罹患失智症對老人接受居家或機構護理照護結果之影響

Effect of home or institutional health care on health outcomes in older people with dementia

10.6288/TJPH201736105074

黃敬淳(Ching-Chun Huang)；吳肖琪(Shiao-Chi Wu)

失智症 ； 照護結果 ； 居家照護 ； 機構照護 ； dementia ； health outcome ； home health care ； institutional heath care

台灣公共衛生雜誌

36卷1期（2017 / 02 / 15）

21 - 30

繁體中文

目標：失智者會出現問題行為等徵狀，使其照顧比起一般人困難。國外研究發現失智者與非失智者在照護結果上存在差異，國內目前尚未有全國性研究探討失智者與非失智者在居家或機構護理之照護結果是否存在差異，故本研究目的為探討罹患失智症對居家或機構照護結果之影響。方法：採用回溯性世代研究，研究對象為2008年至2012年間首次使用健保居家照護時已滿65歲以上之新個案，依照護場域進行分層，並使用邏輯斯迴歸納入性別、年齡、共病症程度計算傾向分數後，以1：1方式進行失智組和參考組之配對。追蹤個案於收案日後一年內呼吸道感染、泌尿道感染、壓瘡、骨折及髖部骨折發生情形，並以Stepwise Cox proportional hazardmodel探討失智症與否對居家或機構照護結果之影響。結果：居家照護中失智組呼吸道感染（HR=1.11）、壓瘡（HR=1.43）風險顯著較高。結論：居家照護失智者呼吸道感染及壓瘡風險顯著較高。建議衛生主管機關持續透過機構評鑑增進機構照護結果及提升民眾失智症照護素養，建議服務提供者加強失智症照護技巧、協助轉介長照資源、給予家庭照顧者照顧指導。

Objectives: Patients with dementia exhibit aggressive behavior, which makes it more difficult to care for them. Several studies have shown that there are differences in health outcomes between people with and without dementia; however, in Taiwan there has not been a national population-based study identifying whether or not health outcomes are different between people with and without dementia who receive home and institutional health care. Methods: The study adopted a retrospective cohort study design, and the subjects were elderly who used National Health Insurance Home Health Care for the first time between 2008 and 2012. Patients were stratified by care site and divided into two groups (dementia and non-dementia) using a propensity score with gender, age, and co-morbidity to match subjects. Each case was monitored from the day of entry until a respiratory tract infection, urinary tract infection, pressure ulcer, all fractures, or hip fracture occurred. Stepwise Cox proportional-hazards regression was used to analyze the effect of patients with dementia on health outcomes. Results: The dementia group receiving home health care had a higher risk for respiratory tract infections (AHR=1.11) and pressure ulcers (AHR=1.43) than the non-dementia group. Conclusions: Dementia patients are at a higher risk for respiratory tract infections and pressure ulcers than patients without dementia receiving home health care. Medical institutions should monitor health outcomes in the institutional setting and enhance the skills of family caregivers. Formal caregivers should strengthen the skills of dementia care, pass the long-term care information to patients who need it, and teach family caregivers the skills of caring for dementia patients.

1. Alzheimer's Society. Pressure ulcers (bed sores). Available at: https://www.alzheimers.org.uk/. Accessed September 20, 2016.
2. Alzheimer's Society. The later stages of dementia. Available at: https://www.alzheimers.org.uk/.Accessed September 20, 2016.
3. Alzheimer's Disease International. About dementia. Available at: ttp://www.alz.co.uk/about-dementia. Accessed November 7, 2015
4. WHO. Dementia. Available at http://www.whoint/mediacentre/factsheets/fs362/en/. Accessed December 16, 2015.
5. Albrecht, JS,McGregor, JC,Fromme, EK,Bearden, DT,Furuno, JP(2013).A nationwide analysis of antibiotic use in hospice care in the final week of life.J Pain Symptom Manage,46,483-90.
6. Baker, NL,Cook, MN,Arrighi, HM,Bullock, R(2011).Hip fracture risk and subsequent mortality among Alzheimer's disease patients in the United Kingdom, 1988-2007.Age Ageing,40,49-54.
7. Doupe, M,Brownell, M,St. John, P,Strang, DG,Chateau, D,Dik, N(2011).Nursing home adverse events: further insight into highest risk periods.J Am Med Dir Assoc,12,467-74.
8. Escott-Stump, S(2008).Nutrition and Diagnosis-Related Care.Philadelphia:Lippincott Williams & Wilkins.
9. Frank, C,Hodgetts, G,Puxty, J(1996).Safety and effcacy of physical restraints for the elderly.Can Fam Physician,42,2402-9.
10. Friedman, SM,Menzies, IB,Bukata, SV,Mendelson, DA,Kates, SL(2010).Dementia and hip fractures: development of a pathogenic framework for understanding and studying risk.Geriatr Orthop Surg Rehabil,1,52-62.
11. Frytak, JR,Henk, HJ,Zhao, Y,Bowman, L,Flynn, JA,Nelson, M(2008).Health service utilization among Alzheimer's disease patients: evidence from managed care.Alzheimers Dement,4,361-7.
12. Guo, Z,Wills, P,Viitanen, M,Fastbom, J,Winblad, B(1998).Cognitive impairment, drug use, and the risk of hip fracture in persons over 75 years old: a communitybased prospective study.Am J Epidemiol,148,887-92.
13. Hamers, JPH,Gulpers, MJM,Strik, W(2004).Use of physical restraints with cognitively impaired nursing home.J Adv Nurs,45,246-51.
14. Holmberg, SK(1997).A walking program for wanderers: volunteer training and development of anevening walker's group.Geriatr Nurs,18,160-5.
15. Huang, SW,Lin, JW,Liou, TH,Lin, HW(2015).Cohort study evaluating the risk of hip fracture among patients with dementia in Taiwan.Int J Geriatr Psychiatry,30,695-701.
16. Jalbert, JJ,Eaton, CB,Miller, SC,Lapane, KL(2010).Antipsychotic use and the risk of hip fracture among older adults afflicted with dementia.J Am Med Dir Assoc,11,120-7.
17. Logemann, J,Kahrilas, P,Kovara, M,Vakil, N(1989).The benefit of head rotation on pharyngoesophageal dysphagia.Arch Phys Med Rehabil,70,767-71.
18. Luk, JK,Chan, KY(2014).Preventing aspiration pneumonia in older people: do we have the 'know-how'?.Hong Kong Med J,20,421-7.
19. Magaziner, J,Zimmerman, S,Gruber-Baldini, AL(2005).Mortality and adverse health events in newly admitted nursing home residents with and without dementia.J Am Geriatr Soc,53,1858-66.
20. Margolis, DJ,Knauss, J,Bilker, W,Baumgarten, M(2003).Medical conditions as risk factors for pressure ulcers in an outpatient setting.Age Ageing,32,259-64.
21. McCloskey, RM(2004).Caring for patients with dementia in the acute care environment.Geriatr Nurs,25,139-44.
22. Moïse, P,Schwarzinger, M,Um, M(2004).Dementia Care in 9 OECD Countries: A Compara-Tive Analysis.OECD Health Working Papers,13
23. Nakrem, S,Vinsnes, AG,Harkless, GE,Paulsen, B,Seim, A(2009).Nursing sensitive quality indicators for nursing home care: international review of literature, policy and practice.Int J Nurs Stud,46,848-57.
24. Silvestre, JH,Bowers, BJ,Gaard, S(2015).Improving the quality of long-term care.J Nurs Regul,6,52-6.
25. Taylor, DH, Jr,Fillenbaum, GG,Ezell, ME(2002).The accuracy of Medicare claims data in identifying Alzheimer's disease.J Clin Epidemiol,55,929-37.
26. Tolppanen, AM,Lavikainen, P,Soininen, H,Hartikainen, S(2013).Incident hip fractures among community dwelling persons with Alzheimer's disease in a Finnish nationwide register-based cohort.PLoS One,8,e59124.
27. Toot, S,Devine, M,Akporobaro, A,Orrell, M(2013).Causes of hospital admission for people with dementia: a sys temat ic review and meta-analysis.J Am Med Dir Assoc,14,463-70.
28. Tuppin, P,Kusnik-Joinville, O,Weill, A,Ricordeau, P,Allemand, H(2009).Primary health care use and reasons for hospital admissions in dementia patients in France: database study for 2007.Dement Geriatr Cogn Disord,28,225-32.
29. Wang, HK,Hung, CM,Lin, SH(2014).Increased risk of hip fractures in patients with dementia-a nationwide population-based study.BMC Neurol,14,175.
30. Wang, WW,Moyie, W(2005).Physical restraint use on people with dementia-a review of the literature.Aust J Adv Nurs,22,46-52.
31. Weller, I,Schatzker, J(2004).Hip fractures and Alzheimer's disease in elderly institutionalized Canadians.Ann Epidemiol,14,319-24.
32. Wullianallur, R,Viju, R(2014).Big data analytics in healthcare: promise and potential.Health Inf Sci Syst,2
33. 宋怡慧(2011)。台南=Tainan，國立成功大學公共衛生研究所=Department of Public Health, National Cheng Kung University。
34. 施至遠、陳人豪(2008)。老年人吞嚥障礙之評估與處置。長期照護雜誌，12，337-46。
35. 高潔純、林麗嬋(2005)。從安全概念探討失智者遊走行為的處置。長期照護雜誌，9，223-32。
36. 張淑卿(2013)。台北=Taipei，國立陽明大學衛生福利研究所=Institute of Health and Welfare Policy, National Yang-Ming University。
37. 許貴英(2014)。台北=Taipei，國立台北護理健康大學護理研究所=Department of Health Care Management, National Taipei University of Nursing and Health Sciences。
38. 陳欣(2007)。台北=Taipei，國立陽明大學衛生福利所=Institute of Health and Welfare Policy, National Yang-Ming University。
39. 陳麗華(2013)。失智症整合照顧。社區發展季刊，141，343-53。
40. 黃惠璣、林季宜、王寶英(2007)。老人或失智老人跌倒危險因子之初探。台灣老人保健學刊，3，1-13。
41. 廖英茵(2008)。長期照護個案之吞嚥困難營養照護。長期照護雜誌，12，361-75。
42. 顏慕庸、顏兆熊(2011)。老人之肺炎。當代醫學，38，87-94。

1. 曾煥裕、石泱(2018)。失智老人及其照顧者使用社區式服務影響因素之研究。社會發展研究學刊，21，34-70。