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  • 學位論文

多面向認知訓練對改善機構老人認知功能之成效

The effectiveness of a multi-domain cognitive training in improving cognitive function for older institutionalized residents

指導教授 : 羅美芳

摘要


研究背景:認知衰退會對老人及其家庭產生負面影響,進而造成健康照護系統在財政上的負擔。近幾十年,國外不斷地發展改善老人認知功能的介入試驗,而根據相關研究的統合分析證實證實『認知參與』為有效降低罹患失智症和認知衰退風險的重要因子之ㄧ;反觀國內,有關此部分的介入研究卻非常缺乏,再者,國內機構的老人接受正式教育的年數與身體功能的狀況遠較西方國家來的低,因此,國外所發展的認知介入措施恐難以適用於國內老人或為其接受,故,發展合乎民情、生活、文化背景的本土化認知介入措施有其必要性。 研究目的:本研究目的主要是測試多面向認知訓練對改善機構老人認知功能、憂鬱程度與生活品質的成效。 研究方法:本研究為一縱貫性、多中心、機構群聚指派、雙盲的臨床試驗。樣本來源為臺北市、新北市等12家小型立案的養護型長期照機構,經EXCEL製成之機構群聚隨機表,分派至控制組、低強度認知訓練組或高強度認知訓練組等三組,總計個案98人。兩組實驗組的研究對象分別接受為期8週,每週2天或5天,每天30分鐘的多面向認知訓練,控制組則為等候名單。所有研究對象將於實驗介入前(前測,T0)、實驗介入後(立即後測,T1)以及實驗介入後8週(追蹤後測,T2)等三個時間點進行認知功能(Cognitive Assessment Screening Instrument, CASI)、憂鬱程度(Geriatric Depression Scale, GDS15)與健康相關生活品質(the Short Form 12-item Health Survey, SF12)等成效指標資料的收集,研究所得資料以描述性統計呈現研究對象基本屬性與成效指標的狀況,並以推論性統計ANOVA與GEE等分析檢定認知訓練介入的成效。 研究結果:本研究共有低強度認知訓練組32人、高強度認知訓練組32人及控制組34人。結果顯示(1)本研究對象屬於年齡偏大(平均80.051歲),教育程度偏低(以國小居多),且為認知中度受損(CASI平均47.724分)的老人;(2)三組個案基本屬性無顯著差異;(3)兩組實驗組無論在T1或T2其認知功能總分均顯著優於控制組,且具有立即性與延遲性成效,然經GEE模式配對Bonferroni比較,兩組實驗組之得分無顯著差異;(4)兩組實驗組對認知次面向的影響,以短期記憶、定向力、語言能力與構圖能力等面向尤具成效,且以高強度認知訓練的成效較為穩定;(5)兩組實驗組無論在T1或T2皆較控制組有較低的憂鬱程度,且具有立即性與延遲性成效,然經GEE模式配對Bonferroni比較,兩組實驗組之得分無顯著差異;(6)兩組實驗組無論在T1或T2其生活品質得分皆顯著高於控制組,且具有立即性與延遲性成效,然經GEE模式配對Bonferroni比較,兩組實驗組之得分無顯著差異;(7)研究對象之基本屬性、健康狀況以及社會支持等部分,僅認知功能前測與研究期間生病情形會影響認知訓練對認知功能總分的成效;(8)研究對象之基本屬性、健康狀況以及社會支持等部分,以憂鬱程度前測、研究期間生病情形、罹患心肌梗塞與罹患無後遺症的腦血管疾病等會影響認知訓練對憂鬱程度的成效;(9)研究對象之基本屬性、健康狀況以及社會支持等部分,以生活品質前測、研究期間生病情形、憂鬱與親友探訪頻率等會影響認知訓練對生活品質的成效。 結論:根據本研究結果證實多面向認知訓練對於教育程度較低,屬於認知功能中度受損的老人是具有改善其認知功能、憂鬱程度與生活品質之立即性與延遲性的正向效益;然由於低強度和高強度認知訓練的效果並無統計上的差異,且低強度認知訓練對注意力、集中/心算力以及思緒流暢度等次面向較具成效,因此,就護理人力與成本效益的考量,建議可採每週2天的低強度認知訓練,作為訓練頻率的最佳強度閾值,不僅具有效果又符合經濟效益,適於機構執行。此外,研究期間生病情形是影響機構老人認知功能、憂鬱程度與生活品質的共同因子,因此,為維持機構老人的認知功能,避免其惡化,並改善憂鬱程度與提高生活品質,如何避免老人生病應是機構照顧的重點。

並列摘要


Background. Cognition decline often had a negative impact on elderly and family and further place a financial burden on healthcare systems. In oversea, there were more increasing clinical trials in elderly for improving cognitive function in recent decades. A recent meta-analysis showed that a fairly consistent association with decreased risk of Alzheimer's disease and cognitive decline was cognitive engagement. However, validation of the efficacy of various interventions improving cognitive function is lacking in Taiwan. Further, the years of formal education of the elderly in Taiwan are less than ones in Western world. Hence, the popular foreign intervention is difficult to be applied to our domestic elderly. To develop some localized interventions adapted for Taiwanese’s life, cultural background were necessary. Aims. To evaluate the effectiveness of the non-computer-based multi-domain cognitive training in improving cognitive function, depression and quality of life for institutionalized older residents. Methods. A longitudinal, multi-center, cluster assigned, double blinded design was developed and implemented. A total of 98 subjects were recruited from 12 institutions in Taiwan. Centers were randomly assigned into wait-list control, treatment I or treatment II groups by randomly assigned lists generated from EXCEL. Treatment I group underwent 30 minutes sessions of multi-domain cognitive training with low frequency, twice a week, for 8 weeks. Treatment II group underwent the same protocol as Treatment I group, but with high frequency, 5 days per week, for 8 weeks. Outcome indictors included global cognitive function (Cognitive Assessment Screening Instrument, CASI), depression (Geriatric Depression Scale, GDS15), and quality of life (the Short Form 12-item Health Survey, SF12). Assessments were performed at baseline (T0), immediate (T1) and 8-week follow-up (T2) after training completion. Data analysis consisted of basic characteristics and outcome indicators presented in term of descriptive statistics; inferential statistics were by ANOVA and generalized estimating equations (GEE). Results. Participants in this study numbered 32 in the treatment I group, 32 in the treatment II group and 34 in the control group. The results of the study were as follows: (1) The subjects are older person (average 80.051 years) with lower educated (mostly elementary school), and moderate cognitive impairment (an average of 47.724 points in CASI). (2) There was no significant difference in demographic data and outcome indictors among the three groups at baseline. (3) The two treatment groups showed significant high scores of cognitive function than the control group at T1 and T2. Post hoc Bonferroni pairwise comparison revealed that there was no significant difference in CASI between two treatment groups. (4) The high frequency cognitive training was more stable on improving short-term memory, orientation, language and drawing than low frequency cognitive training did. (5) The two treatment groups had significantly lower depression scores than the control group at T1 and T2. However, there was no significant difference in GDS15 between two treatment groups by Post hoc Bonferroni pairwise comparison. (6) The two treatment groups demonstrated significantly better quality of life scores than the control group at T1 and T2. However, there was no significant difference in SF12 between two treatment groups by Post hoc Bonferroni pairwise comparison. (7) As for the effects of demographic data, health status and social support, CASI score at baseline and getting sick during the study were significant factors influenced cognitive function. (8) There were four identified factors, GDS15 score at baseline, getting sick during the study, had suffered from myocardial infarction, and cerebrovascular disease without sequelae, did influence depression. (9) SF12 score at baseline, getting sick during the study, depression and the frequency of visits of friends and relatives were significant factors influenced quality of life. Conclusions. The findings revealed that multi-domain cognitive training have positive immediate and delayed effects on global cognitive function, depression and quality of life even for low educated older institutionalized residents with cognitive impairment. The low frequency multi-domain cognitive training was more effective on improving attention, mental manipulation and fluency than high frequency multi-domain cognitive training did, seemed to be more cost-effective in clinical practice. Besides, getting sick during this study is a common factor influencing cognitive function, depression and quality of life of institutionalized elder residents, so as to maintain cognitive function, improve depression and improve quality of life in institutionalized elder residents, to avoid institutionalized elder residents to get sick, should be the focus of institutional care.

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