探討社區長者健康整合式功能評估與衰弱的相關性

Abstract

研究背景與目的：隨著人口老化，長者衰弱的盛行率逐年提高。衰弱常伴隨著整體功能及多重器官的衰退，繼而容易發展至失能階段。世界衛生組織（World Health Organization, WHO）推行社區長者健康整合式功能評估（Integrated Care for Older People, ICOPE），以六大面向快速篩檢長者內在能力（Intrinsic Capacity, IC）。臺灣參考WHO ICOPE初評版本，制定ICOPE初評訪談版；此外，為了推廣社區長者自評與篩檢，另訂定自填版本。目前衰弱評估工具主要分為兩大類包括：Dr. Fried提出的衰弱表現型與Dr. Rockwood提出的缺損累積型工具（accumulation of deficit models）。然而目前臺灣ICOPE篩檢與衰弱評估相關之研究實證較為不足，也少有研究比較訪談版與自填版之篩檢結果。本研究目的包括：（1）比較ICOPE初評訪談版與自填版評估結果之差異；（2）探討ICOPE兩種版本和衰弱評估之相關性。研究方法：本研究對象為居住臺北市社區65歲以上並能獨立行走的長者。評估方式包括：以蒙特利爾認知評估（Montreal Cognitive Assessment, MoCA）評估認知功能；分別採用ICOPE初評訪談版與自填版評估長者內在能力；衰弱狀態則採用心血管健康研究的衰弱表現型評估表（Frailty phenotype of Cardiovascular Health Study, CHS）及艾德蒙頓衰弱評估表（Edmonton Frail Scale, EFS）兩種評估方式。研究資料分析使用SPSS統計軟體第25.0版（IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp.）。依據ICOPE兩個版本評估結果分成兩組：內在能力異常組（Decline in Intrinsic Capacity，DIC group），以及內在能力無異常組（non-DIC group）。採用獨立樣本t檢定（Independent sample t-tests）或卡方檢定分析（Chi-square tests），分別比較兩組間連續變項與類別變項之差異。檢驗ICOPE兩個版本一性則使用克拉默V係數（Cramer's V）分析。最後，採用二元邏輯回歸（Binary logistic regression）檢驗ICOPE初評兩個版本和衰弱之相關性，控制干擾因子包括：年齡、性別、腰圍、小腿圍、教育程度、多重疾病。雙尾檢定顯著程度定義為α < 0.05。研究結果：本研究一共納入135位居住在社區的長者，平均年齡為73.99±5.66歲（65至90歲），女性比例較多（106位，78.5%）。採用ICOPE初評訪談版評估結果顯示，內在能力異常組有87人（64.4%），無異常組為48人（35.6%）。內在能力異常組之認知功能及日常身體活動量顯著較無異常組低（p<0.05），多重用藥及多重疾病比例則顯著較高（p<0.05）。而ICOPE初評自填版的結果則顯示，兩組受試者的年齡（p=0.043）、教育程度（p=0.003）、以及多重疾病（p=0.002）有顯著差異。此外，ICOPE兩個版本的評估結果一致性並未達到統計上顯著（Cramer's V=0.086）。進一步檢定兩個版本在六個分項的一致性，結果顯示營養（Cramer's V=0.567）、視力（Cramer's V=0.414），與憂鬱（Cramer's V=0.448）一致性達統計上顯著意義，但在認知、行動、聽力則未達顯著。另外，以CHS量表評估衰弱狀態，ICOPE初評訪談版異常者中有72.4%呈現衰弱前期和衰弱，無異常者中有70.8%評估為健壯（p<0.001）。而採用EFS量表評估之衰弱狀態與ICOPE初評兩個版本之內在能力異常，無統計上顯著相關（p>0.05）。迴歸分析的結果顯示ICOPE初評訪談版內在能力異常組較於無異常組容易出現衰弱表現型（OR=6.375，95% CI=2.922-13.907），分析加入控制干擾因子後，OR值上升至7.850（95% CI=3.193-19.302）；而缺損累積型與ICOPE初評兩個版本未達統計上顯著相關。結論：本研究發現長者自填ICOPE時有低估自身健康的情況，而ICOPE初評訪談版包含客觀檢測，評估結果與衰弱狀態有顯著相關。本研究提供臺灣兩種版本ICOPE評估差異的資料，以及ICOPE初評訪談版與衰弱評估具顯著相關的實證資料。未來仍須更大樣本數的研究繼續探討ICOPE初評版本與衰弱的相關性，以提供臨床人員選擇適當的評估工具，促進健康老化。

Background and purpose: The prevalence of frailty among the elderly increases annually as the population ages. The World Health Organization (WHO) has introduced the Integrated Care for Older People (ICOPE) framework, which aims to support healthy aging by evaluating the intrinsic capacity (IC) of the elderly in six different areas. In Taiwan, two versions of the ICOPE step 1 screening tools are available: an interview-based version (ICOPE-I) and a self-administered version (ICOPE-S) based on the WHO's model. There are two main models for frailty status assessments: Dr. Fried's phenotype of frailty and Dr. Rockwood's accumulation of deficit models. A comparative study is necessary to assess the consistency of both versions of ICOPE in Taiwan and their associations with frailty. This study aims to (1) compare the assessment outcome of the ICOPE-I and ICOPE-S, and (2) investigate the correlation between both versions of the ICOPE step 1 screening tools and frailty. Methods: We enrolled community-dwelling individuals aged 65 or older who could walk independently and live in Taipei City. Both ICOPE-I and ICOPE-S were used to assess IC. Frailty status was assessed by using the phenotype of frailty in the Cardiovascular Health Study (CHS) and the Edmonton Frail Scale (EFS). Data was analyzed using SPSS Statistics for Windows, Version 25.0 (IBM Corp.). Participants were categorized into decline in one or more IC (DIC) or non-decline in IC (non-DIC) groups based on the results of the ICOPE-I and ICOPE-S. We employed independent sample t-tests or chi-square tests to compare continuous and categorical variables between the groups, respectively. The consistency of the two versions of ICOPE was evaluated using Cramer's V. Lastly, binary logistic regression was used to explore the relationship between the two ICOPE versions and frailty while controlling for variables such as age, gender, waist circumference, calf circumference, education level, and multimorbidity. Statistical significance was set at α < 0.05. Results: The study was conducted on 135 elderly individuals (average age 73.99±5.66 years) from the community. Most of the participants were female (106 individuals, 78.5%). The study found that 64.4% (87 individuals) of the ICOPE-I group had decreased MoCA scores and lower levels of physical activity (p<0.05), along with a higher prevalence of polypharmacy and multimorbidity (p<0.05). Participants from the DIC group in the ICOPE-S were generally older (p=0.043), had lower education levels (p=0.003), and showed a greater prevalence of multimorbidity (p=0.003). An analysis comparing the two versions of ICOPE revealed that the results for assessing IC did not achieve statistical significance (Cramer's V=0.086). However, a subsequent analysis revealed that the two versions of ICOPE demonstrated higher consistency in the domain of nutrition (Cramer's V=0.567), vision (Cramer's V=0.414), and depression (Cramer's V=0.448). In contrast, the consistency for cognition, mobility, and hearing was not as significant. Additionally, the results showed that the ICOPE-I was correlated with the phenotype of frailty as determined by the CHS scale. The prevalence of DIC and pre-frail or frail were 72.4%, while 70.8% of those with non-DIC were categorized as robust (p<0.001). However, no differences were shown between the EFS and either version of the ICOPE. The odds ratio for frailty among participants with DIC and non-DIC was 6.375 (95% CI=2.922-13.907). The odds ratio increased after adjusting for covariates (OR=7.850, 95% CI=3.193-19.302). Neither version of the ICOPE significantly correlated with frailty status as determined by the EFS. Conclusion: The study found that elderly individuals using the ICOPE-S might underestimate their health status. The ICOPE-I involves objective measurements, showing a strong correlation with frailty. These results indicate that the ICOPE-I is closely associated with frailty. The findings highlight the differences between the two versions of ICOPE in Taiwan, and the significant correlation between ICOPE-I and frailty assessment. Further research with larger sample sizes is necessary to confirm the differences between the two versions of the ICOPE and their association with frailty. This would help clinicians to select appropriate assessment tools for early screening and intervention, thereby supporting healthy aging.