嚴重精神疾病住院患者之代謝症候群與死亡之相關因素探討與護理應用

Abstract

研究背景：病人罹患嚴重精神疾患，例如思覺失調症或雙相情感障礙症，因疾病症狀、治療藥物、飲食或生活型態等多重問題，肥胖與代謝症候群之風險增高，在精神科的急性住院治療中，醫護重心可能多在精神症狀的診治照護，病人身體症狀與生理疾病，例如代謝症候群相關因素之評估與照護，是否易被忽略是值得探討的議題。真實世界的病歷除記載病人病況，也完好保存病人接受之評估與治療，透過長期之醫護紀錄資料了解住院嚴重精神病人之代謝症候群情況，以及是否與用藥、醫護照護措施、疾病醫療使用及後續存活有關係等，將能有助於提升嚴重精神疾病病人整體照護品質，包含精神病症狀控制與治療，以及代謝症候群症狀之評估與照護。 研究目的：本研究旨在了解某醫學中心13年（2007至2019年）中，曾在精神科急性病房住院的嚴重精神疾患病人，其代謝症候群風險與相關影響因子，並檢視其後續死亡之風險。 研究方法：本研究採用回溯性世代研究設計，使用臺大醫療體系醫療整合資料庫（Integrated Medical Database, National Taiwan University Hospital）（NTUH-iMD），利用ICD-9-CM與ICD-10-CM診斷碼篩選並蒐集2007年1月1日至2019年12月31日間患有嚴重精神疾病且曾在精神科急性病房住院之病人納為研究樣本，研究期間自2007年1月1日至2019年12月31日，收集住院相關資料，以及出院後資料及後續死亡情形，運用迴歸分析（regression analysis）探討研究對象之人口學特徵、常見之護理健康問題與措施以及相關造成代謝症候群風險之重要相關因子，也利用存活分析探討此樣本族群之死亡及相關危險因素。 結果：本研究納入13年間3342位曾入住精神科急性病房之嚴重精神疾患病人，依據衛生福利部國民健康署對於代謝症候群的指引定義，符合代謝症候群者為28.85%，多元羅吉斯迴歸分析發現研究對象發生代謝症候群相關之因子，包含年齡越大（adjusted odds ratio, [aOR]=1.012，95% confidence interval, [CI]=1.007-1.018）、住院次數越多（aOR=1.102，95% CI=1.057-1.148）、有慢性病史（aOR=2.773，95% CI=2.280-3.372）、特殊處置比例越高（aOR=1.478，95% CI=1.034-2.115）、有服用第二代抗精神病藥物之神經多重受體作用劑類（aOR=1.306，95% CI=1.085-1.571）或是服用鋰鹽者（aOR=1.429，95% CI=1.135-1.801）、有「個人因應能力失調」（aOR=1.746，95% CI=1.424-2.140）或「營養狀況多於身體需要」（aOR=5.085，95% CI=3.544-7.298）之護理問題者更傾向發生代謝症候群，整體模型之曲線下面積為0.6972。另外，追蹤此一嚴重精神疾病急性住院患者之後續死亡狀況，發現共414名個案（12.38%）死亡。死因前三名依序為蓄意自我傷害（自殺）、惡性腫瘤以及高血壓性疾病除外的心臟疾病。存活分析發現研究對象死亡之相關因子，包含年齡越大（adjusted hazard ratio, [aHR]=1.051，95% CI=1.044-1.057）、住院次數越少（aHR=0.890，95% CI=0.836-0.948）、特殊處置比例越高（aHR=1.800，95% CI=1.218-2.659）、有服用第一代抗精神病藥物（aHR=1.337，95% CI=1.092-1.636）更傾向發生死亡情形，男性較女性更傾向發生死亡（aHR=1.656，95% CI=1.363-2.011），但有服用鋰鹽者（aHR=0.537，95% CI=0.363-0.794）較不易發生死亡事件。 結論：嚴重精神疾患病人於急性住院期間，須強化對代謝症候群及相關危險因子的評估與處置，且針對後續重要死因，例如自殺、腫瘤及心臟疾病，提供生理及心理方面的全面性評估、強化自殺防範措施、審慎考量相關精神科藥物之使用、及早發現病人潛在問題與需求及適時提供資源與協助，以降低其代謝症候群及死亡的風險。

Introduction: Patients with severe mental illness (SMI) including schizophrenia and bipolar disorder appear to have an elevated risk of obesity due to the symptoms, medications, diet or lifestyles. There is also a close association between obesity and metabolic syndrome (MetS). However, in the acute inpatient treatment of psychiatry, more focus has been given on treating psychotic symptoms rather than physical problems. Physical and physiological illnesses such as the assessment and care related to MetS in patients with SMI are easily overlooked. Real-world medical records not only record the patient's medical condition, but also well preserve the assessment and treatment received by the patients. Understanding the metabolic syndrome of hospitalized patients with severe mental illness through long-term medical record data, and whether it is related to medication, medical and nursing care, and subsequent survival, etc., will help to improve the overall quality of care for patients with SMIs, including the control and treatment of psychotic symptoms, as well as the assessment and care of MetS. Objective: The purpose of this study was to investigate the related risk factors and common nursing assessed health problems for MetS in patients with SMI who had been hospitalized in the acute psychiatric wards in the medical center during the last 13 years (2007-2019). Methods: This retrospective cohort study was based on the Integrated Medical Database of National Taiwan University Hospital. Patients with the diagnosis of SMI (ICD-9-CM 295, 296, 297, 298, 301, or ICD-10-CM F20-25, F28-31) and had been hospitalized in the acute psychiatric wards from January 1, 2007 to December 31, 2019 were recruited as the study sample. Regression analyses were applied to determine the demographic characteristics, comorbidifty, patients’ health problems assessed by nurses, and other relevant factors associated with the risk of MetS. The main outcomes were the risk of MetS and death. Results: From 2007 to 2019, 3342 patients who had been hospitalized in the acute psychiatric wards were included. According to the definition of metabolic syndrome by Health Promotion Administration, Ministry of Health and Welfare, the prevalence of MetS was 28.85%. Factors associated with MetS in the multivariate logistic regression included age (adusted Odds Ratio [aOR]=1.012, 95% Confidence Interval [CI]=1.007-1.018), frequency of hospitalization (aOR=1.102, 95% CI=1.057-1.148), comorbidities of chronic disease (aOR=2.773, 95% CI=2.280-3.372), inpatient special care rate (aOR=1.478, 95%CI=1.034-2.115), the use of multiple-acting-receptor targeted antipsychotics, one of the second generation antipsychotics, (aOR=1.306, 95% CI=1.085-1.571), the use of lithium (aOR=1.429, 95% CI=1.135-1.801), nursing diagnosis of ineffective individual coping (aOR=1.746, 95% CI=1.424-2.140) and nursing diagnosis of excessive nutritional status (aOR=5.085, 95% CI=3.544-7.298). The area under curve of the final model was 0.6972. Additionally, 414 deaths (12.38%) occurred in patients with SMI in this stduy. The most common causes of death in the study subjects were intentional self-harm (suicide), malignant tumors and non-hypertensive heart diseases. Associated factors for death in the multivariate Cox regression included age (adjusted hazard ratio [aHR]=1.051, 95% CI=1.044-1.057), the use of inpatient special care (aHR=1.800, 95% CI=1.218-2.659), frequency of hospitalization (aHR=0.890, 95% CI=0.836-0.948), being male (aHR=1.656, 95% CI=1.363-2.011), the use of first generation antipsychotics (aHR=1.337, 95% CI=1.092-1.636). At the same time, the use of lithium (aHR=0.537, 95% CI=0.363-0.794) was negatively associated with the occurance of death. Conclusions: For patients with SMI who have risk factors for metabolic syndrome or death, health care providers could give a more comprehensive assessment of the physical and psychological problems, strengthen the intervention of suicide prevention and consider comprehensively in providing the antipsychotics during acute hospitalization. To reduce the risk of MetS and mortality, it is crucial to identify patients’ potential problems and needs promptly and provide adequate assistance and special care.