研究背景及目的
我國至2018年已邁入高齡社會，且老年族群跟其他年齡層相比有較高比率具多重慢性疾病或身心障礙等醫療問題，因此需要提供符合老年人需求的照護。藥師在醫療照護的角色從過去單純進行藥品調劑業務、被動地提供藥物衛教到現今參與醫療團隊直接照護病患，提供即時的藥事服務及減少藥物治療相關問題。在老年族群中，潛在不適當用藥的危險性時常作為討論的議題；Beers criteria是廣泛應用於高齡藥事照護的潛在不適當用藥評估工具，許多老年族群用藥相關研究常以此準則探討潛在不適當用藥的使用，但大部分文獻僅針對潛在不適當用藥型態進行分析，並沒有實際評估病人臨床狀況，確認潛在不適當用藥使用的合理性，且皆以較早期的潛在不適當用藥準則版本進行研究。住院期間是調整藥物及觀察病人反應的最佳時機，本研究擬藉由2019年更新的Beers criteria評估住院老年病患潛在不適當用藥，並結合臨床藥師病房訪視及藥事照護介入，探討此準則在臨床照護的應用程度，及利用潛在不適當用藥型態分析之結果、發現之藥物治療問題作為高齡藥事照護評估的參考依據之一。

研究方法
本研究為前瞻性研究，研究對象為成大醫院2019年10月至2020年5月老年科及一般內科病房65歲以上住院病患。藥師在病患入院72小時內整理其藥歷並使用Medi-span Drug database®檢核藥品適應症、劑量，並以2019 Beers criteria輔助，初步篩選出潛在不適當用藥；接著至病房以「成大醫院藥劑部整合性藥事照護評估表單」訪視及評估潛在不適當用藥使用合理性，進行藥物諮詢及衛教，評估後以發現的2019 Beers criteria列載之潛在不適當用藥或非Beers criteria列載之藥物治療問題與跨領域醫療團隊討論並給予建議。病患出院後將以電子病歷了解後續用藥情形、是否有非計畫再次急診及住院的紀錄。研究結果包含藥師應用2019 Beers criteria結合病房訪視評估用藥後給予藥物治療建議的比率、非2019 Beers criteria列載之其他藥物治療建議情形以及醫師對於建議之接受度，另外也將探討介入後2019 Beers criteria列載之潛在不適當用藥的下降程度、非計畫再次住院及再次急診比率及2019 Beers criteria潛在不適當用藥相關危險因子。

研究結果
本次研究共收案67位病人，其中8位（11.94%）評估結果認為是藥品相關問題導致入院。進行藥歷檢核時共有76.12%的病患被辨別出使用至少一種2019 Beers criteria潛在不適當用藥，總筆數為110筆。依照2019 Beers criteria分類，最常見的潛在不適當用藥類別為建議在老年族群避免使用之藥物。另外在檢核時也發現73筆非Beers criteria表列之潛在不適當用藥相關治療問題。
根據藥師臨床訪視及跨領域團隊查房評估結果，藥歷檢核發現之2019 Beers criteria列載的潛在不適當用藥110筆中共建議55筆，建議率為50%；住院追蹤期間額外發現之潛在不適當用藥共建議8筆；建議之63筆當中，醫師接受建議筆數為59筆，建議接受度93.65%。藥歷檢核發現之非2019 Beers criteria列載的潛在不適當用藥73筆中共建議22筆，且訪視期間額外發現其他非2019 Beers criteria列載之藥物治療問題共97筆，非2019 Beers criteria列載之藥物治療問題相關建議共119筆，醫師建議接受度99.16%。藥師介入後，出院時與入院藥歷檢核時相比，Wilcoxon signed-rank test顯示2019 Beers criteria潛在不適當用藥使用數量整體並無顯著下降（p=0.990）。所有病患一個月內再次急診比率為26.15%、再次住院比率為20.31%。經羅吉斯迴歸分析發現多重用藥為潛在不適當用藥的危險因子。

研究結論
本研究應用2019 Beers criteria發現住院老年病患潛在不適當用藥的使用十分常見，然而經整合性藥事照護評估及查房訪視後僅針對50%的2019 Beers criteria潛在不適當用藥進行建議，可以得知並非所有潛在不適當用藥皆為真正不適當之用藥，Beers criteria無法完全適用於臨床照護；若有實際評估病患情形並從用藥風險及利益中取得平衡，確認潛在不適當用藥之定義與臨床狀況便能給予符合需求之建議。而從非Beers criteria列載之其他藥物治療相關建議筆數較多的情形可以得知，臨床照護上Beers criteria主要作為提醒、輔助評估用藥的角色，其他藥物治療問題對老年病患也可能產生危害，因此高齡藥事照護不應只著重在Beers criteria所列之潛在不適當用藥，否則可能會遺漏其他造成危害的狀況。最後，藥師應用2019 Beers criteria介入的實際成效之量化及潛在不適當用藥危險因子仍有待更大規模的研究證實。

關鍵字
2019年Beers準則、老年族群、潛在不適當用藥、藥師、用藥評估

The objective of this study is to evaluate the applicability of 2019 Beers criteria with pharmaceutical intervention among hospitalized elderly patients. We conducted a single-center, prospective study. Patients aged over 65 and admitted to the geriatric or general medicine floor were included. We conducted medication review within 72 hours of admission, visiting these patients to assess the rationale for potentially inappropriate medication (PIM) use and giving patient education about drug use. After assessment, intervention for Beers-listed PIMs and non-Beers listed drug-related problems (DRPs) identified by clinical pharmacists was conducted. We finally included 67 patients. The prevalence of PIM was 76.12% based on 2019 Beers criteria and the number of Beers-listed PIMs was 110. 55 recommendations were communicated to medical teams, and the recommendation rate was 50%. 8 recommendations were conducted for Beers-listed PIMs added during admission. The acceptance rate was total 93.65%. Besides, the number of recommendations for non-Beers listed DRPs were 119, and the acceptance rate was 99.16%. Pharmaceutical intervention did not result in significant reduction of 2019 Beers-listed PIM number (p = 0.990). Polypharmacy was a potential predictor of PIM in our study. The findings indicated that prevalence of PIM was high in hospitalized elderly patients based on 2019 Beers criteria. However, we should evaluate the rationale for PIM use to give recommendations which met clinical needs. In addition, non-Beers listed DRPs might be another important issue in geriatric pharmaceutical care.

Key words: 2019 Beers criteria, elderly, potentially inappropriate medication, pharmacist, medication evaluation

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