脑外伤患者认知功能障碍的危险因素

doi:10.3969/j.issn.1006-9771.2022.02.012

摘要/Abstract

摘要：

目的探讨脑外伤患者发生认知功能障碍的危险因素。方法 2021年3月至9月多中心选取住院治疗的556例脑外伤患者,采用性别1∶1匹配的病例-对照研究设计,经蒙特利尔认知评估量表(MOCA)评定,将有认知障碍者作为病例组,无认知障碍者作为对照组,收集一般资料和疾病资料,并采用社会支持评定量表、医院焦虑抑郁量表进行评估。结果 Logistic回归分析结果显示,大专及以上文化水平(OR = 0.040)、高水平社会支持(OR = 0.118)是脑外伤患者认知障碍的保护因素(P < 0.05);年龄60~88岁(OR = 9.996)、重度脑损伤(OR = 7.345)、外伤后头痛(OR = 2.159)、夜间易醒或多梦次数≥ 3次/周(OR = 3.705)、脑损伤导致上肢功能严重障碍(OR = 6.072)、抑郁(OR = 5.202)是脑外伤患者认知障碍的危险因素(P < 0.05)。结论脑外伤患者发生认知障碍的相关因素涵盖一般因素、疾病因素、睡眠、心理及社会支持等多元因素。提示临床除疾病治疗外,需要改善睡眠、调整心理、增加支持,以降低患者认知障碍率,促进疾病康复。

关键词: 脑外伤, 认知障碍, 危险因素

Abstract:

Objective To investigate the risk factors of cognitive dysfunction in patients with traumatic brain injury. Methods From March to September, 2021, 556 hospitalized patients with traumatic brain injury were selected from a multicenter study. A 1∶1 sex-matched case-control study design was used. After assessment by Montreal Cognitive Assessment (MoCA), those with cognitive impairment were as case group and those without cognitive impairment were as control group. They were collected general data and assessed with Social Support Rating Scale (SSRS) and Hospital Anxiety and Depression Scale (HADS). Results Logistic regression analysis showed that college education or above (OR = 0.040) and high level of social support (OR = 0.118) were protective factors for cognitive impairment (P < 0.05). Aged 60 to 88 years (OR = 9.996), severe brain injury (OR = 7.345), headache after injury (OR = 2.159), frequent waking at night or multiple dreams ≥ three times per week (OR = 3.705), severe upper limb dysfunction caused by brain injury (OR = 6.072), depression (OR = 5.202) were risk factors for cognitive impairment (P < 0.05). Conclusion The related factors for cognitive impairment in patients with traumatic brain injury include general factors, disease factors, sleep, psychological and social support and other factors. It is suggested that in addition to the treatment of disease, it is necessary to improve sleep, psychology and social support, to reduce the incidence of cognitive impairment and promote the recovery of disease.

Key words: traumatic brain injury, cognitive disorder, risk factor

中图分类号:

R651.1

张雪茹,郝习君,李朝征,陈长香. 脑外伤患者认知功能障碍的危险因素[J]. 《中国康复理论与实践》, 2022, 28(2): 212-219.

ZHANG Xueru,HAO Xijun,LI Chaozheng,CHEN Changxiang. Risk factors for cognitive dysfunction in patients with traumatic brain injury[J]. 《Chinese Journal of Rehabilitation Theory and Practice》, 2022, 28(2): 212-219.

图/表 3

表1

Logistic回归变量赋值"

变量	赋值说明
性别	男= 1,女= 2
年龄	18岁~= 1,45岁~= 2,60岁~= 3
婚姻状况	未婚= 1,已婚= 2,离婚= 3,丧偶= 4
有无高血压病史	无= 0,有= 1
糖尿病病史	无= 0,有= 1
头外伤病史	无= 0,有= 1
损伤原因	交通伤= 1,高空坠落伤= 2,外力击打伤= 3,跌倒= 4
脑损伤程度	轻度= 1,中度= 2,重度= 3
脑损伤部位-颞叶	无= 0,有= 1
脑损伤部位-额叶	无= 0,有= 1
脑损伤部位-顶叶	无= 0,有= 1
脑损伤部位-基底节	无= 0,有= 1
损伤部位个数	0处、一处= 0,两处= 1,三处= 2,四处= 3,五处= 4,六处= 5
脑损伤半球	无= 0,左侧= 1,右侧= 2,双侧= 3
脑损伤类型-颅骨骨折	无= 0,有= 1
脑损伤类型-蛛网膜下腔出血	无= 0,有= 1
脑损伤类型-脑挫裂伤	无= 0,有= 1
脑损伤类型-颅内血肿	无= 0,有= 1
过去是否遭受过脑损伤	无= 0,有= 1
治疗方式	保守治疗= 1,手术方式= 2
是否发生尿路感染	否= 0,是= 1
受伤时失忆	否= 0,是= 1
格拉斯哥昏迷评分	轻度= 1,中度= 2,重度= 3
血压	正常= 0,1级高血压= 1,2级高血压= 2,3级高血压= 3
文化程度	文盲= 1,小学及以下= 2,初中= 3,高中或中专= 4,专科及以上= 5
外伤后是否头痛	否= 0,是= 1
头痛频率	无= 0,偶尔= 1,有时= 2,经常= 3
性格	内向= 1,不明显= 2,比较外向= 3,外向= 4
日常生活中是否容易发怒	否= 0,是= 1
受伤后有无昏迷	无= 0,有= 1
吸烟	否= 0,是= 1
饮酒	否= 0,是= 1
睡眠质量	很差= 1,较差= 2,较好= 3,很好= 4
有无易醒或多梦	每周3次= 1,每周1~2次= 2,每周< 1次= 3,无= 4
有无使用助眠药物	每周3次= 1,每周1~2次= 2,每周< 1次= 3,无= 4
脑损伤是否导致上肢功能障碍	无= 1,轻微= 2,严重= 3
语言状况有无异常	否= 0,是= 1
焦虑	0~7分= 1,8~10分= 2,11~21分= 3
抑郁	0~7分= 1,8~10分= 2,11~21分= 3
社会支持	< 20分= 1,20~30分=2,≥ 31分= 3
MoCA分级	无= 0,认知障碍(轻中重)= 1

表1

表2

脑外伤患者认知功能障碍影响因素的单因素分析单位：n"

因素	分类	对照组(n = 278)	病例组(n = 278)	χ²值	P值	因素	分类	对照组(n = 278)	病例组(n = 278)	χ²值	P值
年龄/岁	18~< 45	129	35	101.898	< 0.001	血压	正常	170	116	26.224	< 0.001
	45~< 60	101	99				一级	64	86
	60~88	48	144				二级	35	46
婚姻状况	未婚	30	12	13.744	0.003		三级	9	30
	已婚	240	246			文化程度	文盲	4	50	103.666	< 0.001
	离婚	4	6				小学及以下	56	118
	丧偶	4	14				初中	131	80
有无高血压病史	无	243	208	14.383	< 0.001		高中或中专	58	25
有无高血压病史	有	35	70				大专及以上	29	5
有无糖尿病	无	257	251	0.821	0.451	外伤后头痛	否	106	73	8.972	0.004
有无糖尿病	有	21	27			外伤后头痛	是	172	205
有无头部外伤	无	276	270	3.666	0.106	生活中容易发怒	否	215	212	0.091	0.841
有无头部外伤	有	2	8			生活中容易发怒	是	63	66
损伤原因	交通伤	166	172	16.036	0.001	外伤后昏迷	无	190	121	34.741	< 0.001
	高空坠落伤	13	15			外伤后昏迷	有	88	157
	外力打击伤	62	31			吸烟	否	202	209	0.457	0.562
	跌倒	37	60			吸烟	是	76	69
脑损伤程度	轻度	247	168	61.403	< 0.001	饮酒	否	215	208	0.484	0.551
	中度	21	55			饮酒	是	63	70
	重度	10	55			睡眠质量	很差	18	44	23.388	< 0.001
部位-颞叶	无	178	141	10.068	0.002		较差	65	90
部位-颞叶	有	100	137				较好	125	99
部位-额叶	无	162	137	4.522	0.041		很好	70	45
部位-额叶	有	116	141			夜间易醒或多梦	无	155	121	14.193	0.003
部位-顶叶	无	197	185	1.205	0.314		< 1次/周	35	38
部位-顶叶	有	81	93				1~2次/周	38	33
部位-基底节	无	270	251	11.007	0.001		≥ 3次/周	50	86
部位-基底节	有	8	27			使用助眠药物	无	259	250	3.156	0.368
类型-颅骨骨折	无	231	197	11.732	0.001		< 1次/周	4	3
类型-颅骨骨折	有	47	81				1~2次/周	3	7
类型-蛛网膜下腔出血	无	207	151	24.598	< 0.001		≥ 3次/周	12	18
类型-蛛网膜下腔出血	有	71	127			上肢功能障碍	无	248	196	34.433	< 0.001
类型-脑挫裂伤	无	200	150	19.279	< 0.001		轻微	24	46
类型-脑挫裂伤	有	78	128				严重	6	36
类型-颅内血肿	无	244	211	13.176	< 0.001	焦虑	未发生	250	147	94.898	< 0.001
类型-颅内血肿	有	34	67			焦虑	可疑发生	17	58
过去是否遭受过脑损伤	否	273	269	1.172	0.418		肯定发生	11	73
过去是否遭受过脑损伤	是	5	9			抑郁	未发生	220	112	105.619	< 0.001
治疗方式	保守治疗	242	207	14.177	< 0.001		可疑发生	37	46
治疗方式	手术治疗	36	71				肯定发生	21	120
是否发生过尿路感染	否	239	234	0.354	0.634	社会支持	低水平	4	15	43.941	< 0.001
是否发生过尿路感染	是	39	44				中水平	168	223
受伤时失忆	否	189	138	19.312	< 0.001		高水平	106	40
受伤时失忆	是	89	140

表2

表3

脑外伤患者认知功能障碍影响因素的Logistic多因素分析单位：n"

因素	分类	对照组(n = 278)	病例组(n = 278)	χ²值	P值	OR	95%CI
年龄/岁				29.306	< 0.001
	18~< 45	129	35
	45~< 60	101	99	10.666	0.001	3.393	1.630~7.062
	60~88	48	144	28.955	< 0.001	9.996	4.322~23.120
婚姻状况				1.078	0.782
	未婚	30	12
	已婚	240	246	0.000	0.997	1.002	0.311~3.227
	离婚	4	6	0769	0.381	0.391	0.048~3.192
	丧偶	4	14	0.006	0.937	0.925	0.133~6.425
有无高血压病史	无	243	208
	有	35	70	0.001	0.981	0.991	0.484~2.030
损伤原因				3.611	0.307
	交通伤	166	172
	高空坠落伤	13	15	1.726	0.189	0.441	0.130~1.496
	外力打击伤	62	31	0.155	0.693	0.853	0.388~1.878
	跌倒	37	60	1.267	0.260	1.498	0.741~3.030
脑损伤程度				15.466	< 0.001
	轻度	247	168
	中度	21	55	6.173	0.013	3.020	1.263~7.224
	重度	10	55	12.991	< 0.001	7.345	2.484~21.722
部位-颞叶	无	178	141
	有	100	137	0.142	0.706	0.893	0.494~1.611
部位-额叶	无	162	137
	有	116	141	1.975	0.160	0.664	0.375~1.175
部位-基底节	无	270	251
	有	8	27	2.060	0.151	2.410	0.725~8.014
类型-颅骨骨折	无	231	197
	有	47	81	0.143	0.706	1.136	0.586~2.205
类型-蛛网膜下腔出血	无	207	151
	有	71	127	0.555	0.456	1.254	0.691~2.273
类型-脑挫裂伤	无	200	150
	有	78	128	1.921	0.166	1.511	0.843~2.708
类型-颅内血肿	无	244	211
	有	34	67	1.158	0.282	1.494	0.719~3.104
治疗方式	保守治疗	242	207
	手术治疗	36	71	0.050	0.823	1.090	0.513~2.313
受伤时是否失忆	否	189	138
	是	89	140	0.575	0.448	1.248	0.704~2.214
文化程度				36.784	< 0.001
	文盲	4	50
	小学及以下	56	118	13.015	< 0.001	0.084	0.022~0.323
	初中	131	80	26.308	< 0.001	0.029	0.007~0.112
	高中或中专	58	25	25.211	< 0.001	0.022	0.005~0.097
	大专及以上	29	5	11.771	< 0.001	0.040	0.006~0.252
血压				2.612	0.455
	正常	170	116
	一级	64	86	1.927	0.165	1.559	0.739~3.264
	二级	35	46	1.353	0.245	1.553	0.483~4.313
	三级	9	30	0.432	0.511	1.444	0.483~3.938
外伤后头痛	否	106	73
	是	172	205	6.294	0.012	2.159	1.183~3.938
受伤后有无昏迷	无	190	121
	有	88	157	1.482	0.224	1.458	0.794~2.677
睡眠质量				3.176	0.365
	很差	18	44
	较差	65	90	1.523	0.217	0.554	0.217~1.416
	较好	125	99	2.399	0.121	0.480	0.190~1.215
	很好	70	45	2.970	0.085	0.402	0.142~1.133
夜间易醒或多梦				5.561	0.135
	无	155	121
	< 1次每周	35	38	1.242	0.265	1.699	0.669~4.314
	1~2次每周	38	33	2.984	0.084	2.128	0.903~5.015
	≥ 3次每周	50	86	5.483	0.019	3.705	1.238~11.087
上肢功能障碍				8.547	0.014
	无	248	196
	轻微	24	46	1.968	0.161	1.763	0.798~3.895
	严重	6	36	7.454	0.006	6.072	1.663~22.162
焦虑				0.358	0.167
	未发生	250	147
	可疑发生	17	58	0.933	0.334	1.514	0.653~3.512
	肯定发生	11	73	3.329	0.068	3.613	0.929~7.877
抑郁				16.530	< 0.001
	未发生	220	112
	可疑发生	37	46	0.641	0.423	1.360	0.641~2.885
	肯定发生	21	120	16.046	< 0.001	5.202	2.321~11.657
社会支持				12.539	0.002
	低水平	4	15
	中水平	168	223	1.429	0.232	0.350	0.063~1.956
	高水平	106	40	5.390	0.020	0.118	0.019~0.717

表3

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