Too Many Pills for Aging Patients 老年人吃太多葯了

老年人吃太多葯了

JANE E. BRODY 報道 2013年01月12日

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我的阿姨92歲了，簡直就是個移動藥房，而一個月前她差點讓這間藥房給害死了。這個小插曲也讓美國醫療系統花費了數十萬美元。
老年人的過度用藥是一個非常常見的問題，堪稱公共衛生危機，從而危及越來越多的老年人的福祉。很多人都在大把大把地定期吃藥，包括處方葯和非處方葯；而這可能會帶來嚴重甚至是致命的副作用及藥物相互作用。

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Yvetta Fedorova

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《美國老年病學會志》(The Journal of the American Geriatrics Society)最近刊發了一系列基於研究的準則，呼籲人們關注對老年人產生不幸影響的特定藥物。如果該準則被執業醫師及他們的患者所接受，應該有助於避免像我阿姨遭受的那種昂貴而傷身的災難。
老年人中的危機
3月初，阿姨因為極度的虛弱、嗜睡和思維混亂，在醫院小住了一陣。她被發現同時服用大量藥物和補劑：左旋甲狀腺素鈉(Synthroid)用於補充甲狀腺素；天諾敏(Tenormin)和奧美沙坦酯(Benicar)用於降血壓；來士普(Lexapro)用於抗抑鬱；美金剛(Namenda)用於控制阿爾茨海默症的癥狀；阿普唑侖(Xanax)用於夜間焦慮發作；蘇為坦(Travatan)滴眼液用於青光眼；複合維生素；維生素C；鈣和維生素D；低劑量阿司匹林；葉黃素補劑；還有科拉切(Colace)，一種軟化大便的葯。
醫院作出的診斷是：低鈉，提示停用已知引起此類副作用的來士普，使用抗抑鬱葯維拉佐酮(Viibryd)替代。注意到她的意識混亂，醫院的神經科醫生還加用了安理申(Aricept)，這是另一種治療阿爾茨海默氏症的藥物，但其實她僅僅是懷疑有這個病。
她的心臟科醫生把天諾敏的劑量加倍，停用了奧美沙坦酯，加入了另一種降血壓的阿普利素寧(Apresoline)。它令血壓急劇下降到了70/40（正常是120/80），這令她暈頭轉向，甚至坐也不起來，站也站不了。
住院10天後，快出院的時候，阿姨摔倒了，臉色發青。醫生給她做了心肺復蘇（這讓她斷了三根肋骨），在急診室做了復蘇後，又轉移到了重症監護病房。她在那兒三次出現痙攣。醫生給她用了苯妥英鈉(Dilantin)來控制發作。
她患上了雙側肺炎，看上去命不久矣。她已經簽署了“不搶救”的同意書。有一晚，她焦慮到難以入睡，醫院給了勞拉西泮(Ativan)，這種鎮靜葯令她昏睡了30小時。
神奇的是，抗生素和吸氧對她有效，她現在已經出院了，在一家康復中心休養，身體慢慢好轉，頭腦不那麼混亂，而且精力日益充沛。
我阿姨這樣的老年人是藥物的最大消費群體。65歲以上人群中，超過40%的人服用5種以上的藥物，而其中有三分之一的人每年會遭遇嚴重的不良反應，如摔倒導致骨折、定向障礙、排尿障礙，甚至心臟衰竭。
在老年病學會的支持下，11名專家組成的一個老年護理和藥理學跨學科小組已經更新了所謂的比爾斯標準（Beers Criteria，老年醫學中關於合理用藥的一個著名的標準，該標準在1991年公布後即被國際廣泛關注和引用——譯註），這是長期用於減少老年用藥相關 災難的指導守則。審閱了2000多項關於老年人用藥的高質量研究後，團隊強調了53種潛在不當使用的藥物或種類，並把它們分為三類：避免在老年人中使用； 避免在有特定疾病和癥狀的老年人中使用；如果確實沒有可接受的替代品，需在老年人中謹慎使用。
比如，鎮靜催眠葯——像我阿姨服用的勞拉西泮——會引起老年人嚴重的鎮靜作用、認知混亂和智力衰退；專家小組強調，應該用其他睡眠措施來替代，如草藥或其他非藥物方法，這會更安全。專家小組的結論是，許多有鎮靜作用的抗組胺藥物，統稱為抗膽鹼能藥物，應避免在老年人中使用，因為它們會引起如思維混亂、嗜睡、視力模糊、排尿困難、口乾、便秘等副作用。
口服的礦物油，如果不慎吸入，可引起吸入性肺炎；許多常用的消炎藥，包括如布洛芬(ibuprofen)和萘普生(naproxen)這樣的非處方葯，都會增加75歲以上老年人消化道出血的風險，65歲以上老年人服用強的松(prednisone)和華法林(warfarin)時有同樣的風險。
團隊還警告說，對80歲以上老年人來說，服用阿司匹林用於預防心臟病發作“弊大於利”，所有的抗抑鬱葯都會使血鈉降低到危險水平，這正是我阿姨遇到的問題。
團隊認為，這一標準應該被制度內外的醫生和病人廣泛使用。但專家也強調，指導守則不能用於推翻醫生對患者需求和價值取向的臨床判斷，也不能作為判斷醫療事故糾紛的依據。
患者的責任
老年病學會的健康老齡化基金(Foundation for Health in Aging)，做了一份一頁紙的“藥物和補劑日記”，可以幫助患者追蹤記錄他們服用的藥物種類和劑量。他們應該在就醫的時候出示這一表格。表格可點擊此處下載。
常見的情況是，人們有多種健康問題，而一個醫生不知道其他醫生開了什麼葯。新開的處方可能會引起藥物有害的相互作用，或者僅是因為同時服用的其他東西而抵消了藥效。
如果不能把使用的處方葯、非處方葯，以及包括酒精在內的軟性毒品毫無保留地告知醫護人員，這完全不會有任何好處，而是有潛在的壞處。此外，任何慢性病或此前發生過的藥物反應，也都不應向醫生隱瞞。
每次得到處方，患者應諮詢相關的副作用。如果出現了不好的或是意外的反應，或是藥物不起效的時候，應立刻告訴開處方的醫生。但是，在沒有諮詢過專業醫生之前，患者絕不能自行停止服藥。
未諮詢醫生之前，也不能在處方中自行任何添加藥物或補劑。即使看起來無害的布洛芬、對乙酰氨基酚（acetaminophen，解熱鎮痛葯）、聖約翰麥芽汁（美國流行多年的一種草藥——譯註），或某種非處方抗組胺藥物，在與特定的處方葯或既有病史相互作用時，也可能導致嚴重的副反應。
如果某種藥物躋身比爾斯標準，並不是說老年人一定會遇到不良反應。該葯可能對某些患者是基礎用藥，而且可能不存在更安全的替代品。說到底，醫生必須權衡用藥的利益和風險。

本文最初發表於2012年4月17日。
翻譯：Skandha

Too Many Pills for Aging Patients

By JANE E. BRODY January 12, 2013

My 92-year-old aunt was a walking pharmacy, and a month ago it nearly killed her. The episode also cost the American medical system several hundred thousand dollars.
Overmedication of the elderly is an all too common problem, a public health crisis that compromises the well-being of growing numbers of older adults. Many take fistfuls of prescription and over-the-counter medications on a regular basis, risking serious and sometimes fatal side effects and drug interactions.

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A series of research-based guidelines, recently updated and published in The Journal of the American Geriatrics Society, calls attention to specific medications most likely to have calamitous effects in the elderly. If adopted by practicing physicians and their patients, the guidelines should help to avert the kind of costly, debilitating disaster that befell my aunt.
A Crisis Among the Elderly
In early March, my aunt was hospitalized for an episode of extreme weakness, sleepiness and confusion. She was found to be taking a number of medications and supplements: Synthroid, for low thyroid hormone; Tenormin and Benicar, for high blood pressure; Lexapro, for depression; Namenda, for symptoms of Alzheimer's disease; Xanax, for nighttime anxiety attacks; Travatan eye drops, for glaucoma; a multivitamin; vitamin C; calcium with vitamin D; low-dose aspirin; a lutein supplement; and Colace, a stool softener.
Diagnosis at the hospital: low sodium, prompting a stoppage of Lexapro, known to cause such a side effect, and substitution of the antidepressant Viibryd. Noting her confusion, the hospital neurologist also added Aricept, another treatment for Alzheimer's disease, although she is only suspected of having this condition.
Her cardiologist doubled the dose of Tenormin, stopped the Benicar and added another blood pressure medication, Apresoline. This caused a precipitous drop in blood pressure to 70/40 (120/80 is normal), leaving her completely disoriented and unable to stand or sit up.
After 10 days in the hospital, as she was being discharged, my aunt collapsed and started turning blue. CPR was administered (which fractured three ribs), followed by resuscitation in the emergency room and then transfer to intensive care, where she suffered three seizures. She was put on Dilantin to control them.
She developed double pneumonia, and the end seemed near. A do-not-resuscitate order was issued. One night, when she was too agitated to fall sleep, she was given a dose of Ativan, a sedative, that left her unable to wake up for 30 hours.
Miraculously, she responded to antibiotics and administration of oxygen, and she has since been discharged to a rehabilitation facility where she is steadily getting stronger, less confused and refreshingly feisty.
Older adults like my aunt are the largest consumers of medications. More than 40 percent of people over age 65 take five or more medications, and each year about one-third of them experience a serious adverse effect, like a bone-breaking fall, disorientation, inability to urinate, even heart failure.
With the support of the geriatrics society, an interdisciplinary panel of 11 experts in geriatric care and pharmacology has updated the so-called Beers Criteria, guidelines long used to minimize such drug-related disasters in the elderly. After reviewing more than 2,000 high-quality research studies of drugs prescribed for older adults, the team highlighted 53 potentially inappropriate medications or classes of medication and placed them in one of three categories: drugs to avoid in general in the elderly; drugs to avoid in older people with certain diseases and syndromes; and drugs to use with caution in the elderly if there are no acceptable alternatives.
For example, instead of a sedative hypnotic - like the Ativan given to my aunt - that can cause extreme sedation, serious confusion and mental decline in older adults, the panel notes that an alternative sleep remedy, perhaps an herbal or nondrug option, is safer. Many sedating antihistamines, in a class of drugs called anticholinergics, should be avoided in older adults because they can cause such side effects as confusion, drowsiness, blurred vision, difficulty urinating, dry mouth and constipation, the panel concluded.
Mineral oil taken by mouth can, if accidentally inhaled, cause aspiration pneumonia, and many commonly used anti-inflammatory medications, including over-the-counter drugs like ibuprofen and naproxen, increase the risk of gastrointestinal bleeding in adults age 75 and older, as well as in those age 65 and older who also take medications like prednisone and warfarin.
In adults over age 80, the team warned, aspirin taken to prevent heart attacks "may do more harm than good," and any antidepressant may lower sodium in the blood to dangerous levels, as happened to my aunt.
The team said its criteria should be used by physicians and patients within and outside of institutional settings. But the experts also emphasized that the guidelines should not override a doctor's clinical judgment or a patient's needs and values, nor be used as grounds for malpractice disputes.
The Patient's Responsibility
The geriatric society's Foundation for Health in Aging has produced a one-page "drug and supplement diary" that can help patients keep track of the drugs and dosages they take. They should show the list to every health care provider they see. The form can be found at www.americangeriatrics.org/files/documents/beers/MyDrugDiary.pdf.
Too often, people with multiple health problems have one doctor who does not know what another has prescribed. A new prescription can lead to a toxic drug interaction, or simply be ineffective, because it is counteracted by something else being taken.
There is nothing to be gained, and potentially much to lose, by failing to disclose to health care professionals the use of prescribed, over-the-counter or recreational drugs, including alcohol. Nor should any chronic medical condition or prior adverse drug reaction be kept from your doctor.
Whenever a medication is prescribed, patients should ask about side effects to watch for. If a bad or unexpected reaction occurs or the drug does not seem to be working, the prescribing doctor should be told without delay. But patients should never stop taking a prescribed medication without first consulting a health care professional.
Nor should they add any drug or supplement to a prescribed regimen without first consulting a doctor. Even something as seemingly innocent as ibuprofen, acetaminophen, St. John's wort or an antihistamine purchased over the counter can sometimes lead to dangerous adverse reactions when combined with certain prescribed medications or pre-existing health problems.
But just because a drug is on one of the lists in the Beers Criteria does not mean every older person would be adversely affected by it. The drug may be essential for some patients, and there may be no safer alternative. When all is said and done, a doctor must weigh the benefits and risks.