Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA.
San Francisco Veterans Affairs Medical Center, San Francisco, California, USA.
J Am Geriatr Soc. 2023 Oct;71(10):3086-3098. doi: 10.1111/jgs.18463. Epub 2023 Jun 5.
BACKGROUND: Persons with dementia (PWD) have high rates of polypharmacy. While previous studies have examined specific types of problematic medication use in PWD, we sought to characterize a broad spectrum of medication misuse and overuse among community-dwelling PWD. METHODS: We included community-dwelling adults aged ≥66 in the Health and Retirement Study from 2008 to 2018 linked to Medicare and classified as having dementia using a validated algorithm. Medication usage was ascertained over the 1-year prior to an HRS interview date. Potentially problematic medications were identified by: (1) medication overuse including over-aggressive treatment of diabetes/hypertension (e.g., insulin/sulfonylurea with hemoglobin A1c < 7.5%) and medications inappropriate near end of life based on STOPPFrail and (2) medication misuse including medications that negatively affect cognition and medications from 2019 Beers and STOPP Version 2 criteria. To contextualize, we compared medication use to people without dementia through a propensity-matched cohort by age, sex, comorbidities, and interview year. We applied survey weights to make our results nationally representative. RESULTS: Among 1441 PWD, median age was 84 (interquartile range = 78-89), 67% female, and 14% Black. Overall, 73% of PWD were prescribed ≥1 potentially problematic medication with a mean of 2.09 per individual in the prior year. This was notable across several domains, including 41% prescribed ≥1 medication that negatively affects cognition. Frequently problematic medications included proton pump inhibitors (PPIs), non-steroidal anti-inflammatory drugs (NSAIDs), opioids, antihypertensives, and antidiabetic agents. Problematic medication use was higher among PWD compared to those without dementia with 73% versus 67% prescribed ≥1 problematic medication (p = 0.002) and mean of 2.09 versus 1.62 (p < 0.001), respectively. CONCLUSION: Community-dwelling PWD frequently receive problematic medications across multiple domains and at higher frequencies compared to those without dementia. Deprescribing efforts for PWD should focus not only on potentially harmful central nervous system-active medications but also on other classes such as PPIs and NSAIDs.
背景：痴呆症患者（PWD）的药物滥用率很高。虽然之前的研究已经检查了 PWD 中特定类型的有问题的药物使用，但我们试图描述社区居住的 PWD 中广泛的药物误用和过度使用。
方法：我们纳入了 2008 年至 2018 年健康与退休研究（Health and Retirement Study）中年龄在 66 岁及以上的社区居住成年人，并使用经过验证的算法将其归类为患有痴呆症。在 HRS 访谈日期前的 1 年内确定药物使用情况。通过以下方法确定潜在有问题的药物：（1）药物过度使用，包括过度积极治疗糖尿病/高血压（例如，血红蛋白 A1c<7.5%时使用胰岛素/磺酰脲类药物）和根据 STOPPFrail 和（2）药物误用接近生命末期时不合适的药物，包括会影响认知的药物和 2019 年 Beers 和 STOPP Version 2 标准的药物。为了进行比较，我们通过年龄、性别、合并症和访谈年份的倾向匹配队列，将药物使用情况与没有痴呆症的人进行了比较。我们应用了调查权重，使我们的结果具有全国代表性。
结果：在 1441 名 PWD 中，中位年龄为 84 岁（四分位距=78-89），67%为女性，14%为黑人。总体而言，73%的 PWD 开了≥1 种潜在有问题的药物，在过去一年中，平均每人开了 2.09 种药物。这在几个领域都很明显，包括 41%的人开了会影响认知的药物。经常出现问题的药物包括质子泵抑制剂（PPIs）、非甾体抗炎药（NSAIDs）、阿片类药物、降压药和抗糖尿病药。与没有痴呆症的人相比，PWD 中使用有问题的药物的比例更高，分别为 73%和 67%（p=0.002），平均为 2.09 和 1.62（p<0.001）。
结论：与没有痴呆症的人相比，社区居住的 PWD 经常在多个领域和更高的频率下接受有问题的药物治疗。针对 PWD 的药物减少治疗应不仅关注潜在的有害中枢神经系统活性药物，还应关注其他类别，如 PPI 和 NSAIDs。
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