開立給加護病房年長病患的藥物通常不適當


  【24drs.com】January 18, 2011 (加州聖地牙哥) — 根據重症照護協會第40屆重症照護研討會中發表的一篇研究,加護病房(ICU)的年長病患有超過半數的出院帶藥處方含不適當的藥物。
  
  Vanderbilt大學醫學院的Alessandro Morandi醫師向Medscape Medical News表示,我們從文獻中得知,一般年長者藥物不適當的情況相當常見,有些地方達60%,我們目前的這個研究發現,病患發生重症之後,實際接受不適當藥物的比率增加約20%,其中半數始於加護病房。
  
  一般認為年長病患在院內的處方可能會不適當,但是在臨床情境上證明是適合他們的。典型的例子是,使用抗精神病藥物對抗ICU中常見的譫妄;Morandi醫師解釋,這類藥物在出院時應停用,因為患者不再需要了。
  
  他表示,年長者用藥過多會惡化認知功能、增加跌倒風險、增加健康照護花費;我們特別探討這群患者,是因為我們懷疑他們出院帶藥不適當的風險較高,特別是因為他們的病情在住院期間有許多轉變。
  
  Morandi醫師等人蒐集了120個病患的家用藥物、ICU與一般病房實際使用的藥物,以及在ICU時與出院時開立的藥物等資訊,這些病患都是Vanderbilt大學醫學中心內外科ICU的住院病患。
  
  這個前瞻世代研究的所有病患年紀都是60歲以上(年紀中位數為68歲),「急性生理及慢性健康評值(Acute Physiology and Chronic Health Evaluation ,APACHE II)」平均分數為27 (範圍從20-32),都是敗血性或心因性休克或呼吸衰竭後存活的病患。
  
  研究人員使用2003年版的Beers氏準則(Beers criteria)與最近的藥物安全文獻辨識可能的不適當藥物(potentially inappropriate medications,PIMs),此外,住院醫學專家、老年醫學專家、臨床藥師等,根據藥物適應症、效果、劑量與藥物交互作用評估出院時是否有明顯不適當的藥物(AIMs)。
  
  他們發現,接受3種以上PIMs的病患比率,從住院前的16%增加到出院時的38%;出院時至少有1種PIM的104名病患中,59%也有至少1種AIM。
  
  後續分析顯示,PIM總數從住院前的159增加到出院時的253種,住院前PIM中位數為1 (範圍從0- 2);出院時,PIM中位數為2(範圍從1-3;P< .001)。
  
  研究人員也發現,49%的出院PIM和58%的出院AIM都起因於ICU。
  
  Morandi醫師指出,最常見的處方藥物是抗膽鹼藥。
  
  他表示,這些資料認為,醫師應小心病情變化,以在病患住院期間隨時適當的調整藥物,如此可避免開立不適當藥物。
  
  他指出,找到這個問題的解決之道特別重要,因為人口正漸漸老化,我們知道,到了2030年,美國將有7,000萬人年紀大於65歲、佔人口的20%;年長病患實際佔了所有ICU住院患者的一半。
  
  Rush大學醫學中心的Jason M. Kane醫師為Medscape Medical News對此研究發表獨立評論時表示,研究結果可能是因為出院醫師不太願意干涉院外既有的醫病關係。
  
  病患住院時,一線照護醫師所開立的不適當藥物,在出院時可能又會照開,這可能是因為ICU團隊或醫院團隊未提供連續性的照護、或不願意破壞病患與其原本照護者的醫療關係。
  
  我認為這個觀念是讓他們回覆到原來的家用藥物,並且讓他們的一線照護醫師處理,這可能是也可能不是適當的策略,我不知道何者為是。
  
  北加州Shriners兒童醫院的Tina L. Palmieri醫師指出,擔心始於ICU之藥物的長期影響是普遍的。
  
  未參與該研究的Palmieri醫師認為,值得探討看看始於ICU之藥物的影響,它們有被更改嗎?它們有停用嗎?照護上一個很重要的看法是,觀察看看ICU照護的長期衝擊為何,藥物只是其中之一環。
  
  Morandi醫師、Kane醫師與Palmieri醫師都宣告沒有相關財經關係。
  
  重照照護協會(Society of Critical Care Medicine,SCCM)第40屆重症照護研討會:摘要569,發表於2011年1月17日。
  

Inappropriate Medications Commonly Prescribed to the Elderly in the ICU

By Fran Lowry
Medscape Medical News

January 18, 2011 (San Diego, California) — More than half of elderly people admitted to the intensive care unit (ICU) receive prescriptions for drugs they do not need when it's time to go home, according to a study presented here at the Society of Critical Care Medicine 40th Critical Care Congress.

"We already know from the literature that potentially inappropriate medications are quite prevalent among the elderly living in the community — somewhere around 60%," Alessandro Morandi, MD, from Vanderbilt University School of Medicine, Nashville, Tennessee, told Medscape Medical News. "What we found in the present study was that after a critical illness, the proportion of patients with both potentially and actually inappropriate medications increased by about 20%, and that half of these were initiated in the intensive care unit."

Elderly patients are often prescribed medications in the hospital that are considered potentially inappropriate in general, but turn out to be appropriate for them in a clinical context. The classic example is the use of an antipsychotic drug to combat the delirium that is common in the ICU. Such a drug should be stopped at discharge because there is no longer a need for it, Dr. Morandi explained.

"Having a lot of drugs in the elderly is associated with worse cognitive function, increases the risk of falls, and also increases healthcare costs. We wanted to look specifically at this population because we suspected that they might have a higher risk of being discharged with inappropriate medications, especially because of their many transitions within the hospital," he said.

Dr. Morandi and his team collected information on home medications, actual medications administered while in the ICU and on the ward, and medications prescribed at ICU and hospital discharge from 120 patients who were consecutively admitted to their medical and surgical ICU at Vanderbilt University Medical Center.

All patients in this prospective cohort study were 60 years or older (median age, 68 years) with a median Acute Physiology and Chronic Health Evaluation (APACHE) II score of 27 (range, 20 to 32) who survived to discharge after septic or cardiogenic shock or respiratory failure.

The investigators used 2003 Beers criteria and recent medication safety literature to identify potentially inappropriate medications (PIMs). In addition, a hospitalist, geriatrician, and clinical pharmacist evaluated whether potentially inappropriate medications at discharge were also overtly inappropriate medications (AIMs) on the basis of their indication, efficacy, dosages, and drug interactions.

They found that the proportion of patients receiving 3 or more PIMs increased from 16% before they were admitted to 38% at hospital discharge.

Of the 104 patients who had at least 1 PIM at discharge, 59% were also considered to have at least 1 AIM.

Further analysis showed that the total number of PIMs increased from 159 at preadmission to 253 at discharge. The median preadmission PIM was 1 (range, 0 to 2); at hospital discharge, the median PIM was 2 (range, 1 to 3; P < .001).

The researchers also found that 49% of the discharge PIMs and 58% of the discharge AIMs were initiated in the ICU.

The most commonly prescribed drugs were anticholinergics, Dr. Morandi noted.

"These data suggest that physicians should be careful at the transition of care to conduct an appropriate medication reconciliation at each time point during the patient's hospitalization so that we can avoid the prescribing of inappropriate medications," he said.

Finding a solution to this problem is especially important because of the graying of the population, he added. "We know that by 2030, 70 million people in the United States will be over the age of 65 and will account for 20% of the population; older patients currently account for about half of all ICU admissions."

Providing independent commentary on this study for Medscape Medical News, Jason M. Kane, MD, from Rush University Medical Center in Chicago, Illinois, noted that the findings might be due to a reluctance on the part of the discharging physician to interfere with the original doctor–patient relationship that exists outside of the hospital.

"Patients coming into the hospital on what are being deemed inappropriate meds prescribed by their primary care physician may be put back on those medications at discharge potentially because the ICU team or the hospital team does not provide continuity of care and does not want to disrupt a pharmaceutical relationship between the patient and his or her primary care giver.

"I think the thought is to put them back on their home medications and let the primary care physician deal with it, which may or may not be an appropriate strategy. I don't know what the answer is."

Tina L. Palmieri, MD, from the Shriners Hospital for Children Northern California in Sacramento, added that worry about the long-term impact of the drugs that are started in the ICU is universal.

"It's very valuable to look and see what happens with the drugs that we start in an ICU. Do they get changed? Do they get discontinued?," wondered Dr. Palmieri, who was not part of the study. "A very important aspect of our care is to take a look and see what the long lasting impact of ICU care is. Drugs are just one aspect of that."

Dr. Morandi, Dr. Kane, and Dr. Palmieri have disclosed no relevant financial relationships.

Society of Critical Care Medicine (SCCM) 40th Critical Care Congress: Abstract 569. Presented January 17, 2011.

    
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