老年慢性病門診病患之潛在性不適當處方的相關危險因子探討

前言：臨床上老人用藥問題亦逐漸受到重視。在國內外老人用藥佔總用藥量比例均甚高，且因老化及慢性疾病狀態，服用潛在性不適當處方可使發生藥物不良反應之機會增加，許多研究都顯示潛在性不適當處方之盛行率均偏高，而相關危險因子未有明確定論。故本研究意欲探究門診老年慢性病患之潛在性不適當處方的盛行率以及相關危險因子。方法：本研究資料取自2009年7月到12月至中部某醫學中心家醫科門診開立慢性處方之65歲含以上558位老年患者，根據病歷紀錄患者之年齡、性別、慢性病狀態以及處方藥物，使用2003年Beers Criteria評估患者潛在性不適當處方。以Student’s t檢定和卡方檢定各變項與潛在性不適當處方之相關性，進而以多變項邏輯斯迴歸模式分析，探究潛在性不適當處方之危險因子。結果：研究對象平均年齡為74.89 ± 6.65歲；平均疾病診斷數目為5.20 ± 2.58種；平均藥物數目為4.88 ± 2.56個；平均看診科別為1.25 ± 0.56科；平均處方籤數為1.40 ± 0.75張。其中107位(19.17%)有一項以上潛在性不適當處方。558位患者常見之慢性病診斷為循環系統疾病(76.88%)、肌肉骨骼與結締組織疾病(56.09%)以及消化系統疾病(46.59%)。107位患者服用之PIM，常見的包括非類固醇抗發炎藥物(24.29%)、benzodiazepine類藥物(16.82%)、抗膽鹼作用藥物(15.88%)以及解痙劑(11.21%)。經多變項邏輯斯回歸分析顯示，潛在性不適當處方與藥物數目(勝算比= 1.35；95%信賴區間= 1.23-1.48；p < 0.001)、年齡(勝算比= 1.03；95%信賴區間= 1.01-1.07；p = 0.049)、以及精神疾病(勝算比= 1.85；95%信賴區間= 1.14-3.00；p = 0.010)有關。結論：本研究顯示潛在不適當處方在家醫科門診的慢性處方中並不少見，臨床醫師對於多種藥物處方、高齡以及情感性精神疾病或失智症患者，應考慮其高風險性潛在不適當處方的可能性。

Objective: Problems related to prescriptions for older patients is considered a major public health issue in recent studies. The elderly patients took a great proportion of total drug use according to different statistical analyses in several countries. Potentially inappropriate medications(PIMs) in elderly could lead to an increase in the likelihood of adverse drug events because of aging and multiple chronic comorbidities. The prevalence of PIM use was high in numerous studies. The factors associated with potentially inappropriate medication had been frequently explored but still had some controversies. The aim of our study is to identify the prevalence and risk factors for PIM use in ambulatory older patients with chronic diseases.Methods: This study included 558 consecutive patients, aged ≥ 65 years with chronic diseases, who received long-term prescriptions during their outpatient visits to family medicine clinics at a university hospital in central Taiwan between July 1 and December 31, 2009. PIM was assessed according to the 2003 updated Beers Criteria. Data regarding demographic characteristics, coexisting diseases, and ambulatory prescriptions were collected and analyzed. The clinical factors related to PIM were determined using logistic regression.Results: The mean age of the 558 patients was 74.89 ± 6.65 years. The mean number of comorbid conditions was 5.20 ± 2.58; the mean number of drugs prescribed was 4.88 ± 2.56. PIM was identified in 107 patients (19.17%). Most common chronic disease was disease of circulatory system (76.88%), followed by musculoskeletal and connective tissue diseases (56.09%), and diseases of digestive system (46.59%). Most common PIMs were non-steroid anti-inflammatory drugs (24.29%), followed by benzodiazepines (16.82%), anticholinergic agents (15.88%), and antispasmotics (11.21%). Multivariate analysis revealed that PIM was significantly associated with the number of drugs prescribed (p< 0.001), advanced age (p= 0.049), and psychiatric illnesses (p= 0.010). Conclusions: Clinicians should be alert to the possibility of PIM in ambulatory older patients with chronic diseases, especially in those taking multiple medications and those who have advanced age or psychiatric illnesses.