台灣中高齡者口腔健康與認知衰退及衰弱相關性之探討

前言隨著全世界高齡人口增加，台灣人口到了2025年將邁入超高齡社會。在高齡化社會的趨勢下，認知衰退與衰弱是一個相當重要的議題。影響認知衰退與衰弱的因子很多，除了老化之外，也有許多流行病學研究指出，口腔健康狀況不佳(包含咀嚼、吞嚥、牙齒脫落及嗅、味覺等)可能會影響進食、進而影響營養成分的攝取，造成營養不良及衰弱的問題。此外，口腔健康亦可能影響說話功能、外表及自我形象等與社交互動有關的因子。因此本研究將探討台灣高齡者口腔健康與認知衰退及衰弱之相關性，並假設憂鬱為壓力源及口腔健康與衰弱之間的中介因子，進一步探討憂鬱的中介效應。研究方法本研究使用2011及2015年台灣中老年身心社會生活狀況長期追蹤調查(Taiwan Longitudinal Study in Aging，TLSA)資料庫探討口腔健康因子與認知衰退及衰弱的相關性。口腔健康因子的部分，本研究將7題版口腔健康衝擊量表 (The Oral Health Impact Profile-7，OHIP-7)以因素分析分為三個類別(生理因子、社會心理因子及味覺因子)，並將是否使用假牙一併列為口腔健康的評估指標。此外，以資庫中與衰弱相關的問題作為衰弱指標，並以簡易心智狀態問卷(Short Portable Mental State Questionnaire, SPMSQ)作為評估認知衰退的工具，並使用憂鬱量表(10-item Centre for Epidemiological Studies Depression Scale，CES-D-10)探討中介效應。納入本研究的樣本皆為55歲以上的台灣中、高齡族群，探討認知衰退的樣本共1,909人，衰弱共1,871人。基本人口學變項採用χ2 test、t test、ANOVA進行分析，並使用Pearson correlation analysis分析口腔健康因子與認知衰退及衰弱的相關；探討2者的相關性則使用multivariable regression、multivariable logistic regression及multinomial logistic regression進行分析；中介效應則使用Sobel test分析。結果口腔健康的三個類別因子及是否使用假牙與認知衰退未達統計顯著意義。以線性回歸分析的結果顯示，女性使用假牙會降低衰弱的風險(β=-0.22，p<0.01)；以multinomial logistic regression分析各變項對衰弱前期及衰弱的結果顯示，男性口腔健康生理因子對衰弱具保護作用(OR=0.83，p<0.05)、女性口腔健康味覺因子對衰弱前期具保護作用(OR=0.64，p<0.01)、女性使用假牙對衰弱前期(OR=0.63，p<0.05)及衰弱(OR=0.32，p<0.01)均具保護作用；以multivariable logistic regression分析各變項對衰弱的相關性顯示，女性口腔健康味覺因子(OR=0.68，p<0.01)及使用假牙(OR=0.61，p<0.05)對衰弱具保護作用。本研究將OHIP三類別因子，依據其分數再分為3組，進行迴歸分析。線性回歸的分析結果顯示，女性使用假牙對衰弱具保護作用(β=-0.22，p<0.01)；以multinomial logistic regression分析各變項對衰弱前期及衰弱的結果顯示，整體個案的口腔健康味覺因子2分以上者對衰弱前期具保護作用(OR=0.60，p<0.05)、女性口腔健康心理社會因子1~2分者對衰弱具保護作用(OR=0.30，p<0.05) 、女性口腔健康味覺因子2分以上者對衰弱前期具保護作用(OR=0.30 p<0.001) 、女性使用假牙對衰弱前期(OR=0.63，p<0.05)及衰弱(OR=0.32，p<0.01)均具保護作用；以multivariable logistic regression分析各變項對衰弱的相關性顯示，整體個案、女性的口腔健康味覺因子2分以上者及女性使用假牙對衰弱均具保護作用。中介分析的部分，由於味覺因子與使用假牙與衰弱達統計上顯著效應，本研究以憂鬱為中介因子，使用Sobel test分析後，皆未達統計上顯著意義。 討論口腔健康因子與認知衰退之間未達統計上顯著相關，但在女性的部分顯示高血脂對於認知衰退具保護作用。經本研究分析女性高血脂個案就醫及服藥的情形後，約6成左右的個案有就醫及服藥，推測可能是因為個案遵醫囑或其他健康行為而導致分析結果呈現保護效應。根據本研究結果及先前的研究，全口假牙、局部假牙的使用或天然的牙齒對於高齡者衰弱的影響均有其重要性；而味覺對衰弱的影響可能因藥物或使用全口假牙所導致，但因本研究無上述兩者的詳細資料，無法進一步進行探討與分析，建議後續的調查及研究能夠取得更詳細的資料加以釐清。結論與建議根據研究結果口腔健康因子對認知衰退未達統計上顯著意義。衰弱的部分則發現，女性使用假牙可以顯著降低衰弱的風險。此外，憂鬱對於口腔健康與衰弱之間無統計上顯著中介效應。建議在未來研究的部分，可增加更廣泛的衰弱及口腔檢測或量表，並可分析性別上的差異；衛生政策的部分，則建議可以針對中高齡者規劃口腔衛教、口腔健康檢查與服務及健康行為的促進，確保高齡者的口腔健康，提升其生活品質。

IntroductionAs the aged population increases around the world, Taiwan will also become a super-aged society in 2025. In the aging society, cognitive decline and frailty are very important issue. There are many factors that affect cognitive decline and frailty. In addition to aging, many epidemiological studies indicated that poor oral health (including chewing, swallowing, tooth loss, smell, taste, etc.) may affect eating and nutrition intake that may cause malnutrition and weakness.In addition, oral health may affect social-related factors such as speech function, appearance and self-image, etc. Therefore, this study will explore the association between oral health, cognitive decline and frailty among older adult in Taiwan. Since depression is hypothesized to be a mediator between oral health and frailty, we further explored the mediating effect of depression.MethodsThis study used 2011 and 2015 TLSA (Taiwan Longitudinal Study in Aging) database to explore the association between oral health, cognitive decline and frailty. We divided Oral Health Impact Profile-7 (OHIP-7) into 3 categories (physiological factors, psychosocial factors and sense of taste) by factor analysis and denture used as oral health indicators. The cognative decline measured by SPMSQ (Short Portable Mental State Questionnaire) and used the frailty-related questions in database as frailty indicators. Subsequently, based on the results of oral health factors and frailty, the CES-D-10 (10-item Center for Epidemiological Studies Depression Scale) was used to explore the mediating effect.The samples in this study were all over 55 years old middle-aged and older adult in Taiwan. There are 1,909 people studied for cognitive decline, and 1,871 people for frailty.We used χ2 test, t test, and ANOVA to analysis demographics, and Pearson correlation analysis was used to analyze the correlation between oral health factors and cognitive decline and frailty; multivariable regression, multivariable logistic regression, and multinomial logistic regression were also used in this study. The mediation effect was analyzed by Sobel test.ResultsThere was no statistical significance of the association between oral healh factors (three factors of oral health and denture use) and cognitive decline. The results of multivariable regression analysis showed that the used of dentures in women may reduce the risk of frailty (β=-0.22); the results of multinomial logistic regression analysis showed that physiological factors in male has protective effect on frailty (OR=0.83); the sense of taste has protective effect on the pre-frailty (OR=0.64) in female; denture use in female has protective effect on pre-frailty (OR=0.63) and frailty (OR =0.32).Multivariable logistic regression analysis showed that sense of taste (OR=0.68) and denture used (OR=0.61 ) in female have protective effect on frailty.We divided the 3 factors of OHIP into 3 categories based on the scores of each factor and performed regression analysis. The multivariable regression analysis showed that the denture used in female has protective effect on frailty (β=-0.22). Multinomial logistic regression analysis showed that sense of taste (score≧2) has protect effect on pre-frailty in total subjects(OR=0.60) and in women (OR=0.30); psychosocial factors (score=1~2) has protect effect on frailty in female (OR=0.30); denture used also has protect effect on pre-frailty (OR=0.63) and on frailty (OR=0.32) in women.The multivariable logistic regression analysis showed that total subjects and female with sense of taste score≧2, and denture used in female have protective effect on frailty.Since the taste factor and denture use have statistically significant effect on frailty, we used Sobel test to exame whether depression mediates the association between oral health factors and frailty, but there was no statistical significance of the mediation effect.DiscussionThere was no statistically significant association between oral health factors and cognitive decline, but hyperlipidemia showed a protective effect on cognitive decline in women. We analyzed the doctor visiting and medication using of female hyperlipidemia cases and found that about 60% had doctor visiting and medication using. We speculated that the protective effect of hyperlipidemia may due to the cases compliance with medical advice or other healthy behaviors.According to the results of this study and previous studies, the natural teeth, use of complete dentures o partial dentures were important factors affecting frailty in older adults. The influence of taste on frailty may be caused by medications or complete denture use, but we did not have detailed information of these two factors to analyze and discuss further.It is recommended that subsequent investigations and research can obtain more detailed information to clarify.ConclusionAccording to the results, the association between oral health factors and cognitive decline had no statistical significance. For the frailty, it was found that using dentures in female can significantly reduce the risk of frailty. Furthermore, depression did not have a statistically significant mediating effect of the association between oral health and frailty.It is recommended that in future research, more frailty and oral health can be measured, and gender differences can be further studied. As for the health policy, it is suggested that oral health education, oral health examinations and services, and the healthy behaviors promotion can be planned to ensure the oral health of the older adults and improve their quality of life.