職能治療於認知障礙老人之研究：評估工具驗證及療效探討

Occupational Therapy in Older Adults with Cognitive Impairments: Assessment Validation and Treatment Efficacy

李孟達(Meng-Ta Lee)

指導教授 ： 張彧

國立臺灣大學/醫學院/職能治療研究所/博士(2019年)

https://doi.org/10.6342/NTU201901211

摘要

前言與研究背景：早期篩檢輕度認知障礙、及失智症有助於提供適宜治療介入。快速輕度認知障礙測驗為一具良好信度、較短施測時間、及較好診斷特徵之認知篩檢工具，其優於蒙特利爾認知評估量表、及簡短式智能評估用以偵測輕度認知障礙、及失智症，值得我國借鏡翻譯應用於早期篩檢。此外，電腦認知訓練於輕度認知障礙較具療效與優勢，但我國療效研究闕如，其值得探究以應用於早期治療。
研究目的：本研究之研究目的為(1) 驗證譯成臺灣版快速輕度認知障礙測驗之心理計量特性、及診斷特徵；(2) 探討電腦認知訓練於輕度認知障礙老人之認知功能、及日常生活功能療效。
研究方法：本研究包含兩個研究主題。研究一、臺灣版快速輕度認知障礙測驗之心理計量特性及診斷特徵驗證：採橫斷面研究設計，盲於診斷之研究者評估健康受試者、輕度認知障礙、及失智症老人之臺灣版快速輕度認知障礙測驗、中文版簡短式智能評估、臺灣版蒙特利爾認知評估量表、巴氏量表、及勞頓工具性日常生活評估量表；資料分析適當運用克隆巴赫係數、組內相關係數、克–瓦二氏單因子等級變異數分析、及接受者操作特徵曲線分析。研究二、電腦認知訓練於輕度認知障礙老人療效之前導研究：採重複量測之臨床試驗，輕度認知障礙老人接受每次 30分鐘、每週 3次、共 12次之 4週療程，且於治療前、治療後、及治療後一個月追蹤期評估認知功能、及日常生活功能；資料分析適當運用弗理曼二因子等級變異數分析、及魏克遜符號等級檢定。
研究結果：研究一：本研究共招募 35位健康受試者、36位輕度認知障礙、及 31位失智症等老人研究受試者。臺灣版快速輕度認知障礙測驗具良好再測信度、內部一致性、及施測者間信度，亦與中文版簡短式智能評估、臺灣版蒙特利爾認知評估量表、及勞頓工具性日常生活評估量表具高度正相關，以及與巴氏量表具中度正相關。臺灣版快速輕度認知障礙測驗從健康受試者區辨輕度認知障礙個案、及從輕度認知障礙個案區辨失智症個案之最佳決斷分數分別為 ≤ 51.5/100分、及 ≤ 31/100分(接受者操作特徵曲線之曲線下面積：0.89、及 0.91，敏感度：0.69、及 0.94，特異性：0.97、及 0.78，陽性預測值：0.96、及 0.78，陰性預測值：0.76、及 0.93)。臺灣版蒙特利爾認知評估量表從健康受試者區辨輕度認知障礙個案具較高準確度，其次依序為臺灣版快速輕度認知障礙測驗、及中文版簡短式智能評估；然而，臺灣版快速輕度認知障礙測驗、及中文版簡短式智能評估從輕度認知障礙個案區辨失智症個案具相同準確度，其次為臺灣版蒙特利爾認知評估量表。研究二：電腦認知訓練之輕度認知障礙個案治療後較治療前於中文版彩色路徑描繪測驗 2完成時間顯著減少，且在治療後一個月追蹤期較治療前於臺灣版快速輕度認知障礙測驗之語言流暢性、及情境式記憶測驗之延遲記憶分數顯著進步。
結論：為了早期診斷，臺灣版快速輕度認知障礙測驗為可用於認知障礙診斷類群之臨床認知篩檢工具。為了早期治療，本研究支持電腦認知訓練或有益於輕度認知障礙老人之認知功能；未來應持續進行更大樣本之隨機對照試驗。

關鍵字

輕度認知障礙 ； 失智症 ； 老人 ； 快速輕度認知障礙測驗 ； 電腦認知訓練

並列摘要

Introduction: Early detection of differentiating among individuals with mild cognitive impairment (MCI), dementia and normal controls (NCs) is critical for appropriate pharmacotherapeutic and nonpharmacotherapeutic interventions. The Quick Mild Cognitive Impairment (Qmci) screen is superior to the Montreal Cognitive Assessment (MoCA) and Mini-Mental State Examination (MMSE) with similar reliability, less administered time and better diagnostic properties for detecting MCI and dementia, thus a Taiwan version is required. In addition, the computerized cognitive training (CCT) is more effective on MCI patients by multimodal and multidomain individualized training. The efficacy of CCT in Taiwanese patients with MCI is still lacking and is worthy for further research.
Objective: This study aims (1) to evaluate the psychometric and diagnostic properties of the Taiwan version of Qmci (Qmci-TW) screen; and (2) to testify the efficacy of CCT on cognitive functions and daily functions in older adults with MCI.
Methods: This study involved 2 sub-studies. Sub-study 1. Validation of the psychometric and diagnostic properties of the Qmci-TW: In this cross-sectional study, the same trained rater, blinded to final diagnosis, alternately and randomly administered the Qmci-TW, MoCA, MMSE, Barthel Index (BI), and Lawton Instrumental Activities of Daily Living scale (Lawton IADL scale) to the participants with dementia, MCI, and NCs. For analysis, the Cronbach’s α, intraclass correlation coefficient, Spearman’s ρ, Kruskal-Wallis test, and receiver operating characteristic curve analysis were used, as appropriate. Sub-study 2. A pilot study of the efficacy of CCT in older adults with MCI: A repeated measure, control group design was used in this pilot study. The participants with MCI received individualized intervention for 30 minutes a day, 3 times a week for 4 consecutive weeks. Outcome measures including evaluations for cognitive functions and daily functions were administered at pre-treatment, post-treatment, and 1 month follow-up after intervention. For analysis, the Friedman test, and Wilcoxon signed-ranks test were used, as appropriate.
Results: Sub-study 1: Thirty-one participants with dementia and 36 with MCI and 35 NCs were recruited in this study. The Qmci-TW exhibited satisfactory test-retest reliability, internal consistency, and interrater reliability as well as a strong positive correlation with results from the MoCA, MMSE, and Lawton IADL scale, and a moderate positive correlation with results from the BI. The optimal cut-off score on the Qmci-TW for differentiating MCI from NC was ≤ 51.5/100 [area under the curve (AUC) of 0.89, sensitivity = 69%, specificity = 97%, positive predictive value (PV+) = 96%, negative predictive value (PV−) = 76%] and dementia from MCI was ≤ 31/100 (AUC = 0.91, sensitivity = 94%, specificity = 78%, PV+ = 78%, PV− = 93%). The MoCA exhibited the highest accuracy in differentiating MCI from NC, followed by the Qmci-TW and then MMSE; whereas, the Qmci-TW and MMSE exhibited the same accuracy in differentiating dementia from MCI, followed by the MoCA. Sub-study 2: The results demonstrated that the time of the Color Trail Test-2 was significantly decreased at post-treatment than that at pre-treatment; furthermore, the scores of the Contextual Memory Test delayed memory subtest and the Qmci-TW verbal fluency subtest were significantly increased at 1 month follow-up after intervention than those at pre-treatment.
Conclusion: For early detection, the Qmci-TW may be a useful clinical screening tool for a spectrum of cognitive impairments. For early treatment, this pilot study supports that CCT might have benefits for older adults with MCI on cognitive funtions; however, larger sample size and randomized controlled trials are needed in the future.

並列關鍵字

mild cognitive impairment ； dementia ； older adult ； Quick Mild Cognitive Impairment screen ； computerized cognitive training

參考文獻

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內政部(2019，3月)。人口年齡結構指標。取自https://www.ris.gov.tw/app/portal/346