研究背景：
台灣已是高齡化社會，面對老年人口日益增多，急性醫療照護、慢性多重疾病的控制、多重用藥的整合能力及各種複雜性的照顧需求也隨之增加。國內外對於藥師執行藥事服務，改善藥物相關問題之文獻報告相當多，但能同時考量來自醫療、身心靈、家庭及經濟環境等因素之研究卻非常少見。在病床前我們看見許多不同的面向在影響著老人，而非只是疾病和藥物的交錯問題。若能建立「周全性高齡藥事照護」的評估方式，將能貢獻實際臨床研究經驗並結合實證資料，做為未來台灣發展高齡藥事照護之學習模式。
研究方法：
研究期間自2014年3月至2014年6月，收案對象為台灣南部某醫學中心老年科65歲及含以上共60位之住院患者，由老年科臨床藥師使用「周全性高齡藥事照護」評估表，初步分析藥事照護結果。
研究結果：
研究對象平均年齡82歲，分析主要住院原因為發燒(34.5%)、意識不清、虛弱、呼吸困難(各佔13.8%) ，前三位常見疾病之診斷分別為高血壓39人(65%)、肺部疾病21人(35%)及老年失智症17人(28.3%)，每位病患的平均診斷數是3.58種。
住院期間經由藥師依據「周全性高齡藥事照護」評估表評估，60位病人共使用780筆藥物。每位病人平均處方藥物筆數為13±4.8種，有16項問題類型，總共發現135筆藥事服務案例問題。其中最常見者為腎功能不佳之藥物建議共22(16.3%)筆，包括6筆在腎功能不佳時不建議使用的藥品，以及16筆藥物在腎功能不佳時須向醫師建議做劑量調整，其次是須定期追蹤與藥物相關之檢驗數值共20(14.8%)筆，與老年病症候群相關共18(13.3%)筆，包括吞嚥困難與不宜磨粉藥物評估11(8.1%)筆以及譫妄與藥物評估7(5.2%)筆；藥物與適應症有疑義共17(12.6%)筆，因藥物遵醫囑性不佳及無法正確執行用藥共12(8.9%)筆，適應症與合理劑量調整共11(8.1%)筆，臨床效益有限且難以評估共6(4.4%)筆等。
另外依據STOPP準則，共發現29位病患(48.3%)有41件潛在不適當用藥問題，依據START準則，發現14位病患(23.3%)有17件有診斷但未開立處方。
結論：
本研究優點在於1.建立臨床藥師參與病房迴診、案例討論及訪視衛教等互動模式，可以了解老人身心狀況、日常活動功能以及主要照顧者對藥事照護的支持程度以及分析各項老年照護與藥物使用之適當性。2.周全性高齡藥事照護評估表的建立，可發現多種不同的藥事照護之問題類型，能分析老人照護上的潛在問題與藥物相關性，包括老年病症候群與藥物問題，同時將所有發掘不同的藥事照護之問題類型，向醫師及老年科跨專業團隊會議上提出討論並且給予病患藥物的回饋建議。3.提升醫師、藥師及護理師對高齡患者跨專業照護的能力，對醫師而言，能增加對處方開立的正確性，對團隊照護而言，能提升彼此對高齡長者於醫療照護上獲得共同提升照護的能力，對病患用藥安全的考量是有特別的意義。

關鍵字：周全性高齡藥事照護、老年病症候群、老人潛在不適當用藥。

The aim of the study is to establish the assessment protocol of comprehensive geriatric pharmaceutical care. We enrolled hospitalized patients aged ≥ 65 years in a geriatric ward from a medical center in Taiwan. The drug utilization evaluation was conducted using the assessment form of comprehensive geriatric pharmaceutical care. The following contents of the evaluation were included: 1) Reasonability of drug utilization; 2) Potential association between medications and geriatric syndrome; 3) Potentially inappropriate medications based on STOPP & START criteria; 4) Patient education and feedback. The application of comprehensive geriatric pharmaceutical care identified 16 types of 135 medication problems, including dosage adjustment according to renal function in 22 (16.3%), medication-related abnormal laboratory data to be followed up in 20 (14.8%), potential association of geriatric syndrome and medications in 18 (13.3%) including crushing the non-crushed medication and delirium, questionable indication in 17(12.6%), non-adherence or incorrect in 12(8.9%), inadequate dosage in 11(8.2%) and limited benefit in 6(4.4%). During the hospital stay, 29 (48.3%) patients received ≥ one inappropriate medications by STOPP criteria and 14 (23.3%) patients needed to be added by START criteria, with a total of 58 medications detected by both criteria. The application of comprehensive geriatric pharmaceutical care might detect medication problems among the hospitalized elderly patients. Further study to clarify the effects of the suggestions by pharmacists for medication problems is needed.

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