老年重度获得性脑损伤患者接受强化住院康复后的功能恢复与死亡率：一项回顾性队列研究

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中文摘要

背景： 重度获得性脑损伤（sABI）是死亡和长期残疾的主要原因。尽管其在老年人（≥65岁）中的患病率不断增加，但关于该人群康复结局独立决定因素的证据仍然有限。本研究旨在识别在重度获得性脑损伤（sABI）后接受强化住院康复的年轻和老年患者中与不良功能结局和死亡率相关的早期因素。
方法： 在这项单中心回顾性队列研究中，纳入了215例入住三级神经康复病房的患者（91例年龄≥65岁；124例年龄<65岁）。评估了人口学特征、sABI病因、合并症、吞咽困难、入院时多重耐药菌（MDRO）定植，以及脓毒症、医院获得性肺炎（HAP）和院内死亡的发生情况。采用多变量线性回归模型识别与出院时格拉斯哥昏迷量表（GCS）、功能独立性评定（FIM）和格拉斯哥结局扩展量表（GOS-E）评分所反映的较差结局独立相关的因素。
结果： 在老年患者中，吞咽困难（FIM p<0.0001；GOS-E p=0.022）和糖尿病（FIM p=0.006）与sABI后较差的功能结局相关。此外，入院时MDRO定植（p=0.016）和脓毒症（p=0.019）与出院时较差的神经状态相关。在年轻患者中，吞咽困难（FIM p<0.0001；GOS-E p=0.002）和MDRO定植（FIM p=0.007）与较差的功能结局相关，而入院时MDRO定植（p=0.014）和HAP（p=0.016）与出院时较差的神经状态相关。尽管出院时功能结局相当，老年患者的住院时间（LOS）显著更长（p=0.049），院内死亡率更高（34 vs. 12，p<0.0001）。HAP是整个队列中与死亡率相关性最强的因素。
结论： 吞咽困难和既存合并症，尤其是糖尿病，与老年sABI患者较差的康复结局相关。MDRO定植、HAP和脓毒症在两个年龄组中均与不良结局相关，这强调了早期识别高风险患者并采取针对性预防策略的重要性，以减少sABI后强化康复期间可改变的并发症、住院时间和死亡率。

英文摘要

BACKGROUND: Severe acquired brain injury (sABI) is a major cause of mortality and long-term disability. Although its prevalence is increasing among older adults (≥65 years), evidence on independent determinant of rehabilitation outcomes in this population remains limited. This study aimed to identify early factors associated with poor functional outcomes and mortality in younger and older patients undergoing intensive inpatient rehabilitation following severe acquired brain injury (sABI).
METHODS: In this single-center, retrospective cohort study, 215 patients (91 aged ≥65; 124 aged <65) admitted to a tertiary neurorehabilitation unit were enrolled. Demographic characteristics, sABI etiology, comorbidities, dysphagia, and multidrug-resistant organism (MDRO) colonization at admission, as well as the occurrence of sepsis, hospital-acquired pneumonia (HAP), and in-hospital mortality, were evaluated. Multivariable linear regression models were used to identify factors independently associated with poorer outcomes in terms of Glasgow Coma Scale (GCS), Functional Independence Measure (FIM), and Glasgow Outcome Scale-Extended (GOS-E) scores recorded at discharge from the unit.
RESULTS: Among older patients, dysphagia (FIM p < 0.0001; GOS-E p = 0.022) and diabetes mellitus (FIM p = 0.006) were associated with poorer functional outcomes after sABI. In addition, MDRO colonization at admission (p = 0.016) and sepsis (p = 0.019) were associated with worse neurological status at discharge. In younger patients, dysphagia (FIM p < 0.0001; GOS-E p = 0.002) and MDRO colonization (FIM p = 0.007) were associated with poorer functional outcomes, whereas MDRO colonization at admission (p = 0.014) and HAP (p = 0.016) were associated with worse neurological status at discharge. Despite comparable functional outcomes at discharge, older patients had significantly longer LOS (p = 0.049) and higher in-hospital mortality (34 vs. 12, p < 0.0001). HAP was the factor most strongly associated with mortality in the overall cohort.
CONCLUSIONS: Dysphagia and pre-existing comorbidities, particularly diabetes mellitus, were associated with poorer rehabilitation outcomes in older patients with sABI. The association of MDRO colonization, HAP, and sepsis with poor outcomes across both age groups underscores the importance of early identification of high-risk patients and targeted preventive strategies to reduce modifiable complications, length of stay, and mortality during intensive rehabilitation after sABI.