A randomized, controlled trial of a clinical pharmacist intervention to improve inappropriate prescribing in elderly outpatients with polypharmacy

PURPOSE

To evaluate the effect of sustained clinical pharmacist interventions involving elderly outpatients with polypharmacy and their primary physicians.

PATIENTS AND METHODS

Randomized, controlled trial of 208 patients aged 65 years or older with polypharmacy (> or = 5 chronic medications) from a general medicine clinic of a Veterans Affairs Medical Center. A clinical pharmacist met with intervention group patients during all scheduled visits to evaluate their drug regimens and make recommendations to them and their physicians. Outcome measures were prescribing appropriateness, health-related quality of life, adverse drug events, medication compliance and knowledge, number of medications, patient satisfaction, and physician receptivity.

RESULTS

Inappropriate prescribing scores declined significantly more in the intervention group than in the control group by 3 months (decrease 24% versus 6%, respectively; P = 0.0006) and was sustained at 12 months (decrease 28% versus 5%, respectively; P = 0.0002). There was no difference between groups at closeout in health-related quality of life (P = 0.99). Fewer intervention than control patients (30.2%) versus 40.0%; P = 0.19) experienced adverse drug events. Measures for most other outcomes remained unchanged in both groups. Physicians were receptive to the intervention and enacted changes recommended by the clinical pharmacist more frequently than they enacted changes independently for control patients (55.1% versus 19.8%; P <0.001).

CONCLUSIONS

This study demonstrates that a clinical pharmacist providing pharmaceutical care for elderly primary care patients can reduce inappropriate prescribing and possibly adverse drug effects without adversely affecting health-related quality of life.

Apolipoprotein E, survival in Alzheimer's disease patients, and the competing risks of death and Alzheimer's disease

The apolipoprotein E (APOE) epsilon 4 allele carries an increased risk of a patient developing Alzheimer's disease (AD) while the epsilon 2 allele carries a decreased risk. We compared survival from the onset of AD in subjects with different numbers of epsilon 4 alleles and evaluated changes in genotypic frequencies with age. Two subject groups were investigated: unrelated AD case and control subjects, and affected and unaffected members from 74 multiplex AD families. In both subject groups, survival from onset decreased with increasing onset age, was longer in women, and was unrelated to epsilon 4 gene dose. The epsilon 2/epsilon 3 genotype became more common with age (p = 0.004). The epsilon 4 allele decreased in frequency with age in all patient groups but, unexpectedly, remained unchanged in control subjects. We conclude that the progression of AD is not strongly related to epsilon 4 gene dose, that the higher prevalence of AD in women may involve the longer survival of affected women, and that AD and death are competing risks involving APOE that change over time.

A summated score for the medication appropriateness index: development and assessment of clinimetric properties including content validity

Inappropriate medication prescribing is an important problem in the elderly, but is difficult to measure. As part of a randomized controlled trial to evaluate the effectiveness of a pharmacist intervention among elderly veterans using many medications, we developed the Medication Appropriateness Index (MAI), which uses implicit criteria to measure elements of appropriate prescribing. This paper describes the development and validation of a weighting scheme used to produce a single summated MAI score per medication. Using this weighting scheme, two clinical pharmacists rated 105 medications prescribed to 10 elderly veterans from a general medicine clinic. The summated score demonstrated acceptable reliability (intraclass correlation co-efficient = 0.74). In addition, the summated MAI adequately reflected the putative heterogeneity in prescribing appropriateness among 1644 medications prescribed to 208 elderly veterans in the same general medicine clinic. These data support the content validity of the summated MAI. The MAI appears to be a relatively reliable, valid measure of prescribing appropriateness and may be useful for research studies, quality improvement programs, and patient care.

Protective effect of apolipoprotein E type 2 allele for late onset Alzheimer disease

Gene dosage of the apolipoprotein E (APOE) epsilon 4 allele is a major risk factor for familial Alzheimer disease (AD) of late onset (after age 60). Here we studied a large series of 115 AD case subjects and 243 controls as well as 150 affected and 197 unaffected members of 66 AD families. Our data demonstrate a protective effect of the epsilon 2 allele, in addition to the dose effect of the epsilon 4 allele in sporadic AD. Although a substantial proportion (65%) of AD is attributable to the presence of epsilon 4 alleles, risk of AD is lowest in subjects with the epsilon 2/epsilon 3 genotype, with an additional 23% of AD attributable to the absence of an epsilon 2 allele. The opposite actions of the epsilon 2 and epsilon 4 alleles further support the direct involvement of APOE in the pathogenesis of AD.

Aging and reactivation of latent murine cytomegalovirus

BALB/c mice were experimentally infected with murine cytomegalovirus (MCMV) to discover whether latent MCMV persisted in aging mice and to examine the effect of aging on MCMV reactivation. Latently infected mice received saline, cyclophosphamide, or allogeneic blood at 6 and 18 months of age. MCMV DNA was detected by polymerase chain reaction in submaxillary salivary gland biopsy specimens from saline-treated young and old mice. Evidence of MCMV reactivation was sought by culture of biopsy specimens and by MCMV IgG ELISA of pre- and posttreatment sera from all animals. Very few cyclophosphamide- or saline-treated mice reactivated MCMV at either age, but young transfused mice reactivated MCMV significantly more often than did old transfused mice. These experiments indicate that MCMV DNA persists in the salivary gland of aging mice but that the likelihood of MCMV reactivation does not increase with age.

A method for assessing drug therapy appropriateness

This study evaluated the reliability of a new medication appropriateness index. Using the index, independent assessments were made of chronic medications taken by 10 ambulatory, elderly male patients by a clinical pharmacist and an internist-geriatrician. Their overall inter-rater agreement for medication appropriateness (ppos) was 0.88, and for medication inappropriateness (pneg) was 0.95; the overall kappa was 0.83. Their intra-rater agreement for ppos was 0.94 overall, for pneg was 0.98 overall while the overall kappa was 0.92. The chronic medications taken by 10 different ambulatory elderly male patients were independently evaluated by two different clinical pharmacists. Their overall inter-rater agreement for ppos was 0.76, and for pneg was 0.93, while the overall kappa was 0.59. This new index provides a reliable method to assess drug therapy appropriateness. Its use may be applicable as a quality of care outcome measure in health services research and in institutional quality assurance programs.

Murine cytomegalovirus gene amplification and culture after submaxillary salivary gland biopsy

An important target tissue for murine cytomegalovirus (CMV) infection is the submaxillary salivary gland. Submaxillary salivary gland biopsy specimens from BALB/c mice latently infected with murine CMV were examined for murine CMV DNA by in vitro enzymatic amplification using the polymerase chain reaction preceding oligonucleotide hybridization. The amplified sequence was a 152-base pair segment from within the immediate early gene of murine CMV. Biopsy and whole gland specimens from acutely infected BALB/c mice and latently infected, immunosuppressed BALB/c mice were compared for active murine CMV infection. After acute infection with murine CMV, virus was recovered in all cultures of both biopsy and whole salivary gland specimens but from none of the latently infected animals. Reactivated virus was detected by culture of both biopsy (90%) and whole salivary gland specimens (100%) from latently infected mice that received antithymocyte serum. Viral nucleic acid was detected in 90% of biopsy specimens from latently infected animals. Hence, active murine CMV infection can be detected in biopsy specimens from mice with acute and reactivated infection and murine CMV DNA can be amplified and detected in salivary gland biopsy specimens from latently infected animals. Biopsy of this or other target tissues can be useful for obtaining tissue for viral studies where the survival of the animal is important and it is useful to distinguish latent from acute or reactivated infection.

Are current therapies useful for the prevention of postherpetic neuralgia? A critical analysis of the literature

STUDY OBJECTIVE

To determine whether current therapies are useful in preventing postherpetic neuralgia (PHN) by analysis of study designs and pooled results.

DESIGN

Meta-analysis of all controlled studies investigating PHN prevention in the immunocompetent host. Articles were identified through MEDLINE, Index Medicus and bibliographic reviews of major texts and review articles. Studies meeting eligibility criteria were independently assessed using explicit methodologic criteria for validity and generalizability in clinical trials. Pooled analysis was also performed where appropriate.

MEASUREMENTS AND MAIN RESULTS

Twenty-one investigations met eligibility criteria and primarily addressed the use of antiviral agents and corticosteroids. Among studies with strong designs, no evidence of benefit was found for acyclovir or corticosteroids. Pooled results showed no significant effect of acyclovir on the prevention of PHN (odds ratio 0.81, 95% confidence interval 0.56, 1.11). The strongest studies that found potential efficacy in PHN prevention involved adenosine monophosphate and idoxuridine in dimethyl sulfoxide, but problems with clinical application limit the use of these compounds. Outcome definition, compliance assessment, power estimation, and method of randomization were infrequently addressed aspects of design.

CONCLUSION

Currently there is no proven useful therapy for the prevention of PHN. The benefits of acyclovir and corticosteroids are limited but key questions remain regarding these medications. A clear consensus definition of PHN is needed to improve future investigations.

Epstein-Barr virus and the elderly host

The ability of the Epstein-Barr virus (EBV) to cause latent lifelong infection in the host and its capabilities of transformation may have important implications for the elderly host. Reports in the literature and hospital records were reviewed to determine the activity of EBV in the elderly. Seroepidemiologic surveys demonstrated that 90%-97% of adults more than 60 years old were seropositive for EBV. Geometric mean antibody titers and the percentage of individuals with high antibody titers to EBV increased with age--changes that were not associated with clinical illness. Only 29 cases of infectious mononucleosis have been reported in adults more than 60 years old. The elderly with infectious mononucleosis had significantly fewer occurrences of pharyngitis, lymphadenopathy, and splenomegaly when compared with young adults. The cases of two patients with illnesses that did not meet full criteria for infectious mononucleosis but may still have represented clinical manifestations of EBV infection are presented. Other EBV-associated diseases reported in the elderly include nasopharyngeal carcinoma and possibly B cell lymphoproliferative disease but not a chronic mononucleosis-like syndrome.