- 學位論文
失智之流行病學研究及其醫療耗用
Epidemiologic Study of Dementia and Its Healthcare Utilization
摘要
目的 1.瞭解65歲以上失智老人的盛行率、發生率，以及不同失智類型的比例。2.比較血管型失智（vascular dementia，VaD）、阿茲海默氏病（Alzheimer disease，AD）、和對照組這三組老人的心血管危險因子。3.比較三組的醫療耗用。 研究方法 採回溯、橫斷的觀察性研究，使用全民健保「歸人檔」。第一階段分析2000至2006年失智老人的盛行率、發生率以及各種不同失智類型的比例。第二階段採用nested case-control study(巢式病例對照研究法)，找出年滿65歲以上，新發生的VaD和AD患者，對照組則需年齡、性別和加入的時間匹配。比較三組(VaD、AD、對照組)在失智診斷前的三高危險因子和失智診斷後的醫療耗用(門診次數和費用、住院天數和費用以及醫療費用總和)有無差異。 研究結果 第一階段自2000-2006年65歲以上老人，歸戶後扣除76名性別不詳者，共有199,924人，分析其流行病學資料。第二階段年滿65歲以上，七年之間共有1589位新增的失智長者，扣除20名找不到對照組之後，失智老人有1569名，其中VaD 274名，AD 1162名。對照組也找1569名。 流行病學。失智盛行率隨著年齡增加而增加，從65-69歲的1.43%，上升到80-84歲的4.11%，但85歲以後降至2.93%。65歲以上總失智盛行率是2.72%。女性平均3.06%，男性2.42%。發生率也是隨著年齡增加而增加，但到了85歲以上還是持續上升。65歲以上總失智發生率是16.35/每千人年，女大於男。失智的類型以AD最多，占74.01%，VaD占17.56%次之，「其他失智類型」只有8.43%。 比較三組（VaD、AD和對照組）的心血管危險因子時，三組人數分別是274，1162，1569人。三組中，罹患糖尿病的比例是31.75%、25.22%、25.11%；高血脂三組分別是19.71%、15.92%、18.67%；高血壓則為72.26%、64.54%、66.79%。檢定後發現：VaD受高血壓的影響超過AD組(p=0.015)；三高「任一項」亦然(VaD大於AD，p=0.007)。糖尿病、高血壓、高血脂個別都不是危險因子，但就三者的聯集而言（出現「任一項」三高），VaD高於對照組(p=0.044)。 醫療耗用。比較醫療耗用時，三組的人數分別是：274、1162、1569人。三組的門診次數是39.7、43.1和44.4次（每人年/每人）(F=2.78，p=0.062)，三組無差異。門診費用三組為59,256.0、60,526.1、59,880.7 (F=0.61，p=0.543)。三組的住院天數是：37.7、30.8、22.9（F=8.18，p<0.001），其中VaD和AD兩組分別都大於對照組(p<0.05)。而三組的住院費用是，VaD 153,817.6、AD 148,278.5、對照組141,975.3（每人年/每人）三組之間統計上無差別(F=0.88，p=0.417)。三組的總醫療費用，VaD患者有213,073.7，AD是208,804.7，對照組201,856.0 (F= 0.88，p=0.415)。 結論和建議 1.失智盛行率或發生率隨著年齡增加而增加，到了85歲以後盛行率開始下降，但發生率仍持續上升。無論盛行率或發生率都是女多男少。2.高血壓和三高「任一項」的聯集影響VaD甚於AD，三高與VaD有微弱相關，但與VaD不相關。3.三組的門診就醫次數無差異，但VaD和AD兩組的住院天數分別都大於對照組。比較三組的門診費用、住院費用或醫療費用總和，彼此之間無差異。據此推論，失智老人受忽略，未能充分使用醫療資源。
並列摘要
OBJECTIVES: The study aimed at estimating the prevalence and incidence of senile dementia and identifying cardiovascular risk factors and healthcare utilization for the subtypes of dementia. METHODS: Dementia assessments were ascertained through the computerized data linkage from National Health Insurance Database from 2000 to 2006. Step 1- We evaluated the prevalence and incidence of senile dementia and subtypes of dementia by analyzing the database from 2000 to 2006. Step 2- A nested case-control study was conducted. Three groups, including vascular dementia (VaD, N=274), Alzheimer disease (AD, N=1162) and control (N=1569), were compared for cardiovascular risk factors and healthcare utilizations. The comparison group was frequency-matched on age, gender and time at enrollment (within 1 month). The cardiovascular risk factors, including diabetes mellitus (DM), hyperlipidemia (HL), and hypertension (HT), should be established before the diagnosis of dementia. Healthcare utilizations, including visit times and costs of outpatients, length of stay and costs of admissions, and total costs, were counted and compared after the diagnosis of dementia. RESULTS: Step 1- After excluding 76 patients with unclear gender from database, 199,924 aged persons entered the epidemiology study. Step 2- There were 1589 incident dementias from 2000 to 2006. Twenty of them were excluded because no matched patients could be identified. So we got 1569 senile dementia, including 274 VaD and 1162 AD patients. And there were 1569 cases selected for control. The prevalence increased with age from 1.43% (65-69 years) to 4.11% (80-84 years), but declined since the age of 85 (2.93%). The prevalence was 2.72% for senile dementia (all causes) and was higher in women (3.06%) than in men (2.42%). The incidence also increased with age, but persisted to climb up even after the age of 85, without falling like the prevalence. The incidence was 16.35 per 1000 person-years for senile dementia. AD (74.01%) was the most common subtype, followed by VaD (17.56%) and miscellaneous types (8.43%). The percentage of cardiovascular risk factors in 3 groups (VaD, AD, control) was listed below: DM, 31.75%, 25.22%, 25.11%; HL, 19.71%, 15.92%, 18.67%; HT 72.26%, 64.54%, 66.79%; ‘any of the 3’ CV risk factors, 78.83%, 70.74%, 73.04%. We found that AD group were healthier than VaD patients, in view of HT (p= 0.015) and ‘any of the 3’ CV risk factors (p=0.007). Individually, the HT, HL, or DM is not the risk factor of VaD & AD. But if ‘any of the 3’ CV risk factors is concerned, it was more common in the VaD group than control (p=0.044). The outpatient clinics visits of 3 groups (39.7, 43.1, 44.4 times) were not significantly different. However, the length of stay (LOS) for admission was 37.7, 30.8, 22.9 for 3 groups (F=8.18, p<0.001), with the LOS of VaD & AD longer than control, respectively. Otherwise, all the costs including outpatients costs, admission costs and total costs, did not differ in the 3 groups. CONCLUSIONS: 1. Prevalence and incidence increased with age. The prevalence declined since the age of 85 but not the incidence. The prevalence and incidence were higher for women. 2. AD is healthier than VaD, regarding of HT and ‘any of the 3’ CV risk factors. There was a weak relation between cardiovascular risk factors and VaD, but not AD. 3. The outpatient visit numbers of 3 groups were not different. However, the VaD & AD had significantly longer LOS for admission than control. No differences in the costs were found in the 3 groups, including outpatients costs, admission costs and total costs. Our results disclosed some evidences that our senile dementias did not receive appropriate treatment.