超高齢慢性硬膜下血腫患者の退院調整

Hospital Discharge Arrangements for Very Elderly Patients with Chronic Subdural Hematoma

Ⅰ．はじめに

　慢性硬膜下血腫は脳神経外科医が日常診療でしばしば遭遇する疾患の1つである．高齢化に伴いその罹患者も増加する．一方で，高齢者は認知機能低下をはじめさまざまな余病を患っていることが多い．75歳超高齢者の8割が2疾患以上，6割が3疾患以上の慢性疾患を併存しているとも報告されている⁶⁾．

　高齢の慢性硬膜下血腫患者は手術目的の入院により余病の悪化や認知機能低下，廃用の進行などを生じ，時に退院調整に難渋することがある．現に，Toiら¹²⁾がわが国の包括医療費支払い制度（Diagnosis Procedure Combination：DPC）データ（2010〜2013年）から検討した慢性硬膜下血腫の報告では，80歳以上の26.2%，90歳以上の38.1%で転院を余儀なくされている．手術を要した慢性硬膜下血腫の退院ないし転院調整に焦点を絞り当院症例を後方視的に検討した．

　INTRODUCTION:Chronic subdural hematoma（CSDH）is a common condition encountered by neurosurgeons. Owing to increasing life expectancy and rapid population aging, the age at disease onset is delayed, which negatively affects hospital discharge arrangements. This retrospective study investigated patients aged ≥90 years who underwent surgery for CSDH.

　SUBJECTS AND METHOD:The study included 53 patients diagnosed with CSDH（63 sides）for the first time, who underwent surgery at our hospital between April 2018 and March 2019. The mean age was 78.7 years, and the study included 40 men. A subdural drain was placed after burr hole surgery performed for hematoma evacuation and lavage. The basic protocol included 8-day hospitalization comprising surgery on the day of admission, rehabilitation initiated the day after surgery, and suture removal 7 days after surgery, followed by hospital discharge. The ‘elderly’ group（Group E）included patients aged ≥90 years, and the ‘others’ group（Group O）included patients aged ＜90 years. This study focused on hospital discharge arrangements.

　RESULTS:The mean length of hospitalization was 7.6 days in 10 patients（19%）in Group E. The rate of intervention by a discharge support nurse or medical social worker（Medical Consultation Team）was 100% in Group E and 65% in Group O. All patients were discharged to planned living arrangements with the assistance of the Medical Consultation Team and rehabilitation intervention.

　CONCLUSION：Among elderly patients, difficulties with hospital discharge arrangements could be attributed to exacerbation of dementia symptoms after hospitalization and manifestations of disuse syndrome and complications. Surgical treatment can be offered to patients with CSDH regardless of age（even to those aged ＞90 years）and facilitates smooth discharge with multidisciplinary intervention.