台灣雲林縣社區共餐長者多重用藥及營養生物標記之關係探討

Abstract

台灣面臨人口老化的社會環境，老人的社區醫療照護為一重大議題。其中社區老人常有不同病症且從不同的醫療院所拿取藥物的使用型，可能會有過度用藥或無效用藥等情形，甚至可能會有不良的藥物反應及跌倒等。政府施行長照2.0計畫，於各社區成立長青食堂，供應老人餐點與社區活動，成為社區介入之良好平台。本主題性統整報告使用於雲林縣之長青食堂架設的遠距通訊軟體，使地方社區長者，可藉由通訊紀錄現有用藥，台大醫院雲林分院提供專業藥師評估用藥之服務。本主題性統整報告的第一段為實際於雲林縣社區共餐據點訪查及收集之用藥資料統計，並且與其營養相關生物標記如社區篩檢的抽血資料(紅血球(Hb)、白蛋白 (Alb)、肌酸酐(Cre)、總膽固醇 (TCHO)、高密度脂蛋白(HDL)、低密度脂蛋白(LDL)、尿酸 (UA)、鐵(Fe))以及社區據點設置的寶貝機收集的生理數值(手部握力、走路速度、坐站秒數、身體質量指數)加以分析，探討其是否與多重用藥使用有相關性。本研究之人口樣本87名來自6個社區長青食堂(元長、北和、西螺、尚義、興中、莿桐)，年齡高於40歲並且使用長青食堂共餐服務之長者。平均年齡為75.29±8.38，66.28% 的樣本為女性。13.76%的個案表示服用藥物有藥物副作用，而慢性病中，高血壓的人數最多，有48.78%。用藥種類依據世界衛生組織解剖學治療學及化學分類系統，本研究中心血管系統藥物使用最多，平均每人使用1.8顆心血管系統藥物。將個案用藥資料與個案營養生物標記分析其相關性，寶貝機之生理數據收集並無相關性，抽血數據中唯獨高密度脂蛋白(HDL)與用藥數量有顯著差異，服用藥物數越多，HDL則越低。在不同種的藥物數量計算方法中結果亦然。多重用藥並無統一的定義，但通常設定為個案使用五種以上藥物。當將本研究個案藥物數量分成大於等於五種及小於五種時，統計也顯示有顯著差異。多重用藥常伴隨藥物不良作用、抗膽鹼負荷上升及不適當用藥產生，因此將其與抽血數據分析相關性，並無有顯著差異。而後使用多變數迴歸分析調整年齡、BMI、慢性病項目探討HDL與藥物數的關係，仍有顯著差異，表示HDL與藥物數之關係可能為獨立的變相。但服用藥物數如何降低HDL數值仍需更多研究去了解。 主題性統整報告的第二段，在第一段中發現了雲林地區的較高的多重用藥情形，因此欲試著改善，然而經文獻回顧並無社區導向之多重用藥改善的前例，因此吾人設計了社區降低多重用藥的研究，運用遠距醫療系統收集社區用藥資料及健康資訊，給予台大醫院雲林分院之專業藥師評估，隨後將評估過後的用藥評估，給予社區個案，如果有需要，經藥師評估會再給予個案一張醫師版本的用藥建議，預期使其達到降低社區多重用藥情形。在三個月、六個月、一年進行計畫評估，探討其成效及可行性。 此研究經調查發現了雲林縣有嚴重的多重用藥情形及多重用藥及血液HDL的逆關係。雲林縣多重用藥情況需要被重視。控制多重用藥可能可以避免低血液HDL而造成之疾病，可供未來醫療在開立藥物時做為參考。此研究也試著解決及建立社區降低多重用藥介入措施的計畫，期許未來能將社區降低多重用藥介入措施更完備成熟，能應用於更多地方，幫助更多民眾的健康。

The social environment in Taiwan is facing the problem of population aging. However, not only Taiwan but the globe is facing this challenge. Community care of geriatrics becomes an important issue. The elderly in society may take medications from different hospitals or clinics due to different discomfort or diseases. It may lead to polypharmacy issues. The Long-term Care Policy 2.0 has established congregate meal services for the intake and social activities of the elderly. This provides a good platform to engage and learn the older adults' needs and information. This comprehensive report using the telemedicine platformed installed in the congregate meal services sites to collect the drug use data and provide the assessment of drug use by the professional pharmacist from National Taiwan University Hospital, Yunlin branch. The first study of this comprehensive report shows the drug use data in congregate meal services sites and the correlation analysis of the nutrition biomarkers by blood test including Hemoglobin (Hb), albumin (Alb), creatinine (Cre), total cholesterol (TCHO), high-density lipoprotein (HDL), low-density lipoprotein (LDL), uric acid (UA), and iron (Fe) and physical data including grip strength, sit-to-stand speed, walking speed, BMI by the Babybot installed in the congregate meal services sites. In the study, 87 participants who are older than 40 years old and participated congregate meal services from 6 congregate meal services sites (Yuanchang, Beihe, Xiluo, Shangyi, Xingzhong, Citong) were recruited. The mean (SD) age was 75.29(8.38). 66.28 percent of the participants were female. 13.76 percent of the participates clammed the adverse drug events. Within the chronic diseases, hypertension was the most in our cohort (48.78%). Divided drugs using Anatomical Therapeutic Chemical (ATC) classification system controlled by the World Health Organization, the category, Cardiovascular system, was used the most (1.8 drugs per person). Correlation between drug uses and bio nutrition biomarkers had been analyzed. The only HDL in the blood test had a significant difference with drug use numbers. When the drug use number increases, the HDL level decreases. The result remained the same when used different ways to count drug count. There was no definition of polypharmacy now but it usually is described as one person using 5 or more drugs. When separated drug usage into 5 or more and less than 5, the correlation between drug use number and HDL remained. Polypharmacy might lead to a higher risk of adverse drug effects, anticholinergic burden, and potentially inappropriate medications. Therefore, the regression analysis was performed and there was no significant difference between nutrient biomarkers with them. To check if the drug usage is an independent variable, the analysis of the association between polypharmacy and HDL adjusted for age, BMI, and comorbidities by multivariate regression analysis was performed. The result showed that the drug number might be a robust independent variable associate with HDL level after adjustment of BMI, age, and comorbidities in our cohort. However, how polypharmacy affects blood HDL level is remained unknown. Further study is needed to understand how drug usage number interacts with HDL. In study 2, after the first study, we learned that there might have a prevalent polypharmacy situation in the community, however, there was no community-oriented polypharmacy intervention study. We want to create a sustainable and practical program to decrease the polypharmacy situation. Therefore, we decided to create a proactive intervention program to introduce pharmacists into communities by using telemedicine platform. Evaluate the drug use of the people and advise them. The outcome of this project will be evaluated for feasibility and cost-effectiveness. In conclusion, in my study we discovered the severe polypharmacy issue in Yunlin. The polypharmacy should be concerned. The inverse relationship between polypharmacy and blood HDL level in our cohort was also found and drug usage number is a robust independent variable associate to HDL. It might be a reference for prescription drugs in the future. A community-oriented polypharmacy intervention also was developed to introduce the hospital pharmacy service into the communities and the intervention will be evaluated in the future. Hope the intervention can be optimized and can be applied to more places even in the other countries to decrease the polypharmacy and promote health.