加護病房四種譫妄亞型於出加護病房三個月後認知軌跡之比較

Abstract

背景 譫妄及認知功能下降是加護病房病人常見併發症。本研究旨在探討譫妄發生與其不同型態，對出加護病房後三個月內認知功能變化軌跡之影響。 方法 本研究為次級資料分析，使用「加護病房出院後一年的生理活動功能恢復」研究計劃案之數據，研究期間為2018年8月至2020年10月，地點為北部某教學醫院之六個內科加護單位。譫妄於加護病房住院後14日內每日以CAM-ICU-7量表進行評估；認知功能則於出加護病房後48小時內、1個月及3個月以MMSE評估。依譫妄出現與變化情形，將個案分為四組型態：無譫妄、持續改善型、復發型（初步改善後48小時再次出現）、持續型（症狀持續或未改善達48小時以上），以比較不同型態下的認知功能變化軌跡。 結果 本研究共納入 289 位內科加護病房病患，依照譫妄型態分為四組（無譫妄、持續改善型、復發型、持續型）進行分析。結果顯示，在三個時間點（T1:出加護病房48小時內、T2:出院後一個月、T3:出院後三個月），無譫妄及持續改善型組別MMSE分數顯著高於復發型及持續型組別（p < .001）。尤其是復發型譫妄患者在三個月內幾乎沒有認知改善，顯示其認知功能受損最為嚴重。多項邏輯斯迴歸分析結果指出，首次譫妄發作的持續時間為最具統計意義的預測因子（χ² = 304.384, p < .001），年齡（p = .092）與加護病房住院天數（p = .065）呈邊緣顯著，顯示其與譫妄型態分類可能具有潛在關聯性。此外，GEE分析進一步指出，譫妄型態（Wald χ² = 22.406, p < .001）與時間（Wald χ² = 14.432, p < .001）皆顯著影響MMSE變化，日常生活功能與 MMSE 呈正相關（B = 0.073, p = .010），而入院時 SOFA 分數則與 MMSE 呈負相關（B = -0.660, p < .001），顯示較佳生活功能有助於認知恢復，病況越重則認知表現越差。死亡分析則發現，復發型與持續型組別具較高三個月內死亡風險（p < .001）。 結論 加護病房獲得性譫妄型態顯著影響患者出院後三個月內的認知功能變化。尤其是復發型及持續型譫妄患者的認知功能恢復有限且死亡風險較高，強調早期辨識及管理譫妄型態的重要性，並建議在臨床照護中納入針對高風險譫妄型態患者的認知功能追蹤及復健計畫。

Background Delirium and cognitive impairment are common complications among ICU patients. This study aims to explore how the presence and patterns of delirium affect the trajectories of cognitive function within three months following ICU discharge. Methodology This secondary analysis used data from the “Functional Improvement for ICU Survivors” cohort, conducted in six medical ICUs in Taipei from August 2018 to October 2020. Delirium was assessed daily using the CAM-ICU-7 during the first 14 ICU days. Cognitive function was evaluated by MMSE at ICU discharge within 48 hours, one month, and three months post-discharge. Patients were categorized into four delirium patterns—normal, continued resolution, recurrent (relapse ≥48 hours after initial resolution), and persistent (continuous or unresolved symptoms ≥48 hours). Cognitive trajectories were analyzed across these subgroups. Result This study included a total of 289 patients admitted to medical intensive care units (ICUs), classified into four delirium pattern groups (Normal, Continued Resolution, Recurrent, Persistent) for analysis. The results showed that at three time points (T1: ICU discharge within 48 hours, T2: one-month post-discharge, T3: three months post-discharge), the MMSE scores in the Normal and Continued Resolution groups were significantly higher than those in the Recurrent and Persistent groups (p < .001). Notably, patients with recurrent delirium exhibited minimal cognitive improvement over the three-month period, indicating the most severe cognitive impairment. Multinomial logistic regression identified first delirium duration as the most significant predictor of delirium pattern classification (χ² = 304.384, p < .001). Age (p = .092) and ICU length of stay (p = .065) showed marginal significance, suggesting potential associations. GEE analysis further revealed that both delirium pattern (Wald χ² = 22.406, p < .001) and time (Wald χ² = 14.432, p < .001) significantly affected MMSE scores. Baseline ADL was positively associated with MMSE (B = 0.073, p = .010), while SOFA score at admission showed a negative association (B = -0.660, p < .001), indicating that better functional status supported recovery, whereas greater illness severity predicted worse outcomes. Mortality analysis showed higher 3-month mortality risk in the recurrent and persistent delirium groups (p < .001). Conclusion ICU-acquired delirium patterns significantly impact cognitive changes within three months post-discharge. Specifically, patients with Recurrent and Persistent delirium exhibited limited cognitive recovery and a higher risk of mortality. These findings highlight the importance of early identification and management of delirium patterns, emphasizing the need to include cognitive monitoring and rehabilitation programs targeting high-risk delirium patterns in clinical care.