醫學中心門診老年慢性病患潛在性不適當處方之相關因子探討

Factors Assocaited with Potentially Inappropriate Prescribing in Older Outpatients

張肇烜(Chao-Hsuan Chang)

指導教授 ： 陳宣志

中山醫學大學/醫學院/醫學研究所/碩士(2018年)

摘要

前言：老人潛在性不適當用藥問題在台灣國內和國外愈來愈受到重視，因老化和慢性疾病狀態，潛在性不適當處方可能會增加發生藥物不良反應之機會。本研究的目的為探討門診老年慢性病患之潛在性不適當處方 (Potentially inappropriate medications, PIMs) 之盛行率以及相關危險因子。

方法：本研究資料取自2015年1月至12月臺灣中部一間醫學中心開立慢性處方之60歲以上25020位老年門診病患，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2015年更新版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(Chi-square Test)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相關危險因子。

結果：本研究對象平均年齡為72.6 ± 8.3歲；平均慢性病數目為3.7 ± 1.8種；平均藥物數目為3.2± 1.8個；平均合併罹病症指數(Charlson’s comorbidity index)為0.9± 1.3分其中11471位(佔45.8%)有一項以上潛在性不適當處方。患者常見之慢性病診斷為心臟血管循環系統疾病(佔62.1%)以及內分泌疾病 (佔45.1%)以及消化系統疾病(佔29.9%)等。11471位患者服用之潛在性不適當處方，常見的處方藥物包括Zopidem (佔23.4%)、Clonazepam (佔18.5%)、以及Estazolam (佔16.6%)等。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(勝算比為 1.402；95%信賴區間為 1.38-1.424；p< 0.001)、合併罹病症指數Charlson’s index (勝算比為1.252；95%信賴區間為 1.227-1.278；p< 0.001)及慢性疾病如心臟血管循環疾病(勝算比為 2.051；95%信賴區間為 1.945-2.163；p< 0.001)、精神科疾病(勝算比為 4.411；95%信賴區間為 4.131-4.711；p < 0.001)等變項有相關。

結論：本研究顯示潛在不適當處方在門診老年慢性病患中並不少見，臨床醫師對於多種藥物處方、合併罹病症指數較高及慢性疾病患如心臟血管循環疾病、精神科疾病者，應考慮其高風險性潛在不適當處方的可能性。

關鍵字

危險因子 ； 潛在性不適當處方 ； 門診老年病患 ； 慢性病

並列摘要

Objective: Problems related to inappropriate prescriptions for older patients is considered a major public health issue in recent studies. 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 older outpatients in previous studies, but the factors associated with potentially inappropriate medication still had some controversies. The aim of our study is to identify the prevalence and risk factors for PIM use in older outpatients.

Methods: This study included 25020 consecutive patients, aged ≥ 60 years receiving long-term (≧28 days) prescriptions at out-patient department visits in central Taiwan between Jan. 1 and December 31, 2015. PIM was assessed according to the 2015 updated Beers Criteria. Data regarding demographic characteristics, coexisting diseases, and prescriptions were collected and analyzed. The clinical factors related to PIM were determined using logistic regression.

Results: The mean age of the 25020 patients was 72.6 ± 8.3 years. The mean number of comorbid conditions was 3.7 ± 1.8; the mean number of drugs prescribed was 3.2 ± 1.8. PIM was identified in 11471 patients (45.8%). Most common chronic disease was diseases of cardiovascular system (60.1%), followed by disease of endocrinological system (45.1%) and disease of gastrointestinal system (29.9%). Most common PIMs were Zopidem(23.4%), followed by Clonazepam (18.5%), and Estazolam (16.6%). Multivariate analysis revealed that PIM was significantly associated with the number of drugs prescribed (p< 0.001) and psychiatric illnesses (p< 0.001).

Conclusion and and Suggestion: The prevalence of PIM in older outpatients was not rare. Clinicians should be alert to the possibility of PIM in older outpatients, especially in those taking multiple medications and those who have psychiatric illnesses such as cardiovascular system and psychiatric illnesses.

並列關鍵字

risk factor ； potentially inappropriate prescribing ； older outpatients ； chronic disease

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