Current State of Appropriate Medication Use in Older Adults and Future Prospects

: Medication is the most common strategy for addressing the healthcare needs of older adults. In order to treat disease, maintain health, prevent further declines in health, prolong survival, and improve quality of life, the proper use of medicine is of great importance in the care of older patients (de Oliveira Alves, Schuelter-Trevisol, & Trevisol, 2014). Since the physician Dr. Beers put forward the concept of potentially inappropriate medication (PIM) almost thirty years ago in 1991 (Beers et al., 1991), scholars around the world have issued explicit criteria related to PIM for clinical and research purposes. It is necessary for the first-line medical personnel who are involved in caring for older patients to increase their knowledge and understanding of the medication status of their older patients, clarify the indications of medicines taken by these patients, and become familiar with the tools used to assess the appropriateness of medications in order to assist the medical team to identify PIM and to serve as a channel between older patients and the medical team. A systematic literature review found prevalences of PIM among older individuals ranging from 3.6% to 92.0% (Nothelle, Sharma, Oakes, Jackson, & Segal, 2017; Redston, Hilmer, McLachlan, Clough, & Gnjidic, 2018; Storms, Marquet, Aertgeerts, & Claes, 2017), subject to different research samples, study sites, and assessment tools. The prevalence of PIM among older patients in Taiwan has been estimated at 9.8%-91.2% (Chang et al., 2011; Huang, Yeh, Hung, Hsieh, & Tsai, 2011; Lin, Peng, Chen, Lin, & Hwang, 2011; Shen, 2008), which indicates that the problem of PIM among older patients in Taiwan is no less serious than in Europe or the United States. A survey of medication used by older adult inpatients at a medical center in northern Taiwan found the incidences of PIM in the sample to be 76.3%, 80.9%, 70.0%, 69.1%, and 75.2%, respectively, at hospital admission, during hospitalization, at discharge, at the first return visit, and 3 months after discharge (Ho, 2017). This not only revealed a high prevalence of PIM among older people in Taiwan but also suggests that PIM may initially decrease and subsequently increase over time after hospital discharge. This possible trend deserves further assessment and attention. Nurses, especially homecare nurses, are frontline personnel in medical care who play an important role in reviewing medication safety. Lou (2016) used focus group research to explore the challenges of medication safety faced by older patients under the care of homecare nurses. The study found that homecare nurses lack the self-confidence necessary to review of the appropriateness of medication due to several factors, including medication complexity, lack of clinical experience, the regular introduction of new drugs, and the fact that homecare nurses are not medical experts. Lou further used PIM-Taiwan criteria (version 1) to design and develop an application software program (app) that reviews automatically the appropriateness of medications given to older patients. This app is a supplemental assistance device for non-drug experts and facilitates the timely reporting of medication review results to prescribing physicians. The app was further shown to have a positive and significant impact in a demonstration trial. The administration of medication is a key part of the routine work of nurses. In addition to administering correct dosages, nurses should have a better understanding of the appropriateness of medications. Nurses should not only be familiar with the medicines that they give to their older patients but should also be able to identify their appropriateness. They should make good use of explicit criteria to identify the appropriateness of medications and apply related technological products in clinical situations in order to improve quality of care in terms of medication safety for older patients. : 藥物是老人健康照護最常見的治療措施，為了治療急慢性病，維持目前健康、預防進一步的衰退、延長存活時間和提高生活品質，正確使用藥物對老人健康照護是非常重要的（de Oliveira Alves, Schuelter-Trevisol, & Trevisol, 2014）。1991年由Beers醫師等人提出潛在不適當用藥（potentially inappropriate medication, PIM）概念迄今已將近30年，世界各國學者也陸續發表明確列舉式準則以供臨床與研究使用，身為老人照護第一線醫療人員，更應加強詢問和瞭解老人的藥品狀況，釐清老人目前服用這些藥品的適應症及藥品訴求或目的，熟悉並善用藥品適當性評估工具，以協助醫療團隊有效率地找出老人PIM，做為老人與醫療團隊之間溝通的橋樑。由系統性文獻回顧發現，隨著研究樣本、研究場所及評估工具的不同，老人PIM使用之盛行率約3.6%–92.0%（Nothelle, Sharma, Oakes, Jackson, & Segal, 2017; Redston, Hilmer, McLachlan, Clough, & Gnjidic, 2018; Storms, Marquet, Aertgeerts, & Claes, 2017）。在臺灣老人PIM使用之盛行率則為9.8%–91.2%（沈，2008；黃、葉、洪、謝、蔡，2011；Chang et al., 2011; Lin, Peng, Chen, Lin, & Hwang, 2011），顯示臺灣老人PIM使用的問題嚴重性並不亞於歐美各國。最近以臺灣北部某醫學中心住院老人用藥研究發現，住院時、住院中、出院時、出院後第一次回診和出院後三個月，至少有一種老人PIM之盛行率分別是76.3%、80.9%、70.0%、69.1%和75.2%（何，2017）。顯示臺灣住院老人PIM盛行率高，即使在出院後略有下降，但隨著出院後時間的推移，老人PIM之盛行率有逐漸上升之趨勢，不容吾等忽視。護理人員，尤其是居家護理師，為醫療照護之第一線人員，對於用藥安全審查更為重要，因此，為了了解居家護理師對於老人用藥安全之挑戰，羅（2016）以焦點團體研究發現，由於老人用藥複雜性高、臨床經驗不足、新藥推陳出新，以及居家護理師非藥物專家等，導致居家護理師缺乏老人用藥審查適當性之自信度，羅進一步運用PIM-Taiwan第一版設計開發應用軟體（application, app），提供居家護理師用以審查老人用藥適當性，以補非藥物專家之憾，並將老人用藥審查結果適時反應給開處方醫師，作為調整藥物與否之依據，成效是顯著的。給藥是護理師常規工作中非常重要的一環，護理人員除了著重給藥正確及作用外，期望進一步對藥品適當性有所認知。護理人員除了要熟知老人常用藥品外，更要能識別老人用藥適當性，善用明確列舉式準則作為識別老人用藥適當性的依據，以紙本或開發成科技產品，應用於臨床情境，以提升老人用藥安全之照護品質。.