身體活動已逐漸被認為是有助於營造良好老年生活的重要生活型態行為。許多不同類型之研究均顯示身：體活動能改善老年人的認知功能。然而，這些研究所指的身體活動泰半都是侷限於休閒時間身體活動。對於家務性身體活動、職業性身體活動與認知功能間之關係反而關注較少。此外，目前在東亞地區之相關研究較少，因此，對於身處這些地區的老年人其身體活動與認知功能的關係，瞭解有就極為有限。

為針對上述這些問題，本研究擬透過具有全國代表性之老年人樣本，探討從事不同種類身體活動與認知功能受損間之關係。具體研究目的為 (i) 探討休閒時間身體活動、費力勞動與認知功能受損之橫斷性關係; (ii) 探究身體活動改變與認知功能下降之7年縱貫性關係。本研究分為兩階段。

階段一係在評估休閒時間身體活動、費力勞動與認知功能受損之橫斷性關係。65以上老年人自陳從事兩種身體活動之參與狀況： (i) 休閒時間身體活動; (ii) 費力勞動。透過兩者相加一併計算出整體身體活動。認知功能受損則透過The Mini Mental State Examination (MMSE)進行評估。運用multivariate logistic regression models估算整體身體活動量與認知功能受損間關係之adjusted odds ratios (1= 有受損, 0= 沒有) 。相同程序也用於估算休閒時間身體活動、費力勞動與認知功能受損間之關係。結果顯示：僅休閒時間身體活動與認知功能受損有關。特別是平均每次運動超過30分鐘之老年人者，其認知功能受損之危險性較低。

階段二使用台灣地區老年人被持續追蹤7年之樣本。認知功能係使用The Short Portable Mental Status Questionnaire其中5題，分數介於0至5分。 2003年認知功能分數減去1996年之分數用於定義認知功能是否下降（編碼 1：差為負數，代表下降；編碼0：差為0或正數，代表認知功能不變或有改善）。參與者自陳每週至少運動三次(含)以上者歸類為高運動量，反之為低運動量。透過比較受試者在1996與1999間運動行為改變，可將受試者分類為四種運動行為改變狀態（低/低，低/高，高/低，高/高）。結果顯示：受試者在1996與1999均為低運動量者 (AOR= 1.50, 95%CI: 1.06-2.14) 或自高運動量改為低運動量者 (AOR= 3.02, 95%CI: 2.14-4.27)具有較高的危險性產生認知功能下降之情形。此外，透過潛在成長曲線模式（The Latent Growth Curve Model）可以發現休閒時間身體活動是認知功能下降之顯著預測因子。

本研究係第一個使用全國性之調查資料探討台灣地區老年人身體活動行為與認知功能之橫斷性與縱貫性關係之研究。它的發現有助於拓展我們對於東亞地區老年人其身體活動參與與認知功能關係之了解，也能彌補目前文獻在此部分之缺憾。基於本研究之發現，有關鼓勵老年人從事身體活動用於預防或延遲其認知功能受損之可能效益應受到政府、相關單位與老年人之關注。

Physical activity as an important lifestyle behavior has been increasingly recognized as a viable vehicle for achieving a good later life. Studies featuring a range of research designs have shown that physical activity may improve older people’s cognitive functioning. However, physical activity in these studies has usually denoted leisure-time physical activity in the form of center-based group exercise programs or self purposeful exercise. Less attention has been paid to domestic and occupational physical activity. Besides, there has been a dearth of research conducted from East Asia, so little is known about the activity–cognition relationship in these countries

To address some of these shortfalls, the aim of the study was to assess the relationships between different types of physical activity and cognitive deterioration using a nationally representative sample of Taiwanese older adults. The specific research objectives was: (i) to explore the cross-sectional association of leisure-time physical activity, heavy labor, and cognitive impairment; (ii) to examine the prospective association of physical activity changes with cognitive decline from 1996 to 2003 after controlling for the effect of disease status, physical functioning and other relevant covariates at baseline. Two-phase studies were conducted.

Phase I was designed to assess the association among leisure-time physical activity, heavy labor, and cognitive impairment. Two types of physical activity were self-reported: (i) leisure-time physical activity; (ii) Heavy labor. Total weekly amount of energy expenditure for overall physical activity was created by adding up the amount of leisure-time physical activity and heavy labor. Cognitive impairment was assessed using the Mini Mental State Examination (MMSE). The adjusted odds ratios using multivariate logistic regression models were assessed to examine the association of overall physical activity with cognitive impairment (1= yes, 0= no) after controlling for potential confounders. The same procedures for assessing the independent effect of leisure-time physical activity and heavy labor were then performed. Participants with lower total physical activity seemed to possess higher risk of cognitive impairment but did not reach the significant level. It is leisure-time physical activity, especially engaging in more than 30 minutes during each session, is associated with lower risk of cognitive impairment.

In Phase II, the analyses were based on nationally representative data. Data from the fixed cohort of 1,743 participants aged 67 and older in 1996 with seven years of follow-up were analyzed. Cognitive status ranging from 0 to 5 was measured using five questions from the Short Portable Mental Status Questionnaire. Two statistical analyses were included in Phase II. First is multiple logistic regression analysis. Cognitive decline was assessed based on the difference between the 5-point scores from 1996 to 2003 (coded 1 if decline, 0 if no change or improvement). Participants engaging in at least three activity sessions per week were classified as being physically active. Based on physical activity status in 1996 and 1999, four categories of activity status were created (low/low, low/high, high/low and high/high). Sensitivity analyses were conducted to examine the effect of missing values, and excluding participants with physical limitation and cognitive decline (<5-point) at baseline. Participants who were low in leisure-time activity at both time points (AOR= 1.50, 95%CI: 1.06-2.14) or from high to low (AOR= 3.02, 95%CI: 2.14-4.27) were at greater risks of developing cognitive decline in 2003, which was further supported by sensitivity analyses. The association of leisure-time physical activity with cognitive change was further tested using the latent growth curve modeling. Both unconditional and conditional models indicated that leisure-time physical activity is a significant predictor of cognitive performance during the seven-year period. However, participants with lower physical activity level did not show significantly distinct slope of cognitive change from those with higher level of physical activity engagement.

The research provided the first opportunity to examine the associations of physical activity behavior and cognition in Taiwanese older adults using two national surveys. It extends the understanding of physical activity with cognition among older adults in East Asia and fill the gap in the literature. Given that the preliminary results are promising, the findings of the studies may draw attention to the potentially role of physical activity, especially activity during leisure time, for preventing or delaying the onset of cognitive impairment in the aged population.

Table of Contents i
Abstract iv
Acknowledgement vi
Table of Figures vii
Table of Tables viii
CHAPTER 1 INTRODUCTION 1
1.1 Global population aging and Taiwan 1
1.2 Age-related cognitive disorder: dementia 1
1.3 Physical activity and cognitive deterioration 2
1.4 Aims of the research 4
1.5 Research hypothesis 4
1.6 Structure of the research 4
CHAPTER 2 LITERATURE REVIEW 6
2.1 Physical activity in older adults 6
2.1.1 Definition of physical activity 6
2.1.2 Prevalence of physical activity in older adults 6
2.1.3 Physical activity and health in older adults 11
2.2 Aging, cognitive impairment and dementia 13
2.2.1 Definition of dementia and mild cognitive impairment 13
2.2.2 Prevalence and incidence of dementia 14
2.2.3 Risk factors of cognitive impairment and dementia 17
2.3 Physical activity and cognitive deterioration in older adults 19
2.3.1 Background 19
2.3.2 Methods 19
2.3.3 Results 20
2.3.4 Discussion 38
2.4 Summary 46
CHAPTER 3 RESEARCH DESIGN 48
3.1 Phase I 48
3.1.1 Research framework 48
3.1.2 Data source and sample 49
3.1.3 Measures 50
3.1.4 Statistical analysis 51
3.2 Phase II 53
3.2.1 Data source and sample 53
3.2.2 Measures 54
3.2.3 Statistical analysis 56
CHAPTER 4 RESULTS AND DISCUSSION 62
4.1 Phase I: Different types of physical activity and cognitive impairment 62
4.2 Phase II: Prospective study of physical activity changes and cognitive decline 69
4.2.1 Descriptive statistics 69
4.2.2 Multiple logistic regression analysis 74
4.2.3 Propensity score and latent growth curve modeling 76
4.3 Discussion 82
4.3.1 A synthesis of the findings 82
4.3.2 Effects of physical activities within different contexts 83
4.3.3 Leisure-time physical activity change and cognition decline 84
4.3.4 Strengths and limitations 86
CHAPTER 5 CONCLUSIONS AND IMPLICATIONS 88
5.1 Conclusions 88
5.2 Implications 88
5.2.1 Policy and practice implications 88
5.2.2 Future research suggestions 90
References 92

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