【作者】 涂秋云；

【导师】 甘霖； 肖水源；

【作者基本信息】 中南大学 ， 社会医学与卫生事业管理， 2012， 博士

【摘要】 第一篇长沙市缺血性脑卒中患者血管性认知功能障碍的发生与分布目的：描述长沙市缺血性脑卒中患者的血管性认知功能障碍(VCI)、非痴呆型血管性认知功能障碍(VCIND)、血管性痴呆(VD)的患病率；描述长沙市缺血性脑卒中患者不同认知功能水平的人口学分布特征；为长沙市缺血性脑卒中患者VCI、VCIND、VD的流行病学调查提供基线数据；为长沙市VCI疾病库的建立提供资料；为相关的卫生政策制定提供科学数据。方法：采用整群随机抽样方法,对长沙市8个社区689例40岁及以上缺血性脑卒中患者进行长沙版蒙特利尔认知评估量表(长沙版MoCA)、简明精神状态检查量表(MMSE)、额叶功能评估量表(FAB)、韦氏逻辑记忆、日常生活活动量表(ADL)、临床痴呆评定量表(CDR)社会功能问卷(FAQ)、流调用抑郁自评量表(CES-D)、美国国立卫生院卒中量表(NIHSS)等量表的评估,参考美国国立神经疾病与卒中研究所和加拿大卒中网(NINDS/CNS)组织召开的血管性认知功能障碍统一标准专题研讨会中诊断指南中的方案进行诊断,根据NINDS-AIREN诊断标准及血管性认知功能损害专家指南中VCIND诊断标准筛查出血管性认知功能障碍者,并通过自主设计的问卷调查研究对象的人口学特征及VCI可能的各相关因素。结果：1.长沙市40岁以上缺血性脑卒中VCI的患病率为41.8%,其中VCIND为32.1%,VD为9.7%；男性中VCI的患病率为39.3%,其中VCIND为29.2%,VD为10.1%；女性中VCI的患病率为45.2%,其中VCIND为36.1%,VD为9.1%。2.缺血性脑卒中后VCI患者在不同年龄(x2=40.745,P=0.000)、不同职业(x2=24.359,P=0.000)、不同文化程度(x2=238.565,P=0.000)、不同婚姻状况(x-=9.206,P=0.010)、不同居住状况(x2=24.359,P=0.000)中的分布差异有统计学意义；而在不同性别(x2=3.686,P=0.158)中的分布差异无统计学意义。3.缺血性脑卒中后认知正常组、VCIND组及VD组在ADL(F=65.601,P=-0.000)、FAQ(F=78.305,P=-0.000)、CES-D(F=5.306,P=0.006)、NIHSS (F=12.340, P=0.000)的得分比较,均有统计学意义。结论：1.长沙市40岁以上缺血性脑卒中患者中VCI的患病率为41.8%,其中VCIND的患病率为32.1%,VD患病率为9.7%。2.长沙市40岁以上缺血性脑卒中后VCI患者在高龄、体力劳动、低文化程度、单身和独居者中分布较多。第二篇长沙市缺血性脑卒中患者血管性认知功能障碍的影响因素研究目的：从社会人口学、疾病史、脑卒中相关临床表现、神经影像学资料、行为生活方式等维度来探讨长沙市缺血性脑卒中患者VCI的影响因素,为缺血性脑卒中患者VCI的防治提供科学依据。方法：采用整群随机抽样方法,对长沙市8个社区689例40岁及以上缺血性脑卒中患者进行长沙版MoCA、MMSE、FAB、韦氏逻辑记忆、ADL、CDR等量表的评估,并进行问卷调查。参考美国国立神经疾病与卒中研究所和加拿大卒中网(NINDS/CNS)组织召开的血管性认知功能障碍统一标准专题研讨会中诊断指南中的方案进行诊断,根据NINDS-AIREN诊断标准和血管性认知功能损害专家指南中诊断标准筛查出血管性认知功能障碍者,将缺血性脑卒中后认知正常者作为对照,采用单一维度非条件logistic回归模型对包括社会人口学、疾病史、脑卒中相关临床表现、神经影像学资料、行为生活方式等维度42个变量进行分析,筛选出有统计学意义的变量。对有统计学意义的变量进行共线性诊断,确认这些变量不存在共线性时,再对这些变量进行多维度非条件logistic回归分析。结果：1.通过单一维度非条件logistic回归分析,从42个变量中分别筛选出16个有统计学意义的变量作为VCIND的影响因素和17个有统计学意义的变量作为VD的影响因素。2.共线性诊断结果发现,VCIND及VD有统计学意义的变量之间均不存在明显的共线性关系。3.通过多维度非条件logistic回归分析,发现有11个变量进入VCIND回归方程,其中高龄(OR=1.256)、侧脑室白质变性评分高(OR=2.015)、大血管病变(OR=2.088)、大量饮酒(OR=3.334)、缺乏业余爱好(OR=5.941)、睡眠时间长(OR=1.880)是缺血性脑卒中患者VCIND发生的危险因素,而文化程度高(OR=0.388)、体力劳动(OR=0.478)、少量饮酒(OR=0.053)、定期体检(OR=0.436)、丰富膳食纤维摄入(OR=0.178)、喝牛奶(OR=0.266)为VCIND的保护因素；在VD影响因素分析时,有9个变量进入回归方程,其中独居(OR=22.235)、高脂血症(OR=33.357)、短暂性脑缺血发作(TIA)(OR=4.624)、脑卒中家族史(OR=14.183)、脑萎缩(OR=26.445)、饮食不规律(OR=18.561)、高脂饮食(OR=3.400)是缺血性脑卒中患者VD发生的危险因素,而文化程度高(OR=0.253)、素食为主(OR=0.268)为VD的保护因素。结论：1.年龄、侧脑室白质变性、大血管病变、大量饮酒、缺乏业余爱好、睡眠时间长是缺血性脑卒中患者VCIND的危险因素；而文化程度高、体力劳动、少量饮酒、定期体检、丰富膳食纤维摄入、喝牛奶为VCIND的保护因素。2.独居、高脂血症、TIA、脑卒中家族史、脑萎缩、饮食不规律、高脂饮食是缺血性脑卒中患者VD的危险因素,而文化程度高、素食为主为VD的保护因素。第三篇长沙市公众对血管性认知功能障碍的认知度调查目的：通过调查长沙公众对VCI的认知度,为VCI防治路径的建立提供依据。方法：采用整群随机抽样方法,对长沙市8个社区689例40岁及以上缺血性脑卒中患者进行长沙版MoCA、MMSE、FAB、韦氏逻辑记忆、ADL、CDR等量表的评估。参考美国国立神经疾病与卒中研究所和加拿大卒中网(NINDS/CNS)所建议的诊断指南进行认知评估,根据NINDS-AIREN诊断标准和血管性认知功能损害专家指南中诊断标准进行认知诊断。同时,分别对患者及其照料者、所在社区基层医务工作者以及随机抽取的一家综合性医院的医务工作者采用自主设计的问卷进行VCI的认知度及态度两个方面的调查。采用描述性分析、t检验或单因素方差分析法对公众VCI的知晓度、早期症状的识别率、就诊情况及其经济承受能力、医务人员对VCI的诊治能力等进行分析。结果：1、公众对VCI的基本知晓率仅为30.9%,其中患者为24.7%,照料者为29.3%,基层医师为61.8%,专科医师为100.0%；公众对VCI的早期症状的识别率仅为22.8～28.9%,其中患者为16.3%-22.6%,照料者为23.3%-31.6%,基层医师为38.2%-47.4%,专科医师为67.4%-74.4%；16.2%的患者和照料者对VCI存在偏见,占知晓人群的52.4%。2、各研究人群的认识度、态度、总得分由大到小排列均为：患者>照料者>医师,且其差异均有统计学意义,(P<0.05)；专业意义提示医师对VCI的认知度较患者、照料者为高。3、不同的医师其认识度、态度、总得分由大到小排列均为：基层医师>专科医师。其差异均有统计学意义,(P<0.05)；专业意义提示专科医生的认知度及态度比基层医生为好。结论：1、普通公众对VCI认知度不够,甚至对VCI存在偏见,这可能是病人及照料者就诊意识不强、诊断滞后、疗效欠佳等重要原因。2、医务人员对VCI认识不足,这可能是影响其早期识别、及时诊治的重要原因。3、基层医师与专科医师对VCI的认识程度不同,这可能是双向转诊困难、VCI治疗的依从性低,以及不能及时反馈治疗效果的重要原因。第四篇缺血性脑卒中患者血管性认知功能障碍的防治对策目的：根据长沙市缺血性脑卒中患者血管性认知功能障碍的人口学分布特征、影响因素以及公众对其认知度和态度的研究结果,探讨VCI的防治策略,为相关卫生政策的制定提供科学数据。方法：综合目前已完成的研究成果：长沙市缺血性脑卒中患者血管性认知功能障碍的人口学分布特征、影响因素以及公众对其认知度和态度,发现目前长沙市缺血性脑卒中患者VCI的防治现状及存在的如下问题：1、缺血性脑卒中患者的VCI患病率高达41.8%；2、VCI的影响因素分为危险因素和保护性因素,通过增强保护因素,减少危险因素等措施,VCI是可以有效的被防治的；3、目前公众对VCI的认知度低下,从多个环节严重地影响了VCI的有效防治。根据上述情况,提出相应的VCI防治策略,并建立VCI的防治路径。对策：1、加强宣传,提高公众意识。2、建立VCI患者的护理培训机构,消除照料者在对VCI患者的照料过程中出现的不良情绪及顾虑。3、提高基层医务工作者的医疗水平,规范化全科医生的培训,确实落实双向转诊制度。4、加强VCI专业技术人才培养,推进VCI相关的基础研究工作。5、建立VCI信息监测体系和居民健康档案。6、建议政府加大扶持力度,增加对VCI防治工作的投入。7、建立VCI防治路径。更多还原

【Abstract】 Part I Cross-sectional Study on Vascular Cognitive Impairment after Ischemic Stroke in ChangshaObjective:To describe the prevalence rate of vascular cognitive impairment (VCI)、vascular cognitive impairment non-dementia (VCIND) and vascular dementia (VD) among the patients with ischemic stroke and to describe the demographic distribution characteristics among the patients with different cognition status after ischemic stroke in Changsha, so as to provide baseline data for further studies on these diseases and to establish VCI library in the same area which can contribute for the government to make the associated health policies in Changsha.Methods:Stratified cluster random sampling method was performed and689patients with both ischemic stroke and his/her age being over40from8communities in Changsha were involved in this study. All subjects had accepted the following neuropsychological assessments:Montreal Cognitive Assessment-Changsha version (MoCA-CS), Mini-Mental State Examination (MMSE), Frontal Assessment Battery-Changsha version (FAB-CS), logical memory from Chinese revised Wechsler Memory Scale (WMS-RC), Activity of Daily Living Scale (ADL), Clinical Dementia Rating (CDR), Functional Activeities (FAQ), Center for Epidemiological Survey (CES-D), National Institute of Health stroke (NIHSS), etc. The criteria of diagnosis were as following:the National Institute of Neurological Disorders and Stroke-Canadian Stroke Network Vascular Cognitive Impairment Harmonization Standards, the NINDS-AIREN criteria. Additionally, Self-designed questionnaires were involved in analysing the demographic characteristics and risk factors of VCI. Results:1. The prevalence rate of VCI among ischemic stroke patients (=40years old) in Changsha was41.8%, which included that of VCI-ND was32.1%and that of VD was9.7%. To male, the prevalence rate of VCI was39.3%, which included that of VCI-ND was29.2%and that of VD was10.1%; To female, the prevalence rate of VCI was45.2%, which included that of VCI-ND was36.1%and that of VD was9.1%.2. The VCI distribution of patients with ischemic stroke was significantly different with age(χ2=40.745, P=0.000), occupations (χ2=24.359, P=0.000), educational level (χ2=238.565, P=0.000), marital status(χ2=9.206, P=0.010), habitation status (χ2=24.359, P=0.000), but not significantly different with gender(χ2=3.686, P=0.158).3. It was statistically significant that The score of ADL (F=65.601, P=0.000), FAQ (F=78.305, P=0.000), CES-D (F=5.306, P=0.006), NIHSS (F=12.340, P=0.000) among the patients with ischemic stroke in cognitive normal group, VCIND group and VD group.Conclusion:1. The prevalence rate of VCI among ischemic stroke patients (=40years old) in Changsha was41.8%, which included that of VCI-ND was32.1%and that of VD was9.7%.2. The VCI distribution of patients with ischemic stroke was significantly different with age, occupations, educational level, marital status, habitation status, but not significantly different with gender. Part Ⅱ Study on the Relevant Influencing Factors of Vascular Cognitive Impairment of the Patients with Ischemic Stroke in ChangshaObjective:To explore the relevant influencing factors of vascular cognitive impairment (VCI) of the patients with ischemic stroke in Changsha as follows:demography, disease history, relevant clinical manifestation of stroke, neuroimaging data, personal living habits, to offer the data for preventing the occurrence of VCI after ischemic stroke.Methods:Stratified cluster random sampling method was performed and689patients with both ischemic stroke and his/her age being over40from8communities in Changsha were involved in this study. All subjects had accepted the following neuropsychological assessments:MoCA-CS, MMSE, FAB-CS, WMS-RC, ADL, CDR, etc. The criteria of diagnosis were as following:the National Institute of Neurological Disorders and Stroke-Canadian Stroke Network Vascular Cognitive Impairment Harmonization Standards, the NINDS-AIREN criteria. All participants were divided into two groups by the diagnosis as follows:the VCI group (including the patients with either VCI-ND or VD) and Control group (including the patients without cognitive imparement). The single factor unconditioned logistic regression analysis was performed to analyze the effects of42different variables from the following aspects (demography, disease history, relevant clinical manifestation of stroke, neuroimaging data, personal living habits) on the occurrence of VCI after ischemic stroke. Collinearity diagnostics was preformed among the variables with statistical significant by the single factor analysis, multi-factor unconditioned logistic regression analysis was done on the variables without any collinearity, to find the independent influencing factors of VCI after ischemic stroke.Results:1. The results of single factor unconditioned logistic regression analysis showed that,16statistical significant variables in the total42 variables could be selected as influencing factors of VCI-ND, but17in that could be selected as influencing factors of VD.2. The results of collinearity diagnostics showed that, there was no collinearity existed in the statistical significant variables of VCI-ND, so was VD.3. The results of multi-factor unconditioned logistic regression analysis showed that, there were12variables entered the regression equation of VCI-ND. Among these variables, advanced age (OR=1.256), high scores of leukoaraiosis in periventricular and deep white matter areas (OR=2.015), existing large vessel lesions (OR=2.088), a large amount of alcohol taking (OR=3.334), lack of hobbies (OR=5.941), long sleeping time (OR=1.880) were risk factors of VCI-ND. While, high educational level (OR=0.388), physical labour (OR=0.478), a small amount of alcohol taking (OR=0.053), regular physical examination (OR=0.436), rich in dietary fiber intake (OR=0.178), drinking milk (OR=0.266) were protective factors of VCI-ND. And there were9variables entered the regression equation of VD. Among them, Living alone (OR=22.235), hyperlipidemia (OR=33.357), TIA (OR=4.624), family history of stroke (OR=14.183), brain atrophy (OR=26.445), eating disorders (OR=18.561), high-fat diet (OR=3.400) were risk factors of VD after ischemic stroke, While, high educational level (OR=0.253), mainly vegetarian diet (OR=0.268) were protective factors of VD after ischemic stroke.Conclusions:1. Age, high scores of leukoaraiosis in periventricular and deep white matter areas, existing large vessel lesions, a large amount of alcohol taking, lack of hobbies, sleep for a long time were risk factors of VCI-ND after ischemic stroke, and high education level, manual labor, a small amount of alcohol taking, regular physical examination, rich in dietary fiber intake, drinking milk were protective factors of VCI-ND after ischemic stroke.2. Living alone, hyperlipidemia, TIA, family history of stroke, brain atrophy, eating disorders, high-fat diet were risk factors of VD after ischemic stroke, and high education level, mainly vegetarian diet were protective factors of VD after ischemic stroke. Part III Investigating the Public Awareness of Vascular Cognitive Impairment in ChangshaObjective:Through investigating the public awareness of vascular cognitive impairment (VCI), to provide the basis for the establishment of the VCI control system.Methods:Stratified cluster random sampling method was performed and689patients with both ischemic stroke and his/her age being over40from8communities in Changsha were involved in this study. All subjects had accepted the following neuropsychological assessments:MoCA-CS, MMSE, FAB-CS, ADL, CDR, etc. The criteria of diagnosis were as following:the National Institute of Neurological Disorders and Stroke-Canadian Stroke Network Vascular Cognitive Impairment Harmonization Standards, the NINDS-AIREN criteria. Self-designed questionnaires were involved in analysing both the awareness of VCI and the attitudes to VCI, investigating subjects are as follows:patients and their caregivers, doctors from communities referred above, doctors from one of complexed hospitals chosen randomly in Changsha. It was described that public awareness, diagnosis of early symptoms, visiting doctors, paying for VCI, and doctors’diagnosis abilities of VCI by T test and one-way ANOVA.Results:1.The public basic awareness of the VCI was Only30.9%, Patient was24.7%, caregivers was29.3%, Grass-roots physicians was61.8%, professional physicians was100.0%; public recognition rate of early symptoms of VCI was22.8%-28.9%, patients was16.3%-22.6%, caregivers was23.3%-31.6%, Grass-roots physicians was38.2%-47.4%professional physicians was67.4%-74.4%;16.2%of the public had discrimination against VCI.2. Awareness score, attitude score and total score of different groups were descending as following:patients>caregivers>physicians, and the differences were statistically significant (P<0.05); Professional significance prompted that physician’s recognition of VCI were better than patients and caregivers.3. Awareness score, attitude score and total score of different physicians were descending as following:grass-roots physicians> professional physicians, and the differences were statistically significant (P<0.05); Professional significance prompted that professional physician’s recognition and attitude for VCI were better than grass-roots physicians.Conclusion:1. The general public awareness of VCI was not enough, even had a prejudice against VCI, which might be an important reason for poor treatment awareness of patients and carers, diagnosis lag and poor efficacy.2. Medical staff was lack of knowledge on VCI, which might affect its early recognition, timely diagnosis and treatment.3. The difference on awareness of VCI between grass-roots physicians and professional physicians might be an important reason,which caused both hard to realize the two-way referral and to do bad compliance and little feedback between doctors and patients. Part IV Prevention and control measures on Vascular Cognitive Impairment after Ischemic StrokeObjective:According to the population distribution characteristics, influence factors and the findings of public awareness and attitudes of vascular cognitive impairment after ischemic stroke in Changsha City, to explore the VCI control strategies and to provide scientific data for the formulation of health policy.Methods:Through integrating the present research results:the population distribution characteristics, influence factors and the public awareness and attitudes of vascular cognitive impairment after ischemic stroke in Changsha City, we found the control situation of VCI after ischemic stroke in Changsha City and the existence of the following questions:1The prevalence rate of VCI among ischemic stroke patients in Changsha was up to41.8%;2Influencing factors of VCI were divided into risk factors and protective factors, and then by enhancing protective factors and reducing risk factors, VCI can be effective prevention and treatment;3Low public recognition of VCI had serious impacts on the effective prevention and treatment of VCI from multiple aspects. Based on the above situation, we proposed corresponding prevention strategies and established prevention and treatment path for VCI.Countermeasures:1. Strengthen the propaganda, raise public awareness.2. Establish nursing training institutions for VCI patients, to eliminate the negative emotions and concerns of caregivers in the care of VCI patients.3. Improve medical standards of primary health care workers, standardized general practitioner training, and indeed the implementation of two-way referral system.4. Strengthen the VCI professional and technical personnel training, to promote the VCI-related basic research.5. Establishment information monitoring system of VCI and the health file of residents.6. Suggest the government to increase support for efforts and to increase the investment in prevention and control work for VCI.7. Establish prevention path for VCI.更多还原