李淑娟，劉 倩，李言洵，蔣曉燕，王笑峰，胡志灝，胡文立*

·論著·

老年認(rèn)知功能障礙與運(yùn)動(dòng)功能的相關(guān)性研究

李淑娟1，劉 倩1，李言洵1，蔣曉燕2，王笑峰3，胡志灝1，胡文立1*

背景 老年人的認(rèn)知功能和軀體運(yùn)動(dòng)功能均會(huì)有不同程度的減退，老年人認(rèn)知功能與簡(jiǎn)單的運(yùn)動(dòng)功能的相關(guān)性鮮見(jiàn)報(bào)道。目的 探討老年認(rèn)知功能障礙(CI)與運(yùn)動(dòng)功能的相關(guān)性。方法 2014-11-13至2014-12-21從如皋市江安鎮(zhèn)招募了1 788例年齡為70～84歲的老年人。根據(jù)改良長(zhǎng)谷川癡呆量表(HDS-R)評(píng)分分為正常組(≥31.0分)、邊緣狀態(tài)組(22.0～30.5分)、可疑癡呆組(10.5～21.5分)、癡呆組(≤10.0分)，采用起立-行走計(jì)時(shí)測(cè)試檢測(cè)老年人運(yùn)動(dòng)功能，記錄測(cè)試時(shí)間、步態(tài)穩(wěn)定性及摔倒危險(xiǎn)性評(píng)分。結(jié)果 共1 655例老年人完成HDS-R及起立-行走計(jì)時(shí)測(cè)試，其中正常組109例、邊緣狀態(tài)組674例、可疑癡呆組833例、癡呆組39例。正常組測(cè)試時(shí)間短于邊緣狀態(tài)組、可疑癡呆組、癡呆組，步態(tài)穩(wěn)定率高于可疑癡呆組、癡呆組，摔倒危險(xiǎn)性評(píng)分低于可疑癡呆組、癡呆組(P<0.05)；邊緣狀態(tài)組測(cè)試時(shí)間短于可疑癡呆組、癡呆組，步態(tài)穩(wěn)定率高于可疑癡呆組、癡呆組，摔倒危險(xiǎn)性評(píng)分低于可疑癡呆組、癡呆組(P<0.05)；可疑癡呆組測(cè)試時(shí)間短于癡呆組，摔倒危險(xiǎn)性評(píng)分低于癡呆組(P<0.05)。HDS-R評(píng)分與起立-行走計(jì)時(shí)測(cè)試的測(cè)試時(shí)間、步態(tài)穩(wěn)定率和摔倒危險(xiǎn)性評(píng)分呈負(fù)相關(guān)(相關(guān)系數(shù)分別為-0.243、-0.120和-0.163，P<0.001)。結(jié)論 老年人認(rèn)知功能和軀體運(yùn)動(dòng)功能減退，隨著步態(tài)不穩(wěn)定以及摔倒危險(xiǎn)性的增加，CI的風(fēng)險(xiǎn)明顯增加。

認(rèn)知障礙；運(yùn)動(dòng)障礙；運(yùn)動(dòng)試驗(yàn)；老年人

李淑娟，劉倩，李言洵，等.老年認(rèn)知功能障礙與運(yùn)動(dòng)功能的相關(guān)性研究[J].中國(guó)全科醫(yī)學(xué)，2017，20(18)：2193-2196.[www.chinagp.net]

LI S J,LIU Q,LI Y X,et al.Correlation between cognitive impairment and motor function in the elderly[J].Chinese General Practice，2017，20(18)：2193-2196.

隨著我國(guó)人口老齡化進(jìn)程的不斷加速，認(rèn)知功能障礙(CI)及癡呆患者的數(shù)量也不斷增加，我國(guó)癡呆患者超過(guò)5%，約占全世界患者總數(shù)的1/4，且每年約30萬(wàn)人發(fā)生癡呆[1]。而近期有研究報(bào)道老年CI者運(yùn)動(dòng)功能減退[2-4]，有CI者運(yùn)動(dòng)功能比無(wú)CI者更差[5]。 BURACCHIO等[6]在一項(xiàng)長(zhǎng)達(dá)20年的研究中發(fā)現(xiàn)，步行、拍手速度等運(yùn)動(dòng)功能與認(rèn)知功能下降密切相關(guān)，步行速度的下降甚至可預(yù)測(cè)CI的發(fā)生。近期的系統(tǒng)綜述也支持步行異常提示CI的發(fā)生[7]。

起立-行走計(jì)時(shí)(TUG)測(cè)試是近20余年來(lái)臨床廣泛使用的簡(jiǎn)單、快速評(píng)價(jià)運(yùn)動(dòng)功能的方法之一[8]。其僅需極少量設(shè)備，測(cè)試了包括從坐到站立及從站立到坐下的轉(zhuǎn)身、直線行走、平衡控制等運(yùn)動(dòng)功能[9]。TUG測(cè)試及其衍生出來(lái)的多種測(cè)試在致殘性疾病、老年人摔倒風(fēng)險(xiǎn)、CI運(yùn)動(dòng)功能評(píng)價(jià)等中得到了廣泛認(rèn)可[9-12]。

隨著年齡增長(zhǎng)，老年人的認(rèn)知功能和軀體運(yùn)動(dòng)功能均會(huì)有不同程度的減退[13]，本研究試圖探索老年人認(rèn)知功能與簡(jiǎn)單的運(yùn)動(dòng)功能的關(guān)系，以期加深對(duì)CI患者合并運(yùn)動(dòng)功能異常的認(rèn)識(shí)，為防止CI老年人群摔倒致殘及通過(guò)運(yùn)動(dòng)鍛煉延緩CI進(jìn)展提供借鑒。

1 資料與方法

1.1 納入與排除標(biāo)準(zhǔn) 納入標(biāo)準(zhǔn)：(1)年齡70～84歲；(2)可以獨(dú)自或借助工具移動(dòng)、轉(zhuǎn)身完成TUG測(cè)試；(3)能夠配合完成改良長(zhǎng)谷川癡呆量表(HDS-R)；(4)簽署知情同意書。排除標(biāo)準(zhǔn)：(1)下肢創(chuàng)傷史造成的行走障礙；(2)重度心肺疾病造成的活動(dòng)受限；(3)有聽(tīng)力或表達(dá)障礙的患者。

1.2 一般資料 2014-11-13至2014-12-21從如皋市江安鎮(zhèn)招募了1 788例年齡為70～84歲的老年人。均由經(jīng)統(tǒng)一培訓(xùn)的醫(yī)務(wù)人員進(jìn)行問(wèn)卷調(diào)查及體格檢查，抽取晨起空腹血檢測(cè)血糖、血脂等常規(guī)生化指標(biāo)。本研究由復(fù)旦大學(xué)生命科學(xué)學(xué)院為牽頭單位完成，通過(guò)了復(fù)旦大學(xué)倫理委員會(huì)審查。

1.3 認(rèn)知功能評(píng)價(jià) 認(rèn)知功能評(píng)價(jià)采用HDS-R[14-15]，對(duì)該人群的定向力、記憶力、近記憶力、計(jì)算力及常識(shí)這5個(gè)方面進(jìn)行評(píng)價(jià)，總分32.5分。根據(jù)HDS-R評(píng)分將老年人分為正常組(≥31.0分)、邊緣狀態(tài)組(22.0～30.5分)、可疑癡呆組(10.5～21.5分)、癡呆組(≤10.0分)。

1.4 運(yùn)動(dòng)功能評(píng)價(jià) 采用TUG測(cè)試[9]評(píng)價(jià)老年人的運(yùn)動(dòng)功能。準(zhǔn)備一張有扶手的靠背椅和一個(gè)秒表，主要評(píng)價(jià)患者的軀體運(yùn)動(dòng)功能。評(píng)定時(shí)患者著平常穿的鞋，坐在有扶手的靠背椅上(椅子座高約45 cm，扶手高約20 cm)，身體靠在椅背上，雙手放在扶手上。如果使用助行具(如手杖、助行架)，則將助行具握在手中。在離座椅3 m遠(yuǎn)的地面上貼一條可見(jiàn)的粗線。測(cè)試者發(fā)出“開(kāi)始”的指令后，患者從靠背椅上站起。站穩(wěn)后，按照平時(shí)走路的步態(tài)，向前走3 m，過(guò)粗線后轉(zhuǎn)身，然后走回到椅子前，再轉(zhuǎn)身坐下，靠到椅背上。測(cè)試過(guò)程中不能給予任何軀體的幫助。正式測(cè)試前，允許患者練習(xí)1～2次，以確保患者理解整個(gè)測(cè)試過(guò)程。測(cè)試者記錄患者背部離開(kāi)椅背到再次坐下(靠到椅背)所用的時(shí)間(測(cè)試時(shí)間)、步態(tài)穩(wěn)定性(是、否)以及在完成測(cè)試過(guò)程中摔倒危險(xiǎn)性評(píng)分(1分：正常；2分：輕微異常；3分：輕度異常；4分：中度異常；5分：重度異常)。

2 結(jié)果

2.1 不同認(rèn)知功能組運(yùn)動(dòng)功能比較 共1 655例老年人完成HDS-R及TUG測(cè)試，其中正常組109例、邊緣狀態(tài)組674例、可疑癡呆組833例、癡呆組39例。不同認(rèn)知功能組的測(cè)試時(shí)間、步態(tài)穩(wěn)定率和摔倒危險(xiǎn)性評(píng)分比較，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。正常組測(cè)試時(shí)間短于邊緣狀態(tài)組、可疑癡呆組、癡呆組，步態(tài)穩(wěn)定率高于可疑癡呆組、癡呆組，摔倒危險(xiǎn)性評(píng)分低于可疑癡呆組、癡呆組，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)；邊緣狀態(tài)組測(cè)試時(shí)間短于可疑癡呆組、癡呆組，步態(tài)穩(wěn)定率高于可疑癡呆組、癡呆組，摔倒危險(xiǎn)性評(píng)分低于可疑癡呆組、癡呆組，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)；可疑癡呆組測(cè)試時(shí)間短于癡呆組，摔倒危險(xiǎn)性評(píng)分低于癡呆組，差異有統(tǒng)計(jì)學(xué)意義(P<0.05，見(jiàn)表1)。

表1 不同認(rèn)知功能組運(yùn)動(dòng)功能比較

注：a為χ2值；與正常組比較，bP<0.05；與邊緣狀態(tài)組比較，cP<0.05；與可疑癡呆組比較，dP<0.05

2.2 CI與運(yùn)動(dòng)功能的相關(guān)性 HDS-R評(píng)分與TUG測(cè)試的測(cè)試時(shí)間、步態(tài)穩(wěn)定性和摔倒危險(xiǎn)性評(píng)分呈負(fù)相關(guān)(相關(guān)系數(shù)分別為-0.243、-0.120和-0.163，P<0.001)。

3 討論

江蘇省如皋市是我國(guó)著名的長(zhǎng)壽之鄉(xiāng)，在全國(guó)第1～5次人口普查中，如皋市老年人在總?cè)丝谥械谋壤黠@高于全國(guó)水平，因此本研究選取該地人群開(kāi)展如皋市衰老隊(duì)列基線調(diào)查以期更好地探討老年人的病理生理特點(diǎn)。隨著我國(guó)人口老齡化進(jìn)程的不斷加速，CI及癡呆患者不斷增加，給家庭及社會(huì)帶來(lái)沉重的經(jīng)濟(jì)負(fù)擔(dān)[16]。研究發(fā)現(xiàn)部分CI患者盡管有一定的日常生活能力，但仍伴有軀體運(yùn)動(dòng)功能下降，這不但增加摔倒風(fēng)險(xiǎn)、加速認(rèn)知功能下降，而且增加了家庭及社會(huì)對(duì)CI患者照看的難度[17]。本研究通過(guò)在如皋市開(kāi)展的以人群為基礎(chǔ)的橫斷面研究，發(fā)現(xiàn)在不同認(rèn)知功能組間TUG測(cè)試的測(cè)試時(shí)間、步態(tài)穩(wěn)定率及摔倒危險(xiǎn)性評(píng)分均有顯著差異，隨著CI的加重，測(cè)試時(shí)間延長(zhǎng)，步態(tài)穩(wěn)定性變差且摔倒危險(xiǎn)度增加。

3.1 隨著CI加重移動(dòng)功能變緩慢 本研究發(fā)現(xiàn)隨著CI進(jìn)展，TUG測(cè)試時(shí)間更長(zhǎng)，提示CI者日常移動(dòng)功能更差，且隨著CI的加重移動(dòng)功能逐漸減退。TUG測(cè)試時(shí)間包括了站立和坐下之間的轉(zhuǎn)換、轉(zhuǎn)身、直線行走所耗時(shí)間[11-12]，其時(shí)間的延長(zhǎng)可能與其中某一過(guò)程或多個(gè)過(guò)程相關(guān)。有研究定量分析了TUG測(cè)試不同過(guò)程，發(fā)現(xiàn)盡管兩組個(gè)體總時(shí)間差異無(wú)統(tǒng)計(jì)學(xué)意義，但CI者站立和坐下之間的轉(zhuǎn)換時(shí)間延長(zhǎng)、轉(zhuǎn)身時(shí)間延長(zhǎng)及步行速變度慢導(dǎo)致行走時(shí)間延長(zhǎng)[18]。

3.2 隨著CI加重步態(tài)穩(wěn)定性更差 本研究中隨著CI進(jìn)展，步態(tài)穩(wěn)定率逐步降低，提示CI者有明顯的步態(tài)變化，這與之前國(guó)外的報(bào)道一致[19]。雖然本研究只是定性判斷步態(tài)情況，但與ALLALI等[4]及LIN等[20]研究對(duì)步態(tài)情況進(jìn)行精確定量后分析得出的結(jié)果一致，這有助于老年照料者通過(guò)觀察患者日常步態(tài)改變意識(shí)到潛在CI的發(fā)生。

3.3 隨著CI加重摔倒危險(xiǎn)性增加 TUG測(cè)試的摔倒危險(xiǎn)性評(píng)分是人為對(duì)整個(gè)測(cè)試中測(cè)試者平衡異常程度的定性評(píng)價(jià)，主要反映了軀體基本運(yùn)動(dòng)功能中的移動(dòng)功能[9]。有關(guān)CI者的平衡控制能力受損及摔倒風(fēng)險(xiǎn)增加已有報(bào)道[17,21]，但相關(guān)機(jī)制尚不明確。有研究結(jié)合頭部影像發(fā)現(xiàn)全腦萎縮是CI者軀體移動(dòng)功能下降的危險(xiǎn)因素[22]，提示全腦退化可能是導(dǎo)致CI及軀體控制功能下降的因素。年齡相關(guān)腦白質(zhì)疏松[23]及相關(guān)腦結(jié)構(gòu)改變所致功能區(qū)纖維聯(lián)系中斷[24]與運(yùn)動(dòng)功能減退相關(guān)亦支持這一觀點(diǎn)。同時(shí)研究表明軀體運(yùn)動(dòng)控制減退者與執(zhí)行功能降低相關(guān)[21,25]。

3.4 本研究結(jié)果的適應(yīng)條件 本研究表明CI老年人群軀體運(yùn)動(dòng)功能減退,對(duì)普通家庭及社區(qū)老年護(hù)理人員而言，照護(hù)CI患者需警惕軀體運(yùn)動(dòng)功能改變所致的潛在摔倒風(fēng)險(xiǎn)。

3.5 本研究局限性 (1)本研究樣本量相對(duì)較小，仍需大規(guī)模、多中心社區(qū)調(diào)查研究來(lái)證實(shí)。(2)作為橫斷面研究不能明確認(rèn)知功能與運(yùn)動(dòng)功能障礙發(fā)生先后及伴隨改變關(guān)系，需行進(jìn)一步前瞻性研究來(lái)明確。

綜上所述，老年人認(rèn)知功能和軀體運(yùn)動(dòng)功能減退，隨著步態(tài)不穩(wěn)定以及摔倒危險(xiǎn)性的增加，CI的風(fēng)險(xiǎn)明顯增加。這有利于社區(qū)醫(yī)療人員及時(shí)發(fā)現(xiàn)老年人CI及追蹤病情變化，為將來(lái)臨床治療老年CI提供理論基礎(chǔ)和診療依據(jù)。

作者貢獻(xiàn)：李淑娟進(jìn)行文章的構(gòu)思與設(shè)計(jì)；李淑娟、蔣曉燕、王笑峰進(jìn)行數(shù)據(jù)收集；李淑娟、劉倩、李言洵進(jìn)行數(shù)據(jù)整理；李淑娟、劉倩、胡志灝進(jìn)行統(tǒng)計(jì)學(xué)處理；李淑娟、劉倩撰寫論文；胡文立對(duì)文章整體負(fù)責(zé)，監(jiān)督管理。

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(本文編輯：崔莎)

Correlation between Cognitive Impairment and Motor Function in the Elderly

LIShu-juan1,LIUQian1,LIYan-xun1,JIANGXiao-yan2,WANGXiao-feng3,HUZhi-hao1,HUWen-li1*

1.DepartmentofNeurology,BeijingChao-YangHospital,CapitalMedicalUniversity,Beijing100020,China2.DepartmentofPathologyandPathophysiology,SchoolofMedicine,TongjiUniversity,Shanghai200092,China3.CollegeofLifeSciences,FudanUniversity,Shanghai200433,China

Background The cognitive and motor functions in the elderly decrease in different degree,but the relationship between them has been seldom reported.Objective To investigate the correlation between cognitive impairment(CI) and motor function in the elderly.Methods The participants were 1 788 70-84-year-old elderly people recruited from Jiang′an Town,Rugao City of China between November 13th and December 21st,2014.Based on the scores of Hasegawa′s Dementia Scale-Revised(HDS-R),they were divided into normal group(≥31.0),conditions between the normal and suspected dementia group(22.0-30.5),suspected dementia group(10.5-21.5) and dementia group(≤10.0).The body movement function of the elderly population was measured by timed up and go(TUG) test.The time needed to complete the TUG test,status of gait stability and the risk of falling were recorded.Results A total of 1 655 participants completed the assessment of cognitive function with the HDS-R,and TUG test,including 109 in the normal group,674 in conditions between the normal and suspected dementia group,833 in suspected dementia group and 39 in dementia group.Among the four groups,participants in the normal group used the least time to complete the TUG test,and they had the highest gait stability rate,and lowest risk of falling(P<0.05).Compared with the suspected dementia group and dementia group,conditions between the normal and suspected dementia group used less time to finish the TUG test,owned higher gait stability rate,and lower risk of falling(P<0.05).Suspected dementia group used less time to complete the TUG test,and owned lower risk of falling than the dementia group(P<0.05).The score of HDS-R presented a negative correlation with the time needed to complete the TUG test,with a correlation coefficient of-0.243,P<0.001.The score of HDS-R was negatively correlated with the status of gait stability with a correlation coefficient of-0.120,P<0.001.The score of HDS-R was negatively associated with the risk of falling with a correlation coefficient of-0.163，P<0.001.Conclusion The cognitive and the body movement function in the elderly are found to be decreased,and the risk of CI grows with the increase of gait instability and risk of falling.

Cognition disorders;Movement disorders;Exercise test;Aged

國(guó)家自然科學(xué)基金資助項(xiàng)目(81301015，81571372，81670465)；北京市自然科學(xué)基金資助項(xiàng)目(7141001)

R 741

A

10.3969/j.issn.1007-9572.2017.18.005

2017-03-11；

2017-05-04)

1.100020 北京市，首都醫(yī)科大學(xué)附屬北京朝陽(yáng)醫(yī)院神經(jīng)內(nèi)科

2.200092 上海市，同濟(jì)大學(xué)醫(yī)學(xué)院病理學(xué)與病理生理學(xué)系

3.200433 上海市，復(fù)旦大學(xué)生命科學(xué)學(xué)院

*通信作者：胡文立，教授，主任醫(yī)師；E-mail：2431965@qq.com

*Correspondingauthor:HUWen-li,Professor,Chiefphysician;E-mail:2431965@qq.com