- 學位論文
布雷斯氏失智量表在老年族群之應用
Application of Blessed Dementia Rating Scale in Elderly Chinese Population
摘要
本研究乃在於決定布雷氏失智量表(Blessed Dementia Rating Scale, BDRS) 之運用價值，與決定此量表在臨床上使用之常模與判斷值，以期在一般之研究篩檢中，能區分出社區中65歲以上老年人口為:正常、輕度認知功能缺損或是失智症之患者。 除此之外，尚要進一步去探討不同之年齡、教育程度及性別對布雷斯氏失智量表之影響。同時，我們也和目前臨床上廣泛使用的簡易智能狀態檢查(Mini-mental Status Examination, MMSE) 相比較，進一步分析此兩種量表在臨床上之適用性。 此為一項兩階段，維持三年追蹤之研究，第一階段為由訓練過之訪員或醫學生進行地區田野式篩選調查，第二階段為由資深神經科專科醫師及臨床神經心理師進行的臨床診斷工作。以高雄市、高雄縣、屏東縣的65歲或以上老人為對象，採三階段分層機率抽樣，共抽樣4015名。 在兩階段訪查方面, 第一階段為篩選調查，包括:詳細人口學資料及個人基本資料、簡易智能狀態檢查，布雷斯氏失智症量表評估、臨床失智症量表( Clinical Dementia Rating Scale) 之評量及醫學病史之獲得。在第一階段為篩選調查之徵召各群中,MMSE低於臨界值者，需接受訪視作第二階段檢查，包括:詳細病程問診、神經學檢查，CERAD 及全套神經心理學測驗。 第一年共完成有效訪視2884名，且持續地追蹤兩年，第二年和第三年分別有100名和43名異常者(CDR>=0.5)接受徵召，總共使我們的統計樣本數到達3027名。此些結果以線性回歸及ROC (Receiver Operating Characteristic ) 曲線分析。 在我們的結果中可以發現，年齡為65-74歲的識字組中，布雷斯氏失智症量表在不論是在正常和輕度認知功能缺損組(組合一)，或是在輕度認知功能缺損和失智症組(組合二)都有著最高之鑑別率(圖形下之面積: 組合一:0.8269；組合二:0.6726)。除此之外，在其他不同年齡和教育程度組別中，布雷斯氏失智症量表運用時，在組合二之鑑別率，比在組合一之鑑別率來的高，此一發現恰好是和簡易智能狀態檢查量表是相反的。 最後我們也找出布雷斯氏失智症量表的判斷值如下所述: (1). 在組合一且年齡為65-74歲的識字組和不識字組中，分別為1 (敏感度=78.79%; 精確度=68.05%) 和1.5 敏感度=51.81%; 精確度=69.47%)。 (2). 在組合一且年齡大於74歲的識字組和不識字組中，分別為1 (敏感度=58.33%; 精確度=65.25%) 和2 (敏感度=51.17%; 精確度=70.86%)。 (3). 在組合二且年齡為65-74歲的識字組和不識字組中，分別為2.5 (敏感度=61.11%; 精確度=72.73%) 和2.5 (敏感度=70.27%; 精確度=72.29%)。 (4). 在組合二且年齡大於74歲的識字組和不識字組中，分別為2.5 (敏感度=72.73%; 精確度=75.00%) 和3 (敏感度=71.26%; 精確度=79.71%)。 布雷斯氏失智症量表是一種省時間，且簡易施行較不受病人失智症嚴重程度干擾之量表。除了在65-74歲有受教育組外，布雷斯氏失智症量表在對於區別失智症和輕度認知功能缺損，有著比區別正常和輕度認知功能缺損組有著較高之鑑別率。 對於65-74歲有受教育組，臨床上遇到不少的病人大多是屬於此相近年齡和教育程度，而布雷斯氏失智症量表，對於此一族群之應用，不論是要鑑別正常和輕度認知功能缺損，或是要鑑別失智症和輕度認知功能缺損，都有著不錯之鑑別率，而且更應該廣泛被應用在這一族群。
並列摘要
The purposes of this study were dedicated to determine the cut-off values of the Blessed Dementia Rating Scale (BDRS) for identifying elderly Chinese population as normal, having mild cognitive impairment (MCI) or demented, to determine the testing consistency in educational level, age, gender and dementia or not, and also revealed its clinical application compared with Mini-mental Status Examination (MMSE). A two-phase cross-sectional study following up for two years was conducted with a demographic questionnaire, Chinese-adapted versions of MMSE, BDRS and Clinical Dementia Rating Scale (CDR) which were performed by trained interviewers in phase1. A comprehensive neuropsychological test, physical and neurological exams were done by senior neurologist in the phase 2 for the questionable subjects recruited from phase 1. Non-demented patients (CDR≦0.5) were kept follow-up continuously till the third year. Multi-step stratified random sampling was applied to recruit 4015 people aged 65 and over from southern Taiwan. 2884 out of the 4015 (71.83 %) participants completed the study in the first year and kept follow-up throughout the following two years. Participants completed the study, and subjects with CDR≧0.5 in the second, and third year were enrolled for statistic analysis. MMSE, BDRS, and CDR were subjected to receiver operating characteristic (ROC) curve and regression analysis. As compared with MMSE, BDRS was suitable discriminative parameter for distinguishing normal form MCI (Combination 1), and MCI from dementia (Combination 2) in literate aged 65-74 subjects for its largest AUC (Combination 1: 0.8279; Combination 2:0.6726). Except this group, BDRS showed its potential in Combination 2 in contrast to MMSE in Combination 1. In Combination 1, BDRS cut-off values were received as follows: (1). literate aged 65-74:1(sensitivity 78.79%; specificity 68.05%). (2). illiterate aged 65-74:1.5(sensitivity 51.58%; specificity 69.47%). (3). literate aged≧75:1(sensitivity 58.35%; specificity 65.25%). (4). illiterate aged≧75:2 (sensitivity 52.17%; specificity 70.86%). In Combination 2: BDRS cut-off values were received as follows: (1). literate aged 65-74:2.5(sensitivity 61.11%; specificity 72.73%). (2). illiterate aged 65-74:2.5(sensitivity 70.27%; specificity 72.29%). (3). literate aged≧75:2.5(sensitivity 72.73%; specificity 75%). (4). illiterate aged≧75:3(sensitivity 71.26%; specificity 79.71%). Apart from literate aged 65-74 subjects, BDRS, a simple, brief, timesaving, and highly reliable questionnaire, may be considered in most clinical application to tell MCI from dementia than MCI from normal in opposite to MMSE does.As far as literate aged 65-74 subjects encountered mostly in clinic are concerned, BDRS still is the most appropriate discriminative parameter not only in distinguishing MCI from normal but in MCI from dementia.