- 學位論文
彰化縣骨質密度社區巡迴篩檢計畫
Community-based screening for osteopenia and osteoporosis among elderly people in Changhua County
摘要
背景：國人平均壽命呈現上升趨勢，為此，促進高齡者健康及延緩失能成為了重要的議題，高齡者的潛在危險疾病非常多，骨質疏鬆症則是高齡者中最常見的疾病之一，且因骨質疏鬆症為沉默的疾病，平時無法察覺，一旦發生跌倒而造成骨折，則會使得高齡者的生活陷入失能甚至臥床、死亡的危險之中，為了預防及提早使得高齡者接受骨質疏鬆篩檢，自2019年開始，彰化縣衛生局與骨質疏鬆症學會合作，打造骨質密度篩檢車，進行骨質密度巡迴篩檢，提供長者可近性及可及性的檢查。本研究以彰化縣高齡者骨質疏鬆症篩檢為基礎，欲達成以下研究目：(1)估計彰化縣高齡者骨質流失及骨質疏鬆症盛行率以了解彰化縣高齡者健康需求；(2)探討彰化縣高齡者骨質流失及骨質疏鬆症的危險因子；(3)了解彰化縣不同社區收案來源的高齡者篩檢族群骨質流失及骨質疏鬆症之間的差異；(4)估計彰化縣高齡者骨質流失至骨質疏鬆症的疾病進展。 研究材料與方法：本研究的研究對象是針對彰化縣65歲以上設籍於彰化縣高齡者，透過三種申請篩檢的來源區分為三個族群，分別是(1)社區單位主動邀約：彰化縣一般社區、村里辦公室、醫療院所、鄉鎮公所、農會、老人會等社區主動向衛生局報名篩檢；(2)長照C據點：由彰化縣衛生局主動安排至彰化縣巷弄長照站(C級據點)進行篩檢；(3)整合式篩檢：參加彰化縣衛生局舉辦彰化縣整合式篩檢(萬人健檢)並有意願參加骨密篩檢者。由衛生局派骨質密度巡迴篩檢車至社區進行篩檢，提供骨質密度(雙能量X光吸光式測定儀, dual energy x-ray absorptiometry, DXA)篩檢及高齡者相關問卷檢測，採骨質密度篩檢及問卷調查之方式進行。本論文使用羅吉斯迴歸、多元迴歸(Polytomous regression)，進行篩檢結果骨質疏鬆症對比骨質正常、骨質流失對比骨質正常及骨質疏鬆症對比骨質流失之結果分析，並以機器學習隨機森林方法分析，各個模式亦使用受試者工作特徵曲線揭示危險因子之敏感性和特異性敏感性和特異性的相互關係，顯示各危險因子在預測骨質疏鬆的預測能力，最後運用骨質疏鬆三階段模型預測骨質疏鬆症疾病進展速率之估計。 結果：共計有5,026位高齡者參與此次篩檢計畫，根據篩檢統計結果，可知彰化縣長者骨質疏鬆症盛行率在男性為24.1%，女性則為66.3%，盛行率隨年齡增加而增加。若以三種篩檢場域分類篩檢結果統計可知，長照C據點長者骨質疏鬆症盛行率(男：28.5%；女：68.4%)高於社區單位主動邀約(男：24%；女：65.6%)及整合式篩檢(男：18%；女：57.4%)。 以機器學習隨機森林方法分析骨質疏鬆症危險因子是以性別、停經年齡、BMI、抽菸及喝酒為相對重要因子，骨質流失的危險因子則是以性別、停經年齡、喝酒、BMI及骨質疏鬆病史為相對重要因子。以受試者工作特徵曲線揭示各項危險因子在預測骨質疏鬆症上有較好得預測能力。 以骨鬆模型症三階模式估計自正常至骨質流失之發生率為0.0543，骨質流失至骨質疏鬆症之估計轉移速率為0.0304，若以30歲的正常個案推估其隨著時間的狀態轉變，約於追蹤第15年時(45歲)處於正常個案之機率開始低於骨質流失個案，追蹤25年時(55歲)處於骨質疏鬆症個案機率則開始高於正常個案機率。依據其結果對比性別，女性轉移速率快於男性。比較各篩檢場域移速率風險，正常至骨質失失的轉移風險為整合式篩檢風險最低；而自骨質流失至骨質疏鬆的風險也是整合式篩檢風險最低。 結論：本研究利用彰化縣主動骨質密度篩檢活動發現長者的骨質疏鬆症在男性為24%、女性為66%，且不同社區場域高齡者的骨質流失及骨質疏鬆症盛行率有所有不同，而篩檢找到的骨質疏鬆症患者有高達76%並不知道自己的病史，在危險因子方面則找出性別、年齡及BMI均為骨質流失及骨質疏鬆症重要因子。因此，若能早期主動進行長者骨質關懷並予以介入，將可避免其後續骨折風險所帶來的生活品質危害。
並列摘要
Background: The life expectancy in Taiwan has been increasing over decades. Therefore, promoting the health of the elderly and decreasing the risk of disability have become important issues. There are many potential diseases for the elderly, and osteoporosis is one of the most common diseases among the elderly. As osteoporosis is a silent disease, it is usually unaware of. Once a fracture occurrs after falling, the life of the elderly will be incapacitated, even bedridden, and become life-threaten. In order to prevent and attain the elderly trust in osteoporosis early screening, the Changhua County Health Bureau has conducted with the Osteoporosis Society since 2019 to build a bone density screening vehicle to carry out bone density screening inspections and provide accessibility for the elderly. This study investigated the prevalence of osteopenia and osteoporosis in the elderly in Changhua County. The purposes of this study are as follows (1) to understand the need for the elderly by investigating the prevalence of osteoporosis and osteoporosis in the elderly (2) to investigate the risk factors of osteopenia and osteoporosis in the elderly; (3) to understand the differences in osteopenia and osteoporosis among the elderly screening groups from different sources; (4) to estimate the progression of osteopenia to osteoporosis in the elderly in Changhua County. Materials and methods: This study targeted at senior residents aged 65 and above in Changhua County. There were three screening settings, including (1) Community-initiated: Changhua community, village office, and medical institution , township offices, peasants’ associations, senior citizens’ associations and other communities actively requested screening from the Health Bureau; (2) Changhua long-term care (LTC) of stronghold C (also called LTC stations around the blocks); (3) Changhua Community-based Integrated Screening (CHCIS) program organized by the Changhua County Health Bureau. The Bone Density Screening Vehicle was sent to the community by the Changhua Health Bureau for screening. Bone density measured with Dual-energy X-ray absorptiometry (DXA) and questionnaires of demographic features and associated risk factors were collected. Logistic regression and Polytomous regression model were performed to compare the risk factors for osteopenia and osteoporosis. Furthermore, random forest method of artificial intelligence and receiver operating characteristic (ROC) curves were applied to evaluate the predictability of risk factors for outcomes of osteopenia or osteoporosis. Finally, a 3-state disease natural history model for osteoporosis was used to estimate progression rate of osteoporosis by gender and screening settings. Results: A total of 5,026 elderly people participated in the screening program. The prevalence of osteoporosis among the elderly in Changhua County is about 24.1% for men and 66.3% for women. In both sex, the prevalence increased with age. The prevalence of osteoporosis was highest in the LTC of stronghold C (men: 28.5%, women: 68.4%), followed by community-initiated (men: 24%, women: 65.6%), and CHCIS (men: 18%, women: 57.4%). Using random forest method, gender, age at menopause, BMI, smoking and drinking were the relatively important factors for osteoporosis. As for osteopenia, gender, age at menopause, drinking, BMI and history of osteoporosis were the main risk factors. According to ROC curve, multiple risk factors have good predictability in predicting osteoporosis. The incidence rate of osteopenia was estimated as 0.0543. The progression rate from osteopenia to osteoporosis was 0.0304. For a 30 years-old subject with normal bone density, the probability of being normal at 15-year follow-up was lower than that of being osteopenia. At 25 years (55 years old) follow-up, the probability of being osteoporosis starts to be higher than the that of being normal. The progression rate for females was faster than that of males. Comparing the risk of progression rate for different screening setting, the risk of progression from normal to osteopenia is the lowest for CHCIS; and the risk of osteopenia to osteoporosis is also the lowest for CHCIS, compared to the other two. Conclusion: The prevalence of osteoporosis in the elderly in Changhua was 24% for men and 66% for women. The prevalence varies in different screening settings. Around three-thirds of patients of osteoporosis were unaware of their osteoporosis history. Gender, age and BMI were important factors for osteopenia and osteoporosis. An acitive screening and accomanpying intervention could prevent elderly from a lost quality of life due to low bone marrow density related falling.