第五章 結論與建議
第二節 建議
雖然不同老年人用藥評估準則會因評估準則不同，評估對象差異而有所差 異，本研究雖然不能代表所有其他醫療用藥型態，但可作為後續其他相關醫療 醫療品質提升改善之參考，可提出以下幾點建議：
1. 建議醫療院所加強針對民眾用藥衛教宣導活動，提升民眾用藥安全的認知，
避免產生多重用藥的情形，增加藥物交互作用與未來藥物不良事件等不確定 風險。
2. 建議醫師於處方醫令宜儘量精簡處方用藥項數，宜審慎評估病人用藥紀錄，
避免同藥理性質重覆開立，增加未來藥物不良反應的風險。
3. 建議醫師在開立上述潛在性不適當用藥時，宜多加審慎評估，當無法取代非 用不可時，應密切監控病人服藥後情形。
4. 針對常見潛在性不適當用藥品項，建立醫療資訊系統警示功能，提醒醫師開 立處方時，能即時警示，做好源頭管理。
5. 老年人用藥安全評估是未來藥事照顧的方向，未來相關長期醫療照護機構如 護理之家或長期照護中心，應建立跨專業醫療團隊，如專責藥師的加入，才 能確保病人用藥安全，提升藥物治療目標。
6. 建議老年人用藥評估能建立醫療資訊系統管控，可藉由醫療資訊系統管理，
篩選異常不當用藥，避免因人為醫療疏失，造成後續嚴重不良後果。
7. 建議藥師應持續充實自我本質學能，主動介入老年人相關用藥安全評估，希 望藉由完整醫療團隊，達到老年人藥物治療的目的。
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附錄 A
65 歲以上老人通常應避免的藥物或藥物種類
藥物或分類 不適當之理由 嚴重度
Propoxyphene and combination drugs 止痛效果沒比普拿疼更好但有麻醉藥物之不良反應 低
Indomethacin NSAIDs 類別中引起最多的中樞神經不良反應 高
Pentazocine (Talwin) 麻醉類止痛劑中引起中樞神經不良反應的機率比較高，如精神
混亂和幻想等 高
Trimethobenzamide (Tigan) 療效最弱的止吐劑，而且還會引起錐體外不良反應 高
Muscle relaxants and antispasmodics:
methocarbamol (Robaxin), carisoprodol (Soma), chlorzoxazone (Paraflexmetaxalone (Skelaxin), cyclobenzaprine (Flexeril), and oxybutynin (Ditropan)
老年人無法耐受其抗膽鹼之不良反應，如鎮靜和虛弱無力，而
老年人可耐受的劑量下，其療效仍有爭議 高
Flurazepam (Dalmane) 此安眠藥在老年人身上的半衰期特長，導致鎮靜作用延長而增
加跌倒和骨折的危險 高
Amitriptyline (Elavil),
chlordiazepoxide-amitriptyline (Limbitrol),and perphenazine-amitriptyline (Triavil)
具有強烈的抗膽鹼作用和鎮靜作用。極不宜當作老年人憂鬱症
的首選藥物 高
Doxepin (Sinequan) 具有強烈的抗膽鹼作用和鎮靜作用。極不宜當作老年人憂鬱症
的首選藥物 高
藥物或分類 不適當之理由 嚴重度
Doxepin (Sinequan) 具有強烈的抗膽鹼作用和鎮靜作用。極不宜當作老年人憂鬱症
的首選藥物 高
Meprobamate 成癮性強，長期使用可令人成癮，停止使用需逐漸調降劑量 高
Doses of short-acting benzodiazepines: doses greater than lorazepam (Ativan), 3 mg; oxazepam (Serax), 60 mg;alprazolam (Xanax), 2 mg; temazepam (Restoril), 15mg;and triazolam (Halcion), 0.25 mg
老年人對此類藥的敏感性增加，低劑量就足夠。每日劑量不應
超過最大建議量 高
Long-acting benzodiazepines: chlordiazepoxide (Librium),chlordiazepoxide-amitriptyline (Limbitrol) clidinium-chlordiazepoxide (Librax), diazepam (Valium),quazepam (Doral), halazepam (Paxipam), and chlorazepate (Tranxene)
在老年人身上的半衰期長達數天，導致鎮靜作用延長而增加跌
倒和骨折的危險 高
Disopyramide (Norpace and Norpace CR) 具有最強烈的抑制心臟收縮效應，易引起心臟衰竭，且具有強
烈的抗膽鹼作用 高
digoxin(should not exceed>0.125mg/d) 老人腎臟廓清能力降低導致增加過量中毒的風險 低
藥物或分類 不適當之理由 嚴重度
short-acting Disopyramide 易引起姿勢性低血壓 低
Methyldopa (Aldomet) 造成心跳緩慢及加重憂鬱症情形惡化 高
reserpine at dose>0.25mg 會誘發憂鬱症、陽痿、鎮靜及姿勢性低血壓 低
Chlorpropamide (Diabinese) 半衰期長，會延長低血糖症狀的恢復。口服降血糖藥物人中唯
一會引起抗利尿賀爾蒙不正常症候群(SIADH) 高
Gastrointestinal antispasmodic drugs: dicyclomine (Bentyl),hyoscyamine (Levsin and Levsinex), propantheline (Pro-Banthine), belladonna alkaloids (Donnatal and others),and
clidinium-chlordiazepoxide (Librax)
具有強烈的抗膽鹼作用且療效未被確認，老年人應避免使用，
尤其是長期使用 高
Anticholinergics and antihistamines:
chlorpheniramine (Chlor-Trimeton),
diphenhydramine (Benadryl), hydroxyzine (Vistaril and Atarax), cyproheptadine (Periactin),
promethazine (Phenergan), tripelennamine, dexchlorpheniramine (Polaramine)
具有強烈的抗膽鹼作用，治療過敏症時，老人宜選擇不具抗膽
鹼作用之抗組織胺藥物 高
Diphenhydramine (Benadryl) 會引起精神混亂和過度鎮靜作用，不應被當成安眠藥。用於過
敏反應之急救時，盡可能使用最小有效劑量 高
藥物或分類 不適當之理由 嚴重度
ergot mesyloid 缺乏療效 低
ferrous sulfate>325mg/d 每日劑量超過325mg 不會增加吸收量，但會大幅提高便秘的
發生率 低
All barbiturates (except phenobarbital) except when
used to control seizures 成癮性強，不良反應比其他大多數的鎮靜劑或安眠藥多 高
Meperidine (Demerol) 口服劑型在常用劑量下之療效不佳，會引起精神混亂，缺點比
其它麻醉類止痛劑多 高
Ticlopidine (Ticlid) 抗血小板凝聚效果不比aspirin 優異，但毒性較強。有更有效和
安全的替代藥物 高
Ketorolac (Toradol) 老年人應避免短期及長期使用，因會引起無預兆的胃腸傷害 高
Amphetamines and anorexic agents 有引起藥物依賴性、高血壓、心絞痛和肌梗塞的風險 高
Long-term use of full-dosage, longer
half-life,non–COX-selective NSAIDs: naproxen (Naprosyn, Avaprox,and Aleve), oxaprozin (Daypro), and piroxicam (Feldene)
可能會導致胃腸道出血.腎衰竭.高血壓與心臟衰竭 高
Daily fluoxetine (Prozac) 半衰期長，導致中樞神經系統過度興奮和睡眠障礙 高
藥物或分類 不適當之理由 嚴重度 Long-term use of stimulant laxatives: bisacodyl
(Dulcolax),cascara sagrada, and Neoloid except in the presence of opiate analgesic use
大腸功能更惡化 高
Amiodarone (Cordarone) 有引起QT interval 異常和誘發 torsades de pointes 的危險。在老
年人可能是無療效的 高
Orphenadrine (Norflex) 抗膽鹼作用和鎮靜不良反應比較多，有更安全的替代藥物 高
Guanethidine (Ismelin) 有導致姿勢性低血壓的風險，有更安全的替代藥物 高
Guanadrel (Hylorel) 有導致姿勢性低血壓的風險 高
cyclandelate 缺乏療效 低
isoxsurpine 缺乏療效 低
Nitrofurantoin (Macrodantin) 有造成腎臟功能受損之風險。有更安全的替代藥物 高
doxazosin 導致低血壓、口乾與泌尿道問題 低
Methyltestosterone (Android, Virilon, and Testrad) 有導致攝護腺肥大和心臟問題之風險 高
Thioridazine (Mellaril) 提高中樞神經系統和錐體外之不良反應風險 高
Mesoridazine (Serentil) 中樞神經系統和錐體外之副作用 高
Short acting nifedipine (Procardia and Adalat) 潛在有造成低血壓及便秘的風險 高
clonidine 有造成姿勢性低血壓及中樞神經系統不良反應的風險 低
Mineral oil 增加潛在性呼吸道方面副作用，有更安全的替代藥物 高
cimetidine 會引起中樞神系統不良反應，包括精神混亂 低
ethacrynic acid 有導致高血壓和體內水分不平衡的風險，有更安全的替代藥物 低
Desiccated thyroid 有心臟方面副作用，有更安全的替代藥物 高
Amphetamines (excluding methylphenidate
hydrochloride and anorexics) 可能造成中樞神經系統副作用 高
estrogens only(oral) 有致癌之慮(乳癌和子宮內膜癌)且無心臟保護的療效 低
資料來源：Donna M. Fick, James W. Cooper, William E. Wade, FASHP, F., Jennifer L. Waller, J. Ross Maclean, et al.(2003). Updating the Beers Criteria for Potentially .Inappropriate Medication Use in Older Adults. ARCH INTERN MED, 163, 2716-272
附錄 B
20 種診斷或情形下應避免不適當藥物及種類
項次 Disease or Condition Drug Concern Severity
Rating
1 Heart failure Disopyramide (Norpace), and high sodium content drugs (sodium and sodium salts [alginate bicarbonate,biphosphate, citrate, phosphate, salicylate, and sulfate])
Negative inotropic effect. Potential to promote
fluid retention and exacerbation of heart failure. High
2 Hypertension
Phenylpropanolamine hydrochloride (removed from the market in 2001), pseudoephedrine; diet pills, and amphetamines
May produce elevation of blood pressure secondary
to sympathomimetic activity. High 3 Gastric or duodenal ulcers NSAIDs and aspirin ( 325 mg) (coxibs excluded) May exacerbate existing ulcers or produce
new/additional ulcers. High
4 Seizures or epilepsy Clozapine (Clozaril), chlorpromazine (Thorazine),
thioridazine (Mellaril), and thiothixene (Navane) May lower seizure thresholds. High
5 Blood clotting disorders or receiving anticoagulant therapy
Aspirin, NSAIDs, dipyridamole (Persantin), ticlopidine (Ticlid), and clopidogrel (Plavix)
May prolong clotting time and elevate INR values or inhibit platelet aggregation, resulting in an increased potential for bleeding.
High
6 Bladder outflow obstruction
Anticholinergics and antihistamines, gastrointestinal antispasmodics, muscle relaxants, oxybutynin (Ditropan), flavoxate (Urispas), anticholinergics,antidepressants, decongestants, and tolterodine (Detrol)
May decrease urinary flow, leading to urinary
retention. High
項次 Disease or Condition Drug Concern Severity Rating
7 Stress incontinence
α-Blockers (Doxazosin, Prazosin, and
Terazosin),anticholinergics, tricyclic antidepressants (imipramine）hydrochloride, doxepin hydrochloride, and amitriptyline hydrochloride), and long-acting benzodiazepines
May produce polyuria and worsening of incontinence High
8 Arrhythmias Tricyclic antidepressants (imipramine hydrochloride,doxepin hydrochloride, and amitriptyline hydrochloride)
Concern due to proarrhythmic effects and ability
to produce QT interval changes. High 9 Insomnia Decongestants, theophylline (Theodur),
methylphenidate(Ritalin), MAOIs, and amphetamines Concern due to CNS stimulant effects. High 10 Parkinson disease Metoclopramide (Reglan), conventional antipsychotics, and
tacrine (Cognex)
Concern due to their antidopaminergic/cholinergic
effects. High
11 Cognitive impairment
Barbiturates, anticholinergics, antispasmodics, and muscle relaxants. CNS stimulants: dextroAmphetamine(Adderall), methylphenidate (Ritalin), methamphetamine(Desoxyn), and pemolin
Concern due to CNS-altering effects. High
12 Depression
Long-term benzodiazepine use. Sympatholytic agents:methyldopa (Aldomet), reserpine, and guanethidine(Ismelin)
May produce or exacerbate depression. High
Disease or Condition Drug Concern Severity Rating 13 Anorexia and
malnutrition
CNS stimulants: DextroAmphetamine
(Adderall),methylphenidate (Ritalin), methamphetamine (Desoxyn),pemolin, and fluoxetine (Prozac)
Concern due to appetite-suppressing effects. High
14 Syncope or falls Short- to intermediate-acting benzodiazepine and tricyclic antidepressants (imipramine hydrochloride, doxepin hydrochloride, and amitriptyline hydrochloride)
May produce ataxia, impaired psychomotor
function, syncope, and additional falls. High 15 SIADH/hyponatremia SSRIs: fluoxetine (Prozac), citalopram (Celexa),fluvoxamine
(Luvox), paroxetine (Paxil), and sertraline(Zoloft) May exacerbate or cause SIADH. High 16 Seizure disorder Bupropion (Wellbutrin) May lower seizure threshold. High 17 Obesity Olanzapine (Zyprexa) May stimulate appetite and increase weight gain. low
18 COPD
Long-acting benzodiazepines: chlordiazepoxide (Librium),chlordiazepoxide-amitriptyline
(Limbitrol),clidinium-chlordiazepoxide (Librax), diazepam (Valium),quazepam (Doral), halazepam (Paxipam), and chlorazepate (Tranxene). -blockers: propranolol
CNS adverse effects. May induce respiratory depression. May exacerbate or cause respiratory depression.
High
19 Chronic constipation
Calcium channel blockers, anticholinergics, and tricyclic antidepressant (imipramine hydrochloride, doxepin
hydrochloride, and amitriptyline hydrochloride) May exacerbate constipation. low
附錄 C
依據國際疾病分類-不適宜診斷分類
項次 疾病或狀況 ICD-9-CM
398 其他風濕性疾病 398.91 風濕性心臟衰竭（充血性）
402.01 惡性高血壓性心臟病，伴有充血性心臟衰竭 402 高血壓性心臟病
402.11 良性高血壓性心臟病，伴有充血性心臟衰竭
404.01 惡性高血壓性心臟及腎臟疾病, 伴有充血性心臟衰竭
404.03 惡性高血壓性心臟及腎臟疾病, 伴有充血性心臟衰竭及腎衰竭 404.11 良性高血壓性心臟及腎臟疾病, 伴有充血性心臟衰竭
404 高血壓性心臟及腎臟疾病
404.13 良性高血壓性心臟及腎臟疾病, 伴有充血性心臟衰竭及腎衰竭 428.0 充血性心臟衰竭
428.1 左心衰竭
1 Heart failure
428 心臟衰竭
428.9 心臟衰竭，未明示者 401 惡性自發性高血壓 401.1 良性自發性高血壓 401 自發性高血壓
401.9 自發性高血壓 402.0 惡性高血壓性心臟病
402.00 惡性高血壓性心臟病,無充血性心臟衰竭 402.01 惡性高血壓性心臟病，伴有充血性心臟衰竭
2 Hypertension
402 高血壓性心臟病
402.1 良性高血壓性心臟病