Drugs & Aging

, Volume 36, Issue 1, pp 73–83 | Cite as

Is the Drug Burden Index Related to Declining Functional Status at Follow-up in Community-Dwelling Seniors Consulting for Minor Injuries? Results from the Canadian Emergency Team Initiative Cohort Study

  • Edeltraut KrögerEmail author
  • Marilyn Simard
  • Marie-Josée Sirois
  • Marianne Giroux
  • Caroline Sirois
  • Lisa Kouladjian-O’Donnell
  • Emily Reeve
  • Sarah Hilmer
  • Pierre-Hugues Carmichael
  • Marcel Émond
Original Research Article



The Canadian Emergency Team Initiative (CETI) cohort showed that minor injuries like sprained ankles or small fractures trigger a downward spiral of functional decline in 16% of independent seniors up to 6 months post-injury. Such seniors frequently receive medications with sedative or anticholinergic properties. The Drug Burden Index (DBI), which summarises the drug burden of these specific medications, has been associated with decreased physical and cognitive functioning in previous research.


We aimed to assess the contribution of the DBI to functional decline in the CETI cohort.


CETI participants were assessed physically and cognitively at baseline during their consultations at emergency departments (EDs) for their injuries and up to 6 months thereafter. The medication data were used to calculate baseline DBI and functional status was measured with the Older Americans Resources and Services (OARS) scale. Multivariate linear regression models assessed the association between baseline DBI and functional status at 6 months, adjusting for age, sex, baseline OARS, frailty level, comorbidity count, and mild cognitive impairment.


The mean age of the 846 participants was 77 years and their mean DBI at baseline was 0.24. Complete follow-up data at 3 or 6 months was available for 718 participants among whom a higher DBI at the time of injury contributed to a lower functional status at 6 months. Each additional point in the DBI lead to a loss of 0.5 points on the OARS functional scale, p < 0.001. Among those with a DBI ≥ 1, 27.4% were considered ‘patients who decline’ at 3 or 6 months’ follow-up, compared with 16.0% of those with a DBI of 0 (p = 0.06).


ED visits are considered missed opportunities for optimal care interventions in seniors; Identifying their DBI and adjusting treatment accordingly may help limit functional decline in those at risk after minor injury.


Compliance with Ethical Standards


This study received financial and logistic support from the Réseau québécois de recherche sur le vieillissement du Fonds de recherche québecois—santé (MJS and study team) and the Quebec Centre for Excellence in Aging of the Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale (CIUSSSCN) (EK, MJS and study team) and from the Centre de recherche du CHU de Québec. None of the financial contributors participated in collection, analysis, or interpretation of data, or in writing the manuscript.

Conflict of interest

Edeltraut Kröger, Marilyn Simard, Marie-Josée Sirois, Marianne Giroux, Caroline Sirois, Lisa Kouladjian-O’Donnell, Emily Reeve, Sarah Hilmer, Pierre-Hugues Carmichael and Marcel Émond declare that they have no conflict of interest relevant to the content of this publication.

Supplementary material

40266_2018_604_MOESM1_ESM.docx (25 kb)
Supplementary material 1 (DOCX 26 kb)


  1. 1.
    Canadian Institute for Health Information. Drug use among seniors in Canada, 2016. Ottawa: CIHI; 2018.Google Scholar
  2. 2.
    Ruxton K, Woodman RJ, Mangoni AA. Drugs with anticholinergic effects and cognitive impairment, falls and all-cause mortality in older adults: a systematic review and meta-analysis. Br J Clin Pharmacol. 2015;80(2):209–20.CrossRefGoogle Scholar
  3. 3.
    Hilmer SN, McLachlan AJ, Le Couteur DG. Clinical pharmacology in the geriatric patient. Fundam Clin Pharmacol. 2007;21(3):217–30.CrossRefGoogle Scholar
  4. 4.
    Kashyap M, Belleville S, Mulsant BH, et al. Methodological challenges in determining longitudinal associations between anticholinergic drug use and incident cognitive decline. J Am Geriatr Soc. 2014;62(2):336–41.CrossRefGoogle Scholar
  5. 5.
    Shamseer L, Moher D, Clarke M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: elaboration and explanation. BMJ. 2015;349:g7647.CrossRefGoogle Scholar
  6. 6.
    Zulman DM, Sussman JB, Chen X, et al. Examining the evidence: a systematic review of the inclusion and analysis of older adults in randomized controlled trials. J Gen Intern Med. 2011;26(7):783–90.CrossRefGoogle Scholar
  7. 7.
    Boyd CM, Darer J, Boult C, et al. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. JAMA. 2005;294(6):716–24.CrossRefGoogle Scholar
  8. 8.
    Mangoni AA, Jackson SH. Age-related changes in pharmacokinetics and pharmacodynamics: basic principles and practical applications. Br J Clin Pharmacol. 2004;57(1):6–14.CrossRefGoogle Scholar
  9. 9.
    Fulton MM, Allen ER. Polypharmacy in the elderly: a literature review. J Am Acad Nurse Practitioners. 2005;17(4):123–32.CrossRefGoogle Scholar
  10. 10.
    Ganjavi H, Herrmann N, Rochon PA, et al. Adverse drug events in cognitively impaired elderly patients. Dement Geriatr Cogn Disord. 2007;23(6):395–400.CrossRefGoogle Scholar
  11. 11.
    Cherubini A, Ruggiero C, Gasperini B, et al. The prevention of adverse drug reactions in older subjects. Curr Drug Metab. 2011;12(7):652–7.CrossRefGoogle Scholar
  12. 12.
    Chumney EC, Robinson LC. The effects of pharmacist interventions on patients with polypharmacy. Pharm Pract. 2006;4(3):103–9.Google Scholar
  13. 13.
    Tamura BK, Bell CL, Inaba M, et al. Outcomes of polypharmacy in nursing home residents. Clin Geriatr Med. 2012;28(2):217–36.CrossRefGoogle Scholar
  14. 14.
    Zed PJ, Abu-Laban RB, Balen RM, et al. Incidence, severity and preventability of medication-related visits to the emergency department: a prospective study. CMAJ. 2008;178(12):1563–9.CrossRefGoogle Scholar
  15. 15.
    Ambrose AF, Paul G, Hausdorff JM. Risk factors for falls among older adults: a review of the literature. Maturitas. 2013;75(1):51–61.CrossRefGoogle Scholar
  16. 16.
    Bennett A, Gnjidic D, Gillett M, et al. Prevalence and impact of fall-risk-increasing drugs, polypharmacy, and drug-drug interactions in robust versus frail hospitalised falls patients: a prospective cohort study. Drugs Aging. 2014;31(3):225–32.CrossRefGoogle Scholar
  17. 17.
    Farrell B, Eisener-Parsche P, Dalton D. Turning over the rocks: role of anticholinergics and benzodiazepines in cognitive decline and falls. Can Fam Physician. 2014;60(4):345–50.Google Scholar
  18. 18.
    Fried TR, O’Leary J, Towle V, et al. Health outcomes associated with polypharmacy in community-dwelling older adults: a systematic review. J Am Geriatr Soc. 2014;62(12):2261–72.CrossRefGoogle Scholar
  19. 19.
    Maher RL, Hanlon J, Hajjar ER. Clinical consequences of polypharmacy in elderly. Expert Opin Drug Saf. 2014;13(1):57–65.CrossRefGoogle Scholar
  20. 20.
    Jano E, Aparasu RR. Healthcare outcomes associated with beers’ criteria: a systematic review. Ann Pharmacother. 2007;41(3):438–47.CrossRefGoogle Scholar
  21. 21.
    Wennie Huang WN, Perera S, VanSwearingen J, et al. Performance measures predict onset of activity of daily living difficulty in community-dwelling older adults. J Am Geriatr Soc. 2010;58(5):844–52.CrossRefGoogle Scholar
  22. 22.
    Lau DT, Briesacher BA, Touchette DR, et al. Medicare part D and quality of prescription medication use in older adults. Drugs Aging. 2011;28(10):797–807.CrossRefGoogle Scholar
  23. 23.
    Peron EP, Gray SL, Hanlon JT. Medication use and functional status decline in older adults: a narrative review. Am J Geriatr Pharmacother. 2011;9(6):378–91.CrossRefGoogle Scholar
  24. 24.
    Gnjidic D, Bell JS, Hilmer SN, et al. Drug Burden Index associated with function in community-dwelling older people in Finland: a cross-sectional study. Ann Med. 2012;44:458–67.CrossRefGoogle Scholar
  25. 25.
    Taipale HT, Bell JS, Gnjidic D, et al. Sedative load among community-dwelling people aged 75 years or older: association with balance and mobility. J Clin Psychopharmacol. 2012;32(2):218–24.CrossRefGoogle Scholar
  26. 26.
    Hilmer SN, Mager DE, Simonsick EM, et al. A drug burden index to define the functional burden of medications in older people. Arch Intern Med. 2007;167(8):781–7.CrossRefGoogle Scholar
  27. 27.
    Hilmer SN, Mager DE, Simonsick EM, et al. Drug burden index score and functional decline in older people. Am J Med. 2009;122(12):1142–1149.e1–2.CrossRefGoogle Scholar
  28. 28.
    Gnjidic D, Cumming RG, Le Couteur DG, et al. Drug Burden Index and physical function in older Australian men. Br J Clin Pharmacol. 2009;68:97–105.CrossRefGoogle Scholar
  29. 29.
    Cardwell K, Hughes CM, Ryan C. The association between anticholinergic medication burden and health related outcomes in the ‘oldest old’: a systematic review of the literature. Drugs Aging. 2015;32(10):835–48.CrossRefGoogle Scholar
  30. 30.
    Tannenbaum C, Farrell B, Shaw J, et al. An ecological approach to reducing potentially inappropriate medication use: Canadian Deprescribing Network. Can J Aging. 2017;36(1):97–107.CrossRefGoogle Scholar
  31. 31.
    Ioannidis G, Papaioannou A, Hopman WM, et al. Relation between fractures and mortality: results from the Canadian Multicentre Osteoporosis Study. CMAJ. 2009;181(5):265–71.CrossRefGoogle Scholar
  32. 32.
    Canadian Institute for Health Information. Seniors’ use of emergency departments in Ontario, 2004–2005 to 2008–2009. Ottawa: CIHI; 2010.Google Scholar
  33. 33.
    Bawa H, Brussoni M, De Gagné D, et al. Emergency Department Surveillance System: Seniors injury data report 2001–2003. Vancouver: BC Injury Research and Prevention Unit; 2004.Google Scholar
  34. 34.
    Sirois MJ, Emond M, Ouellet MC, et al. Cumulative incidence of functional decline after minor injuries in previously independent older Canadian individuals in the emergency department. J Am Geriatr Soc. 2013;61(10):1661–8.CrossRefGoogle Scholar
  35. 35.
    Hoogerduijn JG, Schuurmans MJ, Duijnstee MS, et al. A systematic review of predictors and screening instruments to identify older hospitalized patients at risk for functional decline. J Clin Nurs. 2007;16(1):46–57.CrossRefGoogle Scholar
  36. 36.
    Williams M, Soiza R, Jenkinson AM, et al. Exercising with computers in later life (EXCELL)—pilot and feasibility study of the acceptability of the Nintendo™ WiiFit in community dwelling. Biomed Cent Res Notes. 2010;3(238):1–8.Google Scholar
  37. 37.
    Salvi F, Morichi VGA, Giorgi R, et al. The elderly in the emergency department: a critical review of problems and solutions. Intern Emerg Med. 2007;2:292–301.CrossRefGoogle Scholar
  38. 38.
    Platts-Mills TF, Owens ST, McBride JM. A modern-day purgatory: older adults in the emergency department with nonoperative injuries. J Am Geriatr Soc. 2014;62(3):525–8.CrossRefGoogle Scholar
  39. 39.
    Provencher V, Sirois MJ, Ouellet MC, et al. Decline in basic activities of daily living following visits to Canadian emergency department for minor injuries among independent seniors: Are frail older adults with cognitive impairments at greater risk? J Am Geriatr Soc. 2015;63(5):860–8.CrossRefGoogle Scholar
  40. 40.
    Lee J, Sirois MJ, Moore L, et al. Return to the ED and hospitalisation following minor injuries among older persons treated in the emergency department: predictors among independent seniors within 6 months. Age Ageing. 2015;44(4):624–9.CrossRefGoogle Scholar
  41. 41.
    Fillenbaum G. Multidimensional functional assessment: the OARS methodology—a manual. Durham: Center for the Study of Aging and Human development, Duke University; 1975. p. 134.Google Scholar
  42. 42.
    Agrément Canada, Institut canadien d’information sur la santé, Institut canadien pour la sécurité des patients, et al. Bilan comparatif des médicaments au Canada: hausser la barre—Progrès à ce jour et chemin à parcourir. Ottawa, ON: Agrément Canada; 2012. p. 24.Google Scholar
  43. 43.
    World Health Organization. WHO Collaborating Center for Drug Statistics Methodology. 2009 [Internet]. Available from:
  44. 44.
    Dispennette R, Elliott D, Nguyen L, et al. Drug Burden Index score and anticholinergic risk scale as predictors of readmission to the hospital. Consultant Pharm. 2014;29(3):158–68.CrossRefGoogle Scholar
  45. 45.
    Compendium of Pharmaceuticals and Specialties, online version (e-CPS). © Canadian Pharmacists Association, 2014. Available from:
  46. 46.
    Martindale: The Complete Drug Reference. 37th edition [Internet]. The Pharmaceutical Press. MedicinesComplete © 2015. 2015. Available from:
  47. 47.
    Gnjidic D, Hilmer SN, Hartikainen S, et al. Impact of high risk drug use on hospitalization and mortality in older people with and without Alzheimer’s disease: a national population cohort study. PLoS One. 2014;9(1):e83224.CrossRefGoogle Scholar
  48. 48.
    Haywood KL, Garratt AM, Fitzpatrick R. Quality of life in older people: a structured review of generic self-assessed health instruments. Qual Life Res. 2005;14(7):1651–68.CrossRefGoogle Scholar
  49. 49.
    Haywood KL, Garratt AM, Fitzpatrick R. Older people specific health status and quality of life: a structured review of self-assessed instruments. J Eval Clin Pract. 2005;11(4):315–27.CrossRefGoogle Scholar
  50. 50.
    McCusker J, Bellavance F, Cardin S, et al. Detection of older people at increased risk of adverse health outcomes after an emergency visit: the ISAR screening tool. J Am Geriatr Soc. 1999;47(10):1229–37.CrossRefGoogle Scholar
  51. 51.
    Abdulaziz K, Perry JJ, Taljaard M, et al. National survey of geriatricians to define functional decline in elderly people with minor trauma. Can Geriatr J. 2016;19(1):2–8.Google Scholar
  52. 52.
    Ensrud KE, Ewing SK, Cawthon PM, et al. A comparison of frailty indexes for the prediction of falls, disability, fractures, and mortality in older men. J Am Geriatr Soc. 2009;57(3):492–8.CrossRefGoogle Scholar
  53. 53.
    Rockwood K, Song X, MacKnight C, et al. A global clinical measure of fitness and frailty in elderly people. CMAJ. 2005;173(5):489–95.CrossRefGoogle Scholar
  54. 54.
    Canadian Study of Health and Aging Working Group. Canadian Study of Health and Aging: study methods and prevalence of dementia. CMAJ. 1994;150(6):899–913.Google Scholar
  55. 55.
    Nasreddine ZS, Phillips NA, Bedirian V, et al. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005;53(4):695–9.CrossRefGoogle Scholar
  56. 56.
    Brandt J, Spencer M, Folstein M. The telephone interview for cognitive status. Cogn Behav Neurol. 1988;1(2):111–8.Google Scholar
  57. 57.
    Lacruz M, Emeny R, Bickel H, et al. Feasibility, internal consistency and covariates of TICS-m (telephone interview for cognitive status-modified) in a population-based sample: findings from the KORA-Age study. Int J Geriatr Psychiatry. 2013;28(9):971–8.CrossRefGoogle Scholar
  58. 58.
    Knopman DS, Roberts RO, Geda YE, et al. Validation of the telephone interview for cognitive status-modified in subjects with normal cognition, mild cognitive impairment, or dementia. Neuroepidemiology. 2010;34(1):34–42.CrossRefGoogle Scholar
  59. 59.
    Lee JY, Dong Woo L, Cho SJ, et al. Brief screening for mild cognitive impairment in elderly outpatient clinic: validation of the Korean version of the Montreal Cognitive Assessment. J Geriatr Psychiatry Neurol. 2008;21(2):104–10.CrossRefGoogle Scholar
  60. 60.
    Luis CA, Keegan AP, Mullan M. Cross validation of the Montreal Cognitive Assessment in community dwelling older adults residing in the Southeastern US. Int J Geriatr Psychiatry. 2009;24(2):197–201.CrossRefGoogle Scholar
  61. 61.
    Gallo JJ, Breitner JC. Alzheimer’s disease in the NAS-NRC Registry of aging twin veterans, IV. Performance characteristics of a two-stage telephone screening procedure for Alzheimer’s dementia. Psychol Med. 1995;25(6):1211–9.Google Scholar
  62. 62.
    Vercambre MN, Cuvelier H, Gayon YA, et al. Validation study of a French version of the modified telephone interview for cognitive status (F-TICS-m) in elderly women. Int J Geriatr Psychiatry. 2010;25(11):1142–9.CrossRefGoogle Scholar
  63. 63.
    Whitney SL, Marchetti GF, Schade A, et al. The sensitivity and specificity of the Timed “Up & Go” and the Dynamic Gait Index for self-reported falls in persons with vestibular disorders. J Vestib Res. 2004;14(5):397–409.Google Scholar
  64. 64.
    Tinetti M, Williams C. Falls, injuries due to falls, and the risk of admission to a nursing home. N Engl J Med. 1997;337(18):1279–84.CrossRefGoogle Scholar
  65. 65.
    Ontario Injury Prevention Resource Center. Injuries among seniors in Ontario: a descriptive analysis of emergency department and hospitalization Data. Toronto: Ontario Injury Prevention Resource Centre; 2007.Google Scholar
  66. 66.
    Paniagua MA, Malphurs JE, Phelan EA. Older patients presenting to a county hospital ED after a fall: missed opportunities for prevention. Am J Emerg Med. 2006;24(4):413–7.Google Scholar
  67. 67.
    Yardley L, Beyer N, Hauer K, et al. Development and initial validation of the Falls Efficacy Scale-International (FES-I). Age Ageing. 2005;34(6):614.CrossRefGoogle Scholar
  68. 68.
    Salahudeen MS, Chyou TY, Nishtala PS. Serum anticholinergic activity and cognitive and functional adverse outcomes in older people: a systematic review and meta-analysis of the Literature. PLoS One. 2016;11(3):e0151084.CrossRefGoogle Scholar
  69. 69.
    Salahudeen MS, Hilmer SN, Nishtala PS. Comparison of anticholinergic risk scales and associations with adverse health outcomes in older people. J Am Geriatr Soc. 2015;63(1):85–90.CrossRefGoogle Scholar
  70. 70.
    Wouters H, van der Meer H, Taxis K. Quantification of anticholinergic and sedative drug load with the Drug Burden Index: a review of outcomes and methodological quality of studies. Eur J Clin Pharmacol. 2017;73(3):257–66.CrossRefGoogle Scholar
  71. 71.
    Melady D, Perry A. Ten best practices for the older patient in the emergency department. Clin Geriatr Med. 2018;34(3):313–26.CrossRefGoogle Scholar
  72. 72.
    Tsunoda K, Uchida H, Suzuki T, et al. Effects of discontinuing benzodiazepine-derivative hypnotics on postural sway and cognitive functions in the elderly. Int J Geriatr Psychiatry. 2010;25(12):1259–65.CrossRefGoogle Scholar
  73. 73.
    Curran HV, Collins R, Fletcher S, et al. Older adults and withdrawal from benzodiazepine hypnotics in general practice: effects on cognitive function, sleep, mood and quality of life. Psychol Med. 2003;33(7):1223–37.CrossRefGoogle Scholar
  74. 74.
    Barker MJ, Greenwood KM, Jackson M, et al. Persistence of cognitive effects after withdrawal from long-term benzodiazepine use: a meta-analysis. Arch Clin Neuropsychol. 2004;19(3):437–54.CrossRefGoogle Scholar
  75. 75.
    Salahudeen M, Duffull S, Nishtala P. Impact of anticholinergic discontinuation on cognitive outcomes in older people: a systematic review. Drugs Aging. 2014;31(3):185–92.CrossRefGoogle Scholar
  76. 76.
    Kersten H, Molden E, Tolo IK, et al. Cognitive effects of reducing anticholinergic drug burden in a frail elderly population: a randomized controlled trial. J Gerontol A Biol Sci Med Sci. 2013;68(3):271–8.CrossRefGoogle Scholar
  77. 77.
    Boye NDA, van der Velde N, de Vries OJ, et al. Effectiveness of medication withdrawal in older fallers: results from the Improving Medication Prescribing to reduce Risk Of FALLs (IMPROveFALL) trial. Age Ageing. 2016;46(1):142–6.Google Scholar
  78. 78.
    Hilmer SN, Gnjidic D, Le Couteur DG. Thinking through the medication list - appropriate prescribing and deprescribing in robust and frail older patients. Aust Fam Physician. 2012;41(12):924–8.Google Scholar
  79. 79.
    Tannenbaum C, Martin P, Tamblyn R, et al. Reduction of inappropriate benzodiazepine prescriptions among older adults through direct patient education: the EMPOWER cluster randomized trial. JAMA Intern Med. 2014;174(6):890–8.CrossRefGoogle Scholar
  80. 80.
    Campbell AJ, Robertson MC, Gardner MM, et al. Psychotropic medication withdrawal and a home-based exercise program to prevent falls: a randomized, controlled trial. J Am Geriatr Soc. 1999;47(7):850–3.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2018

Authors and Affiliations

  • Edeltraut Kröger
    • 1
    • 2
    • 4
    Email author
  • Marilyn Simard
    • 2
    • 3
  • Marie-Josée Sirois
    • 2
    • 3
    • 4
  • Marianne Giroux
    • 2
    • 4
  • Caroline Sirois
    • 2
    • 3
    • 4
  • Lisa Kouladjian-O’Donnell
    • 5
    • 6
  • Emily Reeve
    • 5
    • 6
  • Sarah Hilmer
    • 5
    • 6
  • Pierre-Hugues Carmichael
    • 2
    • 4
  • Marcel Émond
    • 2
    • 3
    • 4
  1. 1.Faculté de pharmacieUniversité LavalQuébecCanada
  2. 2.Centre d’excellence sur le vieillissement de Québec du Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale (CIUSSSCN)QuébecCanada
  3. 3.Faculté de médecineUniversité LavalQuébecCanada
  4. 4.Axe santé des populations et pratiques optimales en santéCentre de recherche du Centre Hospitalier Universitaire (CHU) de QuébecQuébecCanada
  5. 5.NHMRC Cognitive Decline Partnership CentreUniversity of SydneySydneyAustralia
  6. 6.Kolling Institute of Medical ResearchUniversity of Sydney and Royal North Shore HospitalSt LeonardsAustralia

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