Drug Burden Index and Its Association With Hip Fracture Among Older Adults: A National Population-Based Study

Jamieson, Hamish A.; Nishtala, Prasad S.; Scrase, Richard; Deely, John; Abey-Nesbit, Rebecca; Hilmer, Sarah N.; Abernethy, Darrell R.; Berry, Sarah D.; Mor, Vincent; Lacey, Cameron; Schlüter, Philip J.

doi:10.1093/gerona/gly176

Cited by 26 publications

(38 citation statements)

References 30 publications

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“…Anticholinergic burden, often the result of concomitant use of multiple MACs [10], has been associated with adverse effects such as cognitive and functional impairment, reduced quality of life, impaired activities of daily living [2] as well as falls [11,12] and fall-related injuries, particularly fractures [13][14][15][16]. These effects are usually associated with the person's total anticholinergic burden, rather than specific medications.…”

Section: Eligibilitymentioning

confidence: 99%

“…Of the 49 articles eligible for full-text assessment, 40 were excluded, as they did not use an anticholinergic burden scale (N = 17), did not assess fractures as an outcome (N = 10), did not report a measure of association (N = 4), or were only published as conference abstracts (N = 9). Nine studies fulfilled all eligibility criteria and were included into the systematic review, corresponding to six cohort [14][15][16][29][30][31] and three case-control studies [13,32,33].…”

Section: Study Selectionmentioning

confidence: 99%

“…The characteristics of the included studies are shown in Table 1. The studies included a total of 610,862 persons, 74% (N = 452,659) of which were women [13][14][15][16][29][30][31][32][33]. Sample sizes ranged from 601 [32] to 202,260 persons [13].…”

Section: Study Population and Data Sourcementioning

confidence: 99%

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Anticholinergic Burden and Fractures: A Systematic Review with Methodological Appraisal

et al. 2020

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Introduction Medications with anticholinergic activity (MACs) are used to treat diseases common in older adults. Evidence on the association between anticholinergic burden (AB) and increased risk of fractures and osteoporosis or reduced bone mineral density (BMD) is inconsistent. Our aim was to conduct a systematic review of observational studies on AB with fractures and osteoporosis or reduced BMD and provide methodological appraisal of included studies. Methods We searched MEDLINE, EMBASE, Science Citation Index and CENTRAL as well as grey literature from database inception up to August 2020. Eligibility criteria were: observational design, AB-exposure measured through a scale, fracture of any type or osteoporosis or reduced BMD as outcome, and reported measure of association between exposure and outcome. No restrictions related to time, language or type of data were applied. Eligibility and risk of bias assessment as well as data extraction were performed independently by two reviewers. Risk of bias of the included studies was assessed using the Newcastle-Ottawa Scale and the RTI Item Bank. Results The majority of the nine included studies had low risk of bias but heterogeneous methodology. No study used a new user design. Seven studies reported an increased risk of fractures associated with AB. In four studies using the Anticholinergic Risk Scale (ARS), adjusted risk of fractures was increased by 2-61% for ARS = 1, by 0-97% for ARS = 2, by 19-84% for ARS = 3, and by 56-96% for ARS ≥ 4; in three studies the ARS was aggregated, risk increased by 39% for ARS = 1-2 and 17% for ARS = 2-3. Two studies reported increased risk of fractures of 14 and 52% in the highest AB-category and one study reported that change in ARS of ≥ 3 during hospitalization was associated with a 321% increased risk in fractures. Two studies did not find an association between AB and fractures. The association between AB and osteoporosis or reduced BMD could only be assessed in two studies, one reporting increased risk of lower BMD at Ward's triangle, the other reporting no association between AB and BMD T-score change at the femoral neck. Discussion Our study suggests an association between AB and increased risk of fractures with possible dose-exposure gradient in studies using the ARS. The low number of studies and heterogeneity of methods calls for the conduct of more studies. Plain language summary We conducted a study investigating the risk of fractures associated with anticholinergic burden, which is the result of taking one or more medication with anticholinergic activity. The results of our study suggest that persons who experience anticholinergic burden might have a higher risk of fractures. However, since we were only able to include nine studies, more studies conducted in a similar way are needed. Oliver Riedel and Federica Pisa share senior authorship. At the time of study conception and coordination, FEP worked at the Leibniz Institute for Prevention Research and Epidemiology-BIPS. From 1st March 2020 she is working at Bayer AG....

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Section: Eligibilitymentioning

confidence: 99%

Section: Study Selectionmentioning

confidence: 99%

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Anticholinergic Burden and Fractures: A Systematic Review with Methodological Appraisal

et al. 2020

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“…Particularly harmful are medications with anticholinergic and sedative properties, which are prescribed to up to a quarter of older persons (3,4). These medications have been associated with poorer cognitive functioning (5)(6)(7)(8)(9), poorer physical functioning (5,9,10), and increased risk of hip fractures (11). Anticholinergic medications exert central antagonistic effects on muscarinic receptors thereby inhibiting acetylcholine transmission within hippocampal, fusiform, inferior prefrontal cortical, and striatal areas (12)(13)(14).…”

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confidence: 99%

Long-Term Exposure to Anticholinergic and Sedative Medications and Cognitive and Physical Function in Later Life

Wouters

Hilmer

Gnjidic

et al. 2019

The Journals of Gerontology: Series A

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“…Cognitive decline and mortality have been found to be associated with an increased DBI score in some cross-sectional studies but not others 8 16. Longitudinal studies have found that an increased DBI score is independently associated with lower physical function over 5 years, poorer delayed memory performance, increased incidence of frailty and hip fracture, physician visits and mortality 14 17. These results represent 20 different studies, span multiple countries (Australia, Canada, Finland, the Netherlands, New Zealand, UK and USA) and provide a substantial argument to reduce DBI score in individuals where possible 8…”

Section: Introductionmentioning

confidence: 87%

Pharmacist-led intervention to improve medication use in older inpatients using the Drug Burden Index: a study protocol for a before/after intervention with a retrospective control group and multiple case analysis

et al. 2020

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IntroductionPolypharmacy and potentially inappropriate medication use is common in older adults and is associated with adverse outcomes such as falls and hospitalisations.Methods and analysisThis study is a pharmacist-led medication optimisation initiative using an electronic tool (the Drug Burden Index (DBI) Calculator) in four hospital sites in the Canadian province of Nova Scotia. The study aims to enrol 160 participants between the preintervention and intervention groups. The Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT 2013 checklist) was used to develop the protocol for this prospective interventional implementation study. A preintervention retrospective control cohort and a multiple case study analysis will also be used to assess the effect of intervention implementation. Statistical analysis will involve change in DBI scores and assessment of clinical outcomes, such as rehospitalisation and mortality using appropriate statistical tests including t-test, χ2, analysis of variance and unadjusted and adjusted regression methods.Ethics and disseminationEthics approval has been granted by the Nova Scotia Health Authority Research Ethics Board. The findings of this study will be published in peer-reviewed journals and presented at local, national and international conferences.Trial registration numberNCT03698487.

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Drug Burden Index and Its Association With Hip Fracture Among Older Adults: A National Population-Based Study

Cited by 26 publications

References 30 publications

Anticholinergic Burden and Fractures: A Systematic Review with Methodological Appraisal

Anticholinergic Burden and Fractures: A Systematic Review with Methodological Appraisal

Long-Term Exposure to Anticholinergic and Sedative Medications and Cognitive and Physical Function in Later Life

Pharmacist-led intervention to improve medication use in older inpatients using the Drug Burden Index: a study protocol for a before/after intervention with a retrospective control group and multiple case analysis

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