Gerlach Lauren B, Olfson Mark, Kales Helen C, Maust Donovan T
Department of Psychiatry, University of Michigan, Ann Arbor, Michigan.
Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York, New York.
J Am Geriatr Soc. 2017 Sep;65(9):2052-2056. doi: 10.1111/jgs.14930. Epub 2017 May 3.
To determine patterns of and trends in contributions to central nervous system (CNS) polypharmacy, defined by the Beers Criteria as three or more CNS-active medications of each medication class, of adults aged 65 and older seen in U.S. outpatient medical practices.
National Ambulatory Medical Care Survey (2004-2013).
U.S. outpatient medical care.
Visits by older adults to outpatient physicians (N = 97,910).
Visits including three or more CNS medications including antipsychotics, benzodiazepines, nonbenzodiazepine benzodiazepine receptor agonist hypnotics (NBRAs), tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), and opioids. The proportion of CNS polypharmacy that each medication class contributed during 2011 to 2013 was determined, and then logistic regression was used to determine trends from 2004 to 2013 in the contribution of individual medication classes to such polypharmacy.
Of recent CNS polypharmacy visits, 76.2% included an opioid, and 61.8% included a benzodiazepine; 66.0% of the polypharmacy visits with benzodiazepines included opioids, and 53.3% of the polypharmacy visits with opioids included benzodiazepines. Between 2011 and 2013, opioid and benzodiazepine co-prescribing occurred at approximately 1.50 million visits (95% confidence interval (CI) = 1.23-1.78 million) annually. From 2004 (reference) to 2013, the proportion of polypharmacy visits with opioids rose from 69.6% to 76.2% (adjusted odds ratio = 2.15, 95% CI = 1.19-3.91, P = .01), and the corresponding proportion that included benzodiazepines fell. Of the polypharmacy visits, the odds of SSRI, NBRA, and antipsychotic use were unchanged, and that of TCAs decreased.
In older adults, opioid use appears to be largely driving the recent national increase in CNS polypharmacy. Although concomitant use of opioids and benzodiazepines is associated with greater mortality, they are the most common contributors to CNS polypharmacy in older adults.
确定美国门诊医疗中65岁及以上成年人中枢神经系统（CNS）多重用药的模式和趋势，根据Beers标准，CNS多重用药定义为每个药物类别使用三种或更多中枢神经系统活性药物。
全国门诊医疗调查（2004 - 2013年）。
美国门诊医疗。
老年人到门诊医生处就诊（N = 97,910）。
就诊时使用三种或更多中枢神经系统药物，包括抗精神病药物、苯二氮䓬类药物、非苯二氮䓬类苯二氮䓬受体激动剂催眠药（NBRAs）、三环类抗抑郁药（TCAs）、选择性5-羟色胺再摄取抑制剂（SSRIs）和阿片类药物。确定了2011年至2013年期间每个药物类别在CNS多重用药中所占的比例，然后使用逻辑回归来确定2004年至2013年期间各个药物类别对这种多重用药的贡献趋势。
在近期的CNS多重用药就诊中，76.2%的就诊使用了阿片类药物，61.8%的就诊使用了苯二氮䓬类药物；在使用苯二氮䓬类药物的多重用药就诊中，66.0%的就诊同时使用了阿片类药物，在使用阿片类药物的多重用药就诊中，53.3%的就诊同时使用了苯二氮䓬类药物。2011年至2013年期间，阿片类药物和苯二氮䓬类药物的联合处方每年约发生150万次就诊（95%置信区间（CI）= 123 - 178万次）。从2004年（参照）到2013年，使用阿片类药物的多重用药就诊比例从69.6%上升至76.2%（调整后的优势比 = 2.15，95% CI = 1.19 - 3.91，P = 0.01），而使用苯二氮䓬类药物的相应比例下降。在多重用药就诊中，使用SSRI、NBRA和抗精神病药物的几率未变，而使用TCAs的几率下降。
在老年人中，阿片类药物使用似乎在很大程度上推动了近期全国范围内CNS多重用药的增加。虽然阿片类药物和苯二氮䓬类药物的同时使用与更高的死亡率相关，但它们是老年人CNS多重用药最常见的促成因素。
