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Article(id=1240950906972336142, tenantId=1146029695717560320, journalId=1227665162245664772, issueId=1240950898113966774, articleNumber=null, orderNo=null, doi=10.20043/j.cnki.MPM.202309157, pmid=null, cstr=null, oa=null, hot=null, price=null, onlineType=0, articleFormat=0, articleType=null, articleTypeStr=null, receivedDate=1694361600000, receivedDateStr=2023-09-11, revisedDate=null, revisedDateStr=null, acceptedDate=null, acceptedDateStr=null, onlineDate=1773795351974, onlineDateStr=2026-03-18, pubDate=1712678400000, pubDateStr=2024-04-10, doiRegisterDate=null, doiRegisterDateStr=null, onlineIssueDate=1773795351974, onlineIssueDateStr=2026-03-18, onlineJustAcceptDate=null, onlineJustAcceptDateStr=null, onlineFirstDate=null, onlineFirstDateStr=null, sourceXml=null, magXml=null, createTime=1773795351974, creator=13701087609, updateTime=1773795351974, updator=13701087609, issue=Issue{id=1240950898113966774, tenantId=1146029695717560320, journalId=1227665162245664772, year='2024', volume='51', issue='7', pageStart='1153', pageEnd='1344', issueExtLink='null', onlineDate='null', pubDate='null', beforeIssueId=null, nextIssueId=null, price=null, status=1, issueComplete=1, articleOrder=1, issueType=-1, specialIssue=null, createTime=1773795349862, creator=13701087609, updateTime=1773795519367, updator=13701087609, preIssue=null, nextIssue=null, ext={EN=IssueExt(id=1240951609136567133, tenantId=1146029695717560320, journalId=1227665162245664772, issueId=1240950898113966774, language=EN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=), CN=IssueExt(id=1240951609136567134, tenantId=1146029695717560320, journalId=1227665162245664772, issueId=1240950898113966774, language=CN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=)}, issueFiles=null}, startPage=1284, endPage=1289, ext={EN=ArticleExt(id=1240950907312074792, articleId=1240950906972336142, tenantId=1146029695717560320, journalId=1227665162245664772, language=EN, title=Structural equation model analysis of the influence of anxiety and cognitive function on self-management behavior in elderly patients with diabetes mellitus, columnId=1228016572451718132, journalTitle=Modern Preventive Medicine, columnName=Health and Social Behavior, runingTitle=null, highlight=null, articleAbstract=
Objective

To explore the relationship among cognitive function, anxiety, and self-management behavior in elderly patients with diabetes mellitus.

Methods

A face-to-face survey was conducted among elderly patients with type 2 diabetes mellitus aged 60 and over in the Department of Endocrinology, Penglai People’s Hospital, Yantai city, Shandong Province from October 2021 to May 2022. The Geriatric Anxiety Inventory-Short Form (GAI-SF), the Montreal Cognitive Assessment (MoCA),and self-designed items were used to assess the anxiety, cognitive function, and self-management behaviors of the patients.Path analysis and mediation effect testing were conducted using a structural equation model.

Results

In total 1 319 diabetic patients aged 60 and above were enrolled, of whom 8.3% had anxiety symptoms. The average scores of MoCA scale and self-management behavior were (23.89±4.12) and (3.74±1.27), respectively. Structural equation model analysis showed that cognitive function had a masking effect between anxiety and self-management behavior, and anxiety had a positive effect on self-management behavior directly (β=0.127, P < 0.019). However, it also had a strong negative effect on cognitive function (β=-0.567, P < 0.001) and then had a negative effect on self-management behavior (β=-0.241, P < 0.001). Therefore, anxiety had a negative effect on self-management behavior (β=-0.115, P < 0.001).

Conclusion

The anxiety of elderly patients with diabetes is negatively correlated with their self-management behavior and can have a negative effect on self-management through cognitive function.

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目的

探讨老年糖尿病患者认知功能、焦虑、自我管理行为之间的关系。

方法

于2021年10月—2022年5月在山东省烟台市蓬莱人民医院内分泌科对60岁及以上老年2型糖尿病患者进行面对面调查，分别采用老年焦虑量表简版（GAI-SF）、蒙特利尔认知评估量表(MoCA)、自设题项评估患者焦虑、认知功能、自我管理重点行为状况。采用结构方程模型进行路径分析及中介效应检验。

结果

共纳入1 319名60岁及以上糖尿病患者，其中110人（8.3%）有焦虑症状，MoCA量表平均得分为（23.89±4.12）分，自我管理行为平均得分为（3.74±1.27）分。结构方程模型分析显示，认知功能在焦虑与自我管理行为之间呈现遮掩作用，焦虑直接对自我管理行为产生正向影响（β=0.127, P=0.019），但又通过对认知功能产生较强的负向影响（β=-0.567, P<0.001）进而对自我管理行为产生一定的负向影响（β=-0.241, P<0.001），从而遮掩了正向影响，故最后焦虑对自我管理行为呈现负向影响（β=-0.115, P<0.001）。

结论

老年糖尿病患者的焦虑情绪与其自我管理行为负相关，并可通过认知功能对自我管理产生负面影响。

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李晋磊，E-mail:;
王宇萍，E-mail:
, copyrightStatement=本刊刊出的所有文章不代表中华预防医学会和本刊编委会的观点，除非特别声明。, copyrightOwner=中华预防医学会和四川大学华西公共卫生学院, extLink=null, articleAbsUrl=null, sourceXml=54SSKw4dW+JIin/UswAnXw==, magXml=Z6G8nsKdt9MWIRUZCuXnDw==, pdfUrl=null, pdf=+elS+u5mQcL1yF90lNO/8Q==, pdfFileSize=811796, pdfExtLink=null, richHtmlUrl=null, mobilePdfUrl=null, reviewReport=null, pdfFirstPage=null, abstractGraph=SFlU+JCob12Lg/4WldASrQ==, abstractGraphContent=null, abstractVideo=null, citation=null, cebUrl=null, magXmlContent=jCbb6uBDj04C9EU4pj7pxg==, mapNumber=null, authorCompany=null, fund=null, authors=

张海鑫（1998—），女，硕士在读，研究方向：流行病与卫生统计学

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Symptoms of depression and anxiety and adherence to antihypertensive medication[J]. American Journal of Hypertension, 2012, 25(4): 505-511., articleTitle=Symptoms of depression and anxiety and adherence to antihypertensive medication, refAbstract=null)], funds=[Fund(id=1240972177814646838, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240950906972336142, awardId=CMB 22-467, language=CN, fundingSource=美国中华医学基金会项目(CMB 22-467), fundOrder=null, country=null)], companyList=[AuthorCompany(id=1240972168973054657, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240950906972336142, xref=1., ext=[AuthorCompanyExt(id=1240972168994026181, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240950906972336142, companyId=1240972168973054657, language=EN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=School of Medicine and Public Health, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100005,China), AuthorCompanyExt(id=1240972169010803399, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240950906972336142, companyId=1240972168973054657, language=CN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=1.中国医学科学院北京协和医学院群医学及公共卫生学院，北京 100005)]), AuthorCompany(id=1240972169153409744, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240950906972336142, xref=2., ext=[AuthorCompanyExt(id=1240972169174381269, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240950906972336142, companyId=1240972169153409744, language=CN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=2.石家庄市第八医院)])], figs=[ArticleFig(id=1240972176761876498, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240950906972336142, language=EN, label=Figure 1, caption=Structural equation model of factors influencing self-management behavior, figureFileSmall=WcIv98dWPgyp0T6HcmOEyQ==, figureFileBig=ztytvgU0L694WIC9teXDUw==, tableContent=null), ArticleFig(id=1240972176921260053, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240950906972336142, language=CN, label=图1, caption=老年糖尿病患者自我管理行为影响因素结构方程模型, figureFileSmall=WcIv98dWPgyp0T6HcmOEyQ==, figureFileBig=ztytvgU0L694WIC9teXDUw==, tableContent=null), ArticleFig(id=1240972177034506269, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240950906972336142, language=EN, label=Table 1, caption=

Basic characteristics of elderly patients with diabetes mellitus ［n（%）,（）］

, figureFileSmall=null, figureFileBig=null, tableContent=
特征调查人数MoCA得分
（分）		自我管理行为得分（分）
总1 319 (100)23.89±4.123.74±1.27
年龄（岁）
60～69837 (63.5)23.98±4.133.67±1.30
≥70482 (36.5)23.75±4.073.85±1.22
t值0.936.07
P值0.3360.014
性别
男724 (54.9)23.82±4.223.71±1.26
女595 (45.1)23.98±3.973.77±1.28
t值0.520.62
P值0.4700.430
受教育程度
小学及以下252 (19.1)23.94±3.263.48±1.24
初中629 (47.7)23.69±4.143.76±1.31
高中/中专362 (27.4)23.78±4.453.82±1.16
大专/大学及以上76 (5.8)25.99±4.154.07±1.44
F值7.295.74
P值<0.001<0.001
婚姻状况
无配偶61 (4.6)22.31±5.543.82±1.20
有配偶1 258 (95.4)23.97±4.013.74±1.28
t值9.560.26
P值0.0020.613
糖尿病病程（年）
0～4369 (28.0)25.20±3.163.79±1.32
5～9402 (30.5)22.99±4.583.75±1.21
≥10548 (41.5)23.68±4.093.70±1.29
F值30.450.65
P值<0.0010.523
BMI
偏瘦/正常409 (31.0)24.64±3.373.90±1.18
超重654 (49.6)23.48±4.533.71±1.31
肥胖256 (19.4)23.75±3.913.55±1.30
F值10.326.14
P值<0.0010.002
独居
否1 301 (98.6)23.91±4.103.74±1.27
是18 (1.4)22.94±4.983.61±1.46
t值0.980.18
P值0.3230.667
空腹血糖（mmol/L）
<7.0317 (24.0)24.64±3.163.88±1.25
7.0～8.5655 (49.7)24.68±3.353.87±1.20
≥8.5347 (26.3)21.73±5.253.37±1.35
F值72.5420.53
P值<0.001<0.001
焦虑
否1 209 (91.7)24.49±3.363.78±1.27
是110 (8.3)17.30±5.603.32±1.20
t值403.7713.26
P值<0.001<0.001
), ArticleFig(id=1240972177172918305, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240950906972336142, language=CN, label=表1, caption=

老年糖尿病患者基本情况［n（%）,（）］

, figureFileSmall=null, figureFileBig=null, tableContent=
特征调查人数MoCA得分
（分）		自我管理行为得分（分）
总1 319 (100)23.89±4.123.74±1.27
年龄（岁）
60～69837 (63.5)23.98±4.133.67±1.30
≥70482 (36.5)23.75±4.073.85±1.22
t值0.936.07
P值0.3360.014
性别
男724 (54.9)23.82±4.223.71±1.26
女595 (45.1)23.98±3.973.77±1.28
t值0.520.62
P值0.4700.430
受教育程度
小学及以下252 (19.1)23.94±3.263.48±1.24
初中629 (47.7)23.69±4.143.76±1.31
高中/中专362 (27.4)23.78±4.453.82±1.16
大专/大学及以上76 (5.8)25.99±4.154.07±1.44
F值7.295.74
P值<0.001<0.001
婚姻状况
无配偶61 (4.6)22.31±5.543.82±1.20
有配偶1 258 (95.4)23.97±4.013.74±1.28
t值9.560.26
P值0.0020.613
糖尿病病程（年）
0～4369 (28.0)25.20±3.163.79±1.32
5～9402 (30.5)22.99±4.583.75±1.21
≥10548 (41.5)23.68±4.093.70±1.29
F值30.450.65
P值<0.0010.523
BMI
偏瘦/正常409 (31.0)24.64±3.373.90±1.18
超重654 (49.6)23.48±4.533.71±1.31
肥胖256 (19.4)23.75±3.913.55±1.30
F值10.326.14
P值<0.0010.002
独居
否1 301 (98.6)23.91±4.103.74±1.27
是18 (1.4)22.94±4.983.61±1.46
t值0.980.18
P值0.3230.667
空腹血糖（mmol/L）
<7.0317 (24.0)24.64±3.163.88±1.25
7.0～8.5655 (49.7)24.68±3.353.87±1.20
≥8.5347 (26.3)21.73±5.253.37±1.35
F值72.5420.53
P值<0.001<0.001
焦虑
否1 209 (91.7)24.49±3.363.78±1.27
是110 (8.3)17.30±5.603.32±1.20
t值403.7713.26
P值<0.001<0.001
), ArticleFig(id=1240972177260998692, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240950906972336142, language=EN, label=Table 2, caption=

Path analysis of the structural equation model

, figureFileSmall=null, figureFileBig=null, tableContent=
路径βB值 C.R.P值
焦虑→自我管理行为0.1270.1840.0712.5800.010
焦虑→认知功能-0.567-1.6390.126-13.036<0.001
认知功能→自我管理行为0.4250.2140.0336.542<0.001
), ArticleFig(id=1240972177357467690, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240950906972336142, language=CN, label=表2, caption=

结构方程模型的路径分析

, figureFileSmall=null, figureFileBig=null, tableContent=
路径βB值 C.R.P值
焦虑→自我管理行为0.1270.1840.0712.5800.010
焦虑→认知功能-0.567-1.6390.126-13.036<0.001
认知功能→自我管理行为0.4250.2140.0336.542<0.001
), ArticleFig(id=1240972177466519596, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240950906972336142, language=EN, label=Table 3, caption=

Mediation effect analysis of cognitive function between anxiety and self-management behavior

, figureFileSmall=null, figureFileBig=null, tableContent=
效应分解路径效应值(Boot 95%CI)BootP值
总效应焦虑→自我管理行为-0.115 (-0.182～-0.049)0.034<0.001
间接效应焦虑→认知功能→自我管理行为-0.241 (-0.344～-0.164)0.046<0.001
直接效应焦虑→自我管理行为0.127 (0.016～-0.238)0.0560.019
), ArticleFig(id=1240972177613320239, tenantId=1146029695717560320, journalId=1227665162245664772, articleId=1240950906972336142, language=CN, label=表3, caption=

认知功能在焦虑与自我管理行为间的中介效应分析

, figureFileSmall=null, figureFileBig=null, tableContent=
效应分解路径效应值(Boot 95%CI)BootP值
总效应焦虑→自我管理行为-0.115 (-0.182～-0.049)0.034<0.001
间接效应焦虑→认知功能→自我管理行为-0.241 (-0.344～-0.164)0.046<0.001
直接效应焦虑→自我管理行为0.127 (0.016～-0.238)0.0560.019
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焦虑、认知功能对老年糖尿病患者自我管理行为影响的结构方程模型分析
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张海鑫 1 , 张一方 1 , 芦萌 2 , 谢芷兰 1 , 张纹菱 1 , 王宇萍 1 , 李晋磊 1
现代预防医学 | 健康与社会行为 2024,51(7): 1284-1289
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现代预防医学 | 健康与社会行为 2024, 51(7): 1284-1289
焦虑、认知功能对老年糖尿病患者自我管理行为影响的结构方程模型分析
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张海鑫1, 张一方1, 芦萌2, 谢芷兰1, 张纹菱1, 王宇萍1 , 李晋磊1
作者信息
  • 1.中国医学科学院北京协和医学院群医学及公共卫生学院，北京 100005
  • 2.石家庄市第八医院

    • 张海鑫（1998—），女，硕士在读，研究方向：流行病与卫生统计学

通讯作者:

李晋磊，E-mail:;
王宇萍，E-mail:
Structural equation model analysis of the influence of anxiety and cognitive function on self-management behavior in elderly patients with diabetes mellitus
Hai-xin ZHANG1, Yi-fang ZHANG1, Meng LU2, Zhi-lan XIE1, Wen-ling ZHANG1, Yu-ping WANG1 , Jin-lei LI1
Affiliations
  • School of Medicine and Public Health, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100005,China
出版时间: 2024-04-10 doi: 10.20043/j.cnki.MPM.202309157
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摘要
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目的

探讨老年糖尿病患者认知功能、焦虑、自我管理行为之间的关系。

方法

于2021年10月—2022年5月在山东省烟台市蓬莱人民医院内分泌科对60岁及以上老年2型糖尿病患者进行面对面调查，分别采用老年焦虑量表简版（GAI-SF）、蒙特利尔认知评估量表(MoCA)、自设题项评估患者焦虑、认知功能、自我管理重点行为状况。采用结构方程模型进行路径分析及中介效应检验。

结果

共纳入1 319名60岁及以上糖尿病患者，其中110人（8.3%）有焦虑症状，MoCA量表平均得分为（23.89±4.12）分，自我管理行为平均得分为（3.74±1.27）分。结构方程模型分析显示，认知功能在焦虑与自我管理行为之间呈现遮掩作用，焦虑直接对自我管理行为产生正向影响（β=0.127, P=0.019），但又通过对认知功能产生较强的负向影响（β=-0.567, P<0.001）进而对自我管理行为产生一定的负向影响（β=-0.241, P<0.001），从而遮掩了正向影响，故最后焦虑对自我管理行为呈现负向影响（β=-0.115, P<0.001）。

结论

老年糖尿病患者的焦虑情绪与其自我管理行为负相关，并可通过认知功能对自我管理产生负面影响。

糖尿病  /  焦虑  /  认知功能  /  自我管理行为  /  结构方程模型
Objective

To explore the relationship among cognitive function, anxiety, and self-management behavior in elderly patients with diabetes mellitus.

Methods

A face-to-face survey was conducted among elderly patients with type 2 diabetes mellitus aged 60 and over in the Department of Endocrinology, Penglai People’s Hospital, Yantai city, Shandong Province from October 2021 to May 2022. The Geriatric Anxiety Inventory-Short Form (GAI-SF), the Montreal Cognitive Assessment (MoCA),and self-designed items were used to assess the anxiety, cognitive function, and self-management behaviors of the patients.Path analysis and mediation effect testing were conducted using a structural equation model.

Results

In total 1 319 diabetic patients aged 60 and above were enrolled, of whom 8.3% had anxiety symptoms. The average scores of MoCA scale and self-management behavior were (23.89±4.12) and (3.74±1.27), respectively. Structural equation model analysis showed that cognitive function had a masking effect between anxiety and self-management behavior, and anxiety had a positive effect on self-management behavior directly (β=0.127, P < 0.019). However, it also had a strong negative effect on cognitive function (β=-0.567, P < 0.001) and then had a negative effect on self-management behavior (β=-0.241, P < 0.001). Therefore, anxiety had a negative effect on self-management behavior (β=-0.115, P < 0.001).

Conclusion

The anxiety of elderly patients with diabetes is negatively correlated with their self-management behavior and can have a negative effect on self-management through cognitive function.

Diabetes  /  Anxiety  /  Cognitive function  /  Self-management behavior  /  Structural equation models
张海鑫, 张一方, 芦萌, 谢芷兰, 张纹菱, 王宇萍, 李晋磊. 焦虑、认知功能对老年糖尿病患者自我管理行为影响的结构方程模型分析. 现代预防医学, 2024 , 51 (7) : 1284 -1289 . DOI: 10.20043/j.cnki.MPM.202309157
Hai-xin ZHANG, Yi-fang ZHANG, Meng LU, Zhi-lan XIE, Wen-ling ZHANG, Yu-ping WANG, Jin-lei LI. Structural equation model analysis of the influence of anxiety and cognitive function on self-management behavior in elderly patients with diabetes mellitus[J]. Modern Preventive Medicine, 2024 , 51 (7) : 1284 -1289 . DOI: 10.20043/j.cnki.MPM.202309157
正文
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随着人口老龄化形势日益严峻，我国老年糖尿病患病率呈快速增长趋势[1]。且我国老年糖尿病患者血糖控制不佳[2-3]，长期慢性高血糖所致的多种慢性并发症，如心血管疾病、足病、肾病等，发展到后期严重威胁患者生命健康、降低患者生活质量，带来严重的疾病负担。科学有效的自我管理行为有助于老年糖尿病患者的血糖控制[4]，从而减少或延缓糖尿病并发症的发生发展。由于长期用药以及机体各项机能减退，老年糖尿病患者对胰岛素、降糖药敏感度降低，血糖长期无法得到有效控制，患者极易产生焦虑情绪[5]，进而导致患者依从性降低[6]，自我管理行为变差[7]。此外，患者自我管理需要记忆、注意、执行和计算等多项认知功能参与，而焦虑又是认知功能障碍的一项重要影响因素[8]，因此焦虑可能通过认知功能间接影响自我管理行为，但目前相关路径研究较少。本研究利用结构方程模型，探讨焦虑和认知功能对自我管理行为影响的作用路径及其潜在的中介机制，为老年糖尿病患者的自我管理提供参考。
1　对象与方法
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1.1　对象
本研究为横断面研究，纳入2021年10月—2022年5月就诊于山东省烟台市蓬莱人民医院内分泌科的60岁及以上2型糖尿病患者作为研究对象。排除临床已诊断为阿尔兹海默症、帕金森症等神经退行性疾病以及患有精神疾病，不能进行有效交流，本人或家属拒绝参与的患者。本项目由中国医学科学院伦理委员会审查并获得批准（批准号：CAMS&PUMC-IEC-2021-022），所有研究对象均签署了知情同意书。
1.2　资料收集
（1）一般情况：性别、出生年月、受教育程度、婚姻状况、糖尿病诊断年份、是否独居等。
（2）焦虑：采用老年焦虑量表简版（geriatric anxiety inventory-short form，GAI-SF）评估患者焦虑状态，共5个条目，满分5分，得分≥3分时认为存在焦虑，量表Cronbach α=0.840[9]，本研究量表Cronbach α=0.889，提示测量信度良好。
（3）认知功能：采用蒙特利尔认知评估（montreal cognitive assessment, MoCA）量表（北京版）评估患者认知功能，包括视空间与执行功能、命名、注意、语言、抽象、回忆、定向7个维度，满分30分，得分越高代表认知功能越好，量表的内部一致性信度系数Cronbach α=0.818[10]，本研究量表Cronbach α=0.678。
（4）糖尿病自我管理行为：采用自行设计的题项对糖尿病患者自我健康管理重点行为进行调查，调查研究对象调查前6个月中遵照医生要求进行饮食控制、科学运动、血糖监测的情况，并进行赋分，经常能够做到记2分，有时能够做到记1分，无法做到记0分，满分6分，得分越高代表自我管理行为越好，本研究该项目Cronbach α=0.765，提示具有相当的测量信度。
（5）体格检查资料（由内分泌科护士提取患者病例资料进行填写）：身高、体重、空腹血糖等，根据身高、体重计算体质指数(body mass index, BMI)，计算公式为“体重（kg）/身高的二次方（m2）”，参考中国肥胖问题工作组标准[11]，BMI<24.0 kg/m2定义为正常/偏瘦，24.0 kg/m2≤BMI<28.0 kg/m2定义为超重，BMI≥28.0 kg/m2定义为肥胖。
1.3　质量控制
采用统一编制并经过预调查的调查表。调查员通过系统培训，以统一的询问和填写方法开展调查工作。调查由督导员进行监督。调查结束后对问卷进行抽查核对，及时进行错填修改和漏填补充，以保证数据质量。
1.4　统计分析
使用SAS 9.4对数据进行整理和统计分析。计数资料采用频数和百分比进行描述。计量资料采用（均值±标准差）进行描述，使用独立样本t检验或方差分析进行组间比较。应用Spearman相关分析探讨焦虑、认知功能与自我管理行为之间的关系。应用Amos 26.0软件构建结构方程模型，并以5 000次Bootstrap法进行中介效应检验。检验水准α=0.05。
2　结果
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2.1　老年糖尿病患者基本情况
共纳入1 319名60岁及以上糖尿病患者，平均年龄（68.0±5.1）岁，男性724人（54.9%）。其中，110人（8.3%）有焦虑症状，MoCA量表平均得分为（23.89±4.12）分，自我管理行为平均得分为（3.74±1.27）分。单因素分析结果显示，伴有焦虑的老年糖尿病患者认知功能、自我管理行为得分低于对照组（P<0.001）。见表1。
2.2　老年糖尿病患者焦虑、认知功能与自我管理行为的相关性分析
Spearman相关分析结果显示，老年糖尿病患者焦虑与认知功能和自我管理行为水平均显著负相关（r=-0.327、-0.093, P<0.001），认知功能与自我管理行为水平显著正相关（r=0.264, P<0.001）。
2.3　老年糖尿病患者自我管理行为的结构方程模型分析
通过Amos 26.0软件，采用极大似然法，以年龄、受教育程度、病程、BMI、空腹血糖为协变量，焦虑为自变量，认知功能为中间变量，自我管理行为为因变量，构建老年糖尿病患者自我管理行为影响因素结构方程模型。见图1。
模型适配度指标显示,卡方自由度比(χ2/v) =5.798、适配度指数(goodness of fit index, GFI)=0.935、调整后适配度指数(adjusted goodness of fit index ,AGFI)=0.911、比较适配指数(comparative fit index,CFI)=0.907、渐进残差均方和平方根(root mean square error of approximation, RMSEA)=0.060，提示模型拟合效果良好。
模型的路径分析结果显示：（1）认知功能对自我管理行为（β=0.425, P<0.001）发挥直接影响；（2）焦虑对自我管理行为（β=0.127, P=0.010）发挥直接影响；（3）焦虑对认知功能（β=-0.567, P<0.001）发挥直接影响。路径系数和标准化路径系数见表2。
2.4　认知功能在焦虑与自我管理行为间的中介效应分析
为验证?认知功能在焦虑影响老年糖尿病患者自我管理行为过程中的间接效应，采用Bootstrap进行检验。通过从样本中重复取样5 000次，估计间接效应的按照偏差矫正的95%CI，若95%CI不包含0，则间接效应显著。检验结果显示，认知功能在焦虑与自我管理行为之间呈现遮掩作用，焦虑直接对自我管理行为产生正向影响（β=0.127, P=0.019），但又通过对认知功能产生较强的负向影响进而对自我管理行为产生一定的负向影响（β=-0.241, P<0.001），从而遮掩了正向影响，故最后焦虑对自我管理行为呈现负向影响（β=-0.115, P<0.001）。见表3。
3　讨论
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本研究发现，认知功能与自我管理行为水平显著正相关。结构方程模型路径分析结果表明，认知功能对自我管理行为有直接影响，标准化路径系数为0.425，即MoCA量表得分每增加1，自我管理行为得分将增加0.425，提示认知功能对自我管理行为存在正向效应。认知功能障碍的患者由于各项认知功能减退，出现“病感失认”[12]，表现出对疾病认识不足、依从性较差[13]，很难执行监测血糖、合理饮食等复杂的自我管理任务，自我管理行为能力随认知功能的衰退而下降[14]。因此，及早识别认知功能障碍对老年糖尿病管理具有重要意义[15]。
焦虑对认知功能有直接影响，标准化路径系数为-0.567，即GAI-SF量表得分每增加1，MoCA量表得分将减少0.567，提示焦虑对认知功能存在负向效应。既往纵向研究meta分析结果表明[8]，焦虑显著增加认知功能障碍发生风险，且焦虑的严重程度越高，认知功能障碍风险越高[16]。焦虑患者精神压力增加，此时糖皮质激素水平升高，导致淀粉样蛋白形成并沉积，内侧颞叶糖皮质激素受体的过度刺激导致海马萎缩[17]。此外，焦虑患者炎性细胞因子（如白细胞介素-6和肿瘤坏死因子）水平增加，脑源性神经营养因子水平降低，对认知功能产生负面影响[18]。
关于焦虑与自我管理行为，相关性分析发现两者显著负相关，与黄玉红[19]、马慧慧等[20]的研究结果一致。焦虑患者面对疾病通常采用回避、逃避和否认等应对机制[21]，进而导致依从性降低，自我管理行为变差[6]，不利于对血糖的控制[7]，发生严重并发症的风险增加，患者生活质量下降，疾病负担加重[22]。《中国老年糖尿病诊疗指南（2021年版）》[15]提出，应关注老年糖尿病患者的精神状态，尽早识别精神疾病并干预，建立和完善多学科团队协同照料模式，改善患者焦虑症状。
但黄晓婷等[23]研究发现，随着焦虑程度加重，患者自我管理水平升高，Distaso等[24]发现，在新冠疫情流行期间，糖尿病患者的疫情焦虑在短期内有助于改善患者的糖尿病自我管理。本研究路径分析结果表明，焦虑对自我管理行为的直接影响为正向效应，标准化路径系数为0.127。Bootstrap检验结果显示，认知功能在焦虑与自我管理行为之间呈现遮掩作用，焦虑直接对自我管理行为产生正向影响（β=0.127, P=0.019），但又通过对认知功能产生较强的负向影响（β=-0.567, P<0.001）进而对自我管理行为产生一定的负向影响（β=-0.241, P<0.001），从而遮掩了正向影响，故最后焦虑对自我管理行为呈现负向影响（β=-0.115, P<0.001）。这一研究结果或许可对既往研究中焦虑与糖尿病自我管理之间较为矛盾的相互关系进行一定解释。对自身疾病产生焦虑情绪的患者一般更加重视自身所患疾病，学习疾病相关知识的积极性较高，能够充分认识到糖尿病的危害性以及自我管理的重要性，从而遵从医嘱执行治疗方案，因而自我管理行为水平较高。但由于疾病长期存在，尤其是老年患者，长期处于焦虑状态，严重影响认知功能，故通过这一路径对糖尿病自我管理产生了更强的负向作用，最后遮掩了正向作用。此外，还有研究[25]认为，焦虑对疾病自我管理的影响可能由患者的自我效能介导，有待进一步研究。
综上所述，本研究使用结构方程模型对老年糖尿病患者焦虑、认知功能和自我管理行为之间的关系进行分析，结果表明，老年糖尿病患者的焦虑情绪与其自我管理行为负相关，并可通过认知对自我管理产生负面影响，提示在老年糖尿病患者的健康管理中应更加关注其精神状态和认知功能，尽早识别焦虑症状和认知障碍并进行干预，促进患者更好地进行自我管理。
基金
收起
  • 美国中华医学基金会项目(CMB 22-467)
文献
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参考文献 引证文献
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2024年第51卷第7期
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doi: 10.20043/j.cnki.MPM.202309157
  • 接收时间：2023-09-11
  • 首发时间：2026-03-18
  • 出版时间：2024-04-10
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  • 收稿日期：2023-09-11
基金
美国中华医学基金会项目(CMB 22-467)
作者信息
    1.中国医学科学院北京协和医学院群医学及公共卫生学院，北京 100005
    2.石家庄市第八医院

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李晋磊，E-mail:;
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鹅膏菌科Amanitaceae 2 11 5.26 鹅膏菌属 Amanita 10 4.78
小菇科 Mycenaceae 2 12 5.74 丝盖伞属 Inocybe 5 2.39
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红菇科 Russulaceae 3 23 11.00 小皮伞属 Marasmius 6 2.87
小菇属 Mycena 11 5.26
光柄菇属 Pluteus 5 2.39
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