研究目的：巴金森氏病（巴病）患者有很高的比例會出現認知功能障礙且會增加巴病患者的死亡率、減少生活品質，造成照顧者的負荷，目前巴病合併失智症的診斷準則以認知功能缺損明顯，並引起社會功能缺損來訂定，然尚未有適用於巴病患者的社會功能量表，因此本研究欲編製巴病的社會功能量表，建立其心理計量學指標，並提供切截分數供臨床使用，以協助正確診斷。
方法：本研究透過巴病與社會功能相關文獻，建立社會功能的初步量表，再以門診患者與家屬的前測結果修訂量表，並邀請熟悉巴病患者的神經心理學專家與神經科醫師進行內容檢核，產生共36題的「巴金森氏病社會功能量表」。本研究共招募231位受試者（157名巴病患者，74名正常人），進行簡易心智量表、畫時鐘測驗、日常生活功能量表、巴金森氏病社會功能量表、簡短版心智精神量表、適應行為評量系統第二版、世界動作障礙學會巴金森病綜合評量表第三部份等測驗之施測，巴病患者皆在有藥效狀態完成評估。探討之心理計量學指標包含內部一致性信度、再測信度、建構效度、已知族群效度、診斷效度。
結果：刪除共同性小於0.3之題目後，本研究量表之KMO值為0.856，Bartlett球型考驗的X^2值為1629.755（自由度253），轉軸後共有三因素，累積解釋變異量為52.350%。內部一致性信度為0.745~0.913；再測信度（時距平均約81.2天）為0.543~0.801。不同組別在量表的得分有顯著差異(p < 0.001)，事後比較發現健康控制組的得分最高，其次為沒有合併失智症之巴病以及巴病合併失智症組。 「巴金森氏病社會功能量表」總分與世界動作障礙學會巴金森病綜合評量表第三部分無顯著相關(r = -0.034, p = 0.736)，與適應行為評量系統第二版中文版分測驗的家庭生活、休閒以及社交總量表分數之相關分別為0.609 (p < 0.001)，而評估是否具有失智症的切截分數為39分，敏感度是0.735，特異度是0.857。
討論：「巴金森氏病社會功能量表」共有三向度，包括家庭生活、嗜好與自理，人際關係與娛樂性休閒活動，及社會連結，且三向度具有可接受的內部一致性信度與再測信度，量表亦具有輻合效度與區辨效度。此外，不同組別在量表的得分有顯著差異，並發現沒有合併失智症之巴病患者社會功能有缺損現象，而區分失智與未失智的ROC曲線之切截分數為39分。

The Development of the Social Functioning Scale for Patients with Parkinson’s Disease
Fang-Te Su and Rwei-Ling Yu
Medical College Institute of Behavioral Medicine, National Cheng Kung University

SUMMARY
Cognitive impairment is common in Parkinson’s disease (PD) and will increase the patients' mortality rate, reduce their quality of life, and cause the caregiver's burden. The current diagnostic criteria for PD dementia are significant cognitive impairment and cause social functioning defects. However, there is no social functioning scale for patients with PD. Therefore, we intend to develop a social functioning scale for Parkinson's disease to aid in the correct diagnosis. Also, we examine the psychometrics of the scale and provide cut-off scores for clinical use. The preliminary scale was established through literature related to PD and social functioning and revised with the pre-test results of outpatients, their family members, a neuropsychologist and a neurologist. The scale has a total of 36 questions entitled "Parkinson's Disease Social Functioning Scale (PDSFS)". The Mini-Mental State Examination (MMSE), Clock Drawing Test (CDT), and Activity of daily living (ADL) were used to discriminate non-demented Parkinson’s disease (PD-ND) and Parkinson’s disease dementia (PD-D). We employed Cronbach's alpha to determine internal consistency reliability, and we used intraclass correlation coefficient (ICC) to confirm the retest reliability. We used Adaptive Behavior Assessment System–Second Edition (ABAS–II), Movement Disorder Society-sponsored revision of the Unified Parkinson's Disease Rating Scale (MDS-UPDRS) part III to assessed construct validity. Last, we used receiver operating characteristic curve (ROC curve) to retrieve cut-off points for the assessment of diagnostic tests. A total of 231 subjects were recruited in this study. The PDSFS has three dimensions: “Family Life, Hobbies and Self-Care”, “Interpersonal Relationship and Recreational Leisure”, and “Social Bond”. The three dimensions have acceptable internal consistency reliability and retest reliability. There were significant differences in the scores of the different groups on the scale. Later found that the healthy control group had the highest score, followed by the PD-ND and PD-D groups. The total score of the scale is correlated with the sum of family life, leisure and social scale scores of ABAS–II, and unrelated with MDS-UPDRS part III. The cut-off score for dementia was 39, with good sensitivity and specificity. The PDSFS is a practical and psychometrically sound social functioning scale.
Keywords: Parkinson’s disease, cognitive impairment, social function, inventory, reliability, validity.
INTRODUCTION
The non-motor symptoms are recognized as a feature of Parkinson’s disease (PD), and cognitive impairment is one of the most common non-motor symptoms of PD. Because cognitive impairment can accelerate patients’ morbidity and reduce their quality of life, it is crucial to recognize the person who is at high risk of cognitive impairment, especially dementia. Dementia is the most critical cognitive impairment. No only Diagnostic and statistical manual of mental disorders- fifth edition (DSM-5) but also frequently used Parkinson’s disease dementia diagnosis criteria and mild cognitive impairment in Parkinson’s disease diagnosis criteria mentioned the distinction between PD dementia and mild cognitive impairment in social functioning. However, due to the motor symptoms in PD, there is no available social functioning scale to use. Therefore, the aim of the present study was to invent a social functioning scale for PD.
MATERIALS AND METHODS
The preliminary scale was established through literature related to PD and social functioning and then revised with the pretest results of outpatients, their family members, a neuropsychologist and a neurologist. The scale has a total of 36 questions entitled "Parkinson's Disease Social Functioning Scale (PDSFS)". A total of 231 subjects were included in the study. Informed consent was obtained from all participants. All participants completed tests, including Mini-Mental State Examination (MMSE), Clock Drawing Test (CDT), Activity of daily living (ADL), Neuropsychiatric Inventory (NPI), Adaptive Behavior Assessment System–Second Edition (ABAS–II), Movement Disorder Society-sponsored revision of the Unified Parkinson's Disease Rating Scale (MDS-UPDRS) part III. MMSE, CDT and ADL were used to discriminate non-demented Parkinson’s disease (PD-ND) and Parkinson’s disease dementia (PD-D). We employed Cronbach's alpha to determine internal consistency reliability, and we used intraclass correlation coefficient (ICC) to confirm the retest reliability. We also used ABAS–II, MDS-UPDRS part III to assessed construct validity. Last, we used receiver operating characteristic curve (ROC curve) to retrieve cut-off points for Assessment of Diagnostic Tests.
RESULTS AND DISCUSSION
There were 74 subjects in the control group, 136 subjects in PD-ND, 21 subjects in PD-D. Clinical characteristics and demographic variables, including sex, age, education, onset, H & Y stage, onset, MDS-UPDRS part III do show a significant difference. After deleted the item whose common factor less than 0.3, we employed Exploratory Factor Analysis (EFA) and found three dimensions: “Family Life, Hobbies and Self-Care”, “Interpersonal Relationship and Recreational Leisure”, and “Social Bond”. The internal consistency coefficient was 0.883 (range from 0.745 to 0.913) and the test-retest reliability was 0.774 (range from 0.543 to 0.801), respectively. There were significant differences in the scores of the three groups on the scale. Later found that the healthy control group had the highest score, followed by the PD-ND and PD-D groups. The total score was not related to the MDS-UPDRS Part III (r = -0.034, p = 0.736), and was significantly related to ABAS-II total score (r = 0.609, p < 0.001). The total score of “Family Life, Hobbies and Self-Care” was significantly related to ABAS-II family life subscle (r = 0.661, p < 0.001), and the sum score of “Interpersonal Relationship and Recreational Leisure” plus “Social Bond” was significantly related to ABAS-II Social Domain t (r = 0.509, p = 0.002). The cut-off score for dementia was 39 (sensitivity: 0.735; specificity: 0.857).
CONCLUSION
Although PD is characterized by its motor symptoms, PD may also suffer from non-motor symptoms such as cognitive impairment. Cognitive impairment can have many unpleasant impacts on patients with PD and their caregivers; it is better to identify the person who is at high risk of cognitive impairment as early as possible, especially those who are at risk of dementia. According to many cognitive impairment diagnosis criteria for PD, social functioning is the most important difference between PD-D and PD-ND. Furthermore social functioning can maintain one’s cognitive function. However, due to the lack of social functioning scale to help distinguish patients with PD-D and PD-ND, we intend to develop a social functioning scale to assist in diagnosis. Through the results of EFA, the PDSFS has three dimensions: “Family Life, Hobbies and Self-Care”, “Interpersonal Relationship and Recreational Leisure”, and “Social Bond”, with an acceptable internal consistency and test-retest reliability. The study also found that there were significant differences between three different groups. The healthy control group scored the highest, followed by the PD-ND group. The PD-D group scored the lowest, confirming that patients with PD-D had the worst social functioning. There was a significant correlation between the total scores and the ABAS–II family life, leisure, and social in this study, indicating that PDSFS has convergent validity, and there was no correlation with the MDS-UPDRS part III, showing that PDSFS has discriminate validity. In other words, the scale of this study can eliminate the confusion effect of the motor symptoms of patients with PD on PDSFS. The cut-off score of the ROC curve is 39 points, with a high degree of clinical utility.

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