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標題: | 老年人多重用藥、潛在性不適當用藥與抗膽鹼用藥負荷之長期趨勢及相關不良結果 Polypharmacy, Potentially Inappropriate Medication and Anticholinergic Burden in the Elderly: Longitudinal Changes and Associated Clinical Outcomes |
作者: | Wan-Hsuan Lu 呂宛璇 |
指導教授: | 蕭斐元(Fei-Yuan Hsiao) |
關鍵字: | 老年人用藥問題,多重用藥,潛在性不適當用藥,抗膽鹼用藥負荷,死亡,住院,骨折, Suboptimal medication use,polypharmacy,potentially inappropriate medication,anticholinergic burden,mortality,hospitalization,fracture, |
出版年 : | 2014 |
學位: | 碩士 |
摘要: | 研究背景─
舉凡多重用藥、潛在性不適當用藥與抗膽鹼用藥負荷等老年人用藥問題,尚未被證實會增加死亡與住院等長期不良結果的風險。綜觀過去文獻,因多數研究採用橫斷性設計,也未能考量用藥隨時間變動的特性以及老年族群的異質性,而這些因素可能會影響用藥問題與長期不良結果相關性的判讀。 研究目的─ 分析不同年齡與性別之老年族群,其多重用藥、潛在性不適當用藥與抗膽鹼用藥負荷的長期趨勢(10年),並且在考量用藥問題隨時間變化的影響下,探討其與不良結果之相關性。 研究方法─ 本研究為一回溯性世代研究,利用台灣健保資料庫2000年百萬人承保歸人檔,篩選於2001年1月1日年滿65歲的門診病人,並依年齡分成「65-74歲」、「75-84歲」、「85歲以上」等三組。首先會蒐集研究對象於2001年度之門診就診與用藥問題概況作為背景資料,之後以每三個月一季為單位,分析研究對象在2002年至2011年間每季之用藥變化和不良結果,總計共40季。多重用藥定義為使用五種藥品以上,潛在性不適當用藥會分別以2012年版本之Beers criteria和PIM-TAIWAN評估,抗膽鹼用藥負荷則是依據Anticholinergic Risk Scale (ARS);所分析之不良結果包含死亡、全部住院事件與骨折相關之住院事件。在描述性分析部分,本研究將探討不同年齡組別與性別的用藥趨勢差異,並以Wilcoxon rank-sum test與Chow test檢定之;在不良結果部分,則會使用廣義估計方程式(generalized estimating equations, GEEs),分析各季用藥問題對不良結果的影響。 研究結果─ 本研究共納入59042位老年人,其中年齡為65-74歲占66.7%, 75-84歲與85歲以上者分別占28.6%和4.7%。於追蹤起始時,研究對象平均每年就診22次,平均每季使用3.12種藥品;多重用藥占整體樣本約28%,潛在性不適當用藥分別占45% (Beers criteria 2012)和20% (PIM-TAIWAN),約12.6%老年人使用一種以上具抗膽鹼作用的藥品,ARS分數平均為0.27分。經過十年追蹤後,整體研究對象的年就診次數平均增加了4.5次,每季用藥約增加2.05種;多重用藥、潛在性不適當用藥與抗膽鹼用藥負荷等問題皆有增加的情形。 追蹤起始時以75-84歲族群的就診次數與用藥總數最多,而十年期間以65-74歲族群的用藥數與用藥問題比例增加最多。多重用藥與抗膽鹼用藥負荷在三組中皆有上升趨勢,然而潛在性不適當用藥在85歲以上族群卻呈現減少使用的情形。 不論多重用藥、潛在性不適當用藥與抗膽鹼用藥負荷,與死亡事件皆未呈現正相關性,但會顯著增加住院風險(5-9 drugs: OR=1.56(95% CI: 1.54-1.59);10+ drugs: OR=2.83(95% CI: 2.76-2.89); PIM-Beers: OR=1.53(95% CI: 1.51-1.55); PIM-Taiwan: OR=1.41(95% CI: 1.39-1.43); ARS≥1: OR=1.70(95% CI: 1.67-1.73))。骨折相關之住院事件與各種用藥問題也呈現顯著相關性。 研究結論─ 本研究觀察到不同年齡層之老年族群,其使用門診資源與藥品的情形有顯著差異,因此建議用藥評估時不宜視作同一族群概括討論。多重用藥、潛在性不適當用藥及抗膽鹼用藥負荷顯示與住院事件有相關性,但對於是否會增加死亡風險仍需更多研究佐證。 Background: Suboptimal medication use, included the problems of polypharmacy, potentially inappropriate medication (PIM) and anticholinergic burden, is an important issue in the elderly. Nevertheless, the association with long-term health-related outcomes is still controversial. Also, few studies exist on the longitudinal changes of suboptimal medication use among the older adults in Taiwan. Objectives: The objectives of this study were to investigate longitudinal changes of polypharmacy, PIM and anticholinergic burden in the elderly over a 10-year period, and to examine the association with risk of mortality and risk of hospitalization, according to different age and gender. Methods: Using Taiwan’s National Health Insurance Research Database (NHIRD), outpatients who aged 65 years old and older in 2001 were identified and divided into three groups (aged 65-74, 75-84 and 85+). The ambulatory care and drug utilization of the study subject were collected at baseline in 2001. And then the changes of drug use from baseline were measured every three months from 2002 to 2011 (40 quarters totally). Drug utilization included polypharmacy (concomitant 5 or more drugs), PIM (according to 2012 Beers criteria and PIM-TAIWAN criteria) and anticholinergic burden (according to Anticholinergic Risk Scale, ARS). Adverse outcomes included mortality, all-cause hospitalization and fracture-specific hospitalization. The Wilcoxon rank-sum test, Kruskal-Wallis test and Chow test were used to examine the patterns of drug use between different age groups and gender. Generalized estimating equations (GEEs) was used to examine the association between drug utilization and adverse outcomes. Results: We identified 59,042 older adults (aged 65-74: 66.7%; aged 75-84: 28.6%; aged 85+: 4.7%). At baseline, the average number of visits was about 22 times (per year) and the average number of medications was 3.12 (per quarter) in each study subject. The incidence of polypharmacy was 28% among the population. About 45% and 20% older adults used PIMs recommended by 2012 Beers criteria and PIM-TAIWAN. And 12.6% older adults used at least one anticholinergic agents, with 0.27 points of ARS in average. After ten years observation, about 4.5 time increase in ambulatory visits and 2.05 drugs increase among the population. The patterns of drug utilization were different between age groups. Aged 75-84 had the highest ambulatory care utilization and drug consumption at baseline; however, the highest increase of drug use was found in aged 65-74 over ten years. While the incidence of polypharmacy and anticholinergic burden raised among the aged groups, the use of PIMs declined in aged 85+ during ten years. The negative association with mortality was found in the elderly for polypharmacy, PIM and anticholinergic burden. The associations between all-cause hospitalization and polypharmacy, PIM or anticholinergic burden were significant, after adjusting age, sex and baseline comorbidities (5-9 drugs: OR=1.56(95% CI: 1.54-1.59);10+ drugs: OR=2.83(95% CI: 2.76-2.89); PIM-Beers: OR=1.53(95% CI: 1.51-1.55); PIM-Taiwan: OR=1.41(95% CI: 1.39-1.43); ARS≥1: OR=1.70(95% CI: 1.67-1.73)). The association remained significant when it focused on fracture-specific hospitalization. Conclusion: The trend of polypharmacy, PIM and anticholinergic burden in the elderly increased over the past ten years. Different drug utilization were found in different elderly populations according to age and gender. These were significant association with hospitalization but remained unclear with mortality. |
URI: | http://tdr.lib.ntu.edu.tw/jspui/handle/123456789/56784 |
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顯示於系所單位: | 臨床藥學研究所 |
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