臺灣博碩士論文加值系統

研究背景：
老年族群疾病種類多，且經常同時合併有許多的慢性疾病，因此服藥品項數高，再加上因多重疾病而到處求醫、看不同的醫生、對於藥物的使用和管理不適當，增加了老人服用藥物的危險性，例如藥物不良反應、跌倒等，因此老年人的用藥適當性日漸受到重視。

研究目的：
本研究的目的在於觀察並分析台北市社區居住之老年人潛在性不適當用藥的盛行率和相關危險因素。

研究方法：
本研究為一橫斷面的研究，對台北市中正區健康服務中心的老人慢性病管理個案抽樣，共抽樣300位，其中170願意接受訪問(Response rate=57%)，執行時間為民國96年9月至12月。研究中利用文字或照片的方式紀錄受訪者在家中實際使用藥物的情形，包括處方和非處方(西藥)、健康食品等，並與醫師、藥師、護理師和社區老人討論，以進行問卷設計來調查受訪者的基本人口學資料、健康狀況和醫療使用情形，並評估老年人使用藥物的態度與對於藥物的認知。不適當用藥的定義採Beers 2003的準則，最後利用統計軟體SAS進行不適當用藥與相關危險因子之間的分析。

結果：
170位受訪的老年人中，平均每位老年人正在使用4.1種不同藥物。而在150位進入分析族群的老年人中，Beers 的不適當用藥盛行率為29.68%，常用之一般老年人常見不適當用藥的品項為Dipyridamole, Doxazosin, Diazepam. 以世界衛生組織藥品ATC分類原則，最常見之不適當藥物類別為Blood and blood forming organs、Cardiovascular system、Muscle-skeletal system、Nervous system、Respiratory system。在46位使用潛在性不適當藥物的老年人中，大部分都是使用一種潛在性不適當藥物，其中有6位是與「與診斷相關」的不適當用藥，包含有「消化性潰瘍」、「高血壓」、「失眠」、「膀胱流量阻塞」、「慢性阻塞性肺部疾病」診斷之老年病人。在單變項分析時，與老人不適當用藥之相關因素包括「服用藥物品項數多」、「獨居」、多「自述疾病數」、多「就診醫院數」、多「就診科別數」與非處方藥物(OTC)使用者。經邏輯複迴歸分析使用不適當用藥的相關因素後發現，服用藥物品項愈多者，有較高比例使用不適當藥物。

結論：
依據Beers的不適當用藥判定標準，台北市中正區有近三成的社區老年人正在使用潛在性不適當藥物，顯示在社區老人的潛在性不適當用藥是一個重要的問題。經過多變量分析的結果，發現老年人服用不適當藥物最重要的相關因素為服用藥物品項多。因此透過加強醫師對於老年病人的用藥安全教育和教導老年人正確自我藥物管理，以避免老年人服藥量過多，來改進老年人的用藥品質。

BACKGROUND：
Because of multiple chronic diseases and co-morbidity, elderly people take more medications than younger people and might see different doctors at the same time. Besides, the inappropriate usage and management of medications will also increase the risks associated with medications such as adverse drug reactions and falls. Therefore, we will attach great importance to the appropriateness of medication in elderly people.
OBJECTIVE：
The aim of this study was to describe the prevalence of inappropriate medication and associative factors among community-dwelling elderly in Taipei City.
METHODS：
This is a cross-sectional study. Three hundred study populations were sampling from the elderly with chronic disease in Health Center of ZhongZheng District and 170 of them were interviewed between September, 2007 and December, 2007 (response rate=57%). Information of socio-demographic characteristics, health status, medication utilization and the characteristics of management of medication were collected with questionnaires designed by researcher ,a doctor ,a pharmacist , nurses and elderly. Finally, it examined the prevalence and associated risk factors of potentially inappropriate medication defined by updated Beers’ criteria among elderly in ZhongZheng District, Taipei city. The study has been approved by research ethics committee in college of public health, National Taiwan University.
RESULTS：
The average number of medication used by elderly among 170 respondents is 4.1. By using Beers’ Criteria, the prevalence of potentially inappropriate medication is 29.68% in 150 elderly in the analysis population. Most of them taking one inappropriate medication and 6 of 46 elderly with potentially inappropriate medication used potentially inappropriate medications related to specific medical conditions including Hyperplasia of prostate elderly patients, hypertension patients, Chronic obstructive pulmonary disease, gastric ulcers patients and Insomnia patients.The most commonly potentially inappropriate medication used by elderly were Dipyridamole、Doxazosin and Diazepam. According to the ATC classification system, blood & blood forming organs drugs, cardiovascular system drugs, muscle-skeletal drugs, nervous system drugs and respiratory system drugs are commonly used in elderly. Using univariate analysis , we investigated that (i) increased number of mediation use, living alone, increased number of self-reported disease, increased number of hospital visited, increased number of department visited and consumption of OTC drug users have higher risk of using potentially inappropriate medication. With multiple logistical regression model, we investigated the higher number of medication used by elderly is very important associated factor of potentially inappropriate medication.
CONCLUSION：
Elderly in community with potentially inappropriate medication was detected in one-third in this study. This study provides strong evidence that potentially inappropriate medication use for elderly is a substantial problem in community. Polypharmacy is independently associated with potentially inappropriate medication use. Therefore, improved pharmacological education of physicians, especially for drug adverse effects and teaching older adults how to self-manage medications are needed to improve the quality of medication in elderly population.

口試委員會審定書 ----------------------------I
Acknowledgement ----------------------------II
中文摘要 ----------------------------------III
Abstract ------------------------------------V
List of tables -----------------------------IX
List of figures -----------------------------X
Chapter 1: Introduction----------------------1
1.1Background--------------------------------1
1.2 Study purpose----------------------------4
Chapter 2: Literature Review ----------------5
2.1 Physiologic changes that can affect drug use in elderly people-------------------------------5
2.2 Chronic disease and polypharmacy in elderly people--8
2.3 Understanding and management of medicines in elderly people--------------------------------------10
2.4 Beers criteria of potentially inappropriate prescribing for elderly people--------------12
2.5 Prevalence and correlates of potentially inappropriate prescribing among elderly people------------14
2.6 Guidelines for Anatomical Therapeutic Chemical (ATC) classification------------------------------16
2.7 Healthcare impact of potentially inappropriate medication use defined by beers’ criteria--17
Chapter3: Materials and Methods-------------23
3.1 Study design----------------------------23
3.2 Study population and sampling-----------24
3.3 Questionnaire design--------------------26
3.4 Definition of potentially inappropriate prescribing for elderly people--------------------------29
3.5 Statistical Analysis--------------------30
Chapter4: Results---------------------------36
4.1 Sample Characteristics------------------36
4.2 Prevalence of potentially inappropriate medication use---------------------------------------------38
4.3 Correlates of Potentially Inappropriate medication use---------------------------------------------39
Chapter5: Discussion------------------------56
5.1 Drug utilization behaviors among elderly56
5.2 Self-reported adverse effects-----------57
5.3 Prevalence of PIM use among elderly-----58
5.4 Factors associated with PIM use---------60
5.5 Contribution and Limitations -----------62
5.6Conclusion ------------------------------63
Reference-----------------------------------88
Appendix
I.Questionnaire-----------------------------65
II.Beers’ criteria 2003- Medications should be avoided in persons aged 65 years and above, independent of their diagnosis-----------------------------------71
III.Beers’ criteria 2003 - Medications should be avoided in persons aged 65 years and above, dependent of their diagnosis-----------------------------------80
IV.Inform consent---------------------------83
V.Medication utilization in study population84
List of tables
Table 2.1 Review of Prevalence and correlated factors of potentially inappropriate medication in elderly--------------------------------------------------------18
Table 2.2 Review of Prevalence and correlated factors of potentially inappropriate medication in elderly in Taiwan----------------------------------------------21
Table2.3 Structure of the ATC classification-----------------------------------------------------------22
Table 2.4 Detail information about 14 Anatomical groups of ATC classification--------------------------22
Table 2.5 Findings of studies defined by Beers’ inappropriate Medication use Criteria-------22
Table 3.1 Sample estimation-----------------31
Table 3.2 Sample size estimation according to population proportion in neighbors---------------------32
Table 3.3 Descriptive characteristics of the total study population, samples and response and non response group study of elderly people.--------------------33
Table 4.1 Underline characteristics of study population------------------------------------------------41
Table 4.2 Self-reported disease classified with ICD-9CM classification------------------------------45
Table4.3 Medication utilization according to ATC classification system-----------------------47
Table4.4 Potentially inappropriate medication use in the study population of elderly people by Beers criteria 2003----------------------------------------------49
Table 4.5 Prevalence of drug use in the study population of elderly people by number of medications used in each ATC drug class------------------------------50
Table 4.6 Bivariate comparison of characteristics of the elderly people according to potentially inappropriate medication use------------------------------51
Table 4.7 Correlation matrix of Pearson Correlation Coefficients of risk factors----------------53
Table 5.8 Multivariable logistical regression analysis of patient characteristics associated with potentially inappropriate medication use----------------54



List of figures

Figure3.1 Flowchart of this study-------------------------------------------------------------- 34
Figure3.2 Key Questions to be covered in questionnaire----------------------------------- 35

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