老年病患出院後影響功能恢復之相關因素探討

Abstract

研究背景與目的:台灣65歲以上人口約佔總人口的14%，已邁入「高齡社會」，老化速度為全球第二，預計在2026年，台灣老年人口將超過20％。隨著人口結構老化，老年失能人口逐年增加，推估至2032年，老年失能人數將高達95萬人。而過去的研究紛紛指出高齡患者特別容易因急性病症或住院導致日常生活功能的下降，且相較於年輕患者，失能的老年患者容易在功能恢復後經歷再度失能。因此本研究針對因急性病症出院的高齡患者，探討其出院後的日常生活功能恢復情形，希望能夠找出影響高齡患者功能恢復的影響因素。 研究方法:本研究為單一機構、前瞻性的世代研究。研究對象為2018年4月至11月12日至台大醫院老年醫學病房出院之患者，符合年齡65歲(含)以上的非機構住民，並排除住院期間死亡或病危自動出院患者，總共收案131人。本研究的依變項為日常生活功能恢復，其定義為簡式巴氏量表與出院時相比增加2分。周全性評估和日常生活功能評估在住院和出院時執行。出院後日常生活功能評估在出院後第30天、90天及180天進行電話追蹤。本研究探討自變項(年齡、共病症、身體質量指數、臨床衰弱分級、出院時簡式巴氏量總分和出院後執行身體活動)與患者出院後日常生活恢復是否相關。 研究結果:本研究高齡患者的出院後日常功能恢復率約36%，多數患者在出院後第30天達到功能恢復，其中大於80歲的患者僅佔2成。功能恢復比率在出院後90天最高，人數總共51人，佔總人數38.93%。多變項分析顯示出院後有執行身體活動的患者，相較於未執行身體活動者，日常功能恢復的機會為9.68倍(OR 9.68，95% CI 2.48-37.79，p=0.001)，達統計上顯著。針對出院時功能較差的患者(出院時簡式巴氏量表總分<12 )進行分析，出院後執行身體活動的患者，出院後第30天、出院後第90天以及出院後第180天，其功能恢復的機會分別為5.79倍(95% CI 2.05-16.32, p=0.0009)、6.59倍( 95% CI 2.25-19.34, p=0.0006)和8.75倍( 95% CI 2.78-27.47, p=0.0002)，也就是說，出院時功能較差的患者，出院後執行身體活動為功能恢復的有利因子，且該變項隨時間演進，影響力更為顯著。此外，出院時身體質量指數愈高，出院後第30天日常生活功能的恢復機會較高(OR 1.13，95% CI 1.00-1.27，p=0.049)。而住院前臨床衰弱分級1-4級的患者相較臨床衰弱分級5-9級的患者，在出院後第180天有較高的日常生活功能恢復機會(OR 2.06，95% CI 0.63-6.72，p=0.002)。最後，出乎意料的是，出院時巴氏量表總分愈高的患者，日常生活功能的恢復機會較低，但未達統計上差異。 結論:高齡患者出院的30天內為功能恢復的重要時期，然而年齡大於80歲患者的功能恢復可能較慢，宜持續追踨至出院後第90天。身體質量指數愈高以及臨床衰弱分級較低可能為出院後功能恢復有利因子，因此建議在住院時常規性監測患者的營養情形，身體質量指數較低的患者建議積極介入治療。出院後執行身體活動為出院後日常生活功能恢復的重要因子，建議應常規衛教患者出院後如何執行身體活動，尤其是出院時功能較差的患者，應強調出院後執行身體活動的重要性，建議出院後身體活動應持續至少到出院後6個月。

Backgrounds:Taiwan's population ageing is the second fastest in the world. Taiwan has been an “aged society” country and will become a super-aged society where at least 20 percent of the population are 65 or older by year 2026. With the population ageing, by 2032, it is estimated that at least night hundred and fifty thousand individuals live with one or more disabling conditions. Disability is thought to arise whenever older adults are hospitalized . Factors contributing to recovery were not clear. Therefore, the aim of this study was to investigate factors predicting elder patients’ functional recovery after being discharged from a geriatric ward in a medical center in Taiwan. Methods: This study was an observational prospective cohort study. We studied 131 patients, who were ≥65 years and discharged from a geriatric ward of the National Taiwan University Hospital between April 11,2018 and November 12, 2018. Comprehensive evaluations were conducted during older adults’ hospital stay, including demographic, nutrition status, fall history, comorbidities, delirium history, clinical frailty scale, length of stay and activities of daily living (ADL) function, evaluated by the Barthel Index (BI)(Collin et al.,1988). ADL function was assessed at discharge, 30 days after discharge, 90 days after discharge, and 180 days after discharge. Levels of physical activities were also collected during follow-up. The main outcome was the recovery of ADL function, defined as at least 2 points improvement in the Barthel Index (BI) compared to discharge. Logistic regressions were used to predict function recovery at each follow-up time point and generalized estimating equation was used to identify possible factors associated function recovery over time. Results: A total of 51 patients (38.93%) experienced functional recovery during study period; a majority of these recovered within 30 days after discharge and maintained their function. In multivariable analysis, patients with physical activity after discharge (OR 9.68, 95% CI 2.48-37.79, p=0.001), patients with higher body mass index (OR 1.13，95% CI 1.00-1.27，p=0.049) and those without frailty at baseline (OR 2.06，95% CI 0.63-6.72，p=0.002) were more likely to improve their functions. Besides, the effects of physical activities after discharge on functional recovery were stronger among patients with poorer BI (BI at discharge below 12); as the time goes, the effects became stronger with better chance of function recovery (at 30 days after discharge, OR 5.79, 95% CI 2.05-16.32, p=0.0009; at 90 days after discharge, OR 6.593, 95% CI 2.25-19.34, p=0.0006; at 180 days after discharge, OR 8.75, 95% CI 2.78-27.47, p=0.0002). Conclusions: Physical activity after discharge, higher body mass index and no frailty were predictive factors of function recovery. The results suggested that body mass index should be monitored at routine among elderly hospitalized patients, and for those with poor nutrition status, interventions and education are recommended before discharge. In addition, physical activity after discharge has shown to be a strong effect to functional recovery and the effects were stronger among patients with poorer BI; as the time goes, the effects became stronger with better chance of functional recovery. Emphasizing the importance and how to perform physical activity to patients and their families after discharge, especially within 30 days of discharge, should be crucial components in patients’ discharge plans.