Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.
Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
J Am Med Dir Assoc. 2017 Sep 1;18(9):806.e1-806.e17. doi: 10.1016/j.jamda.2017.06.005. Epub 2017 Jul 29.
Potentially inappropriate medications (PIMs) are widely used in institutionalized older adults, yet the key determinants that drive their use are incompletely characterized.
We systematically searched published literature within MEDLINE and Embase from January 1998 to March 2017. We searched for studies conducted in the United States that described determinants of PIM use in adults ≥60 years of age in a nursing home or residential care facility, in the emergency department (ED), or in the hospital. Paired reviewers independently screened abstracts and full-text articles, assessed quality, and extracted data.
Among 30 included articles, 12 examined PIM use in the nursing home or residential care settings, 4 in the ED, 12 in acute care hospitals, and 2 across settings. The Beers criteria were most frequently used to identify PIM use, which ranged from 3.6% to 92.0%. Across all settings, the most common determinants of PIM use were medication burden and geographic region. In the nursing home, the most common additional determinants were younger age, and diagnoses of depression or diabetes. In both the ED and hospital, patients receiving care in the West, Midwest, and South, relative to the Northeast, were at greater risk of receiving a PIM. Very few studies examined clinician determinants of PIM use; geriatricians used fewer PIMs in the hospital than other clinicians.
Among older adults, those who are on many medications are at increased risk for PIM use across multiple settings. We propose that careful testing of interventions that target modifiable determinants are indicated to assess their impact on PIM use.
在机构化的老年人群体中，广泛使用了潜在不适当的药物（PIMs），但驱动其使用的关键决定因素尚未完全明确。
我们系统地检索了 1998 年 1 月至 2017 年 3 月期间 MEDLINE 和 Embase 中发表的文献。我们检索了在美国进行的研究，这些研究描述了在养老院或居住护理设施、急诊部（ED）或医院中≥60 岁成年人使用 PIM 的决定因素。配对审查员独立筛选摘要和全文文章，评估质量并提取数据。
在 30 篇纳入的文章中，有 12 篇研究了养老院或居住护理环境中的 PIM 使用情况，4 篇研究了 ED，12 篇研究了急性护理医院，2 篇研究了跨环境。最常用的是 Beers 标准来识别 PIM 使用，范围从 3.6%到 92.0%。在所有环境中，最常见的 PIM 使用决定因素是药物负担和地理位置。在养老院中，最常见的附加决定因素是年龄较小，以及患有抑郁或糖尿病的诊断。在 ED 和医院中，与东北地区相比，在西部地区、中西部地区和南部地区接受治疗的患者接受 PIM 的风险更高。很少有研究检查了临床医生决定 PIM 使用的因素；与其他临床医生相比，在医院中，老年病医生使用的 PIM 更少。
在老年人中，那些服用多种药物的人在多个环境中使用 PIM 的风险增加。我们建议，应仔细测试针对可修改决定因素的干预措施，以评估其对 PIM 使用的影响。
