Inappropriate medication use among frail elderly inpatients

BACKGROUND

Inappropriate prescribing in frail elderly inpatients has not received as much investigation as in frail elderly nursing home patients.

OBJECTIVE

To determine the prevalence and predictors of inappropriate prescribing for hospitalized frail elderly patients.

METHODS

The study was conducted at 11 Veterans Affairs Medical Centers and involved a sample of 397 frail elderly inpatients. Inappropriate prescribing was measured by physician-pharmacist pair's consensus ratings for 10 criteria on the Medication Appropriateness Index (MAI). The MAI ratings generated a weighted score of 0-18 per medication (higher score = more inappropriate) and were summed across medications to achieve a patient score.

RESULTS

Overall, 365 (91.9%) patients had > or =1 medications with > or =1 MAI criteria rated as inappropriate. The most common problems involved expensive drugs (70.0%), impractical directions (55.2%), and incorrect dosages (50.9%). The most common drug classes with appropriateness problems were gastric (50.6%), cardiovascular (47.6%), and central nervous system (23.9%). The mean +/- SD MAI score per person was 8.9 +/- 7.6. Stepwise ordinal logistic regression analyses revealed that both the number of prescription (adjusted OR 1.28; 95% CI 1.21 to 1.36) and nonprescription drugs (adjusted OR 1.17; 95% CI 1.06 to 1.29) were related to higher MAI scores. Analyses excluding the number of drugs revealed that the Charlson index (adjusted OR 1.62; 95% CI 1.12 to 2.35) and fair/poor self-rated health (adjusted OR 1.15; 95% CI 1.05 to 1.26) were related to higher MAI scores.

CONCLUSIONS

Inappropriate drug prescribing is common for frail elderly veteran inpatients and is related to polypharmacy and specific health status characteristics.

Advances in neuropathic pain: diagnosis, mechanisms, and treatment recommendations

Chronic neuropathic pain, caused by lesions in the peripheral or central nervous system, comes in many forms. We describe current approaches to the diagnosis and assessment of neuropathic pain and discuss the results of recent research on its pathophysiologic mechanisms. Randomized controlled clinical trials of gabapentin, the 5% lidocaine patch, opioid analgesics, tramadol hydrochloride, and tricyclic antidepressants provide an evidence-based approach to the treatment of neuropathic pain, and specific recommendations are presented for use of these medications. Continued progress in basic and clinical research on the pathophysiologic mechanisms of neuropathic pain may make it possible to predict effective treatments for individual patients by application of a pain mechanism-based approach.

Treatment and prevention of postherpetic neuralgia

There have been 4 recent major advances in the treatment of postherpetic neuralgia (PHN) that are based on the results of randomized, controlled trials. These advances are the demonstrations that gabapentin, the lidocaine patch 5%, and opioid analgesics are efficacious in patients with PHN, and the report that nortriptyline and amitriptyline provide equivalent analgesic benefits for patients with PHN but that nortriptyline is better tolerated. The results of these clinical trials are briefly reviewed, and their implications for the treatment of patients with PHN are discussed. Despite these treatment advances, many patients remain refractory to current therapy, and the prevention of PHN has therefore become an important focus of current research. Research on administration of the varicella-zoster vaccine to prevent herpes zoster and on treatment of patients who have herpes zoster with combined antiviral and analgesic therapy to prevent PHN is discussed.

Epidemiology and impact on quality of life of postherpetic neuralgia and painful diabetic neuropathy

OBJECTIVE

This article reviews the prevalence, risk factors, natural history, and impact on quality of life of painful diabetic neuropathy (PDN) and postherpetic neuralgia (PHN).

DISCUSSION

Diabetes mellitus afflicts more than 14 million persons in the U.S. An estimated 20% to 24% of these persons experience PDN. Data on risk factors for PDN are limited, but duration of diabetes mellitus and poor glycemic control are probably important factors. Painful diabetic neuropathy may interfere with general activity, mood, mobility, work, social relations, sleep, leisure activities, and enjoyment of life. Herpes zoster strikes an estimated 800,000 persons each year in the U.S., most of whom are elderly or immunosuppressed. Using pain at 3 months after rash onset as a definition of PHN, between 25% and 50% of adults older than 50 years develop PHN, depending on early antiviral therapy for herpes zoster. Increasing age, greater pain and rash severity, greater degree of sensory impairment, and psychological distress are risk factors for PHN. Postherpetic neuralgia may cause fatigue, insomnia, depression, anxiety, interference with social roles and leisure activity, and impaired basic and instrumental activities of daily living.

CONCLUSIONS

Both conditions are common complications of their underlying disorders and can profoundly diminish the quality of life of affected persons.

HIV infection: treatment outcomes in older and younger adults

OBJECTIVES

To determine the effect of antiretroviral therapy (ART) on the immunological and virological outcomes of older human immunodeficiency virus (HIV)-infected patients compared with younger HIV-infected patients.

DESIGN

Matched (1:2) retrospective case-control study (1993-1999).

SETTING

Duke University Infectious Diseases Clinic.

PARTICIPANTS

One hundred one older patients, mean age 56.7 (range 50-79) and 202 younger patients, mean age 32.8 (range 21-39). Patients were matched on baseline CD4+ cell count and date of clinic entry.

MEASUREMENTS

The virological and immunological outcomes were viral suppression (HIV ribonucleic acid (RNA) level < or =400 copies/ml) and change in CD4+ cell count. To estimate differences in antiretroviral drug exposure, the percentage of patients on ART overall and by drug class was compared. To assess antiretroviral drug exposure further, the percentage of patients having interruptions in ART was compared.

RESULTS

The older and younger groups had similar baseline CD4+ cell counts (332 vs 306 cells/mm3; P =.31) and similar increases in CD4+ cell counts (+3.47 vs +4.60 cells/mm3/month; P =.37) over a mean +/- standard deviation of 2.4 +/- 1.7 years of follow-up. The older group had a higher percentage of patients with current plasma HIV RNA levels less than 400 (46% vs 34%; P =.05). The groups had similar rates of non-nucleoside reverse transcriptase, nucleoside reverse transcriptase, and protease inhibitor use. The older group had fewer interruptions in ART than the younger group (11% vs 26%; P =.01).

CONCLUSIONS

Older HIV-infected patients responded well to ART, with a significantly greater percentage achieving a current plasma HIV RNA below detectable limits. Older patients experienced similar increases in CD4+ cell count as younger matched controls. Older patients were less likely to interrupt ART, which suggests better adherence and/or tolerance and may explain the higher rate of HIV RNA suppression.

Impact of inappropriate drug use on mortality and functional status in representative community dwelling elders

BACKGROUND

The predictive validity of Drug Utilization Review (DUR) and drugs-to-avoid criteria in elders is unknown.

OBJECTIVES

To evaluate the relationship between use of inappropriate drugs as determined by these explicit criteria and mortality and decline in functional status in community dwelling elders.

RESEARCH DESIGN

Cohort study.

SUBJECTS

The fourth wave (3234 participants) of the Duke Established Populations for Epidemiologic Studies of the Elderly.

MEASURES

Two sets of inappropriate drug-use criteria: (1) DUR with respect to dosage, duplication, drug-drug interactions, duration, and drug-disease interactions; and (2) Beers-modified criteria regarding drugs-to-avoid were applied to drug use reported in an in-home interview. Death was identified from the National Death Index; change in four functional status measures (basic self-care, intermediate self-care, complex self-management, physical function) was determined during the following 3 years.

RESULTS

Use of inappropriate drugs identified by either set of criteria was not significantly associated with mortality. The drugs-to-avoid criteria identified no significant associations between use of these drugs and decline in functional status. With DUR criteria, however, the association between use of inappropriate drugs and basic self-care was significant and pronounced among those with drug-drug or drug-disease interaction problems (Adj. OR 2.04; 95% CI 1.32-3.16).

CONCLUSIONS

Identifying the impact of inappropriate drug use may depend on the criteria applied. Further studies are needed that measure additional outcomes and use alternate measures of inappropriate drug use.

Use of inappropriate prescription drugs by older people

OBJECTIVES

To determine the prevalence and predictors of inappropriate drug prescribing defined by expert national consensus panel drug utilization review criteria for community-dwelling older people.

DESIGN

Survey.

SETTING

Five adjacent urban and rural counties in the Piedmont area of North Carolina.

PARTICIPANTS

A stratified random sample of participants from the fourth (n = 3,234) and seventh (n = 2,508) waves of the Duke Established Populations for Epidemiological Studies of the Elderly.

MEASUREMENTS

The prescribing appropriateness for digoxin, calcium channel blockers, angiotensin-converting enzyme inhibitors, histamine(2) receptor antagonists, nonsteroidal antiinflammatory drugs (NSAIDs), benzodiazepines, antipsychotics, and antidepressants as determined by explicit criteria (through Health Care Financing Administration expert consensus panel drug utilization review criteria for dosage, duplication, drug-drug interactions and duration, and U.S. and Canadian expert consensus panel criteria for drug-disease interactions). Multivariable analyses, using weighted data adjusted for sampling design, were conducted to assess the association between inappropriate prescribing and demographic, health-status, and access-to-healthcare factors cross-sectionally and longitudinally.

RESULTS

We found that 21.0 of the fourth wave and 19.2 of the seventh wave participants who used one or more agents from the eight drug classes had one or more elements identified as inappropriate. The therapeutic classes with the most problems were benzodiazepines and NSAIDs. The most common problems were with drug-disease interactions and duration of use. Longitudinal multivariable analyses found that participants who were white (adjusted odds ratio (AOR) = 1.67, 95 confidence interval (CI) = 1.28-2.17), were married (AOR = 1.40, 95% CI = 1.01-1.93), had arthritis (AOR = 1.74, 95% CI = 1.27-2.38), had one or more physical function disabilities (AOR = 1.42, 95% CI = 1.02-1.96), and had inappropriate drugs prescribed at wave 4 (AOR = 6.87, 95% CI = 5.11-9.22) were more likely to have inappropriate prescribing at wave 7.

CONCLUSION

These results indicate that inappropriate prescribing is common among community-dwelling older people and persists over time. Longitudinal studies in older people are needed to examine the impact of inappropriate drug prescribing on health-related outcomes.

Suboptimal prescribing in older inpatients and outpatients

Investigators searched Medline and HealthSTAR databases from January 1, 1985 through June 30, 1999 to identify articles on suboptimal prescribing in those age 65 years and older. A manual search of the reference lists from identified articles and the authors' article files, book chapters, and recent reviews was conducted to identify additional articles. The definitions for various types of suboptimal prescribing (polypharmacy, inappropriate, and underutilization) are numerous, and measurement varies from study to study. The literature suggests that suboptimal prescribing is common in older outpatients and inpatients. Moreover, there is significant morbidity and mortality associated with suboptimal prescribing for these older patients. Evidence from well-controlled studies suggests that multidisciplinary teams and clinical pharmacy interventions can modify suboptimal drug use in older people. Future research is necessary to measure and test other methods for tackling this major public health problem facing older people.

Impact of estrogen use on decline in cognitive function in a representative sample of older community-resident women

The authors investigated whether postmenopausal estrogen use helps to maintain cognitive function; a brief screen, the Short Portable Mental Status Questionnaire (SPMSQ), was used. Information was gathered from a stratified, random sample of 1,907 African-American and White women (aged 65-100 years) participating in the longitudinal Duke Established Populations for Epidemiologic Studies of the Elderly project carried out in five urban and rural counties of North Carolina. All women were cognitively unimpaired in 1986-1987 and were evaluated 3 and 6 years later. Decline in cognitive function was measured as an increase of two or more errors on the SPMSQ and crossing of an SPMSQ threshold indicative of cognitive impairment. Recency and continuity of estrogen use were measured. Univariate analyses indicated that recent (crude odds ratio = 0.42, 95% confidence interval: 0.21, 0.86) and continuous (crude odds ratio = 0.32, 95% confidence interval: 0.13, 0.81) estrogen use reduced the risk of cognitive decline but not of cognitive impairment. After adjustment for demographic and health characteristics, protective effects became nonsignificant. While postmenopausal use of estrogen may be protective for Alzheimer's disease, current findings based on a brief cognitive screen suggest that it is not protective for cognitive decline related to aging.

Inappropriate drug use among community-dwelling elderly

This study examined inappropriate drug use defined by updated criteria among respondents in the second and third in-person waves of the Duke Established Populations for Epidemiologic Studies of the Elderly. Information about sociodemographics, health status, access to health care, and drug use was determined by in-home interviews. Drug use was coded for therapeutic class and appropriateness by applying explicit criteria. Among participants, 27% of the second and 22.5% of the third in-person wave took one or more inappropriate agents. Of these drugs, the most common therapeutic classes were central nervous system and cardiovascular. Longitudinal multivariate analyses found that persons taking several prescription drugs, those having continuity of care, those who previously took inappropriate drugs, and those with many health visits were most likely (p<0.05) to use inappropriate drugs. We conclude that inappropriate drug use is common among community-dwelling elderly.

Benzodiazepine use and cognitive function among community-dwelling elderly

OBJECTIVE

To evaluate the relation between benzodiazepine use and cognitive function among community-dwelling elderly.

METHODS

This prospective cohort study included 2765 self-reporting subjects from the Duke Established Populations for Epidemiologic Studies of the Elderly. The subjects were cognitively intact at baseline (1986-1987) and alive at follow-up data collection 3 years later. Cognitive function was assessed with the Short Portable Mental Status Questionnaire (unimpaired versus impaired and change in score) and on the basis of the number of errors on the individual domains of the Orientation-Memory-Concentration Test. Benzodiazepine use was determined during in-home interviews and classified by dose, half-life, and duration. Covariates included demographic characteristics, health status, and health behaviors.

RESULTS

After control for covariates, current users of benzodiazepine made more errors on the memory test (beta coefficient, 0.35; 95% confidence interval [CI], 0.10 to 0.61) than nonusers. Further assessment of the negative effects on memory among current users suggested a dose response in which users taking the recommended or higher dose made more errors (beta coefficient, 0.57; 95% CI, 0.26 to 0.88) and a duration response in which long-term users made more errors (beta coefficient, 0.39; 95% CI, 0.05 to 0.73) than nonusers. Users of agents with long half-lives and users of agents with short half-lives both had increased memory impairment (beta coefficient, 0.32; 95% CI, 0.01 to 0.64 and beta coefficient, 0.38; 95% CI, 0.02 to 0.75, respectively) relative to nonusers. Previous benzodiazepine use was unrelated to memory problems, and current and previous benzodiazepine use was unrelated to level of cognitive functioning as measured with the other 4 tests.

CONCLUSIONS

The results suggested that current benzodiazepine use, especially in recommended or higher doses, is associated with worse memory among community-dwelling elderly.

Medication use patterns among demented, cognitively impaired and cognitively intact community-dwelling elderly people

OBJECTIVE

To determine whether medication use patterns in community-dwelling elderly people vary with level of cognitive function-dementia, cognitive impairment (but not dementia) and intact cognition.

DESIGN

Cross-sectional survey.

SETTING

A five-county area of central North Carolina, USA.

PARTICIPANTS

520 members of the Duke Established Populations for Epidemiologic Studies of the Elderly.

MEASUREMENTS

Medication use in the previous 2 weeks was ascertained during a interview in the patient's home and was coded as to prescription and therapeutic class status. Cognitive status, the primary independent variable, was divided into: (i) dementia (n=100); (ii) cognitive impairment but not dementia (n=117); and (iii) cognitively intact (n=303). The dependent variables were any prescription or over-the-counter (OTC) medication use (vs non-use); number of prescription or OTC medications used; and prescription and OTC use combined within major therapeutic classes. Multivariate analyses controlled for socio-demographic characteristics, health status, functional status and access to health care.

RESULTS

The use of any prescription medication was similar in the three groups. The demented were significantly less likely than cognitively impaired people to use any OTC medications (OR=0.65, 95% CI=0.45, 0.93), cardiovascular medications (OR=0.70, 95% CI=0.49, 0.99) and analgesics (OR=0.54, 95% CI=0.39, 0.75). As a combined group, those who were demented and cognitively impaired were less likely than the cognitively intact group to use any OTC medications (OR=0.78, 95% CI 0.65, 0.92). Compared with the cognitively impaired subjects, the demented group took fewer prescription medications (beta coefficient=-0.31, 95% CI=-0.59, -0.03) and similar numbers of OTC medications. Compared with those who were cognitively intact, the combined group of demented and cognitively impaired subjects took fewer OTC medications (beta coefficient=-0.14, 95% CI=-0.23, -0.05) and similar numbers of prescription medications.

CONCLUSION

Increasing level of cognitive dysfunction is associated with decreased use of OTC, cardiovascular and analgesic medications and the use of fewer prescription medications. These results suggest important differences in medication use patterns among community-dwelling elderly people who vary in cognitive status.

The prevalence and 3-year incidence of dementia in older Black and White community residents

OBJECTIVE

To determine the prevalence and 3-year incidence of dementia in Blacks and Whites age 65 and older in a five-county Piedmont area of North Carolina.

DESIGN

Stratified random sample of members of the Duke Established Populations for Epidemiologic Studies of the Elderly (EPESE) (baseline n = 4,136; 55% Black; weighted n = 28,000). Prevalence study members were differentially selected on the basis of score on the Short Portable Mental Status Questionnaire at the second in-person Duke EPESE wave. Incidence study members included all persons with obvious cognitive decline over a 3-year period, and a 10% sample of the remainder.

MEASUREMENTS

Self- and informant report on health history, functional status, and memory. Consortium to Establish a Registry for Alzheimer's Disease (CERAD) Neuropsychology Battery administered to all subjects, and CERAD Clinical Battery to those with impaired memory. Clinical consensus to determine presence and type of dementia.

RESULTS

Prevalence of dementia for persons > or =68 years old was 0.070 (95% confidence interval = 0.021-0.119) for Blacks and 0.072 (0.022-0.122) for Whites. Rates for Black men (0.078, 0.001-0.155) exceeded those for Black women (0.066, 0.003-0.129), but gender rates for Whites were reversed (men: 0.044, 0.000-0.103), (women: 0.087, 0.015-0.160). Neither race nor gender differences were significant. Prevalence of dementia increased through age 84 and tapered off thereafter. Three-year incidence of dementia was 0.058 (0.026-0.090) for Blacks and 0.062 (0.027-0.097) for Whites. Neither race nor gender differences were significant. Incidence increased through age 84, but moderated thereafter for all but Black men. The proportional representation of different types of dementia varied little by race.

CONCLUSION

Prevalence, 3-year incidence, and types of dementia are comparable in Black and White elderly in the Piedmont area of North Carolina.

The cost-effectiveness of a clinical pharmacist intervention among elderly outpatients

We estimated the cost and cost-effectiveness of a clinical pharmacist intervention known to improve the appropriateness of drug prescribing. Elderly veteran outpatients prescribed at least five drugs were randomized to an intervention (105 patients) or control (103) group and followed for 1 year. The intervention pharmacist provided advice to patients and their physicians during all general medicine visits. Mean fixed and variable costs/intervention patient were $36 and $84, respectively Health services use and costs were comparable between groups. Intervention costs ranged from $7.50-30/patient/unit change in drug appropriateness. The cost to improve the appropriateness of drug prescribing is thus relatively low.

Adverse events after discontinuing medications in elderly outpatients

BACKGROUND

Discontinuation of drug therapy is an important intervention in elderly outpatients receiving multiple medications, but it may be associated with adverse drug withdrawal events (ADWEs).

OBJECTIVE

To determine the frequency, types, timing, severity, and factors associated with ADWEs after discontinuing medications in elderly outpatients.

PATIENTS

One hundred twenty-four ambulatory elderly participants in 1-year health service intervention trial at the Durham Veterans Affairs General Medicine Clinic in Durham, NC, who stopped taking medications.

METHODS

A geriatrician retrospectively reviewed computerized medication records and clinical charts to determine medications no longer being taken and adverse events in the subsequent 4-month period. Possible ADWEs, determined by using the Naranjo causality algorithm, were categorized by therapeutic class, organ system, and severity.

RESULTS

Of 238 drugs stopped, 62 (26%) resulted in 72 ADWEs among 38 patients. Cardiovascular (42%) and central nervous system (18%) drug classes were most frequently associated with ADWEs. The ADWEs most commonly involved the circulatory (51%) and central nervous (13%) systems, and 88% were attributed to exacerbations of underlying disease. Twenty-six ADWEs (36%) resulted in hospitalization or an emergency department or urgent care clinic visit. Only the number of medications stopped was associated with ADWE occurrence (adjusted odds ratio, 1.89; 95% confidence interval, 1.33-2.67).

CONCLUSIONS

Most medications can be stopped in elderly outpatients without an ADWE occurrence. However, when ADWEs occur they resulted in substantial health care utilization. Practitioners should strive to discontinue drug therapy in the elderly but be vigilant for disease recurrence.

Adverse drug events in high risk older outpatients

OBJECTIVE

To describe the prevalence, types, and consequences of adverse drug events (ADEs) in older outpatients with polypharmacy.

DESIGN

A cohort study.

SETTING

General Medicine Clinic at the Durham Veterans Affairs Medical Center.

PATIENTS

A total of 167 high risk (taking > or = 5 scheduled medications) ambulatory older veterans who participated in a year long health service intervention trial.

MEASUREMENTS

Potential ADEs were identified by asking patients during closeout interviews whether, in the past year, they had experienced any side effects, unwanted reactions, or other problems from any medication. All reported medications and corresponding adverse experiences were assessed for plausibility by a research clinical pharmacist using two standard pharmacological textbooks and categorized by predictability, therapeutic class, and organ system.

RESULTS

Eighty self-reported ADEs involving 72 medications taken by 58 (35%) of 167 patients were textbook confirmed. Seventy-six of 80 (95%) ADEs were classified as Type A (predictable) reactions. Cardiovascular (33.3%) and central nervous system (27.8%) medication classes were most commonly implicated. Gastrointestinal (30%) and central nervous system (28.8%) ADE symptoms were common. Sixty-three percent of patients with ADEs required physician contacts, 10% emergency room visits, and 11% hospitalization. Twenty percent of medications implicated with ADEs required dosage adjustments, and 48% of ADE-related medications were discontinued. No significant differences (P > .05) were observed when ADE reporters (n = 58) and nonreporters (n = 109) were compared.

CONCLUSION

Predictable ADEs are common in high risk older outpatients, resulting in considerable medication modification and substantial healthcare utilization.

Reliability of a modified medication appropriateness index in ambulatory older persons

OBJECTIVE

To evaluate the reliability of a medication appropriateness index (MAI) modified for elderly outpatients in a non-Veterans Affairs setting.

DESIGN

Reliability study.

SETTING

General community.

PARTICIPANTS

Ten community-dwelling elderly (> 65 y) taking five or more regularly scheduled medications and participating in a university-based health service intervention study.

MAIN OUTCOME MEASURES

Interrater reliability of MAI ratings of 65 medications made by two clinical pharmacists for individual items and for an overall summed score was calculated by use of kappa statistics and intraclass correlation coefficient.

RESULTS

The interrater agreement for each of the individual MAI items was high for both appropriate and inappropriate ratings and ranged from 80% to 100% (overall kappa = 0.64). Overall agreement for the summed score was good (intraclass correlation = 0.80).

CONCLUSIONS

The modified MAI is a reliable instrument for evaluation of medication appropriateness in a non-Veterans Affairs, ambulatory, elderly population and may provide pharmacists with a practical and standard method to evaluate patients' drug regimens and identify some potential drug-related problems.

Inappropriate prescribing and health outcomes in elderly veteran outpatients

OBJECTIVE

To determine the relationship of inappropriate prescribing in the elderly to health outcomes.

SETTING

General Medical Clinic of the Durham Veterans Affairs Medical Center.

PATIENTS

A total of 208 veterans more than 65 years old who were each taking five or more drugs and participated in a pharmacist intervention trial.

MEASUREMENTS

Prescribing appropriateness was assessed by a clinical pharmacist using the medication appropriateness index (MAI). A summed MAI score was calculated, with higher scores indicating less appropriate prescribing. The health outcomes were hospitalization, unscheduled ambulatory or emergency care visits, and blood pressure control.

RESULTS

Bivariate analyses revealed that mean MAI scores at baseline were higher for those with hospital admissions (18.9 vs. 16.9, p = 0.07) and unscheduled ambulatory or emergency care visits (18.8 vs. 16.3, p = 0.05) over the subsequent 12 months than for those without admissions and emergency care visits. MAI scores for antihypertensive medications were higher for patients with inadequate blood pressure control (> 160/90 mm Hg) than for those whose blood pressure was controlled (4.7 vs. 3.1, p = 0.02).

CONCLUSIONS

Inappropriate prescribing appeared to be associated with adverse health outcomes. This findings needs to be confirmed in future studies that have larger samples and control for potential confounders.

Reliability of drug utilization evaluation as an assessment of medication appropriateness

OBJECTIVE

To test the reliability of drug utilization evaluation (DUE) applied to medications commonly used by the ambulatory elderly.

METHODS

A DUE model was developed for four domains: (1) justification for use, (2) critical process indicators, (3) complications, and (4) clinical outcomes. DUE criteria specific to use in the elderly were developed for angiotensin-converting enzyme (ACE) inhibitors and histamine2 (H2)-antagonists, and consensus was reached by an external expert panel. After pilot testing, two clinical pharmacists independently evaluated these medications, applying the DUE criteria and rating each item as appropriate or inappropriate. Interrater and intrarater reliability was assessed by using kappa statistics.

RESULTS

In a sample of 208 ambulatory elderly veterans, 42 (20.2%) were taking an ACE inhibitor and 56 (26.9%) an H2-antagonist. The interrater agreement for individual domains, represented by kappa statistics, were 0.10-0.58 and 0-0.83 for ACE inhibitors and H2-antagonists, respectively. The kappa statistic for overall agreement, which considered ratings from all criteria across all domains, was 0.24 for ACE inhibitors and 0.18 for H2-antagonists. Intrarater reliability was assessed 3 months later, and kappa statistics were 0.61-0.65 (0.49 overall) and 0-0.96 (0.81 overall) for ACE inhibitors and H2-antagonists, respectively.

CONCLUSIONS

Intrarater reliability for DUE was good to excellent. However, interrater reliability exhibited only marginal reproducibility, particularly where evaluators were required to use subjective judgement (i.e., complications, clinical outcomes). DUE may not be a suitable standard for assessing medication appropriateness in ambulatory elderly patients.

Relation of prescription nonsteroidal antiinflammatory drug use to cognitive function among community-dwelling elderly

PURPOSE

To evaluate the relationship of nonsteroidal antiinflammatory drug (NSAID) use to level of cognitive function in community-dwelling elderly persons.

METHODS

The prospective cohort study included 2765 nonproxy subjects from the Duke University Established Populations for Epidemiologic Studies of the Elderly who were cognitively intact at baseline (1986-1987) and alive at follow-up three year later. Cognitive function was assessed by the Short Portable Mental Status Questionnaire (i.e., intact vs. impaired and change in score) and by the individual domains of the Orientation-Memory-Concentration Test (i.e., number of errors). NSAID use, determined from in-home interviews, was coded for chronicity, dose, frequency of use, and prescription status.

RESULTS

After controlling for demographic factors as well as health status and behavior, continuous, regularly-scheduled, prescription use of NSAID was associated with preservation of one aspect of cognitive functioning: concentration (beta coefficient, 0.29; 95% confidence interval [CI] -0.54 to -0.04, indicating fewer errors). However, no consistent dose-response relationship was found. Current and prior NSAID use was unrelated to level of cognitive functioning across all five measures; among current users, those taking moderate or high doses (beta coefficient, 0.41; 95% CI, 0.08 to 0.74) made more errors on the memory test compared with those taking low doses (beta coefficient 0.03; 95% CI, -.85 to 0.91).

CONCLUSIONS

These results suggest no substantial or consistent protective effect of prescription NSAID use on cognitive function in community-dwelling elderly. However, recent use at higher doses may be associated with memory deterioration in this population.

Assessment of pain in herpes zoster: lessons learned from antiviral trials

Pain typically accompanies acute herpes zoster and, in a proportion of patients, it persists well beyond rash healing. Pain must therefore be analyzed in trials of antiviral agents in herpes zoster, but different methods have been used to analyze pain in recent published trials. These reports are reviewed and their methodological strengths and weaknesses examined. Based on this review, recommendations for the design and analysis of future trials of antiviral agents in herpes zoster are proposed. The principal recommendation is that antiviral efficacy should be evaluated both by distinguishing post-herpetic neuralgia from acute pain and by considering pain as a continuum. The primary endpoint should address both the prevalence and duration of post-herpetic neuralgia and should be examined in those patients who have post-herpetic neuralgia. Adopting the proposed recommendations in design and analysis of future trials should facilitate comparison across trials of the efficacy of antiviral agents in the treatment of herpes zoster.

Is medication use by community-dwelling elderly people influenced by cognitive function?

To determine whether medication use differs by cognitive status among community dwelling elderly, a survey was made of a stratified random sample of 4110 black and white participants, aged 65 or older from the Duke Established Populations for Epidemiologic Studies of the Elderly in five adjacent urban and rural counties in the Piedmont area of North Carolina. Main outcome measures were usage of prescription medications, non-prescription medications, and medicines within therapeutic classes in the previous 2 weeks as determined during an in-home interview; and total number of prescription and non-prescription medicines used in the previous 2 weeks. Multivariate analyses, using weighted data adjusted for sampling design, were conducted to assess the association between drug use patterns and cognitive status, as assessed by the Short Portable Mental Status Questionnaire, while adjusting for demographic, health status, and access to health care factors. Participants with cognitive impairment (13.7% of sample) were less likely to use any prescription medications (Adjusted OR = 0.66, 95% CI = 0.48-0.90) or any non-prescription medications (Adjusted OR = 0. 71, 95% CI = 0.56-0.89) than cognitively intact subjects. Both groups took a similar number of prescription and non-prescription medications. Those who were cognitively impaired were less likely to take analgesics (Adjusted OR = 0.66, 95% CI = 0.52-0.83), but were more likely to take central nervous drugs (Adjusted OR = 1.55, 95% CI 1.18-2.04) than those who were cognitively intact. We conclude that drug use patterns by community-dwelling elderly people differ with cognitive status. Future research needs to examine medication use by specific causes of cognitive impairment.