飲食型態衛教介入對於減少吞嚥障礙長者嗆咳之成效

Abstract

研究目的 臺南市之老年人口比率已超過14%，邁入高齡社會，部分行政區之老年人口比率甚至早已超過20%。為強化社區長者健康，預防衰弱及肌少症，衛生局辦理許多健康促進活動，並透過營養教育加強長者之營養觀念。然而，要攝取到足夠營養，需能夠順利吞嚥食物。吞嚥障礙為年長者在攝取營養時經常遭遇之問題，亦會提高發生吸入性肺炎以及死亡之風險。為減少長者吞嚥困難並減少嗆咳，達到降低嗆咳引致之吸入性肺炎以及死亡，可透過調整食物質地成為不同飲食型態來進行改善，國外有許多針對中風、帕金森氏症，以及長照機構住民等特殊族群進行吞嚥障礙族群質地調整飲食之相關文獻，但目前對於社區民眾提供調整食物質地衛教所能達成之效益仍著墨甚少，在台灣之社區研究則付之闕如，更遑論此一族群性長者介入計畫之成本效益分析。有鑑於臺南市日益趨向高齡社會發展，可預期好發於長者之吞嚥障礙以及相關之吸入性肺炎與死亡風險，是不遠的未來之重要課題，本實習論文將藉由臺南市長者之吞嚥障礙調查，評估目前社區長者此一問題之現況與負擔，進一步藉由文獻搜索對於飲食型態介入衛教之效益，結合兩者進行之成本效益評估。本實習論文將有助於發展及檢視臺南市社區長者之吞嚥問題介入方式，並提供政策建議，以給予社區吞嚥困難長者更合適之飲食衛教。 方法 本實習計畫分為三部分： (1)臺南市長者吞嚥障礙問題與負擔評估：本實習論文於108年7月到108年12月，在臺南市新營、鹽水、學甲、玉井四區，針對65歲以上長者，由轄區衛生所及診所使用結構性問卷，透過長者自評進行吞嚥問題或嗆咳情形調查，並進行區域差異與人口學特徵之吞嚥障礙現況評析。在此一現況評估之基礎上，本實習論文將進行後續之效益評估以及社區飲食型態介入衛教成本效益分析。 (2)飲食型態介入衛教效益評估：透過文獻搜索，收集針對質地調整食物之介入效果，以嗆咳、吸入性肺炎作為主要介入結果評估，運用貝氏隨機效應羅吉斯回歸，統合現行之飲食型態介入可達到之效益以及可能之不確定性。 (3)臺南市社區長者飲食型態介入衛教成本效益分析：本實習論文以前述(1)臺南市社區長者之嗆咳負擔以及發生頻率為基礎，結合(2)飲食型態介入衛教之可達成效益，在台灣長者吸入性肺炎之發生率以及死亡率與健康保險照護體系之情境下進行成本效益分析。初步之評估以介入後追蹤5年作為評估之時程。 結果 本實習研究納入之臺南市社區長者為1,083人，平均年齡為75.3歲，參與調查之長者以女性居多，占61.4%。評估結果，有嗆咳者共122人（11.3%），嗆咳次數最多的為每週21次，所有受評者平均每週嗆咳次數為0.36次，若在至少發生一次嗆咳之長者進行評估，其每週平均嗆咳次數則達3.22次，在吞嚥困難問卷部分，參與調查之社區長者有170人（15.7%）具有吞嚥不順利之問題。 進一步分析年齡、性別對長者嗆咳及吞嚥情形之影響。在納入長者高血壓、糖尿病、高血脂及多重慢性病用藥之結果顯示，是否發生嗆咳僅與年齡有顯著相關（OR=1.063 95% CI 1.033-1.093），嗆咳之發生次數與性別（RR=0.79，95% CI 0.64-0.96）及年齡（RR=1.10，95% CI 1.08-1.11）有顯著相關。 本實習研究在文獻搜索後，納入5篇質地調整食物介入結果進行統合分析，介入組相較於比較組其嗆咳/吸入性肺炎之風險對比值為0.72（95%CI 0.59-0.86），顯示質地調整食物介入可達到顯著降低嗆咳/吸入性肺炎風險達28% (95% CI: 14-41%)。而成本效益分析結果，結果發現飲食型態衛教介入之肺炎(5,979人次對6,336人次)及死亡(649人對714人)人次數均少於一般衛教。對臺南市社區長者提供飲食型態衛教之成本相較於一般衛教將增加台幣365.75元，效益則增加0.006836人命年。相較於一般衛教，飲食型態衛教介入每多挽救一人年命，需多花費台幣 53976.08元。 結論 本市長者吞嚥困難之比例與過往研究大致相符，關於長者個人特性與共病對於嗆咳之影響評估，在考慮多重因素下之評估結果顯示年齡、性別對長者嗆咳及吞嚥情形有所影響，後續評估可將口腔狀況、中風、失智及飲食型態等干擾因素納入考量。本實習研究透過臺南市長者為目標族群之成本效益分析，發現飲食型態衛教具有成本效益，為可執行之方案。未來可針對臺南市飲食狀況及調整食物之製備，進行小區域長者實際之介入評估研究，評量推行社區介入之可行性以及收集實證效益，以確定質地調整飲食是否能在減少吞嚥困難長者嗆咳的情況下，協助長者攝取足夠的營養，並降低吸入性肺炎及死亡之發生率。若本土化之介入研究成效卓著，則可透過實證基礎，發展相關衛教資源，造福更多長者。

Study Purpose The population aged 65 or above is higher than 14% in Tainan City, herald its progression to a society with the characteristic of aging. To promote the health of community-dwelling elders and prevent frailty and sarcopenia among the aging population, a series of health promotion activities including the one targeting at dysphagia have been either implemented or planned by the health bureau of Tainan. On top of the health promotion projects, the nutrition status of the elder’s subjects plays a crucial role due to its close relationship between immunity, body strength, and fitness of the elders. However, one of the barriers precludes the elders from sufficient nutritional supply is dysphagia. Due to the aging process, the swallowing reflex attenuates, the strength of the muscular system associated with the swallowing movement weakened, and the function of masticatory degrades. The situation of dysphagia is further associated with a high risk of aspiration, aspiration pneumonia, and death among the affected elders. The malnutrient status further aggravates this risk. Such an unfavorable situation attributable to dysphagia and chocking can be improved by the measures of modifying the texture of food. In spite of many studies reporting the efficacy of texture-modified food in reducing the risk of aspiration and pneumonia among the special group of elders such as stroke patients, parkinsonism, and institutionalized elders, few have been said on the provision of the intervention programs to the general aging population. The cost-effectiveness of such a population-based intervention programme has barely been addressed up to date. Given the aging society of Tainan mentioned above and the expected threats from dysphagia are to be managed in the near future, the effectiveness and cost-effectiveness of the diet-texture-modifying education programme provided at the population level are urgently needed. Aims This practicum study thus aimed at first evaluate the disease burden of chocking and dysphagia among four Tainan communities. The second aim is to assess the potential effectiveness of the diet-texture-modifying intervention through systematic literature review and meta-analysis. Finally, a cost-effectiveness study on the proposed intervention programme was assessed. Method There are three parts contained in this practicum study. (1)Need assessment for chocking and dysphagia Focusing on the community-dwelling elders aged 65 years and above, this practicum conducted a survey in four districts of Xinying, Yanshui, Syuejia, and Yujing in Tainan from July to December 2019. Structured questionnaires were provided to attendants through the public health centers and clinics to investigate dysphagia or choking through self-assessment. The difference between districts and the associations of dysphagia between demographic characteristics and comorbidities were assessed by using logistic regression model. (2)The potential effectiveness of diet-texture-modifying intervention The effectiveness of the diet-texture-modifying intervention was assessed through a systematic literature review. The effectiveness reported by the literature was summarized and integrated by using a Bayesian logistic regression model with a random effect to taking into account the heterogeneities across studies. (3)Cost-effectiveness analysis for the provision of community-based diet-texture-modifying intervention Based on (1) and (2), a cost-effectiveness analysis for a community-based diet-texture-modifying intervention was assessed with the consideration of the incidence and mortality of pneumonia in Taiwan and the infrastructure of the health care system with the National Health Insurance underpinning. Result There were 1,083 elders who attended the survey for chocking and dysphagia. The average age was 75.3 years old, and the majority of the respondents were women, accounting for 61.4% of all attendants. There were 122 attendants (11.3%) who suffered from choking. The highest frequency of choking among the attended elders was 21 per week. The average frequency of choking was 0.36 per week. Focusing on subjects with at least one chocking event, the corresponding figure was 3.22 per week. Regarding the issue of dysphagia, a total of 170 attendants (15.7%) reported such an issue. The evaluation of the association between the demographic characteristics and comorbidities and chocking showed that age is the only significant determinant (OR=1.063 95% CI 1.033-1.093). The frequency of chocking was significantly affected by gender (RR=0.79，95% CI 0.64-0.96) and age (RR=1.10，95% CI 1.08-1.11) after considering relevant factors including polypharmacy, hypertension, and diabetes. By using the information abstracted from systematic literature review in conjunction with meta-analysis, the diet-texture-modifying intervention results in reducing the risk of choking/aspiration pneumonia by 28% (95% CI: 14-41%; OR=0.72, 95%CI 0.59-0.86). Based on this information, the cost-effectiveness analysis for the population-based diet-texture-modifying intervention showed the efficacy in reducing pneumonia cases (5,979 vs 6,336) and deaths (649 vs 714) compared with ordinary health education. Compared with ordinary health education, the incremental cost of the diet-texture-modifying intervention was NTD 365.75 and the incremental effect was 0.006836 life-years, which gives the incremental cost-effectiveness ratio (ICER) of NTD 53976.08 per life-year gained. Conclusion The proportion of elders with dysphagia in Tainan was consistent with previous studies. Regarding the factors associated with the risk of choking and dysphagia, our results showed a significant association between age and gender with the adjustment of available information on comorbidities. The information on the confounding factors such as oral conditions, stroke, dementia, and diet can be incorporated in future studies. By using the demography of Tainan elders, this practicum thesis shows that a population-based diet-texture-modifying intervention can be a preventive approach to be considered according to the results of cost-effectiveness analysis. For further elucidating the effectiveness and cost-effectiveness of such a population-based preventive strategy for chocking and aspiration among the elders, a randomized controlled trial can be conducted in the district to collect empirical evidence before the implementation of a large scale service programme.