Drug Burden Index Stewardship to Deprescribe Anticholinergic or Sedative Drugs in Older Inpatients

Importance Anticholinergic and sedative medications contribute to poor clinical outcomes in older inpatients. Evidence-based deprescribing strategies are needed. Objective To evaluate whether an intervention bundle increases deprescribing of anticholinergic and sedative medications in older inpatients. Design, Setting, and Participants This stepped-wedge cluster randomized clinical trial was conducted in 6 Australian public hospitals from January 2022 to July 2023. Participants were patients 65 years and older with Drug Burden Index (DBI; a measure of anticholinergic and sedative medication exposure) score greater than 0 at admission and hospitalized for 48 hours or more. Data were analyzed from October 2023 to May 2026. Interventions The intervention bundle had 2 components. The informational component (automated DBI score calculation displayed in the electronic medical record, deprescribing guides, patient leaflets, and education module) was present in all trial phases, although clinicians were not informed of it during the control phase. The stewardship component (study stewardship pharmacists who promoted the informational component and made patient-level deprescribing recommendations to attending teams) was delivered in the intervention phase. The informational component was promoted 1 to 2 times monthly during the sustainability phase. Main Outcomes and Measures The primary outcome was the proportion of patients with 1 or more DBI-contributing medications deprescribed (ceased or dose reduced) at discharge compared with admission. Secondary outcomes included deprescribing recommendations in discharge summaries and in-hospital adverse events. Results Among 4827 included patients, 2798 (58.0%) were female, and the median (IQR) age was 83.0 (76.0-88.0) years. The proportion of patients with 1 or more DBI-contributing medications deprescribed was 38.1% (788 of 2069) in the control phase, 41.4% (326 of 788) in the intervention phase, and 37.0% (729 of 1970) in the sustainability phase. The adjusted absolute difference (aAD) between intervention and control was 5.3 percentage points (95% CI, 0.1-10.6), smaller than hypothesized. Deprescribing was predominantly by cessation; in the intervention phase, 256 of 788 patients (32.5%) had 1 or more DBI-contributing medications ceased, 91 (11.5%) had 1 or more doses reduced, and 21 (2.7%) had both. The aAD between the sustainability and intervention phase estimates was −5.3 percentage points (95% CI, −10.9 to 0.3). Deprescribing recommendations in discharge summaries were more prevalent in the intervention (176 of 751 admissions [23.4%]) than the control phase (287 of 1968 admissions [14.6%]; aAD, 10.5 percentage points; 95% CI, 6.0-15.1) and were lower in the sustainability phase (362 of 1910 [19.0%]; aAD, −4.0 percentage points; 95% CI, −8.7 to 0.8). In-hospital adverse events were similar across phases. Conclusions and Relevance In this stepped-wedge cluster randomized clinical trial, the intervention bundle increased deprescribing less than hypothesized, and the increase was not sustained once the stewardship component ended.