糖尿病患之健康素養、血糖控制與認知功能相關因素之探討-以某醫學中心第二型糖尿病中老年患者為例

研究背景：糖尿病為中老年常見的慢性病，近年來研究指出，糖尿病患與認知功能障礙有密切相關，嚴重影響生活品質，甚至有危及生命可能。健康素養會影響病患對健康資訊的取得及所需的認知及社會技能，進而影響其血糖控制，增加認知功能障礙的風險。研究目的：本研究旨在瞭解第二型糖尿病中老年患者社會人口學特性、健康素養、血糖控制與認知功能的相關性，及對認知功能的預測。 研究方法及資料：本研究採用橫斷式回溯性研究法，方便取樣，以台灣中部某醫學中心內分泌新陳代謝科門診及病房進行收案，選取47歲(含)以上有第二型糖尿病診斷滿二年的患者為收案對象，於107 年 8月 8 日到 109 年 1月 15 日進行收案。收案數共106人，資料收集包括以電子病歷查閱血糖控制情形( 研究對象近二年內的HbA1C值至少有3次以上數據並計算平均值、二年內有無高低血糖入院、二年內HbA1C %最高值與最低值波動有無>1)；及結構式問卷包括：(一) 社會人口學資料、(二) 糖尿病患者健康識能評量問卷、(三)簡易智能評估量表(MMSE）及(四)極早期失智症篩檢量表(AD-8)。以SPSS 20.0版套裝軟體進行分析。統計方法包含描述性統計分析，採次數、百分比、平均值及標準差，及推論性統計，採獨立樣本T檢定(t-test)、皮爾森相關係數(Pearson correlation coefficient)、變異數分析(ANOVA)及回歸分析(Regression Analysis)。研究結果：本研究對象依據社會人口學、健康素養、血糖控制及認知功能進行分析，結果發現：(一)年齡在65歲以上、教育年數2-10年、主要照顧者為自己本人、糖尿病罹病年數未滿5年及有共病史者居多；整體健康素養平均得分為38.48±6.35分；過去二年中有曾因高低血糖入院者佔18.9%；2年內的HbA1C平均值≧8者達39.6%，2年內的HbA1C%波動>1者佔樣本數的61.3%；MMSE平均得分為27.0±5.69分，評估結果為認知功能正常者有77.4%，認知功能障礙者有22.6%；AD-8平均得分為2.18±1.77分，評估結果為認知狀態正常者有44.3%，極早期失智症疑慮者有55.7%。(二)本研究第二型糖尿病中老年患者的年齡(t=2.92, p <0.01)、教育年數(F=22.52, p<0.001)、主要照顧者(F=31.76, p<0.001)、罹病年數(F=4.41, p<0.01)、共病(F=4.43, p<0.01)、健康素養得分(r=0.716, p<0.001)、過去2年內是否高低血糖入院(t=2.33, p<0.05)及2年內HbA1C%波動>1(t=2.54, p<0.05)之不同，其MMSE有顯著差異；年齡(t=-3.42, p<0.01)、主要照顧者((F=12.90, p<0.001)、罹病年數((F=3.53, p<0.05)及健康素養得分(r=-0.408, p<0.001) 之不同，其AD-8有顯著差異。(三) 教育年數、主要照顧者及健康素養總分為MMSE之預測因子，整體解釋變異量為67.5%；主要照顧者及健康素養總分為AD-8之預測因子，整體解釋變異量為29%。結論：本研究結果發現患者健康素養、血糖控制及認知功能普遍偏差，健康素養已被推論為可能降低糖尿病併發症風險的一個重要因素，而認知功能障礙可能被認為是糖尿病潛在長期的後果。本研究結果顯示健康素養與認知功能有關係，且為認知功能的預測因子；血糖控制與認知功能有關係，但並非認知功能的預測因子，推論可能追蹤年限短，不容易發現血糖變動所產生的影響，有待未來研究近一步探討。建議臨床照顧第二型中老年糖尿病患者時應加強認知功能的評估，加強關注低教育年數、無法自我照顧的族群，並提高健康素養，強化其對健康訊息的接收、理解及健康行為的落實，達到降低認知功能下降的風險。

Background: Diabetes is a common chronic disease in middle-aged and elderly people. In recent years, studies have pointed out that diabetic patients are closely related to cognitive dysfunction, which seriously affects the quality of life, and may even be life-threatening. Health literacy affects the patient's acquisition of health information and the cognitive and social skills needed, thereby affecting their glycemic control and increasing the risk of cognitive dysfunction.Objective: This study aimed to understand the correlation among the sociodemographic characteristics, health literacy, glycemic control and cognitive function of middle-aged and elderly patients with type 2 diabetes, and therefore to predict their cognitive function.Research methods and data: Cross-sectional retrospective method was used to facilitate sampling in the study. The case was collected from the Division of Endocrinology and Metabolism outpatient and ward of a Medical Center in Central Taiwan. Patients at the age of 47 and over who had been diagnosed with type 2 diabetes for two years were selected. The object of the case was accepted from August 8, 2018 to January 15, 2020. A total of 106 cases were collected. Data collection included checking glycemic control status with electronic medical records (the subjects' HbA1C values in the past two years had at least three or more data and the average value was calculated, whether they were hospitalized due to high or low glycemic within two years, and whether the fluctuate between the highest and lowest value of HbA1C% within two years is more than 1); and the structured questionnaire included: (1) sociodemographic data, (2) diabetes patient health literacy assessment questionnaire, (3) mini-mental state examination (MMSE) and (4) ascertain dementia 8 (AD-8), and was analyzed with SPSS version 20.0 software package. Statistical methods included descriptive statistical analysis, sampling frequency, percentage, mean and standard deviation, and inferential statistics, using independent sample T test (t-test), Pearson correlation coefficient, analysis of variance (ANOVA) ) and Regression Analysis.Results: According to the analysis of the research objects from the aspects of social demographics, health literacy, glycemic control and cognitive function, it was found that: (1) Most of the patients are over 65 years old, educated for 2-10 years, the main caregiver, diagnosed with diabetes for less than 5 years and have a history of comorbidities. The average score of overall health literacy is 38.48 ±6.35 points; the percentage of those who have been hospitalized due to high or low glycemic in the past two years was 18.9; those who got the average HbA1C value ≧8 within two years reached 39.6%; there are 61.3% of the samples with HbA1C% fluctuations greater than 1 within 2 years; the average MMSE score was 27.0±5.69; from the assessment result, 77.4% of the people were with normal cognitive function while 22.6% were with cognitive impairment, and 44.3% were with normal cognitive status and 55.7% were suspected with very early dementia; the average score of AD-8 was 2.18±1.77. (2) In this study, there are significant differences in MMSE among different ages of middle-aged and elderly patients with type 2 diabetes (t=2.92, p<0.01), years of education (F=22.52, p<0.001), primary caregivers (F=31.76, p<0.001), years of illness (F=4.41, p<0.01), comorbidities (F=4.43, p<0.01), health literacy scores (r=0.716, p<0.001), and whether they were hospitalized due to high or low glycemic within two years (t=2.33, p<0.05), and HbA1C% fluctuations> 1 (t=2.54, p<0.05) within 2 years.; there are significant differences in AD-8 among different ages (t=-3.42, p<0.01), primary caregiver (F=12.90, p<0.001), years of illness ((F=3.53, p<0.05), and health literacy scores (r=-0.408, p<0.001). (3) Education years, main caregivers and health literacy were the predictors of MMSE, and the overall explained variation was 67.5%; primary caregivers and health literacy were the predictors of AD-8, and the overall explained variation was 29%.Conclusion: The results of this study found general deviations in patients’ health literacy, glycemic control, and cognitive function. Health literacy has been inferred as an important factor that may reduce the risk of diabetes complications and cognitive impairment may be considered a potential long-term consequence of diabetes. The results of this study showed that health literacy is a predictor and related to cognitive function. Glycemic control is also related to cognitive function, but is not a predictor. The inference may be that the tracking period was too short to find easily the influence of glycemic changes. It needs further discussion in the future. Therefore, it is suggested that the clinical care of elderly diabetic patients should be focused on the evaluation of cognitive function, and pay more attention to those who have fewer years of education, and are unable to take care of themselves. Moreover, to improve their health literacy, strengthen the reception and understanding of health information, and implement the healthy behaviorto reduce the risk of cognitive decline.