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Drug Burden Index (DBI)
DBI Formula: Σ [ Daily Dose / (Daily Dose + Min Efficacious Dose) ]. Include ONLY drugs with clinically significant anticholinergic or sedative properties.
Add Sedative/Anticholinergic Medication
Note: Only include drugs that cross the blood-brain barrier with sedative/anticholinergic effects.
Guidelines & Evidence
Clinical Details
Section 1
When to Use
When to Use
Quantifying cumulative exposure to anticholinergic and sedative medications in older adults.
Medication review for patients presenting with falls, frailty, or functional decline.
Evaluating the pharmacological contribution to cognitive impairment.
Guiding dose-reduction or deprescribing strategies.
Dose-Responsive Burden
Unlike the Beers Criteria or ACB which assign a fixed risk or score to a drug regardless of dose, the DBI mathematically models the burden based on the actual daily dose prescribed relative to the minimum recommended daily dose. This provides a more sensitive and patient-specific measure of pharmacological load.
Section 2
Formula & Logic
Scoring Formula
DBI = Σ [ D / (D + δ) ]
Where:
D = daily dose taken by the patient
δ = minimum efficacious daily dose approved for adults
Calculated for all drugs with clinically significant anticholinergic OR sedative effects.
Interpretation
Score = 0
No exposure to sedative/anticholinergic drugs.
Score > 0 to 1
Low to moderate burden. Monitor for adverse effects.
Score > 1
High burden. Strong association with functional impairment and falls. Deprescribing indicated.
Section 3
Pearls/Pitfalls
Combining Sedative & Anticholinergic Effects
The DBI is unique in combining both sedative and anticholinergic loads into a single metric. Both classes independently impair physical and cognitive function; their concurrent use is highly prevalent and synergistic in causing falls and delirium.
Section 4
Next Steps
Management
Section 5
Evidence Appraisal
Primary Reference
A drug burden index to define the functional burden of medications in older people.
Hilmer SN et al. • Arch Intern Med.. 2007;167(8):781-7. Validation demonstrating a linear relationship between increasing DBI and decreasing physical and cognitive performance.
Section 6
Origins
Sarah Hilmer
Developed by Sarah Hilmer and colleagues using pharmacological principles of dose-response relationships. It operationalises the concept that toxicity is dose-dependent, addressing a major limitation of criteria-based tools (like Beers) that treat 10mg and 100mg of amitriptyline as equivalent risk.
