Procena adekvatnosti propisivanja terapije kod starih osoba sa kardiovaskularnim bolestima
Аssessment of adequacy of prescribing therapy in the elderly with cardiovascular diseases
Author
Stojanović, GoranMentor
Milovanović, OliveraCommittee members
Đurić, DušanFolić, Marko
Marković-Denić, Ljiljana
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Show full item recordAbstract
Cilj: Istraživanje koje je vršeno imalo je za cilj da odredi prevalencu PIM-a u
populaciji starih ispitanika koji su imali dijagnostikovano kardiovaskularno
oboljenje i da kvantifikuje značaj određenih varijabli na prisustvo PIM-a.
Metoda: Sprovedena je hibridna studija koja je u prvom delu, od početka 2016. godine
do kraja 2017.godine izvedena kao studija preseka (periodična prevalencija), a u
drugom delu, tokom 2018. godine, kao klinička studija sa intervencijom putem
edukacije, sa poređenjem pre i posle intervencije. Studijski uzorak obuhvatao je 1500
pacijenata starijih od 65 godina sa kardiovaskularnim oboljenjima a da su bili
korisnici zdravstvenih usluga i imali dostupnu medicinsku dokumentaciju u Zavodu
za gerijatriju i palijativno zbrinjavanje u Beogradu. Intervencijski deo istraživanja
vršen je sa lekarima koji sprovode zdravstvenu zaštitu starih osoba a samim tim i
propisivanje medikamentozne terapije čija adekvatnost propisivanja je analizirana
upotrebo...m standardnih međunarodnih kriterijumima, American Geriatrics Society 2015
updated Beers Criteria for potentially inappropriate medication use in older adults.
Potrošnja lekova u navedenoj ustanovi za posmatrane periode je vršena prema
utvrđenoj ATC/DDD metodologiji koja je definisana od strane ekperata SZO.
Rezultati: Učestalost PIM-a u ispitivanoj populaciji iznosila je 70,3% za period
2016.-2017. godine i 71,3% u toku 2018. godine. Posmatrano u odnosu na pol,
ispitanice ženskog pola su bile dominatnije u grupi sa PIM-om. Najviše
ispitanika imalo je 4 komorbiditeta uz osnovnu dijagnozu. Komorbiditeti sa visokom
frekvencom su bili u grupi bolesti I00-I99 (bolesti srca i krvnih sudova) (36.9%).
Dijagnoze koje su najviše zabeležene su bile iz podgrupe I10- I15 (hipertenzivne
bolesti) (48,83%), I20-I25 (ishemijske bolesti srca) (20,38%). Po pacijentu je u
periodu 2016-2017 godine propisivano 7,2 leka dok je tokom 2018. godine iznosio 7,3.
Lekovi koji su potencijalno neadekvatno propisivani sa najvećom frekvencom su:
benzodiazepini srednjeg delovanja (79,03%), centralni α blokatori (23,57%),
antipsihotici (tipični i atipični) (30,75%). Potencijalno klinički značajne
neinfektivne interakcije lek-lek koje bi trebalo izbegavati kod starih osoba beleži
pad sa (35,5% na 30,9%) u prospektivnom periodu. Potencijalno neadekvatno
propisivanje lekova koji se moraju koristiti sa oprezom kod starih osoba beleži
smanjenje za: antipsihotike (29,5% na 27,8%), diuretike (69,9% na 63,8%) i SSRI
(22,7% na 19,7%). Potencijalno neadekvatno propisivanje lekova usled lek-bolest ili
lek-sindrom interakcije koje mogu pogoršati bolest ili sindrom zabeleženo je u
periodu 2016.-2017. u 105 slučajeva ili (8,6%) a nakon intervencije 2018.godine u 74
slučajeva odnosno (6,4%) Prediktori za PIM su brojni i to: polifarmacija, pol,
upotreba nikotina, kognitivni status, uhranjenost i komorbiditet za period pre
intervencije a nakon toga je pokazan i uticaj bračnog stanja i emocionalnog statusa.
Zaključak: Kardiovaskularne bolesti u starijoj populaciji povezane su sa visokom
prevalencijom potencijalno neadekvatnog propisivanja lekova. Iako je zabeleženo
smanjenje potrošnje pojedinih kardiovaskualrnih lekova nakon održane edukacije,
prevalenca PIM-a nije se smanjila. Kreiranje zdravstvenih preporuka za propisivanje
lekova kod starijih osoba koje bi naglasile navedene faktore moglo bi uticati na
smanjenje prevalencije PIM-a u navedenoj popilaciji.
Aim: Study has purpose to show prevalence of PIM in the population of elderly person with
the cardiovascular disease and to quantify influence of the specific variable on PIM presence.
Methods: A hybrid study was performed, which in the first part, from the beginning of 2016
to the end of 2017, was performed as a cross-sectional study (periodic prevalence), and in the
second part, during 2018, as a clinical study with interventions during education and after
interventions. Sample of the study inluded 1500 partcipants older then 65 years with
cardiovascular disease and who was used specific health services and had medical data at the
Institute for Gerontology and Palliative Care, Belgrade. Interventional part of the study was
done with medical doctor who presribed drugs at this institution. The adequacy of the
prescribed therapy was assessed by American Geriatrics Society 2015 updated Beers Criteria
for potentially inappropriate medication use in older adults. Drug c...onsumption for the
observed periods was determinated by established ATC/DDD methodology defined by WHO
experts.
Results: PIM frequency in the examined population was 70,3% during the period 2016-2017
and 71,3% during the 2018. Observed in relation to gender, female respondents were more
dominant in the group with PIM. Most subjects had 4 comorbidities with a basic diagnosis.
Comorbidities with high frequency were in the group of diseases I00-I99 (cardiovascular
diseases) (36.9%). The most frequently diagnosed diagnoses were from subgroup I10-I15
(hypertensive diseases) (48.83%), I20-I25 (ischemic heart diseases) (20.38%). In the period
2016-2017, 7.2 drugs were prescribed per patient, while in 2018 it was 7.3. Drugs that are
potentially inadequately prescribed with the highest frequency are: medium-acting
benzodiazepines (79.03%), central α blockers (23.57%), antipsychotics (typical and atypical)
(30.75%). Potentially clinically significant non-infectious drug-drug interactions that should
be avoided in the elderly decreased from 35.5% to 30.9% in the prospective period.
Potentially inadequate prescribing of drugs that must be used with caution in the elderly
decreased for: antipsychotics (29.5% to 27.8%), diuretics (69.9% to 63.8%) and SSRIs
(22.7% to 19.7%). Potentially inadequate drug prescribing due to drug-disease or drugsyndrome interactions that may exacerbate the disease or syndrome was noted in the period
2016-2017. in 105 cases or (8.6%) and after the intervention in 2018 in 74 cases or (6.4%)
Predictors for PIM are numerous, as follows: polypharmacy, sex, nicotine use, cognitive
status, nutrition and comorbidity for the period before interventions and after that the
influence of marital status and emotional status is shown.
Conclusion: Cardiovascular diseases in the elderly population are associated with a high
prevalence of potentially inadequate drug prescribing. Although a decrease in the
consumption of certain cardiovascular drugs was observed after the training, the prevalence of
PIM did not decrease. Creating health recommendations for prescribing drugs in the elderly
that would emphasize these factors could reduce the prevalence of PIM in this population.