多种用药是成年人，尤其是老年人严重关注的问题. Although polypharmacy is preventable, it is a significant contributor to morbidity and mortality.1 Polypharmacy is generally defined as taking multiple medications or more medications than are medically necessary (including over-the-counter drugs and supplements).
Estimates suggest that anywhere from 13 percent to 74 percent of residents in skilled nursing facilities and long-term care take nine medications or more.2 Further, approximately 59 percent of residents in these settings take a potentially inappropriate medication based on STOPP/START criteria (STOPP = screening tool of older persons’ prescriptions; START = screening tool to alert to right treatment).3
因为合并症的数量增加, 新的药物可以有效地治疗更多的疾病, 实践指南经常推荐多种药物治疗方案, 老年人服用多种药物的比例更高.4 Seniors take more medications to control multiple chronic diseases and may have greater difficulty metabolizing them, 这两者都会产生不利的不利影响.
其中一些不良反应包括药物依从性差, 药物之间相互作用, 用药错误, 药物不良反应. 这些影响可能随后导致跌倒, 髋部骨折, 认知障碍，包括精神错乱和谵妄, 还有尿失禁, which account for a significant percentage of potentially preventable emergency department visits and hospitalizations.5
在处方级联中，不良反应可能进一步加剧, in which an adverse reaction to one drug goes unrecognized or misinterpreted, causing a healthcare provider to inappropriately prescribe another drug to treat signs and symptoms. 这可能会导致潜在的危险情况和过度用药.6
为了避免处方过量, providers should look at a senior’s overall medical profile when prescribing medications instead of prescribing for certain therapies. They should evaluate each medication for its utility by considering factors such as the senior’s 预期寿命, 护理目标, 以及效果显现的时间长度.7 Providers also should minimize the number of medications prescribed for seniors, 使给药计划尽可能简单, 限制药物的更换次数.
The following screening tools and guidelines are available to help providers evaluate and discontinue medications that are potentially inappropriate for seniors:
- START8
- STOPP9
- 老年人潜在不适当用药的Beers标准10
Deprescribing is when providers identify and intentionally stop a medication or reduce its dose to improve an individual’s health or reduce the risk of adverse side effects. 以团队为基础的方法，包括医生, 药剂师, 护士是老年人开处方的最佳人选. 停药应该有适当的计划, 沟通, 并与长者和护理人员协调. The nursing staff can help monitor the senior for beneficial or harmful effects from tapering or stopping medications. Seniors and families should also be educated about the dangers of polypharmacy so they are aware that a medication may be discontinued if it harms or no longer benefits them.11
医生在开具处方时可以遵循以下步骤:
- Avoid medications that are inappropriate for seniors because of adverse effects, 缺乏疗效, 和/或相互作用的潜力.
- Discontinue medications when the harms outweigh the benefits in the context of the senior’s 护理目标, 预期寿命, 和/或偏好.12
When seeing and evaluating seniors, providers can use these methods to minimize polypharmacy:
- Scrutinize medication lists during every patient visit and review the dosages. Have seniors bring all of their medications to the office and review them together.
- 评估药物-药物相互作用.
- 监测不良药物停药事件.
- 找出任何与毒品有关的问题.
- Teach seniors about potential side effects, including when to call the office or seek emergency help.
- Inform seniors of any dietary restrictions necessitated by a specific medication.
- 探索非药物干预, 比如饮食改变和行为改变策略.
- 使用逐渐减少的方法.
- Reduce pill burden to improve seniors’ ability to adhere to treatment regimens.13
多药在老年护理中的流行是一个居民安全问题. 它可以产生显著的不良反应和降低功能能力. Reducing polypharmacy and avoiding inappropriate medications is a common goal in senior care, 不管环境如何. Healthcare providers can use resources and interventions to target seniors and prescribing practices associated with higher adverse drug events.
尾注
1 Wang, K. A.卡马戈，M., & Veluswamy R. R. (2013). 循证策略减少多药:综述. 老年医学，1(1):6.
2 Hoel R. W.吉丁斯·康诺利，R. M., & 高桥,P. Y. (2021年1月1日). 老年患者的综合药房管理. 梅奥临床学报，96(1):P242-256. DOI: www.起到了推动作用.com/viewarticle/814861_1
3 Ibid.
4 布鲁克斯,我., & 斯科特,我. A. (2013). 临床实践中的处方化:减少老年患者的多重用药. 起到了推动作用. 从检索 http://www.Medscape.com/viewarticle/814861_1
5 Shah, B., & 西北E. (2012). 综合用药，药物不良反应和老年综合征. 老年医学诊所，28岁:173-186.
6 伍德乐夫K. (2010). 预防老年人服用多种药物. 《梅高美集团4858》第5期(10). 从检索 www.myamericannurse.com/preventing-polypharmacy-in-older-adults/
7 Saljoughian, M. (2019). 老年患者的综合用药与药物依从性. U.S. 44岁的药剂师(7), 33-36. 从检索 www.uspharmacist.com/article/polypharmacy-and-drug-adherence-in-elderly-patients
8 巴里,P. J.加拉格尔，P.瑞安，C., & O’mahony D. (2007). START (screening tool to alert doctors to the right treatment)—an evidence-based screening tool to detect prescribing omissions in elderly patients. 年龄与老龄化，36岁(6):632-638.
9 加拉格尔,P., & O’mahony D. (2008). STOPP (screening tool of older persons’ potentially inappropriate prescriptions): Application to acutely ill elderly patients and comparison with Beers’ criteria. 《美高美集团4688》，37岁(6):673-679.
10 美国老年医学会比尔斯标准更新专家小组. (2019). American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. 美国老年医学会杂志，67(4), 674–694. DOI: http://doi.org/10.1111/jgs.15767
11 Saljoughian，老年患者的综合用药与药物依从性.
12 麦格拉思,K.哈贾尔，E. R.库马尔，C.黄，C., & Salzman B. (2017). 解方:一种减少多药的简单方法. 《美高美集团4688》，66页(7):436-445.
13 法雷尔,B.沙姆吉，S.莫纳汉，A., & Merkley V. F. (2013). 减少老年人服用多种药物. 加拿大药剂师杂志，146(5):243-244.
This document does not constitute legal or medical advice and should not be construed as rules or establishing a standard of care. 因为适用于你的情况的事实可能会有所不同, 或者您所在司法管辖区适用的法律可能不同, please contact your attorney or other professional advisors if you have any questions related to your legal or medical obligations or rights, 州或联邦法律, 合同的解释, 或者其他法律问题.
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