失智患者中醫治療後有較低的接受鼻胃管灌食風險

Dementia Patients Have Lower Risk of Receiving Nasogastric Tube Feeding After Traditional Chinese Medicine Treatment

背景：本研究目的為追蹤中醫治療失智患者是否能延緩安裝鼻胃管的時間，以及減少需要長時間接受鼻胃管灌食的風險，篩選出可能有幫助的方劑，了解中醫在失智病患的長期治療效果。方法：本研究採用回溯式世代研究（Retrospective cohort study），由健保資料庫百萬歸人檔中篩選出失智症診斷的患者，依照有無使用中醫治療分組後，以12年的全國性就醫資料追蹤。評估使用中醫治療的失智症患者，相對於沒有使用中醫的患者，因為喪失進食能力而接受鼻胃管灌食的時間是否有差異。本研究將使用門診與住院處方明細檔，由其中篩選出使用鼻胃管灌食之處置申報碼，並將第一次鼻胃管灌食列為研究標的，計算由失智症到鼻胃管灌食的時間以作為Cox-model regression的定義變項，連續一個月以上均固定申報鼻胃管灌食定義為長時間灌食。同時排除因為接受手術、腸胃道阻塞等其他因素造成的短時間鼻胃管放置。並用年齡、性別、居住地區、家庭收入、共病症及慢性病作校正。以危險比（Hazard Ratio）表示使用中醫及其他變相對失能的影響程度。並依照不同的方劑再做細分，分析對進食能力衰退的預防效果。結果：本研究共納入了9438位新診斷的失智症患者，其中有4094位（43.4％）接受中西醫整合治療，另有5344位（56.6％）則僅有接受西醫治療，經過12年的追蹤後，在中醫治療組中有953位（23.3％）患者因為喪失自行進食能力，而需要接受鼻胃管灌食，而在未接受中醫治療的患者中，則有1906位（35.7％）患者。同時中醫組患者的需要接受鼻胃管灌食的時間平均為5.8年，未接受中醫治療的患者則為4.9年。中醫治療組的比例較少且時間也較長，顯示中醫治療可能降低喪失自行進食能力的風險。以COX model分析其發生的風險比，其校正相對風險約為0.84（0.76－0.92），且使用的時間越長、累積劑量越高，有越好的減少鼻胃管灌食的效果。本研究亦發現服用半夏厚朴湯與理中湯可能有助於減少無法進食的風險，其校正相對風險分別為0.76（0.64－0.88）與0.57（0.35－0.74）。且同時接受中藥與針灸治療的患者，其校正後風險進一步降低至0.67（0.58－0.76）。結論：中西醫合併治療是台灣失智患者常見的就醫習慣，本研究發現失智症患者若接受中醫治療，可以減少因為無法自行進食而需要插鼻胃管的風險，且針灸合併中藥降低風險的效果更佳，建議臨床中西醫師可以採納於臨床實施。

Background: Dementia is an international health issue in elder people. Gastrostomy tube feeding to address eating problems in patients with dementia introduce risks of respiratory tract infection or esophagus trauma. Traditional Chinese medicine (TCM) is widely used to treat swallowing difficulty in Taiwan. We investigated the long-term clinical effects of TCM for reducing the risk of gastrostomy tube feeding in dementia patients. Methods: We used National Health Insurance Research Database to conduct a retrospective study of dementia patients with difficult voiding symptoms between 1997 and 2009 in Taiwan. We collected medical data from the onset of dementia to gastrostomy tube insertion. Cox regression proportional hazards model and cumulative incidence of the gastrostomy tube curve were used to determine the association between the risk of swallowing difficulty and TCM use Results: Data from 11069 patients with dementia was assessed, and 9438 participants who received medication for relief swallowing difficulty were categorized into 2 groups: 4094 (43.4%) were TCM users and 5344 (56.6%) were TCM non-users with a mean follow-up period of 5.4 years. Cox regression demonstrated that using TCM may decrease the need for gastrostomy tube in patients with dementia (adjusted hazards ratio (aHR)=0.84, 95% confidence interval (95% CI): 0.76-0.92) compared to TCM non-users. A relationship between longer TCM use and reduced urinary retention with gastrostomy tube use was observed, especially in patients who used both herbal and acupuncture treatment (aHR=0.67, 95% CI: 0.58-0.76). Ban-Xia-Hou-Pu-Tong (aHR=0.76, 95% CI: 0.64-0.88), Li-zhong Tang (aHR=0.57, 95% CI: 0.35-0.74) were the most two beneficial TCM formulae. Conclusions: The results of this study suggest that TCM is associated with a reduced risk of gastrostomy tube in patients with dementia, with enhanced benefits from longer durations of TCM use.