台灣老年醫學暨老年學雜誌第十卷 第三期 Taiwan Geriatrics & Gerontology Vol. 10 No. 3 民國 104 年 8 月 Aug, 2015 目錄 CONTENTS 綜論 (Review Article) New Oral Anticoagulants in the Elderly... 135 Meng-Chen Wu, Ding-Cheng Chan 新一代口服抗凝血劑在老年人之使用原則 A Preliminary Study on the Future Development of Physician Manpower for Elderly Care... 146 Shiao-Chi Wu, Shin Chen 老年照護醫師人力的未來發展 原著 (Original Article) Post-acute Care Improves Daily Activity Functions of Stroke Patients: An Effectiveness Analysis... 159 Hong-Hsi Hsien, Wen-Chin Liou, Yi-Hua Yang 有效提升中風患者的日常生活功能 - 急性後期照護之成效分析 Prevalence and Associated Risk Factors of Metabolic Syndrome in Old People Living in a Rural Community... 172 Chun-Min Wang, Chin-Sung Chang, Yin-Fan Chang, Ping-Yen Liu, Ching-Ju Chiu, Meng-Tzu Hou, Chuan-Yu Chen, Hsin-Chuan Wu, Chih-Hsing Wu 某鄉村社區老年居民代謝症候群盛行率及相關危險因子之探討
病例報告 (Case Report) A Case Report of Malignant Paroxysmal Positional Vertigo Caused by Bow-Hunter Syndrome... 191 Jiann-Jy Chen, Dem-Lion Chen, Chiao-Jung Lin 持弓獵人症候群造成惡性陣發性姿態性眩暈症 - 個案報告 通訊教育試題
綜論 Vol.10 No.3 吳孟真 Taiwan Geriatr Gerontol 1,2 吳孟真 1,3,4 詹鼎正 摘要 近來新一代口服抗凝血劑陸續上市, 使得臨床醫師在非瓣膜性心臟病的患者身上, 有更多種藥物來降低其中風風險, 但是要如何選擇適當口服抗凝血劑無疑是一項新的挑戰, 尤其老年患者往往有較多的共病症及器官衰竭, 更加重了用藥的複雜性 本篇將介紹各種新一代口服抗凝血劑的特性, 以及其在老年人身上的使用原則 ( 臺灣老年醫學暨老年學雜誌 2015;10(3):135-145) 關鍵詞 : 新型口服抗凝血劑 老年人 心房顫動 中風 1 台大醫院老年醫學部 2 神經部 3 台大金山分院 4 內科部通訊作者 : 吳孟真通訊處 : 台北市常德街 1 號 ( 台大醫院老年醫學部 ) 電話 :0963-225-210 E-mail: rebeccawu1001@gmail.com 135
[Review Article] New Oral Anticoagulants in the Elderly Meng-Chen Wu 1,2, Ding-Cheng Chan 1,3,4 Abstract The recent launch of new oral anticoagulants provides more choices for clinicians to reduce the risk of stroke in patients with non-valvular atrial fibrillation. However, a great challenge is how to choice the most appropriate medication for patients, especially geriatric patients more vunlerable to comorbidity and organ failure that tend to increase the complexity of prescribing medication. The paper accordingly introduce the features of the new oral anticoagulants and the principle for their uses in the elderly. (Taiwan Geriatr Gerontol 2015; 10(3): 135-145) Key words: new oral anticoagulant, elderly, atrial fibrillation, stroke 1 Geriatrics and Gerontology, National Taiwan University Hospital (NTUH); 2 Neurology, National Taiwan University Hospital (NTUH); 3 National Taiwan University Hostpial, Jin-Shan Branch; 4 Internal medicine, National Taiwan University Hospital (NTUH) Correspondence to: Meng-Chen Wu No. 1, Changde St., Zhongzheng Dist., Taipei City 10048, Taiwan (R.O.C.) (Geriatrics and Gerontology, National Taiwan University Hospital) Tel: 0963-225-210 E-mail: rebeccawu1001@gmail.com 145
綜論 臺灣老誌老年照護醫師人力的未來發展第 10 卷第 3 期 吳肖琪陳欣 摘要 未來十年台灣面對人口老化 全民健康保險收入減少的雙重壓力下, 衛生福利部勢必將從以論量為主的支付制度, 朝論診斷關聯群 (Diagnostic Related Groups, DRGs) 論價值 包裹式 論質或論人支付制度改革做改變 隨著人口的老化, 對於老年照護醫師人力的需求會大幅增加, 除了小兒科等少數科外, 各專科醫師都要有提供老年照護的能力 ; 住院改成前瞻性支付, 會使醫院住院日數減短進而減床, 有更多的醫師人力投入門診 社區及居家式照護 建議老年照護醫師人力訓練應朝向強化醫師老年醫學照護的能力 引導病人朝活躍老化 健康的生活型態 及預防跌倒與失能等努力 ; 基層醫師亦需具備常見急性後期老年病人之照護能力 ; 另外, 醫院須及早強化住院部門整合式照護的能力, 以因應支付制度的改變 ( 臺灣老年醫學暨老年學雜誌 2015;10(3):146-158) 關鍵詞 : 老人 醫師人力 支付制度 整合式照護 急性後期照護 國立陽明大學醫學院衛生福利研究所通訊作者 : 吳肖琪通訊處 : 台北市北投區立農街二段 155 號 ( 國立陽明大學醫學院衛生福利研究所 ) 電話 :(886) 2-28267052 傳真 :(886) 2-28204735 E-mail: scwu@ym.edu.tw 146
[Review Article] A Preliminary Study on the Future Development of Physician Manpower for Elderly Care Shiao-Chi Wu, Shin Chen Abstract Under the double pressure of its rapidly aging population and the declining revenues of its National Health Insurance, the Ministry of Health and Welfare in Taiwan may have to shift the NHI payment system from the current fee-for-service basis to DRG (diagnosis-related group) payment, bundled payment, value based payment, pay for performance or capitation payment so as to tackle the upcoming challenges in the next decade. The number of physicians involved in elderly care will rise along with the aging population. Most physicians should therefore be prepared and qualified for geriatric care. Implementing a prospective payment system (PPS) to reimburse hospitals for inpatient care should help shorten length of stay, thereby leading to a decrease in the number of beds in hospitals. More physicians will then be able to participate in outpatient, home, and community care. Medical education should emphasis more on geriatric care and the promotion of active aging, healthy lifestyle, and prevention of fall and disability. General practitioner should also be capable of providing post-acute care services for elderly patients. Furthermore, hospitals need to strengthen their integrated care capacity to cope with the change in payment system. (Taiwan Geriatr Gerontol 2015; 10(3): 146-158) Key words: elderly, physician manpower, payment system, integrated care, post-acute care Institute of Public Health, National Yang-Ming University Correspondence to: Shiao-Chi Wu No. 155, Sec. 2, Linong Street, Taipei, 112 Taiwan (ROC) (Institute of Public Health, National Yang-Ming University) Tel: (886) 2-28267052 Fax: (886) 2-28204735 E-mail: scwu@ym.edu.tw 158
原著 Vol.10 No.3 冼鴻曦 Taiwan Geriatr Gerontol 冼鴻曦劉文欽楊儀華 摘要 探討急性後期照護對於腦中風患者日常生活功能改善的程度, 並分析影響日常生活功能進步差異的因素 收錄本院腦中風急性後期照護結案人數共 107 人為研究對象, 以前瞻性世代研究法登錄每位病人的評估量表, 比較於收案與結案時量表的分數差異進行統計分析 比較收案與結案時巴氏量表分數的差異發現 86 人 (80.4%) 日常生活功能有進步, 分數不變或退步者有 21 人 (19.6%) 以單因子變異數分析發現日常生活功能的進步程度與腦中風的分類 ( 梗塞或出血 ) 迷你營養評估等級, 語言功能評估等級, 以及是否有鼻胃管等變項有顯著的差異 以相關性分析發現巴氏量表的分數差異與住院時的吞嚥功能初評分數呈正相關 以多變項迴歸分析發現對日常生活功能的進步具有顯著預測力者有腦中風的類別 營養障礙的等級與吞嚥功能的初評分數等三個變項 腦中風急性後期照護試辦計劃的經驗顯示, 腦中風發病後黃金治療期間的積極復健可降低病患的失能程度及減輕家庭與社會的負擔 建議急性後期照護未來可擴大服務對象包括其他不同疾病合併有功能障礙的患者, 使得急性後期照護的成功治療模式能夠擴展延伸, 更多的患者能因此而受惠 ( 臺灣老年醫學暨老年學雜誌 2015;10(3):159-171) 關鍵詞 : 腦中風 急性後期照護 日常生活功能 天主教聖功醫療財團法人聖功醫院通訊作者 : 劉文欽通訊處 :802 高雄市苓雅區建國一路 352 號 ( 天主教聖功醫療財團法人聖功醫院 ) 電話 :(886) 7-2238153 ext. 2503 傳真 :(886) 7-2234407 E-mail: wenchin.liou@msa.hinet.net 159
[Original Article] Post-acute Care Improves Daily Activity Functions of Stroke Patients: An Effectiveness Analysis Hong-Hsi Hsien, Wen-Chin Liou, Yi-Hua Yang Abstract Objective: To assess the effectiveness of post-acute care on functional improvement of daily activities (ADL) for stroke patients. Methods: This prospective cohort study enrolled 107 cases of stroke from March 1, 2014 to June 30, 2015. ADL functional improvement was evaluated by examining the differences in the Barthel ADL index scores during the hospitalization of post-acute care. Data were analyzed using descriptive statistics (correlation and one way ANOVA) to examine the effects of patients characteristics on the probability of ADL improvement. Multiple linear regression was used to study the predictors of ADL improvement. Results: Of the 107 patients, 86 (80.4%) reported ADL improvement, 21 (19.6%) showed either no improvement or deterioration. The type of stroke, the use of nasogastric tube, the level of mini-nutritional assessment (MNA) and concise Chinese aphasia test score emerged from One way ANOVA to be significantly associated with the degree of ADL improvement. Correlation analysis found functional oral intake score (FOIS) positively correlated to ADL improvement. Multiple linear regression identified the type of stroke, the level of MNA and FOIS as the significant predictors of ADL functional improvement. Conclusion: The PAC program promoted functional recovery and decreased the severity of dependency for stroke patients. This program should be implemented to provide better care for patients suffering stroke or other diseases associated with disability. (Taiwan Geriatr Gerontol 2015; 10(3): 159-171) Key words: stroke, post-acute care, daily activity function St. Joseph Hospital Correspondence to: Wen-Chin Liou 352, Chien Kuo 1 st Road, Linya district, Kaohsiung 80288, Taiwan, R.O.C. (St. Joseph Hospital) Tel: (886) 7-2238153 ext. 2503 Fax: (886) 7-2234407 E-mail: wenchin.liou@msa.hinet.net 171
原著 臺灣老誌偏遠社區老人代謝症候群與危險因子第 10 卷第 3 期 1 王淳民 2 張秦松 2 張尹凡 吳幸娟 3 劉秉彥 8 吳至行 4 邱靜如 2,4,6 5 侯孟次 7 陳全裕 摘要 代謝症候群為第二型糖尿病 心血管疾病及整體死亡率的危險因子之一, 其盛行率隨著年齡增加而增高 目前台灣已經邁入高齡化社會, 因此代謝症候群的預防將是老人照護的一個重要議題 本研究之目的為評估老化鄉村社區的代謝症候群盛行率及相關危險因子, 以供未來臨床照護參考 2012 年於高雄市田寮區對老年居民進行全區隨機抽樣調查, 總計有 549 位 65 歲以上老年男女接受調查, 粗回覆率為 50% (549/1,098) 每位受檢者均經隔夜空腹抽血檢查生化指標並量測右上臂血壓值及接受測量腹部中線腰圍 以面對面的方式及結構式問卷調查個案基本資料 生活習慣 身體活動量 營養評估 認知功能及疾病史等 採用 2007 年國民健康署公佈標準判定代謝症候群, 最終以 527 位資料完整者進行統計分析 於 527 位老人中 ( 男性 273 人, 女性 254 人 ), 年齡平均 76.0±6.2 歲 (65 至 102 歲 ), 代謝症候群的盛行率為 46.7% ( 男性 36.6%, 女性 57.5%) 經過邏輯斯迴歸分析發現, 和代謝症候群顯著相關的危險因子包含女性 較高身體質量指數 有高尿酸血症以及較低的活動量 進一步將身體質量指數分為正常 過重 肥胖三組, 再度以邏輯斯迴歸分析發現, 和正常組比較起來, 過重組代謝症候群之勝算比為 4.577 (95% 信賴區間 2.868-7.305); 肥胖組之勝算比則為 8.092 (95% 信賴區間 4.625-14.156) 本研究發現老化鄉村社區之代謝症候群盛行率偏高 女性 高尿酸血症與身體活動量低皆為代謝症候群的危險因子之一, 尤其是身體質量指數對於代謝症候群的影響最為顯著 然而因肥胖矛盾的存在, 老人身體質量指數的控制標準則須更多研究探討 172
Vol.10 No.3 王淳民 Taiwan Geriatr Gerontol ( 臺灣老年醫學暨老年學雜誌 2015;10(3):172-190) 關鍵詞 : 老年人 代謝症候群 尿酸 身體活動量 1 國立成功大學醫學院醫學系 4 老年學研究所 6 行為醫學研究所 2 國立成功大學醫學院附設醫院家庭醫學部 3 內科部 5 國立陽明大學醫學院物理治療暨輔助科技學系 7 聖馬爾定醫院社區醫學部 8 中華醫事科技大學食品營養系通訊作者 : 吳至行通訊處 : 台南市勝利路 138 號 ( 國立成功大學醫學院附設醫院家庭醫學部 ) 電話 :(886) 6-2353535 轉 5200 傳真 :(886) 6-2754243 E-mail: paulo@mail.ncku.edu.tw 173
[Original Article] Prevalence and Associated Risk Factors of Metabolic Syndrome in Old People Living in a Rural Community Chun-Min Wang 1, Chin-Sung Chang 2, Yin-Fan Chang 2, Ping-Yen Liu 3, Ching-Ju Chiu 4, Meng-Tzu Hou 5, Chuan-Yu Chen 7, Hsin-Chuan Wu 8, Chih-Hsing Wu 2,4,6 Abstract Background/Purpose: Metabolic syndrome (MetS), increasing its prevalence with age, is one of the risk factors for type 2 diabetes mellitus, cardiovascular disease and all-cause mortality. As Taiwan is now an aged society, the prevention of metabolic syndrome becomes an important issue in health care. This study investigates the prevalence and associated risk factors of MetS in the elderly residents living in a rural community. Method: In 2012, the cross-sectional survey was conducted with whole district random sampling of 1,966 community-dwelling old people in Tian-Liao district, Kaohsiung city. The response rate was 50% (549/1098). A structurized questionnaires including basic characteristics, life style, medical history along with non-invasive assessment tool including International Physical Activity Questionnaires, mini-nutrition assessment and mini-mental status examination were interviewed face-to-face by well-trained staffs individually. Totally, 527 subjects (273 males, 254 females) with complete data were enrolled for final statistical analysis. Results: Of the 527 subjects (mean age=76.0±6.2 y/o, range=65-102 y/o), prevalence of MetS is 46.7% (male=33.6%, female=57.5%). The logistic regression model showed that female, higher body mass index (BMI), hyperuricemia, and lower physical activity were positive independent risk factors of MetS. After dividing subjects into normal BMI, overweight and obesity, the logistic regression analysis revealed that overweight (OR=4.577, 95%CI=2.868-7.305, p<0.001) and obesity (OR=8.092, 95%CI=4.625-14.156, p<0.001) were significant risk factor of MetS. Conclusions: The prevalence of MetS in old people living in this remote, rural community was relatively high. Female, low physical activity and hyperuricemia were risk 189
[Original Article] factors of MetS. BMI is the most predominant risk factor of MetS in this rural community. However, due to obesity paradox, further research and discussion were needed for setting the goal of BMI control in old people. (Taiwan Geriatr Gerontol 2015; 10(3): 172-190) Key words: Old people, metabolic syndrome, uric acid, physical activity 1 Department of Medicine, 4 Institute of Gerontology & 6 Institute of Behavioral Medicine, College of Medicine, National Cheng Kung University, Tainan; 2 Department of Family Medicine, 3 Department of Internal Medicine, Division of Cardiology, National Cheng Kung University Hospital, Tainan; 5 Department of Physical Therapy and Assistive Technology, National Yang-Ming University, Taipei; 7 Department of Community Medicine, St. Martin De Poress Hospital, Chiayi; 8 Department of Food Nutrition, Chung Hwa University Medical Technology, Tainan Correspondence to: Chih-Hsing Wu No. 138, Sheng Li Road, Tainan, Taiwan (Department of Family Medicine, National Cheng Kung University Hospital) Tel: (886) 6-2353535 ext. 5200 Fax: (886) 6-2754243 E-mail: paulo@mail.ncku.edu.tw 190
病例報告 Vol.10 No.3 陳建志 Taiwan Geriatr Gerontol 1 陳建志 2 陳登郎 3 林巧容 摘要 一 88 歲老年男性, 屢屢因頭向右轉時引發陣發性的眩暈長達 9 個月, 起初臆斷為良性陣發性姿態性眩暈症, 卻無法為耳石復位術所緩解 彩色動脈超音波及腦部磁振造影證實是右側椎動脈嚴重狹窄, 當頭向右轉時會使基底動脈的血流減少, 並發現左側橋腦缺血性病變 這種狀況稱之為持弓獵人症候群, 在轉頭時會引起椎基底動脈的血流減少, 避免轉頭可減少病症的復發 當我們在診治老年患者時, 如果陣發性姿態性眩暈症對於耳石復位術的治療反應不好時, 就需要密切的探查, 考慮是否為小腦橋腦角或內聽道的腫瘤, 或是持弓獵人症候群所造成暫時性的前庭神經功能不良 ( 臺灣老年醫學暨老年學雜誌 2015;10(3):191-196) 關鍵詞 : 良性陣發性姿態性眩暈症 惡性陣發性姿態性眩暈症 持弓獵人症候群 椎動脈狹窄 椎基底動脈循環不全 1 元景耳鼻喉科神經科診所 2 吉豐耳鼻喉科診所 3 佛教慈濟醫療財團法人台中慈濟醫院家庭醫學科通訊作者 : 林巧容通訊處 :42743 台中市潭子區豐興路 88 號 ( 佛教慈濟醫療財團法人台中慈濟醫院家庭醫學科 ) 電話 :(886) 4-22052121 傳真 :(886) 4-22344055 E-mail: jiannjy@yahoo.com.tw 191
[Case Report] A Case Report of Malignant Paroxysmal Positional Vertigo Caused by Bow-Hunter Syndrome Jiann-Jy Chen 1, Dem-Lion Chen 2, Chiao-Jung Lin 3 Abstract An 88-year-old man has presented with a 9-month history episodic vertigo when he turned his head to the right. Benign paroxysmal positional vertigo was initially suspected, but Epley s canalith repositioning maneuvers failed to ameliorate the symptom. Carotid duplex and brain magnetic resonance imaging demonstrated right vertebral artery stenosis, and reduction of basilar artery flow by turning his head to the right. An ischemia lesion at the left side of the pons was found. The condition is called Bow-Hunter syndrome which caused diminished vertebrobasilar flow by head turning. Avoidance of head turning led to a decrease in recurrence. In an aged patient, paroxysmal positional vertigo refractory to canalith reposition maneuvers warrants intensive investigation. Besides, cerebellopontine angle or internal acoustic canal tumors, Bow-Hunter syndrome with transient vestibular dysfunction should also be considered. (Taiwan Geriatr Gerontol 2015; 10(3): 191-196) Key words: benign paroxysmal positional vertigo, malignant paroxysmal positional vertigo, Bow-Hunter syndrome, vertebral arterial stenosis, vertebrobasilar insufficiency 1 Prospect Clinic for Otorhinolaryngology and Neurology, Kaohsiung; 2 G-Home Otorhinolaryngologic Clinic, Kaohsiung; 3 Department of Family Medicine, Buddhist Tzu Chi General Hospital, Taichung Branch, Taichung, Taiwan Correspondence to: Chiao-Jung Lin No. 88, Section 1, Fongsing Road, Tanzih District, Taichung City 42743, Taiwan (Department of Family Medicine, Buddhist Tzu Chi General Hospital, Taichung Branch) Tel: (886) 4-22052121 Fax: (886) 4-22344055 E-mail: jiannjy@yahoo.com.tw 196