多种用药是成年人，尤其是老年人严重关注的问题. 虽然多重用药是可以预防的，但它是造成发病率和死亡率的一个重要因素.¹ 服用多种药物通常被定义为服用多种药物或超过医疗需要的药物(包括非处方药和补充剂)。.

据估计，在专业护理机构和长期护理机构中，13%至74%的居民服用九种或更多的药物.² Further, approximately 59 percent of residents in these settings take a potentially inappropriate medication based on STOPP/START criteria (STOPP = screening tool of older persons’ prescriptions; START = screening tool to alert to right treatment).³

Because of increased numbers of comorbid conditions, newer medications that effectively treat more medical conditions, and practice guidelines that often recommend multidrug regimens, seniors have a higher rate of polypharmacy.⁴ 老年人服用更多的药物来控制多种慢性疾病，并且可能在代谢这些疾病方面有更大的困难, both of which can produce unfavorable adverse effects.

Some of these adverse effects include poor medication adherence, drug–drug interactions, medication errors, and adverse drug reactions. These effects may subsequently result in falls, hip fractures, cognitive impairment including confusion and delirium, and urinary incontinence, 哪些占潜在可预防的急诊科就诊和住院的很大比例.⁵

Adverse effects can be further compounded in a prescribing cascade, in which an adverse reaction to one drug goes unrecognized or misinterpreted, 导致医疗保健提供者不恰当地开另一种药物来治疗体征和症状. This can lead to potentially dangerous situations and overprescribing.⁶

To avoid overprescribing, 医生在开处方时应该看一下老年人的整体医疗状况，而不是只开某些治疗方法的处方. 他们应该通过考虑老年人的预期寿命等因素来评估每种药物的效用, care goals, and the length of time until benefits manifest.⁷ 提供者还应该尽量减少为老年人开的药物数量, keep the dosing schedule as simple as possible, and limit the number of medication changes.

以下筛查工具和指南可用于帮助提供者评估和停用可能不适合老年人的药物:

• START⁸
• STOPP⁹
• Beers Criteria for Potentially Inappropriate Medication Use in Older Adults¹⁰

开处方是指提供者确定并有意停止用药或减少剂量，以改善个人健康或减少不良副作用的风险. A team-based approach involving physicians, pharmacists, and nurses is optimal when deprescribing medications for seniors. Discontinuing a medication should involve proper planning, communicating, and coordinating with the senior and the nursing staff. 护理人员可以帮助监测老年人的有益或有害的影响逐渐减少或停止用药. 老年人和家庭也应该了解多种药物的危险，这样他们就会意识到，如果一种药物对他们有害或不再有益，就可以停药.¹¹

Providers can follow these steps when deprescribing:

• 避免因副作用而不适合老年人的药物, lack of efficacy, and/or potential for interactions.
• 在老年人护理目标的背景下，当危害大于益处时，停止药物治疗, life expectancy, and/or preferences.¹²

在观察和评估老年人时，提供者可以使用这些方法来最大限度地减少多种用药:

• 在每次病人就诊时仔细检查药物清单并检查剂量. 老年人是否把他们所有的药物都带到办公室一起检查.
• Assess for drug–drug interactions.
• Monitor for adverse drug withdrawal events.
• Identify any drug-related problems.
• 告诉老年人潜在的副作用，包括什么时候打电话给办公室或寻求紧急帮助.
• 告知老年人任何特定药物所需要的饮食限制.
• Explore nonpharmacological interventions, such as dietary changes and behavioral modification strategies.
• Use tapering approaches.
• 减轻服药负担，提高老年人坚持治疗方案的能力.¹³

The prevalence of polypharmacy in senior care is a resident safety issue. It can produce significant adverse effects and reduced functional capacity. 减少多种用药和避免不当用药是老年护理的共同目标, regardless of the setting. 医疗保健提供者可以利用资源和干预措施来针对老年人和与较高药物不良事件相关的处方做法.

Endnotes

¹ Wang, K. A., Camargo, M., & Veluswamy, R. R. (2013). Evidence-based strategies to reduce polypharmacy: A review. OA Elderly Medicine, 1(1):6.

² Hoel, R. W., Giddings Connolly, R. M., & Takahashi, P. Y. (2021, January 1). Polypharmacy management in older patients. Mayo Clinic Proceedings, 96(1):P242-256. DOI: www.medscape.com/viewarticle/814861_1

³ Ibid.

⁴ Brookes, L., & Scott, I. A. (2013). Deprescribing in clinical practice: Reducing polypharmacy in older patients. Medscape. Retrieved from http://www.medscape.com/viewarticle/814861_1

⁵ Shah, B., & Hajjar, E. (2012). Polypharmacy, adverse drug reactions and geriatric syndromes. Clinics in Geriatric Medicine, 28:173-186.

⁶ Woodruff, K. (2010). Preventing polypharmacy in older adults. American Nurse Today, 5(10). Retrieved from www.myamericannurse.com/preventing-polypharmacy-in-older-adults/

⁷ Saljoughian, M. (2019). Polypharmacy and drug adherence in elderly patients. U.S. Pharmacist, 44(7), 33-36. Retrieved from www.uspharmacist.com/article/polypharmacy-and-drug-adherence-in-elderly-patients

⁸ Barry, P. J., Gallagher, P., Ryan, C., & O’Mahony, D. (2007). START(提醒医生正确治疗的筛查工具)——一种基于证据的筛查工具，用于检测老年患者的处方遗漏. Age and Ageing, 36(6):632-638.

⁹ Gallagher, P., & O’Mahony, D. (2008). STOPP(老年人潜在不当处方筛选工具):在老年急性病患者中的应用及与Beers标准的比较. Age and Ageing, 37(6):673-679.

¹⁰ American Geriatrics Society Beers Criteria® Update Expert Panel. (2019). 美国老年医学会2019年更新了AGS Beers标准®，用于老年人可能不适当的药物使用. Journal of the American Geriatrics Society, 67(4), 674–694. DOI: http://doi.org/10.1111/jgs.15767

¹¹ Saljoughian, Polypharmacy and drug adherence in elderly patients.

¹² McGrath, K., Hajjar, E. R., Kumar, C., Hwang, C., & Salzman, B. (2017). Deprescribing: A simple method for reducing polypharmacy. The Journal of Family Practice, 66(7):436-445.

¹³ Farrell, B., Shamji, S., Monahan, A., & Merkley, V. F. (2013). Reducing polypharmacy in the elderly. Canadian Pharmacists Journal, 146(5):243-244.

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