||The Influences of Environmental Characteristics on the risk of Dementia among Elderly in Taiwan: A Population-Based Nationwide Study
||Graduate Institute of Public Health
Descriptive epidemic study
從2004-2010年間，台灣地區整體失智症和阿茲海默型失智症發生率分別由10.9/1,000人年略微下降至10.7/1,000人年和4.9 /1,000人年略微下降至4.6 /1,000人年；然而，在相同期間，整體失智症和阿茲海默型失智症盛行率的則分別由4.7 /1,000人顯著上升至7.6/100人和2.3 /100人顯著上升至3.5/100人年。較高的發生率與盛行率與女性、年紀較長有關。
第二個研究納入了12,401位新診斷阿茲海默型失智病患和12,401位年齡、性別和年代相匹配的非阿茲海默型失智病患。經多層次邏吉斯迴歸模式發現，在同時考慮研究對象的個人特性和其他環境特性後，居住在遊樂場和運動場可獲得性較高的鄉鎮地區，發生阿茲海默症型失智症的危險性顯著下降3%（95% CI = 0.96-0.99）；但居住於獨居的老年人密度較高的鄉鎮地區發生阿茲海默症型失智症的危險性卻顯著上升5%（95％ CI = 1.01-1.11）。進一步探討此研究結果是否隨居住所在地都市化程度而不同，結果顯示僅有鄉村地區有相同研究結果。除了前述2項環境指標外，居住在鄉下者，若處於較高社區活動中心可取得性，則顯著減少11%阿茲海默型失智症發生的風險（95%CI=0.79-0.99）。然而，居住在郊區者，若處於65歲以上不識字的百分比較高的鄉鎮，則顯著增加24%阿茲海默型失智症發生的風險（95%CI=1.04-1.48）。
Dementia has been regarded as a public health priority worldwide because previous studies have reported that dementia is potentially related to increased disability, mortality, and cost. Alzheimer's dementia (AD) is the most common type of dementia. Recent studies have reported the declining or stable incidence and prevalence of dementia and AD in many Western countries and most of them have been diagnosed at an older age and in women. However, the population-based secular trends in incidence and prevalence of dementia and AD and its differences in age and gender have rarely been reported in Asia. Additionally, most studies were conducted to explore the association between the individual factors and the incidence of dementia and AD, but the influence of physical and social environments on the incidence of dementia and AD were rarely reported.
The aim of this study was to assess secular trends for annual incidence density and prevalence rate of dementia and AD and to analyze the difference in incidence and prevalence of dementia and AD by age and gender. Moreover, this study further explored the association between the township-level features of physical and social environments and the risk of dementia and AD.
We used the Taiwan National Health Insurance Research database (NHIRD) to conduct a descriptive epidemical study and then to analyze the secular trends (2004-2010) for annual incidence density and prevalence rate of dementia and AD. We performed Poisson regression analysis to assess the linear trends in annual incidence and prevalence of dementia and AD, and to assess the effects of age and gender on the variations of dementia and AD incidence and prevalence rates. Furthermore, we conducted 2 population-based case–control studies by using the NHIRD and government statistics. We identified newly diagnosed dementia and AD cases aged≧65 years in 2010. Each case and its age-, sex-, and index year matched control group case was randomly selected with a 1:1 ratio from National Health Insurance claims in Taiwan.
Environmental data were collected from the township level of government statistics, including three physical environment factors ( availability of “parks, greeneries, and square area”, “playgrounds and sport venues”, and “community centers”) and three social environment factors (“Median annual family income”, “Density of illiterate people aged≧65”, “Density of elderly living alone”). These environmental factors may be potentially related to cognition impairment. We employed multilevel logistic regression models to estimate the adjusted odds ratio (AOR) of dementia and AD in relation to these environmental features at the township level after controlling for variables pertaining to individual characteristics (occupational status, insurance premium, and no. of comorbidities) and other environmental characteristics (hospitals and clinics, and urbanization status). Besides, we further explored whether the association of these environmental features with the incidence of AD was altered by the level of urbanization where individuals lived.
From 2004 to 2010, the annual incidence of dementia and AD aged ≧65 in Taiwan showed a slight and non-significant decreasing trend, from 10.9/1,000 person-years to 10.7/1,000 person-years and from 4.9/1,000 person-years to 4.6/1,000 person-years, respectively. However, in the same period, the prevalence of dementia and AD aged≧65 in Taiwan significantly increased from 4.7 to 7.6 per hundred people and 2.3 to 3.5 per hundred people, respectively. We found increased incidence and prevalence rate of dementia and AD were associated with female sex and older age.
As for case-control studies, the first study enrolled age-, gender-, and index year- matched control group subjects with (n=26,206) and without (n=26,206) newly diagnosed dementia. Multilevel logistic regression analysis revealed that people living in townships with higher availability of playgrounds and sport venues were associated with a significantly 12 % decreased AOR (95%CI= 0.81-0.95) of dementia after controlling for individual and other environmental characteristics. Additionally, the availability of community centers was also significantly associated with lower incidence of dementia, but such a significant association did not exist after further adjustment for individual-level characteristics. Although high-level median annual family income was associated with higher odds of dementia, the association was not significant in the full model.
The second study enrolled age-, gender-, and index year- matched control group subjects with (n=12,401) and without (n=12,401) newly diagnosed AD. Multilevel logistic regression analysis revealed a significantly reduced 3 % odds of AD in areas with high playground and sport venue availability (95%CI= 0.96–0.99) independent of individual and other environmental characteristics, while a significantly increased 5% odds of dementia was found in areas with a higher density of elderly living alone in the full model(95%CI= 1.01–1.11). Further examination of urbanization level showed that the above association was found only in rural areas but not in urban areas. In addition to the above two factors, we also found that in rural areas, high availability of community centers was associated with reduced odds of AD (OR=0.89, 95%CI= 0.79-0.99). However, in suburban areas, only high percentage of illiterate people aged≧65 was found to be related to increased odds of AD (OR=1.24, 95%CI=1.04-1.48).
In conclusion, although the overall incidence of dementia and AD was stable between 2004 and 2010 in Taiwan, significantly rising trends in the prevalence of dementia and AD were still observed over the study period. Female sex and older age were associated with the incidence and prevalence of dementia and AD. Living in townships with high playground and sport venue availability were associated with a reduced risk of developing dementia and AD, while living in areas with higher density of elderly living alone were associated with an increased risk of developing AD. Additionally, the effects of some specific physical and social environmental features on the risk of developing AD were altered by levels of urbanization. Public health interventions should consider these demographics and environmental aspects for preventing or delaying dementia and AD incidence.
CHINESE ABSTRACT I
LIST OF TABLES X
LIST OF FIGURES XII
CHAPTER I. INTRODUCTION 1
1.1 Background and significance of research 1
1.2 Research purposes 4
1.3 Research question and hypothesis 5
CHAPTER II. LITERATURE REVIEW 7
2.1 Prevalence and incidence of dementia and AD 7
2.2 Factors related to the development of dementia and AD 16
2.3 Possible mechanisms of environmental effects on cognitive health 47
2.4 Methodological issues of environmental effects on the risk of dementia and AD 49
CHAPTER III. MATERIALS AND METHODS 51
3.1 Data Source 51
3.2 Participants 52
3.3 Study design 60
3.4 Measurements 61
3.5 Statistical analysis 69
CHAPTER IV. RESULTS 74
4.1 Demographic variations and the trends of dementia and AD 74
4.2 Environmental features and the risk of developing dementia 91
4.3 Environmental features and the risk of developing AD 101
CHAPTER V. DISCUSSION 111
5.1 Trends in incidence and prevalence of dementia and AD 111
5.2 Environmental features and the risk of developing dementia 115
5.3 Environmental features and the risk of developing AD 122
CHAPTER VI. CONCLUSIONS 130
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