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作者：Janis C. Kelly  
出處：WebMD醫學新聞

　　【24drs.com】November 10, 2009 — 新研究認為，年長者比年輕人更不容易罹患流感，但是，相較於認知正常者，失智患者死於流感的機率增加50%。此外，居住在鄉下或偏遠地區的年長失智患者，其風險更大。
　　
　　第一作者、麻州波士頓Tufts大學醫學院公共衛生與社區醫學教授Elena Naumova博士向Medscape Psychiatry表示，有鑑於全國對於新型流感病毒株的準備，針對美國越來越多的認知障礙年長者，我們的結果對於他們的流感疫苗接種、檢測與治療策略及實務，將有重要影響。
　　
　　這個三叉式研究，分析了肺炎和流感的地理及人口統計學模式，以及這些疾病與健康照護可近性的關係，結果線上登載於10月26日的美國老年醫學會期刊(Journal of the American Geriatrics Society)。
　　
　　【鄉村居民更須注意】
　　這個觀察型研究使用美國醫療保障與醫療救助服務中心(Centers for Medicare and Medicaid Services)的歷史與平均給付資料，輔以其他大型全國資料庫的資訊，對1998至2002年間、超過600萬例肺炎與流感案例進行回顧分析。
　　
　　研究者分析各郡的特定結果、住院天數、住院中死亡百分比、各郡年長人口密度的關聯、護理之家住民的百分比、家庭收入中位數、鄉村性指標。
　　
　　研究顯示，鄉村與比較貧窮的郡，肺炎與流感的比率最高。此外，雖然失智年長者的流感診斷率低，但是他們的死亡率是全國平均值的1.5倍。
　　
　　Naumova博士表示，應特別注意居住於鄉村地區的年長者，必須發展且加強偏遠地區的住院指引，決策者與健康照護提供者必須仔細規劃適合認知缺損病患的服務。
　　
　　就年長者比較容易感染肺炎和流感以及發生併發症來看，Naumova博士表示，這個發現並不全然令人驚訝，不過，她指出，矛頭指向現有體制的一些重要問題。
　　
　　【迅速診斷相當重要】
　　她表示，迅速診斷與治療年長者的流感是重要的，因為延遲會誘發肺炎。失智的年長者特別容易因為一般的呼吸道感染產生併發症，這是因為他們有症狀表達上的困難、不佳的口腔衛生、還有吞嚥問題。Naumova博士表示，社經因素也會影響而延遲接受健康照護，間接增加了併發症風險。
　　
　　她指出，雖然相當多失智病患居住在照護機構內且有健康照護者監督，但失智患者的流感疫苗接種率與檢測率卻都未知。
　　
　　她表示，取得特定健康照護服務的限制也會延遲流感的診斷和治療，而惡化成肺炎這個年長者的第5高死因。本研究幫助我們檢視此一危險族群，現在，需要後續研究，以確認此研究發現且評估年長失智患者的疫苗接種政策。
　　
　　【初步發現】
　　阿茲海默氏症協會醫療與科學辦公室主任William Thies博士受邀對此研究發現發表評論時表示，雖然這些發現相當有趣而複雜，畢竟還是初步結果。
　　
　　他向Medscape Psychiatry表示，事實上，失智患者較少罹患流感可能只是因為較少和社會接觸，此一議題上似乎沒有足夠的資訊可以用來登高一呼而改變健康實務。我們需要有更多研究來充分瞭解流感、肺炎與鄉村地區醫療照護之間的關聯。
　　
　　Naumova博士與 Thies博士皆宣告沒有相關財務關係。國家過敏與感染症研究中心與國家環境健康科學研究中心資助本研究。
　　
　　J Am Geriatr Soc.s線上發表於2009年10月26日。
　　  

Elderly People With Influenza and Dementia More Likely to Die

By Janis C. Kelly
Medscape Medical News

November 10, 2009 — Elderly individuals are less likely than younger people to contract influenza, but those with dementia are 50% more likely to die from the disease compared with their cognitively intact counterparts, new research suggests.

In addition, older individuals with dementia are at even greater risk if they live in a rural or remote area.

"In light of national preparedness for novel influenza strains, our results have important implications for influenza vaccinations, testing, and treatment policies and practices that target the growing fraction of US elderly with cognitive impairment," lead author Elena Naumova, PhD, professor of public health and community medicine at Tufts University School of Medicine in Boston, Massachusetts, told Medscape Psychiatry.

The 3-pronged study, which analyzed geographic and demographic patterns of pneumonia and influenza and the relationship between these diseases and healthcare accessibility, is published online October?26 in the Journal of the American Geriatrics Society.

Special Attention for Rural Residents

The observational study used historical medial claims data from the Centers for Medicare and Medicaid Services supplemented with information from other large national databases to conduct a retrospective analysis of more than 6?million cases of pneumonia and influenza between 1998 and 2002.

The researchers analyzed county-specific outcomes, length of hospital stay, and percentage of deaths in hospital, as well as associations with county-specific elderly population density, percentage of nursing home residents, median household income, and rurality index.

The study showed that rural and poor counties had the highest rates of pneumonia and influenza. In addition, although elderly patients with dementia had a lower frequency of influenza diagnosis, they had a mortality rate that was 1.5-fold higher than the national average.

"Special attention should be paid to the elderly living in rural communities. Clear guidelines for hospitalizations in remote areas have to be developed and reinforced. Policymakers and healthcare administrators should carefully plan appropriate services for patients with cognitive impairment," Dr. Naumova said.

In view of the elderly population's greater vulnerability to infections such as pneumonia and influenza and susceptibility to complications, Dr. Naumova said that the findings were not entirely surprising. However, she added, the data point to some important problems with the current system.

Rapid Diagnosis "Critical"

Rapid diagnosis and treatment of influenza in elderly people is critical because delays can trigger the development of secondary pneumonia, she said. Elderly people with dementia are particularly vulnerable to complications from common respiratory infections because of difficulties in communicating their symptoms, poor oral hygiene, and swallowing problems. Socioeconomic factors may also delay prompt access to healthcare and indirectly increase the risk of complications, said Dr. Naumova.

Although a high proportion of patients with dementia are institutionalized and under supervision of healthcare personnel, rates of influenza vaccination and testing in dementia patients are unknown, she added.

"Limited access to specialized healthcare services can delay diagnosis and treatment of the flu, causing it to progress to pneumonia, the fifth leading cause of death among the elderly. This study has helped us identify this vulnerable population, and now further study is needed to confirm the findings and assess the testing and vaccination policies for older patients with dementia," she said.

Findings "Preliminary"

Commenting on the study's findings, William Thies, PhD, chief medical and scientific officer of the Alzheimer's Association, cautioned that although the findings are "interesting and complex" they are "preliminary."

"The fact that fewer people with dementia get the flu may simply reflect their restricted levels of social contact. There doesn't seem to be sufficient information on this issue to suggest a clarion call for change in health practices. We would need a significant amount of additional research to truly understand the complicated relationships between flu, pneumonia, and rural medical care delivery," he told Medscape Psychiatry.

Dr. Naumova and Dr. Thies have disclosed no relevant financial relationships. The study was funded by the National Institute of Allergy and Infectious Diseases and the National Institute of Environmental Health Sciences.

J Am Geriatr Soc. Published online October 26, 2009.