Drug Burden Index Scores Research Articles

Drug burden index of people ageing with intellectual disability and cognitive complaints attending a specialist memory service.

Medications with sedative or anticholinergic properties should be prescribed with caution in those with cognitive complaints. This is particularly relevant in people ageing with an intellectual disability (ID). Higher drug burden index (DBI) scores are associated with increased frailty and falls and reduced quality of life in older people and increased risk of adverse effects (daytime somnolence, constipation) in those with ID. While previous studies have shown that the ID population has higher rates of drug burden and a higher propensity to be prescribed an antipsychotic than the general population, the degree of burden has not been assessed specifically in those with ID and cognitive complaints. We assessed drug burden in a cohort of sequential referrals to a national memory service for people with ID. All patients were referred for assessment of cognitive complaints (self-reported or caregiver-reported problems with memory or cognition). DBI was calculated individually for each participant, and the impact of aetiology of ID, level of ID, age, psychiatric/neurological comorbidities and diagnostic outcome on DBI scores was assessed. The study population was 58.6% female with a median age of 55years and aetiology of ID was Down syndrome (DS) in 71.3%. Consensus diagnosis was Alzheimer's dementia in 40.2%, mild cognitive impairment in 29.9% and cognitively unimpaired from baseline in 25.3%. Medication use was high with 95.4% taking medications, with a median number of medications of 4 (interquartile range 4) and a rate of polypharmacy (≥5 medications) of 51.7%. Overall, 65.5% were exposed to sedative or anticholinergic medications with 39.1% exposed to a clinically significant DBI score >1. Those with psychiatric comorbidities, non-DS aetiology or epilepsy were significantly more likely to have a DBI score >1. People with ID and incipient cognitive complaints have a high level of drug burden, which concerningly exceeds that of the general population.

Emergency department visits and hospital readmissions after a deprescribing intervention among hospitalized older adults.

Deprescribing is the planned/supervised method of dose reduction or cessation of medications that might be harmful, or no longer be beneficial. Though benefits of deprescribing are debatable in improving clinical outcomes, it has been associated with decreased number of potentially inappropriate medications, which may potentially reduce the risk of adverse events among hospitalized older adults. With unclear evidence for deprescribing in this population, this study aimed to examine time-to-first unplanned healthcare utilization, which included 90-day emergency department (ED) visits or hospital readmission and associated predictors, during a deprescribing intervention. A secondary data analysis of a clinical trial (Shed-MEDS NCT02979353) was performed. Cox regression was used to compare the time-to-first 90-day ED visit/readmission/death from hospital discharge for the intervention and control groups. Additionally, we performed exploratory analysis of predictors (comorbidities, functional health status, drug burden index (DBI), hospital length of stay, health literacy, food insecurity, and financial burden) associated with the time-to-first 90-day ED visit/readmission/death. The hazard of first 90-day ED visits/readmissions/death was 15% lower in the intervention versus the control group (95% CI: 0.61-1.19, p = 0.352, respectively); however, this difference was not statistically significant. For every additional number of comorbidities (Hazard ratio (HR): 1.12, 95% CI: 1.04-1.21) and each additional day of hospital length of stay (HR: 1.04, 95% CI: 1.01-1.07) were significantly associated with a higher hazard of 90-day ED visit/readmission/death in the intervention group; whereas for each unit of increase in pre-hospital DBI score (HR: 1.08 and HR 1.16, respectively) was significantly associated with a higher hazard of 90-day ED visit/readmission/death in the control group. The intervention and control groups had comparable time-to-first 90-day ED visit/readmission/death during a deprescribing intervention. This finding suggests that deprescribing did not result in a higher risk of ED visit/readmission/death during the 90-day period following hospital discharge.

A pre-post study of pharmacist-led medication reviews within a hospital-based residential aged care support service.

Hospital-based residential aged-care support service teams typically consist of doctors and nurses who provide hospital substitutive care to aged-care residents. There is limited literature evaluating the pharmacist's role in such aged-care support teams. To analyse the effect of residential aged-care support service pharmacist-led medication reviews on polypharmacy, drug burden index, potentially inappropriate medications, and potential prescribing omissions for aged-care residents. Residents referred to a residential aged-care support service pharmacist for medication review over a 12-month period were included. The pharmacist communicated medication-related problems and recommendations to the resident's general practitioner and residential aged-care support service medical practitioner. Residents' medication histories were obtained at baseline and one-month postintervention. The number of medications and their associated drug burden indices were compared using paired t-tests; potentially inappropriate medications and potential prescribing omissions were compared using Wilcoxon's signed rank test. Of 175 residents (mean age 84 years) referred for pharmacist-led medication review, 146 had postintervention evaluation after one-month (median 29 days). Mean number of medications reduced from 12.47 at baseline to 11.84 postintervention (mean difference (95% CI): 0.63(0.33-0.93), P < .001). Mean drug burden index score reduced from 1.54 at baseline to 1.37 postintervention (mean difference (95% CI): 0.17(0.10-0.24), P < .001). More residents experienced a decrease in inappropriate medications (median (IQR) pre: 2(1-3), post: 1(0-2), P < .001) and prescribing omissions (median (IQR) pre: 0(0-1), post: 0(0-0), P = .003) compared with those that had an increase. Medication reviews performed by pharmacists embedded in hospital-based residential aged-care support services may improve medication prescribing. Further research into such preventative health service models is required.

The Drug Burden Index Is Associated With Measures of Cognitive Function Among Older Adults in the Health, Aging, and Body Composition Study.

Anticholinergic and sedative medications affect cognition among older adults. The Drug Burden Index (DBI) is a validated measure of exposure to these medications, with higher DBI scores indicating higher drug burden. This ancillary analysis investigated the association between DBI and cognition assessed by the Modified Mini-Mental State Examination (3MS) and the Digit Symbol Substitution Test (DSST). The Health, Aging, and Body Composition Study was a prospective study of community-dwelling adults aged 70-79 years at enrollment. Using data from years 1, 5, and 10, DBI was calculated using medication data per participant. Linear mixed modeling was used to assess cross-sectional and longitudinal effects of DBI on 3MS and DSST. Adjusted models included biological sex, race, education level, APOE status, and death. Sensitivity analyses included testing the strength of the associations for each year and testing attrition due to death as a possible confounding factor via Cox-Proportional Hazard models. After adjustment, DBI was inversely associated with 3MS and DSST scores. These associations became stronger in each subsequent year. Neither DBI at year 1 nor within-person change in DBI were predictive of longitudinal declines in either cognitive measure. Sensitivity analyses indicated that DBI, 3MS, and DSST were associated with a greater risk of attrition due to death. Results suggest that in years when older adults had a higher DBI scores, they had significantly lower global cognition and slower processing speed. These findings further substantiate the DBI as a useful pharmacological tool for assessing the effect of medication exposure.

THE EFFECT OF A DRUG-BURDEN INDEX ON FALLS RISK INCREASING MEDICATIONS DEPRESCRIBING IN VETERANS AT RISK OF FALLING

Abstract Falls risk-increasing medications (FRIMs) have negative effects on balance and psychomotor functioning which increase the risk of falling in older adults. Thus, deprescribing of FRIMs is a recommended fall prevention intervention. The Drug Burden Index (DBI) measures total exposure to anticholinergic and sedative medications and has been associated with falling risk in older adults. We evaluated if inclusion of a DBI score would influence deprescribing of FRIMs in older veterans at risk of falling. A pharmacist conducted a medication review for FRIMs in two cohorts of older veterans participating in a fall prevention group. The primary care prescriber (PCP) was alerted to recommendations through the electronic medical record. Inclusion of the DBI was included and shared with the PCP in the second cohort only. Changes to FRIMs and reduction in DBI score was calculated for all participants three months after initial FRIM review. Nearly all (95%) participants (n=44) were prescribed a FRIM. The most common active prescriptions contributing to DBI score were for anticholinergics (37.9%), antidepressants (33.3%) or anticonvulsants (31.8%) agents. DBI improved in both cohorts, but DBI change was greatest in the second cohort (n=18) (first cohort mean DBI change= 0.168; second cohort mean DBI change= 0.189; p 0.002). Percentage of recommendations accepted and acted upon by PCP was similar between both groups (60% vs 59%). Inclusion of a DBI is a helpful measure of FRIM deprescribing and may further encourage deprescribing behaviors. Feedback from PCPs will clarify the role of DBI in fall prevention medication reviews.

Elderly patients whose hospitalization was medication-related were more likely to receive medication recommendations by clinical pharmacist than patients whose hospitalization was unlikely medication-related in non-geriatric units

BackgroundElderly patients are often polymedicated, and drug-related hospitalizations are common in this population. In our hospital, pharmacists from the mobile geriatric team (MGT) coordinate medication reviews (MR) for elderly patients hospitalized in non-geriatric wards, to prevent iatrogenic. ObjectiveThe aim of this work is to determine whether the drug-related origin of hospitalizations can be considered as a targeting criterion for performing MRs. Material and methodWe conducted a retrospective study of data from patients who received a MGT's MR between March 2021 and December 2022, from a single center of more than 1000 beds. The drug-related origin of the hospitalization was estimated as probable or unlikely by the AT-HARM10 tool. Between the two groups, we compared the number of potentially inappropriate prescriptions detected by the PIM-check and START/STOPP tools, drug-drug interactions (DI), unintended discrepancies (UDI) at entry reconciliation, the drug burden index (DBI), and the number of drug-related problems (DRP) i.e., START/STOPP score + DI + UDI. Linear regression of the number of DRP by AT-HARM10 score was computed. Results110 patients were included. 56 hospitalizations were estimated MRH and 54 non-MRH. Mean age (85.1 ± 7.0), ADL (3.8 ± 1.9), IADL (2.0 ± 1.6), and number of medications at entry (8.9 ± 3.8) were comparable in the 2 groups. Compared with non-MRH group, MRH group had a higher number of START/STOPP criteria (5.7 ± 3.5 vs 3.0 ± 2.6; p < 0.05), PIM-check overuses (2.1 ± 1.7 vs 1.4 ± 1.4; p < 0.05), DI (8.4 ± 9.0 vs 4.7 ± 4.7; p < 0.05), UDI at entry (4.0 ± 3.34 vs 2.2 ± 2.1; p < 0.05), and higher DBI score (0.9 ± 0.7 vs 0.3 ± 0.4; p < 0.05). The number of DRP was higher in group P (17.6 ± 10.8 vs 9.8 ± 6.3; p < 0.00.5). Linear regression showed a positive correlation between AT-HARM10 score and the number of DRP (r = 0.5, p < 0.05) with a coefficient of 7.7 (CI95% = [4.3; 11.1]) and an intercept of 9.8. DiscussionThese results allow us to consider AT-HARM10 score as a targeting criterion for performing MR for elderly patients, as part of a curative approach to drug iatrogenic for these patients.

Impact of a Comprehensive Intervention Bundle Including the Drug Burden Index on Deprescribing Anticholinergic and Sedative Drugs in Older Acute Inpatients: A Non-randomised Controlled Before-and-After Pilot Study.

Implementation of the Drug Burden Index (DBI) as a risk assessment tool in clinical practice may facilitate deprescribing. The purpose of this study is to evaluate how a comprehensive intervention bundle using the DBI impacts (i) the proportion of older inpatients with at least one DBI-contributing medication stopped or dose reduced on discharge, compared with admission; and (ii) the changes in deprescribing of different DBI-contributing medication classes during hospitalisation. This before-and-after study was conducted in an Australian metropolitan tertiary referral hospital. Patients aged ≥75 years admitted to the acute aged care service for ≥48h from December 2020 to October 2021 and prescribed DBI-contributing medication were included. During the control period, usual care was provided. During the intervention, access to the intervention bundle was added, including a clinician interface displaying DBI score in the electronic medical record. In a subsequent 'stewardship' period, a stewardship pharmacist used the bundle to provide clinicians with patient-specific recommendations on deprescribing of DBI-contributing medications. Overall, 457 hospitalisations were included. The proportion of patients with at least one DBI-contributing medication stopped/reduced on discharge increased from 29.9% (control period) to 37.5% [intervention; adjusted risk difference (aRD) 6.5%, 95% confidence intervals (CI) -3.2 to 17.5%] and 43.1% (stewardship; aRD 12.1%, 95% CI 1.0-24.0%). The proportion of opioid prescriptions stopped/reduced rose from 17.9% during control to 45.7% during stewardship (p = 0.04). Integrating a comprehensive intervention bundle and accompanying stewardship program is a promising strategy to facilitate deprescribing of sedative and anticholinergic medications in older inpatients.

Association of drug burden index with delirium in community-dwelling older adults with dementia: a longitudinal observational study.

The Drug Burden Index (DBI) is a validated tool for assessing the dose-dependent cumulative exposure to sedative and anticholinergic medications. However, the increased risk of delirium superimposed dementia (DSD) with high DBI levels has not yet been investigated. This study aimed to examine the potential association between DBI scores and delirium in community-dwelling older adults with dementia. A total of 1105 participants with cognitive impairment underwent a comprehensive geriatric assessment. Experienced geriatricians made the final diagnosis of delirium based on DSM-IV-TR and DSM-V. We calculated the DBI as the sum of all sedatives and anticholinergics taken continuously for at least four weeks before admission. Polypharmacy was defined as regular use of five or more medications. We classified the participants as having no exposure (DBI = 0), low exposure (0 < DBI < 1), and high exposure (DBI ≥ 1). Of the 721 patients with dementia, the mean age was 78.3 ± 6.7years, and the majority were female (64.4%). In the whole sample, low and high exposures to anticholinergic and sedative medications at admission were 34.1% (n = 246) and 38.1% (n = 275), respectively. Patients in the high-exposure group had higher physical impairment (p = 0.01), higher polypharmacy (p = 0.01), and higher DBI scores (p = 0.01). In the multivariate Cox regression analysis, high exposure to anticholinergic and sedative medications increased the risk of delirium 4.09-fold compared to the no exposure group (HR = 4.09, CI: 1.63-10.27, p = 0.01). High exposure to drugs with sedative and anticholinergic properties was common in community-dwelling older adults. A high DBI was associated with DSD, highlighting the need for an optimal prescription in this vulnerable population. The trial was retrospectively registered at ClinicalTrials.gov. Identifier: NCT04973709 Registered on 22 July 2021.

Drug Burden Index in Older Adults with Psychiatric Illnesses: A Cross-Sectional Study.

Medications with anticholinergic and/or sedative properties are commonly used in the management of psychiatric illnesses. The burden of anticholinergic and sedative medication use has been measured by the Drug Burden Index (DBI) score tool. A higher DBI score has been associated with increased risk of falls, bone and hip fractures, and functional and cognitive impairment, among other serious health outcomes, especially in older adults. We aimed to describe the drug burden in older adults with psychiatric illnesses using DBI, determine the factors that are associated with the drug burden measured by DBI, and examine the association between DBI score and Katz for activities of daily living (ADL) index. A cross-sectional study was conducted in the psychogeriatric division of an aged-care home. The study sample comprised all inpatients, aged ≥ 65 years, diagnosed with psychiatric illness. The data obtained included demographic characteristics, duration of hospital stay, primary psychiatric diagnosis and comorbidities, functional status using the Katz ADL index, and cognitive status using the Mini-Mental State Examination (MMSE) score. DBI score was calculated for each anticholinergic and sedative medication used. Of the 200 patients eligible for analysis, 106 (53.1%) were females and the mean age was 76 ± 9 years. The most commonly encountered chronic disorders were hypertension 102 (51%) and schizophrenia 94 (47%). The use of drugs with anticholinergic and/or sedative effects was seen in 163 (81.5%) patients; the mean DBI score was 1.25 ± 1. The results of the multinomial logistic regression showed that schizophrenia (odds ratio (OR) = 2.1 (95% confidence interval (CI) 1.57-4.45), p = 0.01), level of dependency (OR = 3.50 (95% CI 1.38-5.70), p = 0.001), and polypharmacy (OR = 2.99 (95% CI 2.15-4.29), p = 0.003) were significantly associated with DBI score ≥ 1 compared to DBI score 0. The study showed that anticholinergic and sedative medication exposure measured by DBI was associated with higher levels of dependency on the Katz ADL index in a sample of older adults with psychiatric illnesses from an aged-care home.

A stewardship program to facilitate anticholinergic and sedative medication deprescribing using the drug burden index in electronic medical records.

The drug burden index (DBI) measures a person's total exposure to anticholinergic and sedative medications, which are commonly associated with harm. Through incorporating the DBI in electronic medical records (eMR) and implementing a DBI stewardship program, we aimed to determine (i) uptake of the steward's recommendations to deprescribe anticholinergic and/or sedative drugs by the medical team and (ii) whether accepted recommendations were actioned in hospital or recommended for follow-up by the General Practitioner post-discharge. A single-arm, non-randomised feasibility study was performed at an Australian tertiary referral metropolitan hospital. The stewardship pharmacist reviewed eMRs of patients aged ≥75 years with DBI scores > 0, during admission. The steward identified and discussed potential opportunities to deprescribe anticholinergic and/or sedative medications with the medical registrars. Amongst 256 patients reviewed, the steward made 170 recommendations for 117 patients. Registrars agreed with 141 recommendations (82.9%) for 95 patients (81.2%), and actioned 115 deprescribing recommendations for 80 patients, most commonly for antidepressants and opioids. The 115 actioned recommendations resulted in 125 changes, with 44 changes to the inpatient drug chart and 81 additional changes recommended post-discharge in the discharge summary. Opportunities exist for deprescribing anticholinergic and sedative medications in older inpatients and a DBI stewardship program may help implement these. It is important to capture different outcomes of deprescribing interventions, including in-hospital medication changes, recommendations in the Discharge Summary, sustainability of deprescribing and clinical outcomes.

Polypharmacy in Australian Veterans with Post-traumatic Stress Disorder upon Admission to a Mental Health Facility: A Retrospective Chart Review.

ObjectivePolypharmacy increases the risk of adverse drug events and drug–drug interactions, and contributes to falls, hospital admissions, morbidity and mortality. Veterans with post-traumatic stress disorder often have psychological and physical comorbidities, increasing the likelihood of general and psychotropic polypharmacy. This study investigates the prevalence of general and psychotropic polypharmacy in inpatient veterans with post-traumatic stress disorder, and illustrates potential risks associated with polypharmacy in this population.MethodsMedical records of 219 veterans admitted to a mental health facility for post-traumatic stress disorder management were retrospectively reviewed. Medication lists on admission were extracted and coded according to Anatomical Therapeutic Chemical Classification classes. The prevalence of general (five or more total medications), psychotropic (two or more N-code medications), and sedative (two or more medications with sedating effects) polypharmacy and Drug Burden Index were calculated. Class combinations were reported, and associations between demographic characteristics and polypharmacy were determined.ResultsMean age was 62.5 (± 14.6) years. In addition to post-traumatic stress disorder, 90.9% had a diagnosis of at least one other psychiatric condition, and 96.8% had a diagnosis of at least one non-psychiatric medical condition. The prevalence of general polypharmacy was 76.7%, psychotropic polypharmacy was 79.9% and sedative polypharmacy was 75.3%. Drug Burden Index scores ranged from 0 to 8.2, with 66.2% of participants scoring ≥ 1.ConclusionsThis cohort of inpatient veterans with post-traumatic stress disorder had a high prevalence of general, psychotropic and sedative polypharmacy, and were at high risk for drug-related adverse events. This highlights the importance of increasing awareness of polypharmacy and potentially inappropriate drug combinations, and the need for improved medication review by prescribers.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40801-022-00298-3.

An Increased Anticholinergic Drug Burden Index Score Negatively Affect Nutritional Status in Older Patients Without Dementia.

Introduction/AimAnticholinergic drugs, which have severe central and peripheric side effects, are frequently prescribed to older adults. Increased anticholinergic drug burden is associated with poor physical and cognitive functions. On the other side, the impact of anticholinergics on nutritional status is not elaborated in the literature. Therefore, this study was aimed to investigate the effect of the anticholinergic burden on nutrition.Materials and MethodsPatients who underwent comprehensive geriatric assessment (CGA) 6 months apart were included in the study. Patients diagnosed with dementia were excluded because of the difference in the course of cognition, physical performance and nutrition. Nutritional status and global cognition were evaluated using Mini Nutritional Assessment-short form (MNA-SF), Mini-Mental State Examination (MMSE). Anticholinergic drug burden was assessed with the Drug Burden Index (DBI), enabling a precise dose-related cumulative exposure. Patients were divided into three groups according to DBI score: 0, no DBI exposure; 0–1, low risk; and ≥1, high risk. Regression analysis was performed to show the relationship between the difference in CGA parameters and the change in DBI score at the sixth month.ResultsA total of 423 patients were included in the study. Participants' mean age was 79.40 ± 7.50, and 68.6% were female. The DBI 0 score group has better MMSE and MNA-SF scores and a lower rate of falls, polypharmacy, malnutrition, and risk of malnutrition in the baseline. Having malnutrition or risk of malnutrition is 2.21 times higher for every one-unit increase in DBI score. Additionally, during the 6-month follow-up, increased DBI score was associated with decreased MNA-SF and MMSE score, albumin.ConclusionsThe harmful effects of anticholinergics may be prevented because anticholinergic activity is a potentially reversible factor. Therefore, reducing exposure to drugs with anticholinergic activity has particular importance in geriatric practice.

The Impact of Drug Burden Index on Unplanned Hospital Readmission and Length of Hospital Stay

Background: The Drug Burden Index (DBI) is a pharmacotherapy risk assessment tool explored to evaluate its association with unplanned hospital-related outcomes. Objective: To evaluate the DBI association with unplanned hospital readmissions, develop a prediction model for unplanned readmissions. To investigate DBI association with length of hospital stay (LOS). Setting: Unplanned readmission data were collected for 1000 adult hospitalized patients at Antrim Area Hospital in Northern Ireland. Method: The study was designed as a retrospective analysis. Logistic regression models were developed to determine the prediction power. Discriminative ability testing was carried out using the Receiver Operating Characteristic (ROC) curve. Youden's index formula was used to detect the cut-off points. Analysis of covariance (ANCOVA) was performed to determine whether LOS differed based on the DBI score. Finally, negative binomial regression was used to predict LOS based on DBI. Results: Of the 1000 patient records, 43% were females, and a total of 885 (88.5%) were exposed to sedative and anticholinergic medications (DBI&gt;0). Readmission rates at 7, 14, 30 and 90 days were 5.4%, 9.0%, 15.0% and 28.8% respectively. The odds ratio (OR) of readmission within seven days for patients with DBI&gt;1 was 3.42 times higher than those who had their DBI=0 (OR= 3.42, 95% CI: 1.6–7.3; P= 0.001). The DBI category significantly predicts 7-day readmission (P=0.002), the area under the curve for the ROC curve was 0.65 (95% CI: 0.58 - 0.71; P&lt;0.001). For 14-day readmissions, patients with a DBI &gt;1, compared with DBI=0, had a reported higher Odds Ratio (OR = 2.19, 95% CI: 1.1– 4.4; P= 0.025). However, the DBI category prediction power for 14-day readmission was not significant (P=0.069). DBI failed to show an association with 30- and 90-day readmissions. The adjusted estimated marginal difference for LOS of patients with DBI&gt;1 vs. DBI=0 was 2.7 (95%CI: 0.89 – 4.5; P=0.003). Conclusion: DBI was a statistically significant tool to predict 7-days unplanned readmission. DBI was not a statistically significant predictor for readmission over longer periods. Higher DBI was associated with a longer LOS. Impact on Practice Statements: Readmission within seven days of a patient's discharge can be predicted by the DBI, and a longer hospital stay was also associated with higher DBI. Accordingly, the hospital teams can consider reporting DBI scores and performing tailored discharge plans for patients who are at risk for seven days of unplanned readmission.

Association of Drug Burden Index With Measures of Cognitive Function Among Older Adults

Abstract Objectives Many conditions associated with aging result in polypharmacy, and certain medications may impact cognition. One way to assess exposure to such medications is through the use of the drug burden index (DBI)- a validated measure of exposure to anticholinergic and sedative medications, with a higher DBI score indicating a higher drug burden. The objective of this cross-sectional analysis was to investigate the association between DBI and cognitive function assessed by two widely utilized cognitive tests among older adults. Methods The Health, Aging, and Body Composition Study was a prospective study of community-dwelling adults ages 70–79 years at enrollment. Using baseline data, DBI was calculated by dividing the daily dose of the medication taken by the sum of the daily dose taken and the minimum efficacious dose as approved by the Food and Drug Association. After adjusting for biological sex, race, education, and APOE genotype, the association between DBI and the Digit Symbol Substitution Test (DSST) and Modified Mini-Mental Status Exam (3MS) score was assessed by partial Spearman's rank correlation. Kruskal-Wallis tests were employed to assess significance among DBI scores by tertile. Results Among those with completed measures (n = 790, 52.4% male, 63.3% white), mean scores were as follows: DBI 0.84 ± 0.48, 3MS 90.12 ± 7.9, and DSST 34.7 ± 14.6. Results suggest that DBI was not significantly associated with either 3MS or DSST. However, DBI scores by tertile were significantly associated with DSST scores. Compared to tertile 2, participants in the lowest tertile had significantly lower DBI scores along with significantly higher DSST scores. Mean differences between tertile 1 and 2 were as follows: DBI = 0.1666 and DSST = 3.39. Conclusions Analyses among the full cohort suggest that DBI was not associated with slower processing speed as assessed by the DSST or with global cognition as assessed by 3MS. Yet with expanded analysis by tertile, results suggest that DBI scores were significantly associated with DSST scores. Future investigations on cognitive function among older adults may benefit from including the DBI analysis by tertile to explain some variance in cognitive test scores. Funding Sources This is an ancillary analysis, there is no funding applicable.

Prevalencia de prescripción de fármacos con carga anticolinérgica/sedante en adultos mayores institucionalizados con demencia

Background and objectiveDementia is one of the most frequent diseases in the elderly, being its prevalence of up to 64% in institutionalized people. In this population, in addition to antidementia drugs, it is common to prescribe drugs with anticholinergic/sedative burden that, due to their adverse effects, could worsen their functionality and cognitive status.The objective is to estimate the prevalence of the use of drugs with anticholinergic/ sedative burden in institutionalized older adults with dementia and to assess the associated factors. Materials and methodsA cross-sectional study developed in older with dementia living in nursing homes. The prevalence of prescription of anticholinergic/sedative drugs was estimated according to the Drug Burden Index (DBI). A comparative analysis of the DBI score was performed between different types of dementia as well as among various factors and according to the anticholinergic/sedative risk, establishing as a cut-off point of DBI≥1 (high anticholinergic/sedative risk). Results178 residents were included. 83.7% had some drug with anticholinergic/sedative burden according to DBI. 50% had a DBI≥1 score. Residents with vascular dementia had a mean DBI of 1.34 (SD 0.84), a significantly higher score than residents with Alzheimer's disease (0.41, 95% CI 0.04-0.78).). Likewise, a higher DBI was associated with more polypharmacy (3.36; 95% CI 2.64-4.08), more falls, hospital admissions and emergency room visits (P<.05). ConclusionsPolypharmacy and prescription of anticholinergic/sedative drugs is frequent among institutionalized older adults with dementia, finding an association between DBI, falls and hospital admissions or emergency department visits. Therefore, it is necessary to propose interdisciplinary pharmacotherapeutic optimization strategies.

Frailty, and not medicines with anticholinergic or sedative effects, predicts adverse outcomes in octogenarians admitted for myocardial infarction: Population-level study.

To determine independent associations between the use of medicines with anticholinergic or sedative effects and frailty with outcomes of length of stay (LOS), coronary artery procedure performed and 30-day deaths in octogenarians admitted for a myocardial infarction (MI). We quantified patient exposure to medicines with anticholinergic or sedative effects using the drug burden index (DBI) and frailty using the hospital frailty risk score (HFRS). We used multivariable regression methods to determine the association between DBI and HFRS with outcomes of LOS, coronary artery procedures performed and 30-day deaths. HFRS and not DBI score was significantly associated with receipt of coronary artery procedures (odds ratio [OR] 0.42; 95% CI 0.28-0.62 for high- versus low-risk groups) and 30-day deaths (OR 1.58; 95% CI 1.12-2.24 for high- versus low-risk groups). Frailty risk is a more important predictor of outcomes than DBI score for octogenarians with an MI.

Impact of the Goal-directed Medication Review Electronic Decision Support System on Drug Burden Index: A cluster-randomised clinical trial in primary care.

The Goal-directed Medication Review Electronic Decision Support System (G-MEDSS) assesses and reports a patient's goals, attitudes to deprescribing and Drug Burden Index (DBI) score, a measure of cumulative exposure to anticholinergic and sedative medications. This study evaluated the effect of implementing G-MEDSS in home medicines reviews (HMRs) on DBI exposure and clinical outcomes. A cluster-randomised clinical trial was performed across Australia. Accredited clinical pharmacists were randomised into intervention (G-MEDSS with usual care HMR) or comparison groups (usual care HMR alone). Patients were recruited by pharmacists from those routinely referred by general practitioners for HMR. The primary outcome was the proportion of patients with any reduction in DBI at 3-months follow-up. Secondary outcomes included change in DBI continuous score at 3-months, HMR recommendations to change DBI and clinical outcomes. There were 201 patient participants at baseline (n = 88 intervention, n = 113 comparison), with 159 followed-up at 3-months (n = 63 intervention, n = 96 comparison). The proportion of patients with a reduction in DBI was not significantly different at 3-months (intervention 17%, comparison 11%; adjusted odds ratio 1.44, 95% confidence interval 0.56-3.80). Regarding secondary outcomes, there was no difference in change in DBI score at 3-months. However, the HMR report made recommendations to reduce DBI for a significantly greater proportion of patients in the intervention than in the comparison group (intervention 37%, comparison 14%; adjusted odds ratio 3.20, 95% confidence interval 1.50-6.90). No changes were observed in clinical outcomes. Implementation of G-MEDSS within HMR did not reduce patients' DBI at 3 months compared with usual care HMR.

Use of potentially inappropriate medications among older outpatients and inpatients in a tertiary care hospital in Malaysia.

Older individuals are seemingly having more medical conditions, which predispose them to a greater risk of polypharmacy. Potentially inappropriate medications (PIMs), including those having anticholinergic and sedative properties, are common in their prescriptions, often associated with functional decline and negative health outcomes. Thus, this study reports proportions of inappropriate drugs and drug burden exposures and its correlation with patient-reported outcomes (PROs) among cognitively intact older adults admitted to a ward or visiting the outpatient clinic at a tertiary care hospital in Malaysia. This cross-sectional study included data from 344 older (173 inpatients and 171 outpatients) patients, aged 60years and above, through validated questionnaires. Medication appropriateness was assessed via Medication Appropriateness Index (MAI) tool, whereas Beers and Screening Tool of Older Person's Potentially Inappropriate Prescribing (STOPP) criteria were used to evaluate PIMs and potentially inappropriate prescribing (PIP), respectively. The Drug Burden Index (DBI) and polypharmacy, as well as PROs, included Groningen Frailty Indicator (GFI), Katz Index of Independence in Activities of Daily Living (Katz ADL) and Older People's Quality of Life (OPQOL) were also evaluated. Overall, inpatients received significantly higher medications (6.90±2.70 vs 4.49±3.20) than outpatients. A significantly higher proportion of inpatients received at least one PIM (65% vs 57%) or PIP (57.4% vs 17.0%) and higher mean MAI score (1.76±1.08 and 1.10±0.34) and DBI score (2.67±1.28 vs 1.49±1.17) than outpatients. Inpatients had significantly higher total OPQOL (118.53 vs 79.95) and GFI score (5.44 vs 3.78) than outpatients. We only found significant correlations between GFI and DBI and total OPQOL and the number of PIMs. Proportions of PIMs and DBI exposure were significantly higher in an inpatient setting. No significant correlations between exposures to inappropriate medications or drug burden and PROs were observed.

Using the Drug Burden Index to identify older adults at highest risk for medication-related falls

BackgroundThe Drug Burden Index (DBI) was developed to assess patient exposure to medications associated with an increased risk of falling. The objective of this study was to examine the association between the DBI and medication-related fall risk.MethodsThe study used a retrospective cohort design, with a 1-year observation period. Participants (n = 1562) were identified from 31 community pharmacies. We examined the association between DBI scores and four outcomes. Our primary outcome, which was limited to participants who received a medication review, indexed whether the review resulted in at least one medication-related recommendation (e.g., discontinue medication) being communicated to the participant’s health care provider. Secondary outcomes indexed whether participants in the full sample: (1) screened positive for fall risk, (2) reported 1+ falls in the past year, and (3) reported 1+ injurious falls in the past year. All outcome variables were dichotomous (yes/no).ResultsAmong those who received a medication review (n = 387), the percentage of patients receiving at least one medication-related recommendation ranged from 10.2% among those with DBI scores of 0 compared to 60.2% among those with DBI scores ≥1.0 (Chi-square (4)=42.4, p < 0.0001). Among those screened for fall risk (n = 1058), DBI scores were higher among those who screened positive compared to those who did not (Means = 0.98 (SD = 1.00) versus 0.59 (SD = 0.74), respectively, p < 0.0001).ConclusionOur findings suggest that the DBI is a useful tool that could be used to improve future research and practice by focusing limited resources on those individuals at greatest risk of medication-related falls.

Impact of STEADI-Rx: A Community Pharmacy-Based Fall Prevention Intervention.

To evaluate the effects of a community pharmacy-based fall prevention intervention (STEADI-Rx) on the risk of falling and use of medications associated with an increased risk of falling. Randomized controlled trial. A total of 65 community pharmacies in North Carolina (NC). Adults (age ≥65 years) using either four or more chronic medications or one or more medications associated with an increased risk of falling (n = 10,565). Pharmacy staff screened patients for fall risk using questions from the Stopping Elderly Accidents, Deaths, and Injuries (STEADI) algorithm. Patients who screened positive were eligible to receive a pharmacist-conducted medication review, with recommendations sent to patients' healthcare providers following the review. At intervention pharmacies, pharmacy staff used standardized forms to record participant responses to screening questions and information concerning the medication reviews. For participants with continuous Medicare Part D/NC Medicaid coverage (n = 3,212), the Drug Burden Index (DBI) was used to assess exposure to high-risk medications, and insurance claims records for emergency department visits and hospitalizations were used to assess falls. Among intervention group participants (n = 4,719), 73% (n = 3,437) were screened for fall risk. Among those who screened positive (n = 1,901), 72% (n = 1,373) received a medication review; and 27% (n = 521) had at least one medication-related recommendation communicated to their healthcare provider(s) following the review. A total of 716 specific medication recommendations were made. DBI scores decreased from the pre- to postintervention period in both the control and the intervention group. However, the amount of change over time did not differ between these two groups (P = .66). Risk of falling did not change between the pre- to postintervention period or differ between groups (P = .58). We successfully implemented STEADI-Rx in the community pharmacy setting. However, we found no differences in fall risk or the use of medications associated with increased risk of falling between the intervention and control groups. J Am Geriatr Soc 68:1778-1786, 2020.