开立给加护病房年长病患的药物通常不适当


  【24drs.com】January 18, 2011 (加州圣地牙哥) — 根据重症照护协会第40届重症照护研讨会中发表的一篇研究,加护病房(ICU)的年长病患有超过半数的出院带药处方含不适当的药物。
  
  Vanderbilt大学医学院的Alessandro Morandi医师向Medscape Medical News表示,我们从文献中得知,一般年长者药物不适当的情况相当常见,有些地方达60%,我们目前的这个研究发现,病患发生重症之后,实际接受不适当药物的比率增加约20%,其中半数始于加护病房。
  
  一般认为年长病患在院内的处方可能会不适当,但是在临床情境上证明是适合他们的。典型的例子是,使用抗精神病药物对抗ICU中常见的谵妄;Morandi医师解释,这类药物在出院时应停用,因为患者不再需要了。
  
  他表示,年长者用药过多会恶化认知功能、增加跌倒风险、增加健康照护花费;我们特别探讨这群患者,是因为我们怀疑他们出院带药不适当的风险较高,特别是因为他们的病情在住院期间有许多转变。
  
  Morandi医师等人搜集了120个病患的家用药物、ICU与一般病房实际使用的药物,以及在ICU时与出院时开立的药物等信息,这些病患都是Vanderbilt大学医学中心内外科ICU的住院病患。
  
  这个前瞻世代研究的所有病患年纪都是60岁以上(年纪中位数为68岁),「急性生理及慢性健康评值(Acute Physiology and Chronic Health Evaluation ,APACHE II)」平均分数为27 (范围从20-32),都是败血性或心因性休克或呼吸衰竭后存活的病患。
  
  研究人员使用2003年版的Beers氏准则(Beers criteria)与最近的药物安全文献辨识可能的不适当药物(potentially inappropriate medications,PIMs),此外,住院医学专家、老年医学专家、临床药师等,根据药物适应症、效果、剂量与药物交互作用评估出院时是否有明显不适当的药物(AIMs)。
  
  他们发现,接受3种以上PIMs的病患比率,从住院前的16%增加到出院时的38%;出院时至少有1种PIM的104名病患中,59%也有至少1种AIM。
  
  后续分析显示,PIM总数从住院前的159增加到出院时的253种,住院前PIM中位数为1 (范围从0- 2);出院时,PIM中位数为2(范围从1-3;P< .001)。
  
  研究人员也发现,49%的出院PIM和58%的出院AIM都起因于ICU。
  
  Morandi医师指出,最常见的处方药物是抗胆碱药。
  
  他表示,这些资料认为,医师应小心病情变化,以在病患住院期间随时适当的调整药物,如此可避免开立不适当药物。
  
  他指出,找到这个问题的解决之道特别重要,因为人口正渐渐老化,我们知道,到了2030年,美国将有7,000万人年纪大于65岁、占人口的20%;年长病患实际占了所有ICU住院患者的一半。
  
  Rush大学医学中心的Jason M. Kane医师为Medscape Medical News对此研究发表独立评论时表示,研究结果可能是因为出院医师不太愿意干涉院外既有的医病关系。
  
  病患住院时,一线照护医师所开立的不适当药物,在出院时可能又会照开,这可能是因为ICU团队或医院团队未提供连续性的照护、或不愿意破坏病患与其原本照护者的医疗关系。
  
  我认为这个观念是让他们回覆到原来的家用药物,并且让他们的一线照护医师处理,这可能是也可能不是适当的策略,我不知道何者为是。
  
  北加州Shriners儿童医院的Tina L. Palmieri医师指出,担心始于ICU之药物的长期影响是普遍的。
  
  未参与该研究的Palmieri医师认为,值得探讨看看始于ICU之药物的影响,它们有被更改吗?它们有停用吗?照护上一个很重要的看法是,观察看看ICU照护的长期冲击为何,药物只是其中之一环。
  
  Morandi医师、Kane医师与Palmieri医师都宣告没有相关财经关系。
  
  重照照护协会(Society of Critical Care Medicine,SCCM)第40届重症照护研讨会:摘要569,发表于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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