營養(yǎng)干預(yù)對老年頭頸部腫瘤放療病人營養(yǎng)狀態(tài)及情緒的影響

王劍鋒方芳于雷

目的探討營養(yǎng)干預(yù)對老年頭頸部腫瘤放療病人營養(yǎng)狀態(tài)、體質(zhì)量及情緒的影響。方法49例接受放療的老年頭頸部惡性腫瘤病人隨機(jī)分為營養(yǎng)干預(yù)組(24例)和對照組(25例),分析比較2組病人在放療前、放療開始1月、放療結(jié)束時、放療結(jié)束后1月的營養(yǎng)狀況、體質(zhì)量及焦慮/抑郁指數(shù)。結(jié)果(1)放療前后，營養(yǎng)干預(yù)組營養(yǎng)評估分?jǐn)?shù)保持穩(wěn)定,對照組放療開始后1月、放療結(jié)束時、放療結(jié)束后1月時的營養(yǎng)評估分?jǐn)?shù)明顯高于放療前;放療開始后1月、放療結(jié)束時對照組的營養(yǎng)評估分?jǐn)?shù)明顯高于相同時間點營養(yǎng)干預(yù)組。(2)放療前后，營養(yǎng)干預(yù)組體質(zhì)量基本保持穩(wěn)定;對照組在放療開始1月、放療結(jié)束時平均體質(zhì)量明顯低于放療前;放療結(jié)束時對照組的平均體質(zhì)量明顯低于相同時間點營養(yǎng)干預(yù)組。(3)營養(yǎng)干預(yù)組各個時間點焦慮指數(shù)與放療前比較,差異無統(tǒng)計學(xué)意義;對照組放療開始1月、放療結(jié)束時的焦慮指數(shù)明顯高于放療前;放療開始1月、放療結(jié)束時、放療結(jié)束后1月時對照組的焦慮指數(shù)明顯高于相同時間點營養(yǎng)干預(yù)組。(4)放療前后，營養(yǎng)干預(yù)組的抑郁指數(shù)保持穩(wěn)定;對照組放療開始1月、放療結(jié)束時、放療結(jié)束后1月時的抑郁指數(shù)明顯高于其放療前和相同時間點營養(yǎng)干預(yù)組。結(jié)論營養(yǎng)干預(yù)治療可以維持老年頭頸部腫瘤放療病人的營養(yǎng)狀態(tài),緩解焦慮和抑郁情緒。

營養(yǎng)干預(yù); 頭頸部腫瘤; 放療; 老年人; 焦慮； 抑郁

頭頸部腫瘤是老年人常見的惡性腫瘤,因為年齡、不良的生活習(xí)慣和腫瘤因素的影響,許多病人在診斷和治療前就伴隨著營養(yǎng)不良。放射治療也會引起味覺喪失、黏膜炎、口干、吞咽困難等不良反應(yīng),影響食物的攝入,使病人營養(yǎng)狀況進(jìn)一步惡化,導(dǎo)致治療中斷、影響療效[1-2]。營養(yǎng)狀態(tài)還與焦慮和抑郁等負(fù)性情緒密切相關(guān),恰當(dāng)?shù)氖澄飻z入可以使心理需求得到滿足,改善病人的情緒[3]。本研究旨在觀察老年頭頸部腫瘤放療病人的營養(yǎng)風(fēng)險,探討適時的營養(yǎng)干預(yù)對病人營養(yǎng)狀況和情緒的影響,以期為該類病人的診治提供參考。

1 對象與方法

1.1 研究對象 選取2014年6月至2016年6月在吉林大學(xué)第二醫(yī)院放療科收治的老年頭頸部腫瘤病人49例,入選標(biāo)準(zhǔn):(1)病理證實為鱗癌;(2)Karnofsky評分≥70分;(3)無嚴(yán)重并發(fā)癥;(4)同意進(jìn)入本項研究。其中男32例,女17例,年齡65～76歲,平均(70.5±5.5)歲;疾病種類:鼻咽癌15例,口咽癌13例,口腔癌6例,下咽癌5例,其他10例;按國際抗癌聯(lián)盟(UICC)的第七版分期標(biāo)準(zhǔn)進(jìn)行臨床分期,Ⅰ期5例,Ⅱ期15例,Ⅲ期24例,Ⅳ期5例。病人按隨機(jī)數(shù)字表法隨機(jī)分為營養(yǎng)干預(yù)組24例(接受營養(yǎng)教育和營養(yǎng)干預(yù)治療),對照組25例(接受營養(yǎng)教育)。2組間一般資料比較,差異無統(tǒng)計學(xué)意義,具有可比性。

1.2 治療方法 2組病人均接受適形調(diào)強(qiáng)放療,根據(jù)腫瘤放射治療協(xié)作組62號報告勾畫治療靶區(qū),采用計算機(jī)治療計劃系統(tǒng)制定放療計劃,使用醫(yī)科達(dá)公司醫(yī)用直線加速器進(jìn)行治療。根據(jù)治療中腫瘤的消退情況,放療劑量設(shè)定為66～72 Gy。

1.3 營養(yǎng)篩查和營養(yǎng)干預(yù)方法 病人入院后由專門的營養(yǎng)支持小組(由醫(yī)生、護(hù)士和營養(yǎng)師組成)按照營養(yǎng)風(fēng)險篩查2002(NRS2002)進(jìn)行營養(yǎng)風(fēng)險篩查,之后每周按照病人主觀整體營養(yǎng)狀況評估量表(scored patient-generated subjective global assessment,PG-SGA)進(jìn)行營養(yǎng)評估。目標(biāo)喂養(yǎng)量為總供能25～30 kcal/(kg·d),總蛋白1.2～1.5 g/(kg·d),在營養(yǎng)干預(yù)組，當(dāng)普通飲食攝入未達(dá)到目標(biāo)或PG-SGA評分≥4分時給予口服營養(yǎng)補(bǔ)充或鼻飼管營養(yǎng)治療,以達(dá)到目標(biāo)需要量。對照組給予營養(yǎng)教育,幫助病人調(diào)整飲食結(jié)構(gòu),有針對性地指定個體化的飲食方案。

1.4 觀察指標(biāo) 在放療前、放療開始1月、放療結(jié)束時、放療結(jié)束后1月測量并記錄病人的體質(zhì)量、PG-SGA評分和焦慮/抑郁指數(shù)。情緒指數(shù)采用綜合醫(yī)院焦慮/抑郁情緒測定表(hospital anxiety and depression scale,HADS)。

2 結(jié)果

2.1 營養(yǎng)風(fēng)險與營養(yǎng)評估 2組放療前存在營養(yǎng)風(fēng)險的病人比例分別為66.7%、68.0%,差異無統(tǒng)計學(xué)意義(P>0.05)。放療開始后營養(yǎng)干預(yù)組的PG-SGA評分雖略有增高,但與放療前比較，差異無統(tǒng)計學(xué)意義;放療開始后1月、放療結(jié)束時、放療結(jié)束后1月時對照組的PG-SGA評分明顯高于放療前(P<0.05);放療開始后1月、放療結(jié)束時對照組的PG-SGA評分明顯高于相同時間點營養(yǎng)干預(yù)組(P<0.05),見表1。

表1 2組不同時間點營養(yǎng)狀況PG-SGA評分比較,分)

注:與放療前比較,*P<0.05;與營養(yǎng)干預(yù)組比較,△P<0.05

2.2 體質(zhì)量變化 營養(yǎng)干預(yù)組與對照組在放療前平均體質(zhì)量差異無統(tǒng)計學(xué)意義,放療開始后營養(yǎng)干預(yù)組體質(zhì)量基本保持穩(wěn)定;放療中對照組的平均體質(zhì)量明顯下降,在放療開始1月、放療結(jié)束時平均體質(zhì)量明顯低于放療前;放療結(jié)束時對照組的平均體質(zhì)量明顯低于相同時間點營養(yǎng)干預(yù)組(P<0.05),見表2。

表2 2組不同時間點平均體質(zhì)量比較,kg)

注:與放療前比較,*P<0.05;與營養(yǎng)干預(yù)組比較,△P<0.05

2.3 情緒指數(shù) 放療中營養(yǎng)干預(yù)組焦慮指數(shù)有下降的趨勢,但各個時間點與放療前比較差異無統(tǒng)計學(xué)意義;而放療開始1月、放療結(jié)束時對照組的焦慮指數(shù)明顯高于放療前;放療開始1月、放療結(jié)束時、放療結(jié)束后1月時對照組的焦慮指數(shù)明顯高于相同時間點營養(yǎng)干預(yù)組(P<0.05),見表3。

營養(yǎng)干預(yù)組的抑郁指數(shù)與放療前比較,差異無統(tǒng)計學(xué)意義;而放療開始1月、放療結(jié)束時、放療結(jié)束后1月時對照組的抑郁指數(shù)明顯高于其放療前和相同時間點營養(yǎng)干預(yù)組(P<0.05),見表4。

表3 2組不同時間點焦慮指數(shù)比較,分)

注:與放療前比較,*P<0.05;與營養(yǎng)干預(yù)組比較,△P<0.05

表4 2組不同時間點抑郁指數(shù)比較,分)

注:與放療前比較,*P<0.05;與營養(yǎng)干預(yù)組比較,△P<0.05

3 討論

營養(yǎng)不良情況在頭頸部腫瘤病人中十分常見,而放射治療所產(chǎn)生的不良反應(yīng)如味覺減退、口腔黏膜炎、吞咽困難等會惡化病人的營養(yǎng)狀況[4]。老年病人因為身體機(jī)能的減退更容易出現(xiàn)營養(yǎng)問題。營養(yǎng)不良會減低病人的免疫力,加重治療的不良反應(yīng),延長住院時間,影響病人的療效和生活質(zhì)量[5]。同時,頭頸部腫瘤病人由于外觀和社會活動減少等原因,存在焦慮和抑郁等心理問題比例較高,這種情況在老年病人中更是普遍[6]。

病人在放療前就有相當(dāng)高的營養(yǎng)風(fēng)險,對老年頭頸部腫瘤病人的營養(yǎng)狀態(tài)應(yīng)該高度關(guān)注。當(dāng)病人能量-蛋白質(zhì)攝入不足時,應(yīng)給予積極的營養(yǎng)干預(yù),防止?fàn)I養(yǎng)不良的發(fā)生[7]。對于有高度營養(yǎng)風(fēng)險的病人給予早期的營養(yǎng)評估和積極的營養(yǎng)干預(yù)是十分必要的,可以有效地減少體質(zhì)量下降、改善預(yù)后[8]。本研究發(fā)現(xiàn)給予適時的營養(yǎng)評估和積極的營養(yǎng)干預(yù),可以維持病人的營養(yǎng)狀態(tài)。

體質(zhì)量是營養(yǎng)狀況的重要參數(shù),體質(zhì)量下降是蛋白質(zhì)-熱量營養(yǎng)不良的主要表現(xiàn)。體質(zhì)量下降伴隨著肌肉和器官等非脂肪組織的失去,伴隨著惡化的生活質(zhì)量、嚴(yán)重的不良反應(yīng)[9]。體質(zhì)量下降是頭頸部腫瘤放療中最常出現(xiàn)的情況,病人在治療過程中平均丟失5.87%的體質(zhì)量,體質(zhì)量下降可導(dǎo)致治療中斷、感染、死亡和住院時間延長[10]。本研究發(fā)現(xiàn)放療中單純接受營養(yǎng)教育的病人平均體質(zhì)量明顯下降,而接受營養(yǎng)干預(yù)的病人通過增加能量的攝入能夠維持體質(zhì)量,防止?fàn)I養(yǎng)不良風(fēng)險。

老年腫瘤病人多伴有悲觀失望,情緒低落等負(fù)性情緒,容易產(chǎn)生焦慮和抑郁等心理問題,伴有焦慮與抑郁的比例可達(dá)20%～30%[11]。焦慮與抑郁等心理問題與體質(zhì)量下降明顯相關(guān),顯著影響治療的過程,降低生活質(zhì)量,是預(yù)后不良的標(biāo)志[12]。有研究表明進(jìn)食可以緩解抑郁狀態(tài),口服營養(yǎng)補(bǔ)充能有效地增加蛋白質(zhì)-能量攝入,改善病人在急性期的生活質(zhì)量和情緒[13-14]。本研究發(fā)現(xiàn)積極的營養(yǎng)干預(yù)可以改善病人的情緒,維持病人焦慮/抑郁指數(shù)。

綜上所述,老年頭頸部腫瘤病人的營養(yǎng)風(fēng)險高,應(yīng)加強(qiáng)營養(yǎng)評估工作。積極的營養(yǎng)干預(yù)可以維持病人的營養(yǎng)狀態(tài),還可以改善病人的情緒問題,值得推廣應(yīng)用。

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Effectofnutritionalinterventiononnutritionalstatusandemotioninelderlypatientswithheadandneckcancerreceivingradiotherapy

WANGJian-feng.DepartmentofRadiotherapy,China-JapanUnionHospitalofJilinUniversity,Changchun130033,China;FANGFang.

DepartmentofNutrition,SchoolofPublicHealthofJilinUniversity,Changchun130033,China;YULei.DepartmentofRadiotherapy,No.2HospitalofJilinUniversity,Changchun130033,China

ObjectiveTo explore the effect of nutritional intervention on nutritional status and emotion in elderly patients with head and neck cancer receiving radiotherapy.MethodsForty-nine elderly patients with head and neck malignant tumor receiving radiotherapy were randomly divided into nutritional intervention group (NI group, 24 cases) and control group (CG group, 25 cases) according to whether they received the nutrition intervention. The status of nutrition, weight and anxiety/depression index before radiotherapy, 1 month after radiotherapy beginning, at the end of radiotherapy, 1 month after radiotherapy in two groups were compared.Results(1)The nutritional assessment score in NI group showed no significant change before and after radiothrapy. The assessment scores of the nutrition in CG group 1 month after radiotherapy beginning, at the end of radiotherapy, 1 month after radiotherapy were significantly higher than that before radiotherapy, and were significantly higher than those in NI group 1 month after radiotherapy beginning, at the end of radiotherapy. (2)The average weight in NI group showed no significant change before and after radiotherapy. The average weight in CG group 1 month after radiotherapy beginning, at the end of radiotherapy was significantly lower than that before radiotherapy. At the end of radiotherapy, the average weight in CG group was significantly lower than that in NI group. (3)The anxiety index and depression index in NI group showed no significant change before and after radiotherapy. The anxiety index and depression index in CG group 1 month after radiotherapy beginning and at the end of radiotherapy were significantly higher than those before radiotherapy. The anxiety index and depression index in CG group 1 month after radiotherapy beginning, at the end of radiotherapy, 1 month after radiotherapy were significantly higher than those in NI group.ConclusionsNutritional intervention can effectively maintain the nutritional status of elderly patients with head and neck cancer receiving radiotherapy, and relieve anxiety and depression.

nutritional intervention; head and neck cancer; radiotherapy; aged; anxiety; depression

吉林省衛(wèi)生計生科研計劃(20152009)

130033吉林省長春市，吉林大學(xué)中日聯(lián)誼醫(yī)院放療科(王劍鋒)；130033吉林省長春市，吉林大學(xué)公共衛(wèi)生學(xué)院營養(yǎng)教研室(方芳)；130033吉林省長春市，吉林大學(xué)第二醫(yī)院放療科(于雷)

于雷，Email：radiation1978@163.com

R 473.73

A

10.3969/j.issn.1003-9198.2017.09.013

2016-11-15)