憂鬱對骨質疏鬆骨折之老年人患者再骨折次數之影響

Depression correlates with increased risk for re-fracture in osteoporotic fractured elder patients.

徐于茹(YU-JU HSU)

指導教授 ： 黃君瑜

中原大學/理學院/心理學研究所/碩士(2014年)

https://doi.org/10.6840/cycu201400018

摘要

研究背景與目的：骨質疏鬆症為影響患者發生骨折風險之危險因子之一，然患者在骨質流失過程中幾乎不會感受到任何疼痛或不適，此疾病也因此經常被忽視，至發生骨折時才被發覺。對老年人而言，骨折風險不僅會增加其生活自理及行動力上的困難，甚至會增加再次骨折風險、提高死亡威脅。近年來研究以生理、心理及社會層面，分別探究心理因素與骨質疏鬆症及骨折之間的關聯性，發現憂鬱症患者較一般健康者有較低的骨質密度、於患部復原情形及疾病適應狀態亦較不理想。因此，本研究主要目的在探討憂鬱對骨質疏鬆骨折之老年患者後續發生再骨折次數之影響，依據骨折時間點區分為骨折前憂鬱及骨折後憂鬱對再骨折次數的影響。
研究方法：本研究資料來自全民健康保險研究資料庫，屬大樣本縱貫性之研究方式。自門診處方及治療明細檔中篩選2006年至2010年間，年齡65歲以上、於2006年未具備骨質疏鬆骨折代碼但2007年有骨質疏鬆骨折代碼者，並同時排除罹患癌症、曾因交通意外而住院或有門診紀錄者為對象，並追蹤計算患者於2007至2010年間發生再骨折之次數。依據上述篩選條件，初步得門診患者共計58064位，後續為提升資料正確性及分析便利性，故將篩選條件更嚴格定義為2007年具備骨科診斷之骨質疏鬆骨折代碼者，得門診患者共計3896位進入後續統計分析。進一步依據骨折前後罹患憂鬱症之情形，分為骨折前憂鬱組及骨折後憂鬱組，分析不同性別、年齡、骨質疏鬆症診斷與憂鬱組別之間之關聯，並採共變數分析，檢驗骨折前後憂鬱組別於再骨折次數之差異性。
研究結果：於門診資料中初步篩選56084名患者，其中2006至2010年間具備憂鬱診斷者共6916人，佔總人數12.3%，且以骨折前無憂鬱但骨折後有憂鬱者最多，共3519人，佔總人數6.3%。進一步以3896名患者進行分析，結果發現：(1)女性患者明顯多於男性患者，且女性罹患骨質疏鬆症及發生再骨折之比例皆顯著高於男性，然年齡與再骨折次數之間無顯著相關，顯示對已經邁入老年階段之患者而言，年齡的增長與其後續再次經歷骨折之間無顯著關聯存在。(2)罹患骨質疏鬆者發生再骨折之次數，顯著高於未罹患骨質疏鬆症者。再者，2006年診斷有骨質疏鬆者共有575位，佔整體患者14.8%，2007年診斷有骨質疏鬆症者則有1572位，佔整體患者40.3%，有明顯增加之情形，推測多數患者可能在骨折就醫後才發現罹患骨質疏鬆症，因此有人數懸殊之情形。(3)共821位患者於骨折後四年內會發生不同部位之再骨折，佔整體患者21%。(4)憂鬱分組部分，患者中共1946名患者於骨折前罹患憂鬱症，1963名患者於骨折後罹患憂鬱症，且骨折前有無憂鬱及骨折後有無憂鬱，於性別分佈上無顯著差異，然骨折前後罹患憂鬱症者，其平均年齡皆顯著低於骨折前後未罹患憂鬱症者。(5)骨折前後皆有憂鬱症者，較骨折前後皆無憂鬱或骨折前有憂鬱但骨折後無憂鬱症者，有顯著較高罹患骨質疏鬆症之比例。進一步分析發現，骨折前罹患憂鬱症與否，於骨質疏鬆症之比例無顯著差異，然骨折後罹患憂鬱症者，其同時罹患骨質疏鬆症之人數比例顯著高於骨折後無憂鬱症者。(6)排除性別與骨質疏鬆症之影響後，骨折前憂鬱對再骨折次數仍具有顯著影響，即骨折前罹患憂鬱症者，較未罹患憂鬱者有更高的再骨折次數，然骨折後罹患憂鬱與否，於再骨折次數則無明顯差異。
討論：研究支持骨折前憂鬱於患者發生再骨折風險扮演重要影響角色，且骨折後憂鬱之效果雖未獲支持，然結果驗證骨折後罹患憂鬱症者同時罹患骨質疏鬆症之比例顯著高於骨折後無憂鬱者，可知低骨密度與骨質疏鬆症被視為導致骨折之危險因子，故不可忽視骨折後憂鬱之患者可能存在的再骨折風險。除需注重對年長者、女性或罹患骨質疏鬆症等危險因子之預防外，著重骨折前有憂鬱症之患者在後續藥物使用及預防跌倒等處遇亦同等重要，且提供老年患者在骨折後的疾病適應、情緒照顧及衛教之介入，亦可作為預防骨折後發展出憂鬱症狀、進而降低憂鬱影響骨質疏鬆症及再骨折惡性循環之建議。

關鍵字

憂鬱症 ； 骨質疏鬆症骨折 ； 再骨折次數 ； 骨質疏鬆症

並列摘要

Background: Osteoporosis is a major risk of fracture due to low bone mass, especially for the elderly, fractures will lead to disability, loss of independence and increased mortality, but there is no sign for osteoporosis, therefore underestimate the incidence and prevalence of it. Many studies now support that depression is associated with increased risk for both low bone Mineral Density (BMD) and fractures, and worse recovery and adaptation compare with normal fractures patients. Therefore, the present study was designed to examine whether depression influences the risk for re-fracture in osteoporotic fractured elder patients, and basis on time, the study will examine the different between outpatients with or without depression, and outpatients with or without depression after fractured.
Method: This was a longitudinal study of outpatients who were enrolled in the National Health Insurance (NHI) research database in Taiwan, and aged at least 65, and recorded if the codes fit in with osteoporotic fracture in 2007, and did not fit in with any osteoporotic fracture codes in 2006. Then followed up the same outpatients in 2006-2010, and calculated the numbers of re-fractured times. A primary sample of 58064 elderly outpatients were selected, to enhance the correction and the appropriateness of the data, this study defined the outpatients should recorded if the codes fit in with osteoporotic fracture diagnosed in orthopedics in 2007. There are 3896 outpatients categorized into different depression groups basis on whether they had depression diagnosis before or after fracture. Thereafter, examining the different between gender, age and osteoporosis in patients with or without depression, and then used ANCOVA analysis to examine the different between depression groups in re-fracture times.
Result: In primary sample of 58064 elderly outpatients, there are 6916 (12.3%) outpatients had been diagnosed in depression before or after fractured in 2006-2010. In analysis sample of 3896 elderly outpatients, found that female had higher risk both in osteoporosis and re-fracture times, but there are no different between any ages in elderly. Otherwise, outpatients with depression after fractured had higher prevalence in osteoporosis compare to outpatients without depression after fractured. There are 821 (21%) outpatients had at least once re-fracture experience in 2007-2010, and according to the hypothesis of the study, after controlled the effect of gender and osteoporosis, outpatients with depression before fractured still have higher re-fracture times compared with outpatients without depression before fractured. But there is no significant different in re-fractured times between outpatients with or without depression after fractured.
Discussion: The research result demonstrates that outpatients with depression before fractured had higher re-fracture risk in future. There is no significant difference in outpatients with or without depression after fractured in re-fracture risk, but compare to normal outpatients, outpatients with depression after fractured still had higher prevalence in osteoporosis, so take notice of depression developed after fractured remain important. This may prove to be a useful suggestion for future interventions.

並列關鍵字

Depression ； re-fracture risk ； osteoporotic fracture ； Osteoporosis

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