作者：Jill Stein
出處：WebMD醫學新聞
March 2, 2010 (德國慕尼黑) — 根據歐洲精神科協會第18屆歐洲精神疾病研討會中發表的小型研究資料，年長的住院精神病患經常有多重用藥的情況，事實上，出院處方也會有多重用藥，可能會有傷害性的交互作用。
英國Cheadle Woodhouse醫院諮商精神科Ashwani Kumar醫師向Medscape Psychiatry解釋，年長的住院精神病患容易有多重用藥情況，他們可能被排除於任何的臨床決策之外，因為他們一般有認知不佳、又有精神疾患，同時年紀也大。
Kumar醫師發表的研究評估了25名年長精神科病患從醫院出院返家(或護理之家或社福照護機構)時的藥物內容與可能的藥物交互作用。
Kumar醫師表示，一般開業醫師與精神科對於年長患者的多重用藥問題日漸關心，且統計證明可能會有問題，80%的75歲以上者服用至少1種處方藥物，有36%服用4或5種藥物。
他指出，多重用藥對於臨床和財務都有影響，這類病患會增加意識混亂、跌倒與後續的功能性衰退的風險，治療多重用藥引起之問題的費用，對於大眾健康照護體系而言，是相當有負擔的龐大支出。
【出院時的多重用藥】
研究者在
www.BNF.org這個英國網站上，輸入病患病歷中的藥物處方資訊，以確認可能的交互作用，BNF(British National Formulary)這個組織的目的，以清楚、簡明扼要、容易理解的方式，提供可靠且實用的資訊給英國的健康照護專業人士。
整體而言，在出院時，8名病患(32%)處方藥物項目4項或以下、10人(40%)處方有5-8項、7人(28%)有9種或以上。
出院處方項目的中位數為6.5，有風險的交互作用項目中位數為3.1。
有6項或以上之藥物的處方更容易引起藥物與藥物的交互作用，以及有危險的藥物與藥物交互作用。
Kumar醫師表示，我呼籲精神科醫師和非精神科醫師在對年長精神科住院病患處方增加用藥時要三思，因為醫師們認為的「治療新症狀而用藥」，可能實際上是原本的藥物引起的副作用，新處方可能增加新的問題。
精神科醫師急著開處方而未認真尋找病患症狀的起因，有部份是因為當代醫學皆是如此。
他指出，我們今天太執著在專科、次專科和超專科，有時候忘記了基本，顯然地，我們需要更整體的方法、用更全人的角度來看待病患，而不是只有針對他的精神症狀進行治療。
【預防多重用藥】
為了改善病患的結果，Kumar醫師回應之前發表的一些建議：
* 開始治療前，充分暸解你的病患；
* 開立治療配套，而非只有一張處方；
* 教育病患
* 選擇適當藥物
* 確定病患服用藥物
* 儘可能使用較少項的藥物
* 根據病患需求調整治療
* 自己要熟捻藥物
* 需有高度懷疑；並且
* 考量病患的觀點。
顯然地，由於年長病患比較難溝通，精神科醫師須和護士及社工合作，以確保這些建議可以被運用。
他也表示，專門的家庭藥師對於減少年長住院精神病患的多重用藥也是重要的。
他表示，藥師可以對治療計畫提出一些具有實證基礎的思維，有時候，在情緒緊張狀況下，精神科醫師須立即處方，以讓情況混亂的病房中的病患迅速安定下來，藥師可以和精神科醫師及護士合作，以保障用藥安全。
北卡羅萊納州Durham杜克大學醫學中心生物精神科小組組長P. Murali Doraiswamy醫師表示，多重用藥在美國也是個重要問題。
最近的研究認為，美國有200萬年長成人有藥物交互作用問題，美國有超過半數的年長成人服用5種以上藥物。
他指出，一名護士最近告訴他，有一名年長患者每天服用各個醫師開立的50多種藥物和補給品，幸好，其中少有禁止併用的項目，這或許是交互作用監測系統還有發揮功效，但是，可能有許多併用是我們毫無所悉的，因此，風險依舊存在。
他指出，昏倒或跌倒之後，隨之而來的最大風險是出血問題，所以，要特別注意重症照護患者。
Doraiswamy醫師同意Kumar醫師所提的，藥師最能發現這些交互作用，因為多數醫師對於藥物交互作用所知有限。
研究者皆宣告沒有相關財務關係。
歐洲精神科協會第18屆歐洲精神疾病研討會：摘要2052，發表於2010年3月2日。
Polypharmacy Common in Elderly Psychiatric Inpatients
By Jill Stein
Medscape Medical News
March 2, 2010 (Munich, Germany) — Older psychiatric inpatients may be a “vulnerable target” for polypharmacy and are, in fact, frequently discharged with multiple medications that have potentially hazardous interactions, according to data from a small study reported at the European Psychiatric Association 18th European Congress of Psychiatry.
"Older psychiatric inpatients are susceptible to polypharmacy," Ashwani Kumar, MRCPsych, who is a consultant psychiatrist at Woodhouse Hospital in Cheadle, United Kingdom, explained to Medscape Psychiatry. "They are likely to be excluded from any clinical decision-making given that they may be cognitively impaired because of both their psychiatric illness and age."
Dr. Kumar presented the results of a study that assessed the extent of polypharmacy and potential drug interactions in 25 elderly psychiatric inpatients at the time they were discharged from the hospital to their home, a nursing home, or residential care.
"There is increasing concern about the use of multiple medications in elderly populations in general practice and in psychiatric services, and the ‘statistics’ illustrate the potential scope of the problem. Eighty percent of individuals over age 75 years take at least 1 prescription medication, with 36% taking 4 or 5 medications," said Dr. Kumar.
Polypharmacy has both clinical and financial implications, he added. "It has been widely documented to increase the risk of confusion, falls, and consequent functional decline in this vulnerable population, and the cost of treating all the outcomes of polypharmacy is exorbitant for a publicly financed health care system that is already burdened by high costs," he said.
Multiple Medications at Discharge
For their study, the researchers identified potential interactions by entering information on the patient’s medication prescriptions as documented in their medical records on a UK Website known as
www.BNF.org. The organization aims to provide UK health professionals with authoritative and practical information on the selection and clinical use of medicines in a clear, concise, and accessible manner.
Overall, 8 patients (32%) had prescriptions for 4 or fewer medications at discharge, 10 (40%) had 5 to 8 prescriptions, and 7 (28%) had 9 or more prescriptions at discharge.
The median number of prescriptions at discharge was 6.5.The median number of hazardous interactions was 3.1.
A prescription for 6 or more medications was more likely to cause drug-drug interactions and hazardous drug-drug interactions.
"I would urge psychiatrists and nonpsychiatrist physicians to think twice before adding additional medications in older psychiatric inpatients as the new ‘symptom’ the doctor may think he is treating may actually be a side effect of a drug already on board," Dr. Kumar said. "A new prescription may actually potentiate new problems."
Part of the reason psychiatrists may rush to prescribe without conscientiously seeking the causes for a patient’s symptoms may lie in the "nature" of contemporary medicine.
"It may be that we are so fixated today on specialization and subspecialization and superspecialization that we sometimes forget the basics," he added. "But what is clear is that we need a more holistic approach where we focus more on the patient as a whole rather than exclusively on his psychiatric symptoms."
Preventing Polypharmacy
To improve patient outcomes, Dr. Kumar echoed prior published recommendations:
Know your patient well before starting treatment;
Order a treatment package, not just a prescription;
Educate the patient;
Choose the right medicine;
Ensure that the patient takes the medication;
Use as few drugs as possible;
Tailor the treatment to the patient’s needs;
Familiarize yourself with the drug;
Have a high index of suspicion; and
Consider the patient’s viewpoint.
Obviously, the psychiatrist may need to work with nurses and social workers to ensure that these recommendations are implemented given that older patients may have difficulty in communicating.
He also said that a dedicated in-house pharmacist may be pivotal in reducing the risk of polypharmacy in elderly psychiatric inpatients.
"A pharmacist can add some evidence-based thinking to treatment planning," he said. "Sometimes in an emotionally charged situation, a psychiatrist is pressured to prescribe in order to provide a quick fix for a patient in a disturbed ward. A pharmacist can work with the psychiatrist and nurse to safeguard against this practice."
P. Murali Doraiswamy, MD, head of the Biological Psychiatry Division at Duke University Medical Center in Durham, North Carolina, said that polypharmacy is also a significant problem in the United States.
"A recent study suggests that 2 million older adults in the US may be at risk for drug interactions, and more than half of older adults in the US take 5 or more pills," he said.
"A nurse recently told me about a senior who was taking more than 50 drugs and supplements given by various doctors. Fortunately, forbidden combinations are still rare, which suggests that the system for monitoring those is still working. But there are many combinations we know nothing about, and so the risk is still substantial," he added.
"Bleeding problems are the biggest risk followed by risk for fainting or falls, so people taking critical medicines should be particularly cautious," he added.
Dr. Doraiswamy agrees with Dr. Kumar that "pharmacists are the best at detecting these interactions since most doctors still know very little about drug interactions."
The investigators have disclosed no relevant financial relationships.
European Psychiatric Association (EPA) 18th European Congress of Psychiatry: Abstract 2052. Presented March 2, 2010.
