Langford Aili V, Chen Timothy F, Roberts Chris, Schneider Carl R
The University of Sydney School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, 2006, Australia.
The University of Sydney School of Medicine, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, 2006, Australia.
Res Social Adm Pharm. 2020 Jun;16(6):746-759. doi: 10.1016/j.sapharm.2019.08.035. Epub 2019 Aug 20.
Psychotropic medication use in the elderly population is associated with significant adverse effects. Robust evidence for the efficacy of psychotropic medications for behavioural and psychological symptoms of dementia is lacking. Despite national bodies, governments, and policymakers employing interventions to optimise the use of psychotropic medicines in this population, there is little research on their overall impact.
To identify and categorise system level strategies that have been implemented internationally and assess their impact on psychotropic medicine use in aged care facilities.
A systematic search of health-related databases including Medline, Embase, CINAHL, Web of Science and Scopus was performed. Empirical studies published in English prior to March 2019 that reported on the impact of system level strategies on psychotropic medicine use in aged care facilities were included. Studies were mapped to the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework to measure impact and were assessed for risk of bias.
This review identified 36 studies which examined mandatory (n = 22) and non-mandatory (n = 14) system level strategies. The impact of strategies was highly dependent on implementation as well as organisational and patient factors. Mandatory strategies had greater evidence of impact on drug utilisation patterns compared to non-mandatory strategies which primarily focussed on adoption and implementation, rather than outcomes. The Omnibus Budget Reconciliation Act 1987 (OBRA-87) in the United States of America had the greatest reach and implementation of the interventions examined, with an observed reduction in psychotropic medicine use post-implementation. There was no substantive body of evidence reporting on the sustainability of strategies or the influence of cost on outcomes.
Despite the implementation of system level strategies, psychotropic medicine use in aged care facilities remains problematic. There is a need for revised or novel system level strategies which consider sustainability, economic influences and patient outcomes in their design and implementation.
老年人群使用精神药物会产生显著的不良反应。目前缺乏有力证据证明精神药物对痴呆症行为和心理症状有效。尽管国家机构、政府和政策制定者采取了干预措施来优化该人群精神药物的使用，但对其总体影响的研究较少。
识别并分类国际上已实施的系统层面策略，并评估其对老年护理机构中精神药物使用的影响。
对包括Medline、Embase、CINAHL、科学引文索引和Scopus在内的健康相关数据库进行系统检索。纳入2019年3月之前发表的英文实证研究，这些研究报告了系统层面策略对老年护理机构中精神药物使用的影响。研究被映射到RE-AIM（覆盖范围、有效性、采用率、实施情况、维持情况）框架以衡量影响，并评估偏倚风险。
本综述确定了36项研究，这些研究考察了强制性（n = 22）和非强制性（n = 14）系统层面策略。策略的影响高度依赖于实施情况以及组织和患者因素。与主要关注采用和实施而非结果的非强制性策略相比，强制性策略对药物使用模式的影响有更多证据。美国1987年的《综合预算协调法案》（OBRA-87）在所考察的干预措施中覆盖范围和实施程度最大，实施后精神药物使用有所减少。没有实质性的证据报告策略的可持续性或成本对结果的影响。
尽管实施了系统层面策略，但老年护理机构中精神药物的使用仍然存在问题。需要修订或制定新的系统层面策略，在设计和实施过程中考虑可持续性、经济影响和患者结果。
