操作式工具性日常生活活動測驗在台灣老年人的發展與使用

Development and use of a performance-based measurement of IADL for the elderly adults in Taiwan

陳惠媚(Hui-Mei Chen)

指導教授 ： 顏正芳 ； 羅怡卿

高雄醫學大學/醫學院/醫學研究所博士班/博士(2019年)

摘要

日常生活活動(Activity of Daily Living; ADL)功能的健康是一個老年人維持獨立之重要因素。工具性日常生活(Instrumental ADL; IADL)功能被定義為處理日常生活的認知複雜任務之能力，是評估社區獨立生活所必需的指標，傳統問卷式評估IADL有信效度不足的問題，操作式IADL評估可能可以改善此問題。研究目標為驗證一項在台灣新發展的IADL工具，作為老年人認知障礙族群之使用與發展。此工具參照當前國外操作式IADL工具，並考量台灣老年人特性，發展出台灣版操作型工具性日常生活測驗(Taiwan Performance-based IADL; TPIADL)。評估任務內容包括電話簿查詢、金錢計算、食物組成命名、商品挑選以及服藥的規則判斷。本研究第一部分包括研究(一)和研究(二)，分別驗證TPIADL在阿茲海默氏症(Alzheimer’s Disease, AD)及血管性失智者(Vascular Dementia, VaD)之效度。第二部分是研究(三)驗證TPIADL工具在慢性腎臟病(Chronic Kidney Disease, CKD)病患的早期IADL失能之有效性，並探討與身體功能之相關性。
結果在研究(一) AD之效度: TPIADL內在一致性為0.82，與問卷式IADL日常生活量表(r=-0.756) 相關性高；接收者操作特徵(receiver operating characteristic, ROC)曲線下面積達0.90 (95% CI = 0.84–0.97, p<0.01)，TPIADL能區辨AD及非AD狀態，且切分點6/7為最佳判斷值，同時敏感度與特異度依序達為84.6%與75.6%。 結果顯示TPIADL對認知障礙老年人族群為具有效度之IADL施測工具，能替代傳統問卷作為具效度與方便施測的新工具。 研究(二) VaD之效度: TPIADL內在一致性為0.84，與中文版簡易智能狀態檢查 (Mini-Mental State Examination, MMSE) 相關性最高 (r=-0.806)，其次為Lawton IADL的認知項目 (r=-0.756)，為高度相關； ROC曲線下面積為0.888 (95% CI=0.812- 0.965)，TPIADL能區分VaD及非VaD狀態，TPIADL 6/7分為最佳判斷值，敏感度為73.3%，特異度為84.5%。研究(三) 早期偵測CKD失能之有效性:共徵招146名，57名正常老年人和99名第4-5期CKD。兩組TPIADL達差異(p<0.01)，兩分鐘踏步具差異(p<0.01)；且在CKD組，有TPIADL障礙和無TPIADL障礙者，其兩分鐘踏步具差異(p<0.01)。
研究顯示TPIADL對認知障礙老年人族群為具有效度施測工具，能替代傳統問卷作為具效度與方便施測的新工具。對CKD老年人族群的應用，具能早期發現IADL障礙的潛力，對延緩CKD患者日常生活功能是有利的，而CKD的心肺功能的維持或恢復，將有效降低CKD進入失能的風險。

關鍵字

台灣 ； 老年人 ； 失智症 ； 慢性腎臟病 ； 工具性日常生活活動 ； 操作式評估

並列摘要

Objective: The health of the Activity of Daily Living (ADL) function is an important factor in maintaining independence for the elderly. Instrumental ADL is defined as the ability to perform adequately those cognitively complex tasks of daily living considered essential indicator for living on one's own in this society. Performance-based instrumental activities of daily living (IADL) measurement is thought to improve the validity and reliability of conventional tools relying on proxy-reports. The aims of this study were to develop and validate a performance-based measurement of IADL for use in elderly patients with cognitive impairment in Taiwan and other Chinese-speaking communities. Additional aim was to verify the performance-based IADL test for identifying early disability and their association with physical function for advanced chronic kidney disease (CKD) patients.
Methods: Referring to current versions of performance-based IADL, we developed a new Taiwan Performance-based IADL (TPIADL) measurement to minimize literacy dependency and render it compatible with local culture. Participants performed tasks, including finding a telephone number, calculating the correct amount of change, reading the ingredients on a can of food, finding food items on a shelf, and reading instructions on a medicine container. The TPIADL, as well as the Mini Mental State Examination (MMSE), Lawton-IADL and Barthel Index (BI), were performed. The internal consistency, convergent and criteria validity of the TPIADL were examined for elderly patients with cognitive impairment of dementia due to Alzheimer’s disease (DAD) or vascular cognitive impairment (VCI). Additionally, Lawton-IADL and Barthel Index (BI), TPIADL and physical function (2MST, 30 sec-CST, handgrip dynamometer) also be assessed for advanced chronic kidney disease (CKD) patients.
Results: First, The internal consistency of the TPIADL was 0.82. The TPIADL scores were significantly correlated with the Lawton-IADL (r = 0.76, p < 0.001). The area under the relative operating characteristic (ROC) curve was 0.90 (95% CI = 0.84–0.97) to differentiate AD and others. The optimal cut-off point for the TPIADL was 6/7, which gives a sensitivity of 84.6% and a specificity of 75.6%. Second: Cronbach’s alpha of the TPIADL test was 0.84. The TPIADL scores were significantly correlated with the Lawton IADL (r = –0.683, p <0.01). Notably, the TPIADL had a greater correlation with the cognitive domain of Lawton IADL (r = –0.756) than with physical domain of Lawton IADL (r = –0.616). The area under the relative operating characteristic curve was 0.888 (95% CI = 0.812-0.965) to differentiate VaD from other groups. The optimal cut-off point of the TPIADL for detecting VaD was 6/7, which gives a sensitivity of 73.3% and a specificity of 84.5%. Third, only IADL impairment, as detected by TPIADL, was greater than normal health elderly adults. The greater impaired at TPIADL remained statistically associated with the lower ability of 2MST.
Conclusion: TPIADL is a validated instrument for the measurement of IADL in elderly subjects. It is a brief and sensitive tool for the detection of IADL impairment in patients with AD or VaD. Moreover, performance-based measure, as TPIADL, may detect a function limitation before it becomes measurable by traditional self-reported BADL and IADL scales and is mainly associated with cardiac endurance for the advanced CKD. TPIADL might replace conventional assessment as a valid and easily-administered measurement.

並列關鍵字

Taiwan ； The Aged ； Dementia ； Chronic kidney disease ； Instrumental activities of daily living ； Performance- based measurement

參考文獻

1. Ng TP, Niti M, Chiam PC,Kua EH. Physical and cognitive domains of the Instrumental Activities of Daily Living: validation in a multiethnic population of Asian older adults. J Gerontol A Biol Sci Med Sci 2006; 61: 726-35.

2. 林佳臻, 杜明燦, 陳俊傑, 陳宣志, 顏啟華,李孟智. 台灣地區老人自覺健康狀況相關因子之探討. 臺灣老年醫學暨老年學雜誌 2013; 8: 75-89.

3. 台灣失智症協會. 103~150年臺灣地區失智症人口推計報告. 2014; Available from: http://www.ncbi.nlm.nih.gov/pubmed/21058751.

4. Lin RT, Lai CL, Tai CT, Liu CK, Yen YY,Howng SL. Prevalence and subtypes of dementia in southern Taiwan: impact of age, sex, education, and urbanization. J Neurol Sci 1998; 160: 67-75.

5. Liu CK, Lin RT, Chen YF, Tai CT, Yen YY,Howng SL. Prevalence of dementia in an urban area in taiwan. J Formos Med Assoc 1996; 95: 762-8.