RESUMEN
OBJECTIVE： To evaluate the medication of elderly inpatients receiving multiple medication， to evaluate the effects of pharmaceutical care provided by clinical pharmacists， and to provide reference for clinical drug use of elderly patients. METHODS： The elderly inpatients receiving multiple medication were selected from Beijing Friendship Hospital Affiliated to Capital Medical University during Oct. 2018 to Feb. 2019. The process of pharmaceutical care for elderly inpatients was established and developed through the CGA team of the elderly. PCNE classification system was used to analyze drug-related problems； Bayliff tool was used to evaluate the harmfulness of drug-related problems； Morisky questionnaire was used to analyze medication compliance. Drug use was followed up 3 months after discharge to evaluate the effect of clinical pharmacist’s intervention. RESULTS： A total of 71 elderly inpatients with multiple medication were included， 73.24％ of them （52 patients） suffered from 54 drug-related problems， 32 of which were related to therapeutic effects （59.26％）， 13 （24.07％） drug adverse events （possible）， 9 unnecessary drug therapy problems （16.67％）. There were 69 causes of pharmaceutical related problems， of which 58 （84.06％） were doctor’s orders. The main causes were drug selection （36.23％）， drug dosage （24.64％） and drug dosage form （20.29％）. Totally 143 interventions were conducted by clinical pharmacists， including 102 successful interventions， with success rate of 71.33％. The highest acceptance of intervention was adverse drug events reporting（100％）， followed by patient level （97.56％）， doctor level （65.12％） and drug level （52.83％）. Among 54 pharmaceutical-related problems， the most potential hazards were grade 1 hazards， involving 35 problems （64.81％）. The score of medication compliance in patients who received medication education from clinical pharmacists was （6.19±0.58）， which was significantly higher than （4.13±1.62） at the initial stage of admission （P＜0.05）. Follow-up results showed that 6 patients discontinued drugs by themselves， and 13 patients took drugs additionally by themselves. CONCLUSIONS： Drug related problems were common in elderly inpatients receiving multiple medication. Clinical pharmacists can establish a feasible pharmaceutical care process suitable for clinical needs according to the actual clinical situation. With the help of relevant evaluation tools such as relevant drug criteria， drug instructions and drug software， and at the same time， according to the physiological and pathological conditions of patients， they can cooperate with clinicians to select suitable therapeutic drugs for elderly patients to reduce the phenomenon of unreasonable medication and multiple medication， so as to improve the effectiveness and safety of drug use in the elderly.