體能表現測量對於門診慢性疾病老人衰弱與失能起伏之預測分析

Physical Performance-based Measurements as Predictors of Frailty and Disability Transition in Clients of Geriatric Clinics

何偉強(Wai-Keong Ho)

指導教授 ： 胡名霞

國立臺灣大學/醫學院/物理治療學研究所/碩士(2012年)

https://doi.org/10.6342/NTU.2012.02491

摘要

衰弱症是指多系統的惡化(multisystem deterioration)和生理性的儲備(physiological reserves)下降，也是跌倒、行動不能(immobility)、住院、機構化、死亡的高危險群。衰弱症老人的生活功能和生活品質都會受重大的影響，日常生活需要依賴，進機構率和住院率都比一般老人來得高，使整個醫療體系經濟負擔加重。因此對於台灣衰弱老人的預防，早期偵測，給予介入，逆轉其惡化過程，是極為重要的議題。
老人的體能表現可以反映個人的身體健康狀況，本篇研究目的是以老人的體能表現，如計時起走測驗、行走速度、握力、計時坐到站測試等測試結果作為預測因子，探討與比較衰弱老人和失能老人的體能表現特徵，並預測老人在六個月和二十四個月內衰弱和失能的起伏。進一步，預測衰弱老人進入失能狀態的機率，分析何種體能表現的變異最大，以提供日後給予介入和訓練的參考。
本研究使用國家衛生研究院群體健康科學研究所老人醫學研究組進行中的縱向前溯性觀察研究(longitudinal prospective observational study)的資料作分析，資料收集由2007年5月至2009年1月，在台大醫院家庭醫學部門診及老年醫學部門診徵召個案，基本資料收集後，進行初次的衰弱、失能評估和各項體能測量，並每半年追蹤評估一次，共追蹤兩年。本篇使用邏輯式迴歸分析(Logistic regression analysis) (SPSS PC Version 16.0)進行資料處理與分析，以計時起走測驗、行走速度、握力、計時坐到站測試等體能表現作為自變項，建立各個迴歸模式。以單變項方式來描述體能表現與各個預測變數之間的關係，並進一步以逐步多變項羅吉斯廻歸分析(stepwise multivariate logistic regression analysis)探討何種體能評估最具影響力，並加入年齡、性別、慢性疾病數大於或等於5種、使用慢性藥物數目大於或等於8種等混淆因子(confounding factor )的變項作為共變項。依變項分別為(1)個案六個月和二十四個月內是否發生衰弱起伏，(2)六個月和二十四個月內是否發生失能起伏，(3) 六個月和二十四個月內衰弱老人是否進入失能。
共188位個案完成二十四個月的追蹤，有93位(49.47%)男性，95位(50.53%)女性，平均年齡為78.78±6.26歲(67-90歲)。身體質量指數BMI平均值為25.51±3.75 (16.4-39.2)。沒有衰弱、衰弱傾向、衰弱的個案分別為53位(27.53%)、117位(62.43%)、19位(10.05%)。沒有失能與失能人數為114位(76.2%)和45位(23.8%)。個案的衰弱起伏主要是從沒有衰弱進入衰弱傾向居多(55.6~69.6%)，其次為衰弱傾向進入衰弱(14.7~42.2%)，幾乎沒有個案從沒有衰弱直接進入衰弱狀態(0~2.2%)。個案的失能起伏率為3.8~12.3%。衰弱老人退化至失能的比率為4.1~14.9%。研究結果顯示：(1) 不同衰弱狀態和失能狀態的個案間，行走速度、計時起走測驗、握力、計時坐到站測試(10秒內完成3次)等體能表現均達顯著差異。(2)單變項羅吉斯廻歸分析顯示，老人六個月和二十四個月內發生衰弱起伏、失能起伏、衰弱老人進入失能狀態的預測模式中握力和行走速度為顯著的預測因子，計時起走測驗則只有在六個月內的失能起伏和六個月內衰弱老人進入失能的預測模式中具有顯著意義。(3)多變項羅吉斯廻歸分析顯示，在控制了其他共變量和體能表現的情況下，在衰弱起伏的預測模式中，握力和行走速度為顯著因子。失能起伏的預測模式中，只有行走速度為顯著因子。衰弱老人進入失能的預測模式中沒有達顯著的因子。
本研究結果指出體能表現的評估對於老人的衰弱和失能具有區辨性指標的能力，臨床上可作為初步的篩檢測試(screening test)以找出衰弱和失能的高危族群個案，若篩檢結果為正，則可進一步作其他檢查或給予介入，以逆轉或延緩老人的衰弱退化，預防失能。體能表現的評估能有效預測老人在短期(6個月內)或長期(24個月內)發生衰弱和失能起伏的機率，其中握力、行走速度最重要的指標，計時起走測驗則只有在預測老人短期失能起伏上，也許是一個良好的參考指標。本研究未能找出最具影響力的體能指標來預測衰弱老人退化轉變為失能狀態的發生機率，但以單變項的體能表現來看，握力、行走速度能預測都能預測衰弱老人在短期或長期進入失能的機率，計時起走測驗則只能預測衰弱老人短期的轉變。

關鍵字

衰弱 ； 失能 ； 體能表現 ； 預測 ； 起伏

並列摘要

Frailty is a common geriatric condition that is multisystem deterioration and loss of physiological reserve. The prevalence of frailty was from 11.0% to 14.9% in Taiwan. Several studies confirmed that frailty was associated with adverse health outcomes. It is becoming recognized that frailty may be a pre-disability state with multidimensional and unstable characteristics in the dynamic progression from robustness to multi-organ functional decline. Many common geriatric syndromes have been proposed to contribute to frailty, such as sarcopenia, malnutrition, osteoporosis, and depressive symptoms etc.With advancing age, physical performance declines in older adults. The assessment of physical performance is a critical component in the evaluation of older persons in both clinical and research, because that can represent the personal health statues. Performance based measures should be included in screening protocol to identify older adults who are at high risk to become frail or transit from frailty to disability, how to early detect and to develop effective intervention on frailty, to reverse the deterioration process is a very important issue.
The aims of this study were (1) to compare the physical performance between different frail states and disabled states, (2) to establish a prediction model for frailty transition and disability transition, furthermore, to predict transition from frailty to disability using physical performance measurements.
This present study employed data from the Division of Geriatric research, Institute of Population Health Sciences, National Health Research Institutes, an ongoing prospective, observational study of 65 years and older adults between May 2007and January 2009. Fried's phenotype and Barthel index were used to identify frail and disabled older adults in baseline evaluation. Physical performance, including grip strength, timed chair rise up test (3times/10s), walking speed, time up and go test, were evaluated at baseline. Data were analyzed using forward stepwise binary logistic regression model that performance measure as independent variables and frailty, disability, transition from frailty to disability as dependent variables.
Only 188 participants completed all the baseline and follow up tests were reported. 93 (49.47%) male, 95 (50.53%) female. Mean age was 78.78 ± 6.26 years (67-90 years). Non frail, prefrail and frail peoples were 53 (27.53%), 117 (62.43%), 19 (10.05%). No disabled and disabled peoples were 114 (76.2%) and 45 (23.8%). The results showed that: (1) there were significant differences in physical performances between different frail states and diffetent disabled states, (2) Univariate logistic regression analysis showed that, grip strength and walking speed were significant predictors for frailty transition, disability transition and transition from frailty to disability. Timed up and go test was significant predictors for disability transition and transition from frailty to disability during 6months. (3) Multivariate logistic regression analysis showed that, grip strength (β=-0.06, odds ratio =0.94, 95%CI= 0.89-0.98, p=0.005) and walking speed (β=-1.32, odds ratio =0.27, 95% CI= 0.08-0.89, p=0.03) were significant predictors for frailty transition. In the prediction of disability transition, walking speed (β=-3.48, odds ratio =0.03, 95% CI= 0.01-0.01, p<0.001) was the only significant predictor. There hadn’t find any significant predictors in the prediction model of transition from frailty to disability,
Physical performance assessments have the ability to discriminate the high risk frail or disabled older adults among clients of geriatric clinics, and can be used as a screening test. If the screening results are positive, then further for other examinations or interventions to reverse or delay the degradation in the older adults. Grip strength and walking speed are the important indicators for predict the occurrence probability of frailty transition and disability transition. Timed up and go test is the indicator for the short-term disability transition. The presented study failed to identify the most influential physical indicators to predict the transition from frailty to disability. However, univariate logistic regression analysis showed that, grip strength and walking speed can predict transition from frailty to disability.

並列關鍵字

frailty ； disability ； physical performance ； prediction ； transition

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