老年人药物重整的应用效果分析

Application of medication reconciliation in a geriatric ward and its effect analysis

目的应用药物重整方法对老年住院患者不合理用药进行调整。方法入选2012年6月至2013年10月北京协和医院老年示范病房所有965岁的老年住院患者208例，年龄（76．0±6．8）岁。由药师参与每日老年科病房的查房，医师与药师合作，对老年住院患者进行药物重整。结果208例患者有多种慢性状况（MCC）（8．0±3．8）种，195例入院时有长期用药，用药（4．8±3．5）种，多重用药占48．1％；女性用药种类显著多于男性[（5．3±3．7）vs（4．3±3．2）种，P=0．035]。最常使用药物种类依次与下列慢性病有关：心脑血管病（78．8％）、消化系统问题（51．4％）、前列腺疾病（30．8％）、骨质疏松（24．5％）、糖尿病（24．5％）。入院时发现不合理用药占63．9％，药物不良反应13．9％，最常见潜在导致不良反应的药物为中枢神经和心血管系统药物。≥85岁患者多重用药（χ^2=4．78，P=0．03）及不合理用药情况（χ^2=3．91，P=0．048）显著高于〈85岁患者。63．9％（133／208）老年患者调整了用药。结论老年科住院患者慢性病及老年问题多，多重用药发生率高，需要与药师合作通过药物重整发现问题并及时干预。

Objective To modify inappropriate prescription by means of medication reconciliation in the elderly inpatients. Methods Pharmacists were asked to participate in daily rounds and help geriatrician to perform medication reconciliation in the geriatric ward in our hospital from June 2012 to October 2013, and a total of 208 inpatients aged over 65 （ 76.0 ± 6. 8 ） years were enrolled. The outcomes were observed and analyzed. Results The participants had multiple chronic conditions （MCC） of 8.0 ±3.8, and drug types of 4. 8 ±3.5. There were 48. 1% of them having polypharmacy. Women took more types of drug than men [ （5.3 ±3.7 ） vs （4. 3 ±3.2） , P = 0. 035 ]. The most commonly used drugs were for cardio-cerebrovascular diseases （78.8%） , followed by those for digestive system diseases （51.4%）, prostate diseases （30. 8% ）, osteoporosis （24. 5% ） and diabetes （24. 5% ）. Irrational drug use was found in 63.9% subjects at admission, and the rate of adverse drug reaction was 13.9%. The most common drugs with potential risk for adverse reaction were those for central nervous system and cardiovascular system. Those older than 85 years had significantly higher percentage of polypharmacy （ χ^2 =4. 78, P = 0.03 ） and inappropriate prescription （ χ^2 = 3.91, P = 0. 048 ）. Totally 133 patients （63.9%） accepted medication reconciliation with a changed drug list. Conclusion Elderly inpatients had more multi-comorbidities as well as more frequent polypharmacy. Medication reconciliation is an effective method to find inappropriate prescription and make timely intervention.