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研究生：	蔡相德 Tsai, Hsiang-Te
論文名稱：	譫妄患者使用抗精神藥物與死亡預測因子分析 Assessment of Antipsychotics and Predictors Associated with Mortality in Patients with Delirium (PRE-MODE): a population-based nested case-control study
指導教授：	賴嘉鎮 Lai, Edward Chia-Cheng
學位類別：	碩士 Master
系所名稱：	醫學院 - 臨床藥學與藥物科技研究所 Institute of Clinical Pharmacy and Pharmaceutical sciences
論文出版年：	2021
畢業學年度：	109
語文別：	英文
論文頁數：	64
中文關鍵詞：	譫妄、抗精神藥物、藥物劑量、死亡風險
外文關鍵詞：	Delirium, Antipsychotics, Dose-response, Mortality
相關次數：	點閱：134 下載：0
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研究背景: 譫妄為患者住院常見的併發症，患者抗精神藥物使用與死亡風險的相關性一直備受討論，另外，對於相關預測因子的探討也相對缺乏。
研究目的: 本研究之目的為評估臺灣譫妄病人使用抗精神藥物之死亡風險，並且找出死亡風險之預測因子。
研究方法: 本研究採用巢式病例對照研究，資料來源為2011-2018的健保資料庫。研究對象為新診斷譫妄的住院病人，排除其他潛在精神疾病後，挑選出院後180天內死亡為案例組，並以年齡、性別進行1:5配對，挑選出院後180日仍存活的對照組，並比較兩組抗精神藥物暴露與其它預測因子與死亡風險之關聯性。本研究使用多變項條件邏輯斯迴歸模型進行分析與校正共變數。
研究結果: 本研究總共收錄了69,520名病人，案例組人數為13,219名；對照組人數為56,301名。案例組與對照組的平均年齡分別為80.3歲（標準差 13.3）和78.9歲（標準差 13.0）。結果顯示，使用抗精神藥物與死亡風險並無統計顯著相關性 (OR, 1.06; 95% CI, 0.95-1.19)，然而當患者接受高的haloperidol等效劑量時，有較高的死亡風險(OR, 1.36; 95% CI, 1.19-1.56)。其它預測因子包括感染、癌症與呼吸器使用。
結論: 研究指出譫妄病人使用抗精神藥物不會增加其死亡風險，而感染、癌症與呼吸器使用可能為潛在的危險因子。雖然當患者接受高劑量時，有較高的死亡風險，但無法排除是與病人潛在的疾病狀況有關。
關鍵字: 譫妄、抗精神藥物、藥物劑量、死亡風險

Delirium is one of the critical issues for the hospitalized patients. Limited information is available on the risk profiles of mortality in patients with delirium receiving antipsychotics. We, therefore, conducted a nested case-control study using Taiwan’s National Health Insurance Database (NHID) from 2011-2018. We included patients who were newly diagnosed with delirium during hospitalization. Case group was defined as those who expired within 180-day after discharge; control group was 1: 5 matched by age and sex. We performed multivariable conditional logistic regression models to evaluate the association between antipsychotics and mortality. We also included several covariates, including patients’ demographics, comorbidities and comedication to assess to explore the predictors for mortality. We included a total of 13,219 cases and matched them to 56,301 controls. We found no association between antipsychotics and mortality (OR, 1.03; 95% CI, 0.98-1.09). Although we observed a dose-response relationship between antipsychotics and mortality risk (OR, 1.36; 95% CI, 1.19 1.56). However, confounding by indication could be not completely ruled out. Predictors such as patients’ underlying infection, malignancy or ventilator support were identified.

摘要 i
誌謝 v
CONTENTS vii
LIST OF TABLES x
LIST OF FIGURES xi
LIST OF ABBREVIATIONS xii
Chapter 1 BACKGROUND INFORMATION	1
Epidemiology 1
Pathophysiology of patients with delirium 1
Diagnosis of delirium 2
Management of delirium 2
Chapter 2 RELEVANT LITERATURE 5
Randomized controlled trial of patients with delirium receiving antipsychotics 5
Real world evidence of patients with delirium receiving antipsychotics 5
Caregiver burden and distress 7
Summary 7
Chapter 3 STUDY OBJECTIVES AND CLINICAL RELEVANCE 8
Study objective 8
1	Aim 1 8
2	Aim 2 8
3	Aim 3 8
Clinical relevance 8
Chapter 4 STUDY METHOD 9
Study design 9
Data source 9
Case and control group identification 9
Exposure definition 10
Covariates 10
Statistical analyses 11
Chapter 5 RESULT 12
Pilot study: patterns of delirium diagnoses 12
Patients’ characteristics 12
Exposure of antipsychotics 14
Association between antipsychotics and mortality 14
Predictors of mortality 15
Sensitivity analyses and subgroup analyses 17
Chapter 6 DISCUSSION 18
Chapter 7 CLINICAL IMPLICATION 22
Chapter 8 FUTURE WORK 22
Chapter 9 CONCLUSION 23
Chapter 10 臨床藥事服務-第一部分: 腎臟科病房臨床藥師 24
服務源起 24
服務內容 24
服務成果 24
1	病房特色 24
2	抗生素照會 25
3	血中藥物濃度監測 25
4	藥物不良反應評估 26
5	病房諮詢與科部會議 27
個案討論 27
1	案例一 27
2	案例二 28
3	案例三 29
建議與未來方向 29
1	心得 29
2	未來展望 30
Chapter 11 臨床藥事服務-第二部分: Medi-Span評估效率優化計畫 31
服務源起 31
服務目的 32
服務內容 32
1	執行方式 32
2	服務成果 33
3	統計分析 34
結果 34
1	藥師總評估比數 34
2	有效警訊 35
3	無效警訊 35
4	Medi-Span警訊與院內非Medi-Span警訊成本效益 36
討論 37
結論 38
Chapter 12 REFERENCES 39
Chapter 13 LITERATURE REVIEW 44
Chapter 14 SUPPLEMENTARY INFORMATION 47
Flow charts 47
1	Death within 180 days after discharge 47
2	Death in hospitalization 48
Patient characteristics 49
Patient characteristics stratified by haloperidol equivalent dose groups 52
Multivariable logistic regression among patients with delirium 54
Subgroup analyses on patients with delirium with coexisting dementia 56
Chapter 15 APPENDIX 58
Delirium definitions 58
Diagnostic codes in ICD-9 and ICD-10 coding system 62
Use of drugs 64
                                    

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