闡述臺灣慢性腎臟病及透析族群身體性、認知性及社會性衰弱之特徵與相關，以及三種衰弱與其危險因子及預後指標之關連情形

To elucidate the relationship among physical frailty, cognitive frailty, and social frailty and their associations with the risk factors and outcome indicators in Taiwan’s CKD and ESRD population

陳殷正(Yin-Cheng Chen)

指導教授 ： 張睿詒

國立臺灣大學/公共衛生學院/健康政策與管理研究所/博士(2020年)

https://doi.org/10.6342/NTU202002240

摘要

研究目的：臺灣已於民國107年3月進入高齡社會，老年人健康與照護是重要議題，尤其是會導致老年人依賴的失能，更加值得注意。在2016年，臺灣十大失能調整生命年（DALY）的前十大原因中，糖尿病(DM)（排名第一）和慢性腎臟病(CKD)（排名第十）造成的DALY是少數幾個高於全球均值的疾病。因為DM後期也會進入CKD狀態，CKD可謂是兩者共同最終途徑，臺灣需要特別關注CKD造成的失能。衰弱是失能的前期，仍具可逆性，是防止失能的關鍵時期。傳統衰弱定義主要侷限於身體功能面向，不過衰弱的概念持續進展，全面的衰弱應涵蓋更多面向，包括心理和社會面向的衰弱。心理面向的衰弱目前以較多證據的認知性衰弱(CF)代表，輕度認知障礙為衰弱指標；社會性衰弱(SF)則以缺乏資源滿足個人社會需求的概念來陳述。根據以往的研究，在CKD族群，身體性衰弱(PF)與腎絲球過濾率呈負相關，但與CF和SF之間的關係尚不清楚。本研究針對一個CKD/HD/PD世代進行PF、CF和SF的調查，並闡述三種衰弱及其危險因子和預後指標的關係，期望藉此找出可介入的危險因子，並了解三種衰弱對預後的衝擊，提供台灣因應CKD造成失能重大危害的最佳應對之道。
研究方法：本研究為前瞻性多中心調查研究，納入符合收案標準的CKD/HD/PD病人進行研究。PF以SOF測量，SOF量表總共有3個項目，每個項目計1分：0分是健壯，1分是衰弱前期，等於或超過2分是衰弱。CF以MoCA測量，MoCA量表：MoCA >= 24為正常，MoCA <= 23為MCI，但排除MoCA <=19因為恐有嚴重認知障礙已造成失能了。SF以Makizako量表測量，Makizako量表共有5個項目，每個項目計1分：0分是健壯，1分是衰弱前期，等於或超過2分是衰弱。失能狀況以ADL和IADL來共同來評估。一般健康識能由基本，溝通和批評識能組成。腎臟病健康識能包括腎臟基本知識、CKD預防、日常腎臟健康和促進、CKD飲食和藥物使用。同時也收集受試者的基本資料及相關檢驗報告共同分析。本研究提出以結合PF、CF及SF為整體的全面性衰弱模型架構來評估衰弱，並針對三種衰弱與其危險因子，以及三種衰弱與預後指標，分別進行分析比較，同時採用結構方程式來檢驗整體模型配適情形，以p < 0.05為顯著性標準。
研究結果：本研究共收案337位CKD病人，233位PD病人，154位HD病人。在CKD族群，PF方面，64.26％為健壯，26.13％為衰弱前期，9.61％為衰弱。CF方面，68.46％為正常，31.5％為衰弱。SF方面，45.21％為健壯，31.14％為衰弱前期，23.65％為衰弱。傳統身體性衰弱評估非衰弱的病人實際上仍有超過3成尚有CF或SF。衰弱相較於健壯者導致失能的風險：PF（OR = 14.14，p<0.05），CF（OR = 13.38，p<0.05）和SF（OR = 9.57，p<0.05）。三種衰弱和年齡、性別、運動，共病、單身、獨居及腎臟病健康識能等危險因子各有不同顯著相關。調整上述因子後，仍與年齡、運動、共病、單身及腎臟病健康識能顯著相關。PF與eGFR呈負相關（p <0.05），CF與eGFR呈微弱負相關（p < 0.1），SF則與eGFR無關。三種衰弱皆和營養相關指標，包括白蛋白、血紅素、血脂肪等有不同程度負相關。三種衰弱都和失能顯著相關，也和門急住診利用增加相關。HD和PD族群也和CKD族群有相近的結果，他們的危險因子相關性較CKD族群少，但失能和醫療利用增加亦皆達顯著相關，HD和PD都有更顯著的社會性衰弱。用結構方程式檢驗全面性衰弱理論架構顯示尚可接受模型配置，腎臟功能與三種衰弱皆達顯著負相關，而三種衰弱也顯著相關於失能。
研究討論：在CKD族群PF的盛行率為9.61％，高於普通人群（5%）約一倍；CF的盛行率（31.5％）也遠高於一般人群（18％）。SF的盛行率亦高達23.65％，CKD病人整體衰弱的情形非常驚人，傳統身體性衰弱評估也大大低估病人的實際衰弱狀況。三種衰弱和年齡均呈負相關，遺傳因子、抽菸、喝酒及檳榔與三種衰弱皆未相關，推測這些因子影響生命早期，對老年的影響式微。運動可減少PF，甚至也可以降低SF及CF，更廣泛的運動概念的介入是可採行策略。共病理論上會增加衰弱風險，本研究病人三高控制良好，所以衰弱風險增加並不顯著，有效的慢性共病控制應也是防治衰弱的重要策略。單身、獨居、貧窮等社會環境因子也會增加衰弱，尤其是SF。在PD族群獨居者有顯著較高SF，HD族群貧窮且獨居者有更高的SF，獨居透析病人的社會資源缺乏與支持不足要更加重視，應避免上述族群與社會互動減少，造成與社會隔絕導致衰弱。營養狀態也與三種衰弱負相關，不只是白蛋白，血紅素也是重要指標，營養狀態不良的病人須注意是否有衰弱，若有衰弱應盡速矯正營養不足情形。腎臟病健康識能和三種衰弱皆有顯著相關，政策面積極推動慢性疾病健康照護，經由衛教提升病人慢性病相關知識，增進自我健康照護，有助於對抗衰弱。三種衰弱皆顯著相關於ADL/IADL，及其組成的失能，從勝算比看對失能的衝擊PF大於CF及SF。當資源有限時，可考量針對個人衝擊性較大的衰弱面向介入。衰弱也造成無論門診、急診及住院的次數增加的趨勢，造成較高的醫療耗用。面對人口老化，醫療照護資源有限，控制衰弱以減少醫療耗用，應也是對人口老化所帶來醫療照護的衝擊的重要應對之道。
研究結論：CKD是台灣前十大DALY，所造成的DALY並高出世界均值，對臺灣老年人的失能是一大風險。若一路進展到透析治療，更造成社會全體及個人的重大財務及照護負擔。對臺灣而言，減少CKD造成的DALY十分重大，積極介入衰弱以防止失能是關鍵。應針對CKD族群進行全面性衰弱評估，包括PF、CF及SF，並針對各自不足提供客製化的介入策略。運動及營養是傳統有效策略，仍應持續進行；共病的控制也有助於減少衰弱，慢性腎臟病照護也要持續推廣；獨居及貧窮等環境因子應更加關注，適時的社會資源挹注與支持非常重要；深化腎臟病衛教以提升病人腎臟病相關健康識能，也能對抗衰弱發生。納入更多其他醫事專業人員，更全面涵蓋老年腎臟病人照護需求，協助對抗衰弱，減少失能發生，應可有效降低CKD失能對台灣的危害。

關鍵字

慢性腎臟病 ； 身體性衰弱 ； 認知性衰弱 ； 社會性衰弱 ； 失能 ； 健康識能

並列摘要

Objectives: Taiwan entered the aged society in 2018. Disability, making elders dependent, was one of the most concerned health and care issues. In 2016, among the leading 10 causes of disability-adjusted life years (DALY) in Taiwan, diabetes mellitus (DM) and chronic kidney disease (CKD) were the fewer two with higher local DALY than the global average. Since most DM was complicated with nephropathy lately and CKD was the final common pathway for DM and CKD, the reduction of CKD-related disability is relevant for Taiwan. Frailty, the preceding stage of disability and potentially reversible, was the important target. Frailty was raised in 2001 and the physical aspect was assessed initially. The concept of frailty kept evolving and more comprehensive approaches, including psychological and social aspect, were suggested. The frailty in psychological aspect was assessed mainly in cognitive function, so cognitive frailty (CF), indicated by mild cognitive impairment, was used as the representative. Social frailty (SF) was defined as the lack of resources to fulfill the social needs oneself. About the relationship between CKD and frailty, physical frailty (PF) had been found to be negatively associated with estimated glomerular filtration rate (eGFR), but the relationships between eGFR and CF or SF were not clear. The aim of our study is to find the features of the 3 frailties in Taiwan’s elder CKD/HD/PD population and explore how each frailty was associated with personal risk factors and outcome indicators. More modifiable risk factors and the different impact to the outcome of the 3 frailties were explored to help the policy do the best reaction to the threats of CKD related DALY.
Methods: This study was a prospective, multi-center survey research. PF was measured by SOF score. CF was measured by MoCA. SF was measured by Makizako’s score. Disability was evaluated by the combination of ADL and IADL. General health literacy was composed by basic, communicative and criticizing components. Kidney health literacy was assessed by basic kidney knowledge, prevention of CKD, kidney health promotion, CKD diet and CKD related pharmacy. The personal basic data and the lab data were also collected. The “comprehensive frailty model” hypothesis, including PF, CF and SF, was raised to evaluate the individual frailty completely. The relationship between 3 frailties and the risk factors were explored first. And the relationship between 3 frailties and the outcome indicators were analyzed then. Structured equation modeling was used to testify the fitness of our model. p<0.05 was used as the criteria of significance.
Results: Totally 337 CKD, 233 PD, and 154 HD patients were enrolled. In CKD population, for PF, 64.26% was accounted as robust, 26.13% as prefrail, and 9.61% as frail; for CF, 68.46% was accounted as normal and 31.5% as frail; for SF, 45.21% was accounted as robust, 31.14% as prefrail, and 23.65% as frail. The odds ratio of the risk of disability was: PF (14.14), CF (13.38), and SF (9.57) respectively. As for the risk factors, age, exercise, comorbidities, single and CKD health literacy, after adjustment, were related to 3 frailties differently. As for eGFR, PF was negatively associated with eGFR, CF was mildly negatively associated with eGFR, and SF was not associated. 3 frailties were also negatively related to nutritional index. As for outcome indicators, 3 frailties were all related to disability significantly. And they were also related to increased medical use, including outpatient clinics, emergency service and hospitalization. The similar results were shown in HD and PD population. More living alone and poverty, significantly related to SF, were noted in HD/PD population. The “comprehensive frailty model” hypothesis, testified by structural equation model, showed acceptable fitness. eGFR was negatively related to all 3 frailties. 3 frailties were all related to disability.
Discussions and Conclusions: The prevalence of PF, CF and SF in CKD population was 9.61%, 31.5% and 23.65% respectively, much higher than 5%, 18% and 12% in general population. Traditional frailty evaluation mainly on physical aspect underestimated the real frailty status by at least 30%. Exercise helped decrease PF, and even improved SF and CF. Wider exercise concept should be adopted. Nutrition was also negatively associated with 3 frailties. The traditional strategies to frailty, including exercise and nutrition, were effective and should be maintained. Comorbidities increased the risk of frailty and good control helped confine frailty. Besides, kidney health literacy helped resist 3 frailties. The ongoing CKD care and health promotion program, helping CKD control and raise the patients’ kidney health literacy, should be continued and expanded further. More medical professionals should be included. Poor environmental factors, like living alone or poverty, increasing the risk of SF, especially in HD/PD, should be paid much more attention. Timely and sufficient social support was important. All 3 frailties were associated with increased disability and medical use. The impact of each frailty to disability appeared PF > CF ≈ SF. Increased medical use brought more medical consumption. Control of frailties helps save the medical and care expenses. It is urgent meanwhile when Taiwan’s society is getting old rapidly. CKD was top 10 causes of DALY in Taiwan. CKD brought a big threatening to the elders’ health. If CKD progressed into ESRD, the dialysis therapy consumed more personal and societal financial burden. It’s huge for Taiwan to control CKD related DALY. Comprehensive frailty evaluation and aggressive intervention were critical to lower the burden of CKD related DALY in Taiwan.

並列關鍵字

chronic kidney disease ； physical frailty ； cognitive frailty ； social frailty ； disability ； health literacy

參考文獻

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