广州城区60岁以上老人认知功能特点及正常老人认知功能变化特征的随访研究

发布时间：2018-07-13 14:54

【摘要】：目的:1、基于“广州城区60岁及以上老人认知功能特点与正常老人认知功能变化特征”课题开展前瞻性随访研究,分析和比较基线期(2011年)、第一次随访(2012年)、第二次随访(2016年)纵向资料的变化,探索基线期不同年龄段正常认知功能老人随着时间的推移认知功能不同维度变化的特征和轨迹。2、分析随访期内认知功能保持超常水平(成功老人)、平常水平(正常老人)、发生损害(包括轻度认知损害及痴呆)老人的生活习惯、情绪症状、社会支持、躯体状况等的异同,探索认知功能的相关保护因素。3、了解在调查期内死亡老人的死亡原因、生前合并的躯体疾病。4、研究第二次随访时不同认知功能状态老人对自身认知功能水平主观与客观评价的一致性及影响该一致性的相关因素。方法:采用整群抽样方法在广州抽取一个具有代表性的社区,以该社区60岁及以上人群为研究对象,按入组标准纳入被试人群,用简明精神状态评定量表(MMSE)、蒙特利尔认知评定量表(Mo CA)[1-5]、世界卫生组织成套神经心理测验(WHO-BCAI)[6-12]等为调查工具,对60岁及以上老人进行一对一神经心理测试,全面评估被试认知功能的状况。此外,使用焦虑自评量表(SAS)、老年抑郁量表(GDS)评估被试人群情绪状态;用社会支持评定量表评估被试人群社会支持情况;用日常生活量表(ADL)了解该被试人群生活功能情况。一年及五年后,分别以同套调查工具和相同的测评程序,由背景相同的调查人员对被试人群进行随访,调查员不了解基线及第一次随访老人情况。二次随访中,在上述随访内容的基础上,加用死亡调查量表,了解调查期内死亡老人的病因、合并躯体疾病、死亡时间等情况。另,加入自我主观评估项目,在每小节认知功能测评结束后,由被试评价自己刚刚完成的测试成绩在同等教育程度、同年龄被试组中所处的水平(范围为极差-100%到极好100%,以10%为等距间隔),将客观得分的原始分转换为标准分和百分位数,将主观评估的水平转换为百分位数,计算自我意识指数AI(Awareness Index)=主观测试水平-客观测试水平,观察所有认知测试项目中AI值的离散程度,及差异的显著程度[13]。用SPSS20.0进行数据的录入、统计和分析。结果:1.基本资料:基线期(2011年):应查660人,实查341人,其中男性为162(47.5%)人,女性为179(52.5%)人。调查老人平均年龄约为70.96±8.29岁,其中60-69岁161人(47.2%)、70-79岁125人(36.7%)、80-89岁46人(13.5%)、90岁以上9人(2.6%)。第一次随访(2012年):应查341人,实查283人,应答率为83%。其中男性132人(46.8%),女性150人(53.2%),平均年龄71.69±8.50岁,其中60-69岁125人(44.3%),70-79岁112人(39.7%),80岁及以上45人(16.0%)。第二次随访(2016年):应查315人,实查210人,应答率为66.7%。其中女性116人(55.2%),男性94人(44.8%);65-75岁共108人(52.2%),76-85岁共71人(34.3%),86岁及以上共28人(9.9%)。2.认知状态构成:基线期:正常老人共225例(66.0%),成功老人共45例(13.2%),轻度认知损害共42例(12.3%),痴呆老人共12例(3.5%)。第一次随访:正常老人共195例(69.1%),成功老人共23例(8.2%),轻度认知损害共39例(13.8%),痴呆老人共8例(3.2%)。第二次随访:正常老人共154例(73.3%),成功老人8例(3.8%),轻度认知损害老人30例(14.3%),痴呆老人18例(8.3%)。且四组老人所有认知测评项目之间差异均具有显著的统计学意义(P0.05)。3.用混合线性模型探索基线期正常认知功能老人随着时间的推移,MMSE、MOCA及成套神经心理测试(NTB)中不同认知功能维度(数字广度、听觉词语、联想学习、视觉辨认、语言流畅性、延迟回忆、韦氏填图、韦氏木块图)测试分变化的轨迹,结果如下:按年龄段区分时:(1)三个年龄段(60-69岁,70-79岁,≥80岁)基线与随访1之间MMSE和Mo Ca得分无显著差异;而在随访2与基线、随访1对比时,各年龄组的MMSE和Mo Ca得分均有显著下降(P0.05)。(2)三个年龄组老人在数字广度得分随访2与基线差值比较时,只有低龄组60-69岁年龄组得分显著下降(P0.05),(基线-随访2=0.69±0.25分);在韦氏木块图和韦氏填图中的随访2与随访1比较时,亦是低龄组老人下降显著(P0.05),(韦氏木块图:随访1-随访2=1.19±0.33分;韦氏填图:随访1-随访2=1.21±0.46分)。(3)三个年龄组听觉词语测试中,随访1与基线对比时,只有≥80岁组得分无差异;60-69岁(基线-随访1=-0.72±0.19分)及70-79岁组(基线-随访1=-0.94±0.24分)老人得分均显著上升(P0.05);随访2与基线对比,只有60-69岁组老人得分(基线-随访2=-0.66±0.22分)显著上升(P0.05),其余两组无差异;随访2与随访1对比,各年龄段得分均无显著差异。按性别区分时:(1)随访1同基线期相比,总体观察及男性和女性分别比较时,听觉词语学习的均分均有所升高。在韦氏填图中,总体观察时均分有所升高(P0.05),女性组亦有所升高(P0.05),但男性组无显著性变化。其余各项测试中两次的均分无显著性差异。(2)随访2同基线期相比,MMSE,Mo CA中,总体观察及男性和女性分别比较,均分均有所升高(P0.05)。数字广度、韦氏填图测试总体来看均分均有所下降(P0.05);男性组均有所下降(P0.05),女性组则无显著性变化。听觉词语中,总体观察时均分有所上升(P0.05);女性组均分有所上升(P0.05),而男性组无显著性变化。(3)随访2同随访1相比,总体观察时,MMSE,Mo CA,数字广度,视觉辨认功能,韦氏填图测试中均分均有所下降(P0.05)。两性分别比较,女性组数字广度测试均分下降有统计学意义(P0.05),但男性组无显著性差异;男性和女性组视觉辨认功能均分均无显著性差异;而韦氏填图则男性和女性组均分的下降则均有统计学意义(P0.05)。4.(1)运用卡方检验,分析可能与不同认知功能状态(成功老人、正常老人、认知损害老人)相关的因素。纳入分析的自变量有性别、生活习惯(吸烟史、饮酒史、饮茶史、是否运动、是否食鱼、青年、中年、晚年时是否午睡)、业余爱好(读书、音乐、绘画书法、棋牌、上网、摄影、钓鱼、太极拳等)。结果发现,上述所有的自变量中,只有是否运动(P=0.01)、业余爱好(P=0.03)、音乐(P=0.00)、上网(P=0.02)、摄影(P=0.01)和是否食用鱼(P=0.02)与不同层次的认知功能状态相关。(2)用非参数检验分析运动频率、青、中、老年时午睡频率是否和诊断成功老人、正常老人、认知损害老人相关,结果发现上述频率均非显著的影响因素(P0.05)。(3)运用多重线性回归模型探索影响老人MMSE、MOCA、NTB总分的相关因子,纳入分析的变量有:人口学资料(年龄、性别、受教育年数)、生活习惯(吸烟史、饮酒史、饮茶史、是否运动、运动频率、是否食用鱼、青年、中年、老年期平均每晚睡眠时间,是否午睡、午睡频率)、业余爱好(读书、音乐、绘画书法、棋牌、上网、摄影、太极拳等)、患病史(高血压、心脏病、内分泌系统代谢疾病、有明确诊断的其他疾病、手术史、脑外伤史);量表分(SAS、老年抑郁量表、社会支持量表总分)。结果发现,影响MMSE总分的因素:受教育年数(β=-0.24)、音乐(β=0.19);影响MOCA总分的因素有:年龄(β=-0.26)、中午午睡(β=0.14);影响NTB总分的因素有:基线NTB总分(β=-0.76)、受教育年数(β=-0.17)、高血压病史(β=-0.11)。5.随访期内死亡人口调查概况:(1)共有26位老人死亡,女性9人(34.6%),男性17人(65.4%)。其中在第一次随访时死亡的老人共13人,男性8人、女性5人;在第一次随访后至第二次随访期间死亡的老人共13例,男性9人,女性4人。(2)老人死亡原因汇总:因多种疾病去世的老人8例;因肺部感染死亡的老人共5例;因脑出血死亡的老人共5例;因肿瘤死亡的老人共4例;因心肌梗死死亡的老人共1例;因意外跌倒死亡的老人1例;家属称老人“自然老死”,具体原因不详的老人2例。(3)死亡老人生前病史:有卒中史的共10人(38.5%);肿瘤4人(15.4%);有痴呆病史、心脑血管、内分泌系统疾病各3人(均占11.5%);骨折2人(7.7%);消化和泌尿系统疾病各1人(3.8%);家属称不清楚的共12人(46.2%)。6.不同认知状态组老人主观和客观评价一致性:(1)(1)成功老人组:MMSE、MOCA、各认知功能模块AI(Awareness Index)值均为负数,最低值-31.20,最高值-8.54;除韦氏填图、语言流畅性测试中主观和客观的评价差异无统计学意义外(P0.05),其余各认知功能模块均具有统计学意义(P均0.05)。(2)正常认知老人组:MMSE、MOCA、各认知功能模块AI值均值正负不均,最低值-7.32,最高值8.27;除联想学习、视觉辨认功能有统计学意义(P0.05)外,其余各认知功能模块P值均0.05,主客观测评的差异均不具有统计学意义;(3)认知损害组:MMSE、MOCA、各认知功能模块AI值均值均为正数,最低值9.85,最高值21.84;除韦氏木块图P0.05外,其余各认知功能模块P均0.05,主客观测评的差异均具有统计学意义。(2)用单因素方差分析比较三个分组老人在MMSE、MOCA、各认知功能模块测试中的AI值,总体比较和两两比较时P值均0.05,差异具有显著的统计学意义。(3)多元线性回归显示,成功老人组中,受教育年数对AI值有显著影响(P0.05);正常认知老人组,性别对AI值有显著影响(P0.05);认知损害组,受教育年数、性别对AI值均有显著的影响(P0.05)。结论:1.(1)纳入观察老人的总体认知功能评估量表(MMSE,Mo CA)分数随着时间的推移显著下降,但成套神经心理测试(NTB)及其各维度的量表分呈不同规律的变化轨迹。(2)随着时间推移,低龄老人的持续注意、短时记忆功能以及视空间结构的辨认、记忆和理解能力较高龄老人下降速率更快;但学习和近记忆能力能够保持。此外言语性情节记忆、视觉记忆、语义记忆、短时记忆在低龄和高龄层老人中无明显差异。(3)正常认知功能老年人群中女性的事件记忆在一定时间范围内随年龄增长维持较好,而男性老人无此现象,且更容易受学习效应的影响;男性老人视觉空间结构功能随着年龄增长较女性下降更明显。2.不同认知状态的老人在认知测评各个维度的得分中均具有显著的差距。3.(1)运动、食鱼、业余爱好、音乐、上网、摄影和不同层次的认知功能状态相关,且对认知功能有着保护作用。(2)基线期神经心理测试中得分较高、受教育程度高的老人,认知功能下降速度更快。(3)合并高血压是老年认知损害的危险因素。4.随访期内死亡的老人,男性比例较女性高。位列老人非自然死亡原因前三的是心脑血管栓塞、肺部感染和肿瘤。5.成功老人在语义记忆和再现以及视觉结构的辨认、记忆、理解中对自身评估较为准确,在其余认知领域对自身的主观评价均低于客观认知水平,且受教育年限越高越容易低估自己的认知水平。正常认知功能老人对自身认知水平评价较为中肯,其中男性较女性对自身的认知水平评价更为确切。认知损害老人除了在空间关系的辨认、理解中对自身的了解较为恰当外,在其余各认知领域均对自身的认知均有主观的过高评估,且男性较女性更易高估自身的认知水平,受教育年限越低越容易高估自身的认知水平。
[Abstract]:Objective: 1, a prospective follow-up study was conducted based on the "cognitive function characteristics of the elderly 60 years old and above in Guangzhou city and the characteristics of cognitive function change of normal people", and to analyze and compare the baseline (2011), the first follow-up (2012), the second follow-up (2016) longitudinal data, and explore the normal cognitive function at different age groups in the baseline period. The characteristics and trajectories of different cognitive functions of the elderly with the passage of time.2, the analysis of cognitive function in the follow-up period to maintain the supernormal level (the successful old man), the normal level (normal old man), the damage (including mild cognitive impairment and dementia) the living habits of the elderly, emotional symptoms, social support, physical condition, and other similarities and differences, exploration and recognition. .3, a related protective factor of cognitive function, to understand the cause of death of the elderly in the period of investigation and the combination of physical disease.4, and to study the consistency between the subjective and objective evaluation of the cognitive function level of the elderly in the second follow-up period and the related factors affecting the consistency. In Guangzhou, a representative community was selected to study the population of 60 years and older in the community. According to the standard of entry group, the subjects were included in the group. The MMSE, the Mo CA [1-5], the WHO psycho psychological test (WHO-BCAI) [6-12] and so on were used as the investigation tools, and 60 years old and with the research tools. The elderly were tested by one to one neuropsychological test to evaluate the cognitive function of the subjects. In addition, the emotional state of the subjects was assessed using the self rating Anxiety Scale (SAS) and the old age depression scale (GDS); the social support of the subjects was assessed by the social support scale, and the daily life scale (ADL) was used to understand the living function of the subjects. Situation. A year and five years later, with the same survey tool and the same evaluation procedure, the subjects were followed up with the same background, the investigators did not understand the baseline and the first time of the elderly. In the two follow-up, on the basis of the following follow-up, the death questionnaire was added to understand the death of the elderly in the investigation period. The cause, the combination of somatic disease, the time of death and so on. Besides, after the assessment of the cognitive function of each section, the subjects evaluated the test results that they had just completed at the same level of education and the level of the subjects in the same age group (range of -100% to excellent 100%, 10% as the interval interval). The original score is converted into standard score and percentile, the level of subjective evaluation is converted into percentile, the self consciousness index AI (Awareness Index) = subjective test level and objective test level, the degree of discretization of AI values in all cognitive test projects, and the significant degree [13]. of the differences are recorded with SPSS20.0 for data entry, statistics and statistics. Results: 1. basic data: baseline (2011): 660 people should be examined in 341 people, including 162 (47.5%) men and 179 (52.5%) people. The average age of the elderly is about 70.96 + 8.29 years old, among them, 60-69 years and 161 (47.2%), 70-79 years of 125, years old and above (2012): the first follow-up (2012): should look up The response rate of 41 people was 283. The response rate was 132 (46.8%) for men and 150 (53.2%) for women. The average age was 71.69 + 8.50 years old. Among them, 125 people (44.3%), 70-79 year old 112 (44.3%), 132 years old and above were followed up (2016). 65-75 years of age (52.2%), 76-85 years old and 71 (34.3%), 86 years old and more than 28 people (9.9%).2. cognitive status: baseline: the normal elderly 225 cases (66%), successful elderly total 45 cases (13.2%), mild cognitive impairment in a total of 52.2% cases. There were 39 cases of mild cognitive impairment (13.8%) and 8 cases of Dementia Elderly (3.2%). Second cases were followed up: 154 cases of normal elderly (73.3%), 8 (3.8%), 30 cases (14.3%) of elderly patients with mild cognitive impairment and 18 (8.3%) dementia elderly. All the differences of all cognitive assessment items in the elderly were statistically significant (P0.05).3. with mixed linear The model explored the track of different cognitive function dimensions (Digital breadth, auditory word, association learning, visual identification, language fluency, delayed recall, Wechsler's filling, Wechsler block diagram) in MMSE, MOCA, and complete neuropsychological test (NTB). The results are as follows: according to the age section Timelines: (1) there was no significant difference in the scores of MMSE and Mo Ca between the baseline of three age groups (60-69 years old, 70-79 years old or 80 years old) and the follow-up 1, while the scores of MMSE and Mo Ca in all age groups were significantly decreased (P0.05) during the follow-up 2 and the baseline and the follow-up 1. (2) there was only a lower age in three age groups when compared with the baseline difference of the digital breadth. The scores of the 60-69 year old age group were significantly decreased (P0.05) (baseline - follow up 2=0.69 + 0.25), while the follow-up of the Wechsler block map and the Wechsler map was 2 compared with the follow-up 1 (P0.05). (Wechsler wood block diagram: follow up 1- follow-up 2=1.19 0.33 points; Wechsler fill: follow up 1- follow-up 2=1.21 + 0.46). (3) three age groups hearing. In the word test, there was no difference in the score between the 1 and the 80 years old, and the scores of the elderly (baseline - 1=-0.72 + 0.19) and 70-79 years old (baseline - 1=-0.94 + 0.24) were significantly increased (P0.05), and only 60-69 years old scores (baseline - follow-up - 0.22) were significantly increased (P0.05). There was no difference in the rest of the two groups; there was no significant difference in the scores of all ages between the follow-up 2 and the follow-up 1. (1) compared to the baseline period, the total observation of auditory words learning increased in the overall observation and in the male and female comparison. In the Wechsler mapping, the overall observation was increased (P0.05), and the female group was also somewhat higher. There was no significant change in the male group. There was no significant difference between the two times in the other tests. (2) compared to the baseline period of the 2 same baseline period, the overall observation and the male and female comparison in the 2 and the Mo CA were all increased (P0.05). There was no significant change in the female group (P0.05). In the auditory words, the average score of the total observation was increased (P0.05), the average score of the female group increased (P0.05), but there was no significant change in the male group. (3) compared with the follow-up period of 1, the overall observation, MMSE, Mo CA, the digital breadth, the visual identification function, and the Wechsler mapping were all subdivided. P0.05. There was a significant difference between the two sexes, but there was no significant difference between the female group and the male group (P0.05), but there was no significant difference in the male and female groups, while the Wechsler and the Wechsler mapping were statistically significant (P0.05).4. (1) using chi square test, Analysis of factors related to different cognitive functions (successful elderly, normal elderly, cognitive impairment). The independent variables included sex, living habits (smoking history, drinking history, tea history, sports, fish eating, youth, middle age, NAP), hobbies (reading, music, painting, calligraphy, chess, Internet, and photography) It was found that among all the variables, only exercise (P=0.01), hobby (P=0.03), music (P=0.00), Internet (P=0.02), photography (P=0.01) and food fish (P=0.02) were related to the cognitive energy status of different levels. (2) the frequency of exercise was analyzed by nonparametric test, in green, middle and old, the nap frequency was The results showed that the above frequency was not significant (P0.05). (3) the multiple linear regression model was used to explore the related factors affecting the total score of MMSE, MOCA, and NTB. The variables included: demographic data (age, sex, year of Education), living habits (smoking) History, drinking history, drinking tea history, sports frequency, eating fish, youth, middle age, average sleep time, nap, nap frequency), hobbies (reading, music, painting and calligraphy, chess and cards, Internet, photography, Taijiquan, etc.), history of disease (hypertension, heart disease, endocrine system metabolic diseases, and other definite diagnosis) Disease, surgical history, brain trauma history); scale (SAS, senile depression scale, social support scale). The results showed that the factors affecting the total score of MMSE were the year of Education (beta =-0.24) and music (beta =0.19); the factors affecting the total score of MOCA were age (beta =-0.26) and noon nap (beta =0.14); the factors affecting the total score of NTB were: baseline NTB total score (beta =-0.76), teaching The number of years of birth (beta =-0.17), the history of hypertension (beta =-0.11).5. during the follow-up period of the death population survey: (1) there were 26 elderly deaths, 9 women (34.6%) and 17 men (65.4%). Among them, 13 people died at the first follow-up, 8 men and 5 women, and the elderly who died during the first follow-up to second follow-up were 13, male 9. There were 4 people and women. (2) the reasons for the death of the elderly were 8 cases, 8 elderly patients died of various diseases; 5 elderly patients died of pulmonary infection; 5 elderly patients died of cerebral hemorrhage; 4 elderly patients died of cancer; 1 elderly patients died of myocardial infarction; 1 elderly deaths due to accidental fall; the family called the old man "natural death", specific original 2 cases of unknown elderly. (3) the history of the death of the elderly: 10 (38.5%) with a history of stroke; 4 tumors (15.4%); 3 (11.5%) with the history of dementia, cardio cerebral vessels, and endocrine system diseases; 2 (7.7%) of the fracture, 1 (3.8%) of digestive and urinary system diseases; the family members who were not well known (46.2%).6. different cognitive state group. The conformance of view and objective evaluation: (1) (1) the successful elderly group: MMSE, MOCA, each cognitive function module AI (Awareness Index) values are negative, the minimum value -31.20, the highest value -8.54; except Wechsler filling, the subjective and objective evaluation differences in the language fluency test are not statistically significant (P0.05), and the other cognitive functional modules have statistical significance (P). (0.05) 0.05) (2) normal cognitive elderly group: MMSE, MOCA, the mean value of each cognitive function module is positive and negative, the minimum value is -7.32, and the maximum value is 8.27. Except association learning, the visual identification function is statistically significant (P0.05), the other cognitive function modules P values are all 0.05, and the difference of subjective and objective evaluation is not statistically significant; (3) cognitive impairment group: MMSE, MOC A, the mean value of AI values of each cognitive function module were positive, the minimum value was 9.85, the highest value was 21.84. Except the Wechsler block diagram P0.05, the other cognitive function modules P were 0.05, and the differences in subjective and objective evaluation were statistically significant. (2) the AI values in the tests of MMSE, MOCA, and the cognitive function modules were compared with the three groupings of variance analysis. The P value of the comparison and 22 was 0.05, and the difference had significant statistical significance. (3) multiple linear regression showed that the number of educated years had significant influence on the value of AI (P0.05) in the successful elderly group (P0.05); the normal cognitive elderly group had significant influence on the value of AI (P0.05); the cognitive impairment group, the number of years of education, the gender had significant influence on the AI value (P0.05). Conclusion: 1. (1) the total cognitive function assessment scale (MMSE, Mo CA) of the elderly was significantly decreased with time, but the set of neuropsychological tests (NTB) and its dimensions were changed in different rules. (2) the continuous attention, short-term memory function and visual spatial structure of the low age old people with time. The ability of memory and understanding is faster than that of older people, but learning and near memory ability can be maintained. There is no significant difference in verbal plot memory, visual memory, semantic memory and short-term memory in old and elderly people. (3) the event memory of women in the normal cognitive function elderly population follows a certain period of time. Age growth is maintained well, while male elderly do not have this phenomenon, and are more susceptible to learning effects; male elderly visual spatial structure.
【学位授予单位】：广州医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R749.1

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