【摘要】：目的:1、基于“廣州城區(qū)60歲及以上老人認知功能特點與正常老人認知功能變化特征”課題開展前瞻性隨訪研究,分析和比較基線期(2011年)、第一次隨訪(2012年)、第二次隨訪(2016年)縱向資料的變化,探索基線期不同年齡段正常認知功能老人隨著時間的推移認知功能不同維度變化的特征和軌跡。2、分析隨訪期內認知功能保持超常水平(成功老人)、平常水平(正常老人)、發(fā)生損害(包括輕度認知損害及癡呆)老人的生活習慣、情緒癥狀、社會支持、軀體狀況等的異同,探索認知功能的相關保護因素。3、了解在調查期內死亡老人的死亡原因、生前合并的軀體疾病。4、研究第二次隨訪時不同認知功能狀態(tài)老人對自身認知功能水平主觀與客觀評價的一致性及影響該一致性的相關因素。方法:采用整群抽樣方法在廣州抽取一個具有代表性的社區(qū),以該社區(qū)60歲及以上人群為研究對象,按入組標準納入被試人群,用簡明精神狀態(tài)評定量表(MMSE)、蒙特利爾認知評定量表(Mo CA)[1-5]、世界衛(wèi)生組織成套神經(jīng)心理測驗(WHO-BCAI)[6-12]等為調查工具,對60歲及以上老人進行一對一神經(jīng)心理測試,全面評估被試認知功能的狀況。此外,使用焦慮自評量表(SAS)、老年抑郁量表(GDS)評估被試人群情緒狀態(tài);用社會支持評定量表評估被試人群社會支持情況;用日常生活量表(ADL)了解該被試人群生活功能情況。一年及五年后,分別以同套調查工具和相同的測評程序,由背景相同的調查人員對被試人群進行隨訪,調查員不了解基線及第一次隨訪老人情況。二次隨訪中,在上述隨訪內容的基礎上,加用死亡調查量表,了解調查期內死亡老人的病因、合并軀體疾病、死亡時間等情況。另,加入自我主觀評估項目,在每小節(jié)認知功能測評結束后,由被試評價自己剛剛完成的測試成績在同等教育程度、同年齡被試組中所處的水平(范圍為極差-100%到極好100%,以10%為等距間隔),將客觀得分的原始分轉換為標準分和百分位數(shù),將主觀評估的水平轉換為百分位數(shù),計算自我意識指數(shù)AI(Awareness Index)=主觀測試水平-客觀測試水平,觀察所有認知測試項目中AI值的離散程度,及差異的顯著程度[13]。用SPSS20.0進行數(shù)據(jù)的錄入、統(tǒng)計和分析。結果:1.基本資料:基線期(2011年):應查660人,實查341人,其中男性為162(47.5%)人,女性為179(52.5%)人。調查老人平均年齡約為70.96±8.29歲,其中60-69歲161人(47.2%)、70-79歲125人(36.7%)、80-89歲46人(13.5%)、90歲以上9人(2.6%)。第一次隨訪(2012年):應查341人,實查283人,應答率為83%。其中男性132人(46.8%),女性150人(53.2%),平均年齡71.69±8.50歲,其中60-69歲125人(44.3%),70-79歲112人(39.7%),80歲及以上45人(16.0%)。第二次隨訪(2016年):應查315人,實查210人,應答率為66.7%。其中女性116人(55.2%),男性94人(44.8%);65-75歲共108人(52.2%),76-85歲共71人(34.3%),86歲及以上共28人(9.9%)。2.認知狀態(tài)構成:基線期:正常老人共225例(66.0%),成功老人共45例(13.2%),輕度認知損害共42例(12.3%),癡呆老人共12例(3.5%)。第一次隨訪:正常老人共195例(69.1%),成功老人共23例(8.2%),輕度認知損害共39例(13.8%),癡呆老人共8例(3.2%)。第二次隨訪:正常老人共154例(73.3%),成功老人8例(3.8%),輕度認知損害老人30例(14.3%),癡呆老人18例(8.3%)。且四組老人所有認知測評項目之間差異均具有顯著的統(tǒng)計學意義(P0.05)。3.用混合線性模型探索基線期正常認知功能老人隨著時間的推移,MMSE、MOCA及成套神經(jīng)心理測試(NTB)中不同認知功能維度(數(shù)字廣度、聽覺詞語、聯(lián)想學習、視覺辨認、語言流暢性、延遲回憶、韋氏填圖、韋氏木塊圖)測試分變化的軌跡,結果如下:按年齡段區(qū)分時:(1)三個年齡段(60-69歲,70-79歲,≥80歲)基線與隨訪1之間MMSE和Mo Ca得分無顯著差異;而在隨訪2與基線、隨訪1對比時,各年齡組的MMSE和Mo Ca得分均有顯著下降(P0.05)。(2)三個年齡組老人在數(shù)字廣度得分隨訪2與基線差值比較時,只有低齡組60-69歲年齡組得分顯著下降(P0.05),(基線-隨訪2=0.69±0.25分);在韋氏木塊圖和韋氏填圖中的隨訪2與隨訪1比較時,亦是低齡組老人下降顯著(P0.05),(韋氏木塊圖:隨訪1-隨訪2=1.19±0.33分;韋氏填圖:隨訪1-隨訪2=1.21±0.46分)。(3)三個年齡組聽覺詞語測試中,隨訪1與基線對比時,只有≥80歲組得分無差異;60-69歲(基線-隨訪1=-0.72±0.19分)及70-79歲組(基線-隨訪1=-0.94±0.24分)老人得分均顯著上升(P0.05);隨訪2與基線對比,只有60-69歲組老人得分(基線-隨訪2=-0.66±0.22分)顯著上升(P0.05),其余兩組無差異;隨訪2與隨訪1對比,各年齡段得分均無顯著差異。按性別區(qū)分時:(1)隨訪1同基線期相比,總體觀察及男性和女性分別比較時,聽覺詞語學習的均分均有所升高。在韋氏填圖中,總體觀察時均分有所升高(P0.05),女性組亦有所升高(P0.05),但男性組無顯著性變化。其余各項測試中兩次的均分無顯著性差異。(2)隨訪2同基線期相比,MMSE,Mo CA中,總體觀察及男性和女性分別比較,均分均有所升高(P0.05)。數(shù)字廣度、韋氏填圖測試總體來看均分均有所下降(P0.05);男性組均有所下降(P0.05),女性組則無顯著性變化。聽覺詞語中,總體觀察時均分有所上升(P0.05);女性組均分有所上升(P0.05),而男性組無顯著性變化。(3)隨訪2同隨訪1相比,總體觀察時,MMSE,Mo CA,數(shù)字廣度,視覺辨認功能,韋氏填圖測試中均分均有所下降(P0.05)。兩性分別比較,女性組數(shù)字廣度測試均分下降有統(tǒng)計學意義(P0.05),但男性組無顯著性差異;男性和女性組視覺辨認功能均分均無顯著性差異;而韋氏填圖則男性和女性組均分的下降則均有統(tǒng)計學意義(P0.05)。4.(1)運用卡方檢驗,分析可能與不同認知功能狀態(tài)(成功老人、正常老人、認知損害老人)相關的因素。納入分析的自變量有性別、生活習慣(吸煙史、飲酒史、飲茶史、是否運動、是否食魚、青年、中年、晚年時是否午睡)、業(yè)余愛好(讀書、音樂、繪畫書法、棋牌、上網(wǎng)、攝影、釣魚、太極拳等)。結果發(fā)現(xiàn),上述所有的自變量中,只有是否運動(P=0.01)、業(yè)余愛好(P=0.03)、音樂(P=0.00)、上網(wǎng)(P=0.02)、攝影(P=0.01)和是否食用魚(P=0.02)與不同層次的認知功能狀態(tài)相關。(2)用非參數(shù)檢驗分析運動頻率、青、中、老年時午睡頻率是否和診斷成功老人、正常老人、認知損害老人相關,結果發(fā)現(xiàn)上述頻率均非顯著的影響因素(P0.05)。(3)運用多重線性回歸模型探索影響老人MMSE、MOCA、NTB總分的相關因子,納入分析的變量有:人口學資料(年齡、性別、受教育年數(shù))、生活習慣(吸煙史、飲酒史、飲茶史、是否運動、運動頻率、是否食用魚、青年、中年、老年期平均每晚睡眠時間,是否午睡、午睡頻率)、業(yè)余愛好(讀書、音樂、繪畫書法、棋牌、上網(wǎng)、攝影、太極拳等)、患病史(高血壓、心臟病、內分泌系統(tǒng)代謝疾病、有明確診斷的其他疾病、手術史、腦外傷史);量表分(SAS、老年抑郁量表、社會支持量表總分)。結果發(fā)現(xiàn),影響MMSE總分的因素:受教育年數(shù)(β=-0.24)、音樂(β=0.19);影響MOCA總分的因素有:年齡(β=-0.26)、中午午睡(β=0.14);影響NTB總分的因素有:基線NTB總分(β=-0.76)、受教育年數(shù)(β=-0.17)、高血壓病史(β=-0.11)。5.隨訪期內死亡人口調查概況:(1)共有26位老人死亡,女性9人(34.6%),男性17人(65.4%)。其中在第一次隨訪時死亡的老人共13人,男性8人、女性5人;在第一次隨訪后至第二次隨訪期間死亡的老人共13例,男性9人,女性4人。(2)老人死亡原因匯總:因多種疾病去世的老人8例;因肺部感染死亡的老人共5例;因腦出血死亡的老人共5例;因腫瘤死亡的老人共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;家屬稱老人“自然老死”,具體原因不詳?shù)睦先?例。(3)死亡老人生前病史:有卒中史的共10人(38.5%);腫瘤4人(15.4%);有癡呆病史、心腦血管、內分泌系統(tǒng)疾病各3人(均占11.5%);骨折2人(7.7%);消化和泌尿系統(tǒng)疾病各1人(3.8%);家屬稱不清楚的共12人(46.2%)。6.不同認知狀態(tài)組老人主觀和客觀評價一致性:(1)(1)成功老人組:MMSE、MOCA、各認知功能模塊AI(Awareness Index)值均為負數(shù),最低值-31.20,最高值-8.54;除韋氏填圖、語言流暢性測試中主觀和客觀的評價差異無統(tǒng)計學意義外(P0.05),其余各認知功能模塊均具有統(tǒng)計學意義(P均0.05)。(2)正常認知老人組:MMSE、MOCA、各認知功能模塊AI值均值正負不均,最低值-7.32,最高值8.27;除聯(lián)想學習、視覺辨認功能有統(tǒng)計學意義(P0.05)外,其余各認知功能模塊P值均0.05,主客觀測評的差異均不具有統(tǒng)計學意義;(3)認知損害組:MMSE、MOCA、各認知功能模塊AI值均值均為正數(shù),最低值9.85,最高值21.84;除韋氏木塊圖P0.05外,其余各認知功能模塊P均0.05,主客觀測評的差異均具有統(tǒng)計學意義。(2)用單因素方差分析比較三個分組老人在MMSE、MOCA、各認知功能模塊測試中的AI值,總體比較和兩兩比較時P值均0.05,差異具有顯著的統(tǒng)計學意義。(3)多元線性回歸顯示,成功老人組中,受教育年數(shù)對AI值有顯著影響(P0.05);正常認知老人組,性別對AI值有顯著影響(P0.05);認知損害組,受教育年數(shù)、性別對AI值均有顯著的影響(P0.05)。結論:1.(1)納入觀察老人的總體認知功能評估量表(MMSE,Mo CA)分數(shù)隨著時間的推移顯著下降,但成套神經(jīng)心理測試(NTB)及其各維度的量表分呈不同規(guī)律的變化軌跡。(2)隨著時間推移,低齡老人的持續(xù)注意、短時記憶功能以及視空間結構的辨認、記憶和理解能力較高齡老人下降速率更快;但學習和近記憶能力能夠保持。此外言語性情節(jié)記憶、視覺記憶、語義記憶、短時記憶在低齡和高齡層老人中無明顯差異。(3)正常認知功能老年人群中女性的事件記憶在一定時間范圍內隨年齡增長維持較好,而男性老人無此現(xiàn)象,且更容易受學習效應的影響;男性老人視覺空間結構功能隨著年齡增長較女性下降更明顯。2.不同認知狀態(tài)的老人在認知測評各個維度的得分中均具有顯著的差距。3.(1)運動、食魚、業(yè)余愛好、音樂、上網(wǎng)、攝影和不同層次的認知功能狀態(tài)相關,且對認知功能有著保護作用。(2)基線期神經(jīng)心理測試中得分較高、受教育程度高的老人,認知功能下降速度更快。(3)合并高血壓是老年認知損害的危險因素。4.隨訪期內死亡的老人,男性比例較女性高。位列老人非自然死亡原因前三的是心腦血管栓塞、肺部感染和腫瘤。5.成功老人在語義記憶和再現(xiàn)以及視覺結構的辨認、記憶、理解中對自身評估較為準確,在其余認知領域對自身的主觀評價均低于客觀認知水平,且受教育年限越高越容易低估自己的認知水平。正常認知功能老人對自身認知水平評價較為中肯,其中男性較女性對自身的認知水平評價更為確切。認知損害老人除了在空間關系的辨認、理解中對自身的了解較為恰當外,在其余各認知領域均對自身的認知均有主觀的過高評估,且男性較女性更易高估自身的認知水平,受教育年限越低越容易高估自身的認知水平。
[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.
【學位授予單位】：廣州醫(yī)科大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R749.1

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