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J Gerontol A Biol Sci Med Sci. 2019 Jun 18;74(7):1127-1133. doi: 10.1093/gerona/gly176.

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

Author information

Department of Medicine, University of Otago, Christchurch, New Zealand.
Older Persons Health Specialist Service, Burwood Hospital, Christchurch, New Zealand.
School of Pharmacy, University of Otago, Dunedin, New Zealand.
Department of Nursing, Canterbury District Health Board, Christchurch, New Zealand.
Cognitive Decline Partnership Centre, Ageing and Pharmacology, Kolling Institute of Medical Research, School of Medicine, University of Sydney, St Leonards, NSW, Australia.
Drug Safety Office of Clinical Pharmacology, U.S. FDA, U.S. Department of Health and Human Services, Baltimore, Maryland.
Department of Medicine, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, Massachusetts.
Department of Health Services, Policy and Practice, Brown University, School of Public Health, Providence, Rhode Island.
West Coast District Health Board, Greymouth.
School of Health Sciences, College of Education, Health and Human Development University of Canterbury, Christchurch, New Zealand.
Primary Care Clinical Unit, School of Clinical Medicine, The University of Queensland, Brisbane, Australia.



The Drug Burden Index (DBI) calculates the total sedative and anticholinergic load of prescribed medications and is associated with functional decline and hip fractures in older adults. However, it is unknown if confounding factors influence the relationship between the DBI and hip fractures. The objective of this study was to evaluate the association between the DBI and hip fractures, after correcting for mortality and multiple potential confounding factors.


A competing-risks regression analysis conducted on a prospectively recruited New Zealand community-dwelling older population who had a standardized (International Resident Assessment Instrument) assessment between September 1, 2012, and October 31, 2015, the study's end date. Outcome measures were survival status and hip fracture, with time-varying DBI exposure derived from 90-day time intervals. The multivariable competing-risks regression model was adjusted for a large number of medical comorbidities and activities of daily living.


Among 70,553 adults assessed, 2,249 (3.2%) experienced at least one hip fracture, 20,194 (28.6%) died without experiencing a fracture, and 48,110 (68.2%) survived without a fracture. The mean follow-up time was 14.9 months (range: 1 day, 37.9 months). The overall DBI distribution was highly skewed, with median time-varying DBI exposure ranging from 0.93 (Q1 = 0.0, Q3 = 1.84) to 0.96 (Q1 = 0.0, Q3 = 1.90). DBI was significantly related to fracture incidence in unadjusted (p < .001) and adjusted (p < .001) analyses. The estimated subhazard ratio was 1.52 (95% confidence interval: 1.28-1.81) for those with DBI > 3 compared with those with DBI = 0 in the adjusted analysis.


In this study, increasing DBI was associated with a higher likelihood of fractures after accounting for the competing risk of mortality and adjusting for confounders. The results of this unique study are important in validating the DBI as a guide for medication management and it could help reduce the risk of hip fractures in older adults.


Falls; Medications; Polypharmacy; RAI


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