36 (−0.64, −0.08)	0.01
Medication exposure time window				0.00%
≤ 14 days	12	Ref.
> 14 days to 3 months	5	0.02 (−0.33, 0.37)	0.92
> 3 months	3	0.003 (−0.38, 0.39)	0.99
Unclear	10	0.09 (−0.18, 0.36)	0.51
Geographical regions				6.88%
VIC	4	Ref.
NSW	4	−0.42 (−0.85, 0.02)	0.06
SA	3	0.45 (−0.01, 0.91)	0.06
TAS	3	−0.06 (−0.52, 0.41)	0.82
Mixed regions	10	−0.38 (−0.76, 0.0001)	0.50

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Note: Dummy variables were created for each factor, with one level designated as the reference.

Abbreviations: CI, confidence interval; NSW, New South Wales; Ref., reference; SA, South Australia; TAS, Tasmania; VIC, Victoria.

An inverse relationship was observed between overall prevalence of benzodiazepines and/or Z‐drugs and proportions of residents with dementia (26% [95% CI: 21.8%–30.6%] for six studies [55, 59, 60, 79, 83, 85] with 50 to < 100% dementia compared to 41% [95% CI: 35.8%–45.5%] for seven studies [20, 46, 47, 50, 57, 61, 62] with < 50% dementia, Table 1, Figure S2a). There was no statistically significant association between the overall benzodiazepine and/or Z‐drug prevalence and either the medication exposure time windows or geographical regions (Table 1, Figure S2b,c).

3.5. Secondary Outcomes

3.5.1. Regular and PRN Prevalence of Benzodiazepines, Z‐Drugs and/or Melatonin

Prevalence of regular benzodiazepines, Z‐drugs and/or melatonin use was higher (20% [95% CI: 16.3%–24.1%], 17 studies) than PRN benzodiazepine and/or Z‐drug use (16% [95% CI: 11.9%–21.9%], 12 studies) (Figure S3). Only one study reported the combined prevalence of regular benzodiazepine, Z‐drug and melatonin use [54]. Prevalence of PRN benzodiazepines and/or Z‐drugs in administration data was lower but more variable (12% [95% CI: 5.2%–26.1%], four studies) compared to prevalence of prescribing PRN benzodiazepines and/or Z‐drugs (18% [95% CI: 12.7%–25.2%], 10 studies). In contrast, administration of regular benzodiazepines, Z‐drugs and/or melatonin (19% [95% CI: 12.9%–27.9%], five studies) and regular prescribing rates (20% [95% CI: 15.7%–25.6%], 12 studies) were comparable. Studies based on dispensing data were excluded from regimen‐specific (i.e., regular or PRN) analyses, as these studies did not distinguish regular and PRN medication use.

3.5.2. Overall, Regular and PRN Prevalence of (i) Benzodiazepines, (ii) Z‐Drugs and (iii) Melatonin

The pooled prevalence of benzodiazepine use was 35% (95% CI: 32.5%–36.9%, 24 studies for overall use), 20% (95% CI: 15.5%–25.3%, 15 studies for regular use), and 15% (95% CI: 10.6%–21.0%, 11 studies for PRN use) (Figure S4). Reported rates ranged from as low as 5% for PRN administration [64] to as high as 60% for regular prescribing [72]. Overall prevalence of Z‐drugs was 0.4% (95% CI: 0.1%–1.1%, three studies [59, 62, 82]), and regular prevalence was 0.2% (95% CI: 0.2%–0.3%, four studies [36, 39, 53, 54]) (Figure S5), with prevalence varying from 0%, reported by the only study assessing PRN use, to 2% for overall use (Table S6). There were insufficient studies to meta‐analyse prevalence of melatonin. Four reports provided unpublished prevalence rates for regular melatonin use ranging from 1% [53] to 9% [43], and one report presented unpublished regular ORA prevalence as 0.2% [53] (Table S6).

3.5.3. Prevalence of Individual Benzodiazepines

The three most commonly used benzodiazepines (Table S6, Figure S6) were temazepam (overall median 18%, IQR 9.8%–22.6%, 15 studies), oxazepam (overall median 12%, IQR 6.9%–16.9%, 14 studies) and diazepam (overall median 4%, IQR 2.8%–6.2%, nine studies).

4. Discussion

This is the most comprehensive systematic review of benzodiazepine, Z‐drug and melatonin use in Australian RACFs. Approximately one‐third of residents used benzodiazepines and/or Z‐drugs. One in five residents used benzodiazepines, Z‐drugs and/or melatonin regularly, and one in six residents used PRN benzodiazepines and/or Z‐drugs.

Overall, benzodiazepines were used by more than a third of residents, exceeding the historical pooled prevalence of 27% reported in an earlier review of six studies [1]. This was notably higher than utilisation trends reported in the United States (declining from 12.1% to 10.6% for short‐acting and from 3.9% to 4.1% for long‐acting benzodiazepines between 2013 and 2018) [87], but lower than the prevalence commonly observed across European settings [1]. The high benzodiazepine prevalence may reflect the complex clinical challenge prescribers and residents face when managing sleep disturbance [88], psychiatric comorbidities [89] and changed behaviours [90]. Regarding individual benzodiazepines, the high prevalence of temazepam and oxazepam may reflect a clinical preference for short‐acting benzodiazepines in older adults. Although diazepam, a long‐acting benzodiazepine, was the third most commonly reported, its use was substantially lower (4%). Nevertheless, there is a need for strategies targeting residents, healthcare professionals and healthcare systems to ensure appropriate use of both regular and PRN benzodiazepines. Patient‐targeted interventions have demonstrated consistent effectiveness in promoting benzodiazepine deprescribing in broader older adults, whereas physician‐targeted interventions, (e.g., prescribing algorithm, clinical audit and medication review) have produced mixed results, making multifactorial interventions often yield greater success [91]. Within RACFs, both patient‐targeted and physician‐targeted interventions, as well as multi‐strategic programs (medication audits, staff education and interdisciplinary case reviews), have proven effective in reducing benzodiazepine use [52, 92, 93]. National initiatives, such as the psychotropic self‐assessment tool implemented by Australia's Aged Care Quality and Safety Commission, could be leveraged to support aged care providers in maintaining a register of residents who use benzodiazepines [94]. Another strategy may be to introduce a benzodiazepine‐specific indicator as part of the National Aged Care Mandatory Quality Indicator Program [95], as audit and feedback is a widely used and successful strategy to improve health practices [96]. Since an antipsychotic indicator was introduced in July 2021, the quarterly proportion of residents using antipsychotics has declined from 22% in 2021 to 17% in 2024 [97, 98]. The possible benefit of additional indicators would need to be weighed against the administrative workload associated with collecting these data. However, improvements in information technology and electronic national resident medication chart (eNRMC) software should help to streamline these processes by capturing real‐time medication prescription and administration data [99].

Z‐drug prevalence in Australian RACFs was considerably lower than that reported in Korea (5.8%) [100], France (12.3%) [101] and Denmark (12.3%) [102]. This is despite some healthcare professionals perceiving Z‐drugs to be safer than benzodiazepines in older adults [103, 104]. The lower prevalence may be because Z‐drugs are not subsidised through Australia's Pharmaceutical Benefits Scheme (PBS) and do not contribute to the Safety Net (a scheme that helps lower the annual cost of medications for those who are on multiple regular medications) [105]. The higher out‐of‐pocket cost for residents may result in socio‐economic variation in Z‐drug use, which aligns with findings indicating higher Z‐drug use in more socioeconomically advantaged area in Australia [106]. The low number of studies reporting Z‐drug prevalence may also be linked to Z‐drugs not being PBS‐listed as PBS‐datasets are commonly used in pharmacoepidemiological research [107].

No published reports of melatonin use were identified. Unpublished prevalence estimates for regular use varied from 1% [53] to 9% [43]. A recent meta‐analysis of 17 studies reported melatonin and ramelteon (a melatonin agonist) improved total sleep time, sleep latency and sleep quality in older adults, compared with placebo, though no benefit was observed for sleep efficiency [108]. However, evidence in dementia is mixed: While some studies suggested potential benefits for sleep efficiency or sundowning, others showed no significant improvement in key sleep parameters (e.g., total sleep time, sleep efficiency and sleep latency) [109, 110, 111, 112]. It is possible that melatonin may be a lower‐risk pharmacological option for managing sleep disturbance or sundowning when used as an adjunct to non‐pharmacological strategies. However, its role in dementia remains uncertain. The fact that melatonin is also not PBS subsidised and is available without a prescription [113], may have contributed to the absence of published studies reporting its prevalence. There is a need to further understand prevalence and effectiveness of melatonin use in RACFs.

Our results showed lower benzodiazepine and/or Z‐drug use in studies with ≥ 50% dementia prevalence compared to those with < 50% dementia prevalence. Findings from included studies were mixed, with some reporting higher [61], lower [79] or similar [46] usage for residents with dementia compared to those without. However, benzodiazepine and/or Z‐drug use was still high with overall prevalence ranging from 23% to 46% in studies involving cohorts of individuals living with dementia, consistent with findings from the Netherlands [114] and Belgium [115]. Evidence on the association between benzodiazepine use and dementia risk in older adults remains inconclusive: while earlier meta‐analysis suggested a positive association [116], two recent population‐based studies reported inconsistent findings [117, 118], and a recent systematic review found no significant association with chronic benzodiazepine use [119]. The Australian Clinical Practice Guidelines for the Appropriate Use of Psychotropic Medications in People Living with Dementia and in Residential Aged Care conditionally recommend against the routine use of benzodiazepines for managing sleep disturbances [120]. Knowledge brokers could be used to support efficient and sustained guideline implementation, as they could work to address both local and system‐wide barriers to implementation [121, 122]. There is also a need to better understand healthcare professionals' and residents' preferences, trade‐offs and perceived barriers when selecting benzodiazepines, Z‐drugs or melatonin for managing sleep disturbance in dementia, including how preferences may change over the life course of dementia.

Our review highlighted the need for increased consistency and clearer reporting of medication prevalence across studies. Only 23% of included studies reported specific ATC codes, despite their recognition as a gold standard for medication utilisation research [123]. The use of ATC codes reduces ambiguity in medication definitions and improves interpretability. Additionally, only 19% of the studies provided clear and detailed definitions for ‘regular’ or ‘PRN’ medication use, while 37% did not define these terms entirely, with unclear usage regimen potentially leading to misclassification bias. Inconsistency in regimen definitions and variability in medication exposure windows limit the interpretation of pooled prevalence estimates. Adopting standardised definitions of medication use (e.g., at least 3 days per week during the previous 3 months for regular use) [124] would improve consistency across studies. Transparency in defining study medication, usage regimen and exposure window should be integrated into future studies, aligning with the Reporting Of MEdication use in Observational studies (ROMEO) Statement to facilitate reliability, comparability and reproducibility [125].

This study is the first comprehensive systematic review of benzodiazepine, Z‐drug and melatonin use in Australian RACFs. It adhered to PRISMA reporting standards, involved a comprehensive literature search and citation tracking, and screening, data extraction and quality appraisal were conducted independently by two authors. A limitation of this review is the variability in sampling across studies (e.g., inclusion of all residents vs. exclusively those with dementia), which may affect the generalisability of the findings. Nonetheless, consistent results in sensitivity analyses strengthens the robustness of the overall prevalence estimate. Furthermore, the high I ² values across meta‐analyses may be due to epidemiological variations across populations, the high statistical precision of large observational cohorts and the natural variability of non‐comparative proportional data [126]. This heterogeneity may reduce the reliability of prevalence estimates—an issue frequently observed in meta‐analyses of prevalence studies [126]. The low R ² values and small number of eligible studies in the subgroup analyses further reduce the reliability of findings regarding potential sources of heterogeneity. Additionally, the selective inclusion of only certain benzodiazepines [64] likely underestimated overall use, and the proportion of benzodiazepines used for sleep disturbance versus other clinically appropriate indications (e.g., anxiety) was unclear. Moreover, 55 reports (89%) omitting benzodiazepine dosage and psychotropic polypharmacy data further complicated the interpretation, as variation in dose and polypharmacy may reflect varying clinical intentions. A proposed integrated diazepam milligram equivalent‐defined daily dose metric may enhance population exposure estimates by accounting for both benzodiazepine consumption and pharmacologic potency [127]. Generalisability of the prevalence of Z‐drugs should be considered with caution as studies included within the meta‐analysis had low numbers of Z‐drug users. Divergent medication sources (e.g., prescribing and dispensing data) may also inflate medication exposure. Two included studies reported that 75%–87% of prescribed PRN benzodiazepines in Australian RACFs were never administered [29, 61].

5. Conclusions

One‐third of people living in Australian RACFs are exposed to benzodiazepines and/or Z‐drugs, with benzodiazepines being the most frequently reported. The prevalence of melatonin and ORA use remains unclear due to a lack of published evidence. These evidence gaps and the high heterogeneity in included studies highlight the need for further robust research using standardised reporting frameworks to get a complete clinical picture of benzodiazepine, Z‐drug and melatonin use in Australian RACFs. Given the potential risks associated with benzodiazepine and/or Z‐drug use in older adults, targeted resident‐ and system‐level strategies are needed to support healthcare professionals and aged care organisations in ensuring safe prescribing to minimise preventable medication‐related harm.

Funding

Y.J.L. is supported by the Monash University Faculty Graduate Research Scholarship and Faculty International Tuition Scholarship. A.M.L.E. is supported by the Australian Government Research Training Scholarship [DOI: https://doi.org/10.82133/C42F‐K220]. A.J.C. is supported by a National Health and Medical Research Council (NHMRC) Emerging Leadership 1 grant (APP2009633).

Ethics Statement

This study is a systematic review of previously published literature, and no human participants were involved. Therefore, ethics approval and informed consent were not applicable.

Conflicts of Interest

J.S.B. has received grant funding or consulting funds from the National Health and Medical Research Council, Medical Research Future Fund, Victorian Government Department of Health and Human Services, Dementia Australia Research Foundation, Yulgilbar Foundation, Aged Care Quality and Safety Commission, Dementia Centre for Research Collaboration, Pharmaceutical Society of Australia, Society of Hospital Pharmacists of Australia, GlaxoSmithKline Supported Studies Programme, Amgen, and several aged care provider organisations unrelated to this work. A.J.C. has received grant funding or consulting funds from the National Health and Medical Research Council, Medical Research Future Fund, Dementia Australia Research Foundation and Pharmaceutical Society of Australia. All grants and consulting funds were paid to the employing institution. A.J.C. also declares she is a national board director for the Pharmaceutical Society of Australia. Y.J.L., A.M.L.E., M.C., H.C. and F.H. have no conflicts of interest to declare.

Supporting information

Figure S1: (a) Sensitivity analysis of overall prevalence of benzodiazepines and/or Z‐drugs, limited to studies published in the past 10 years. (b) Sensitivity analysis of overall prevalence of benzodiazepines and/or Z‐drugs, limited to studies of ≥ 100 residents. (c) Sensitivity analysis of overall prevalence of benzodiazepines and/or Z‐drugs, excluded studies that reported data for only subsets of residents.

Figure S2: (a) Overall prevalence of benzodiazepines and/or Z‐drugs stratified by dementia status. (b) Overall prevalence of benzodiazepines and/or Z‐drugs stratified by medication exposure time window. (c) Overall prevalence of benzodiazepines and/or Z‐drugs stratified by geographical regions.

Figure S3: (a) Regular prevalence of benzodiazepines, Z‐drugs, and/or melatonin stratified by medication sources. (b) PRN prevalence of benzodiazepines and/or Z‐drugs stratified by medication sources.

Figure S4: (a) Overall prevalence of benzodiazepines stratified by medication sources. (b) Regular prevalence of benzodiazepines stratified by medication sources. (c) PRN prevalence of benzodiazepines stratified by medication sources.

Figure S5: (a) Overall prevalence of Z‐drugs. (b) Regular prevalence of Z‐drugs.

Figure S6: Median prevalence of the three most commonly used benzodiazepines with IQR.

Table S1: Searching strategy.

Table S2: Summary of quality assessment using adjusted Joanna Briggs Institute Checklist for studies reporting prevalence data.

Table S3: Characteristics of included studies.

Table S4: Medication exposure and prevalence measures.

Table S5: Summary: Concurrent psychotropic use, indication prevalence, and equivalent doses of benzodiazepines, Z‐drugs, and melatonin.

Table S6: Studies reporting the prevalence of individual benzodiazepines, Z‐drugs, and melatonin.

AJAG-45-0-s001.docx^{(2.5MB, docx)}

Acknowledgements

Open access publishing facilitated by Monash University, as part of the Wiley ‐ Monash University agreement via the Council of Australasian University Librarians.

Data Availability Statement

The article and its Supporting Information contain all data relevant to the research.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Figure S5: (a) Overall prevalence of Z‐drugs. (b) Regular prevalence of Z‐drugs.

Figure S6: Median prevalence of the three most commonly used benzodiazepines with IQR.

Table S1: Searching strategy.

Table S2: Summary of quality assessment using adjusted Joanna Briggs Institute Checklist for studies reporting prevalence data.

Table S3: Characteristics of included studies.

Table S4: Medication exposure and prevalence measures.

Table S5: Summary: Concurrent psychotropic use, indication prevalence, and equivalent doses of benzodiazepines, Z‐drugs, and melatonin.

Table S6: Studies reporting the prevalence of individual benzodiazepines, Z‐drugs, and melatonin.

AJAG-45-0-s001.docx^{(2.5MB, docx)}

Data Availability Statement

The article and its Supporting Information contain all data relevant to the research.

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PERMALINK

Prevalence of Benzodiazepine, Z‐Drug and Melatonin Use in Australian Residential Aged Care Facilities: A Systematic Review and Meta‐Analysis

Yuxing Joyce Liu

J Simon Bell

Annie M L Ea

Mingxuan Cui

Ho Chan

Faiza Hoda

Amanda J Cross

ABSTRACT

Objectives

Methods

Results

Conclusions

1. Introduction

2. Methods

2.1. Search Strategy

2.2. Study Eligibility

2.3. Study Selection

2.4. Quality Assessment

2.5. Outcomes

2.6. Statistical Analyses

3. Results

FIGURE 1.

3.1. Study Characteristics

3.2. Medication Exposure and Prevalence Measures

3.3. Quality Assessment

3.4. Primary Outcome

3.4.1. Overall Prevalence (Regular and PRN) of Benzodiazepines, Z‐Drugs and/or Melatonin

FIGURE 2.

TABLE 1.

3.5. Secondary Outcomes

3.5.1. Regular and PRN Prevalence of Benzodiazepines, Z‐Drugs and/or Melatonin

3.5.2. Overall, Regular and PRN Prevalence of (i) Benzodiazepines, (ii) Z‐Drugs and (iii) Melatonin

3.5.3. Prevalence of Individual Benzodiazepines

4. Discussion

5. Conclusions

Funding

Ethics Statement

Conflicts of Interest

Supporting information

Acknowledgements

Data Availability Statement

References

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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