血液透析患者衰弱改善成效之探討:一項運動方案的介入

背景: 台灣末期腎臟病發生率及盛行率高居世界之冠，全台洗腎人口有9萬人，國內透析品質死亡率11%讓患者延長生命，然血液透析病患有許多健康問題包括：身體功能下降、疲倦、肌肉質量減少、身體不活動、體重減輕等問題，透析病患屬高危險群，需重視衰弱議題可避免或延緩身體退化、惡性循環的開始。目的:本研究目的為瞭解因腎臟疾病接受血液透析治療病患衰弱程度，並以椅子肌力訓練運動方案為介入措施及搭配營養指導，探討其對能改善病患衰弱、生活品質、憂鬱及營養之成效。方法:採類實驗及追蹤研究設計，以方便取樣方式選取台灣中部某醫院附屬診所血液透析病患為對象。分兩組，收集60位受試者；以椅子肌力訓練運動方案為介入措施者為實驗組，接受常規透析照護為對照組並使用生活品質問卷、流行病學研究中心抑鬱症量表、衰弱評估量表ヽ主觀整體營養評估成效。統計:以 SPSS 22.0電腦套裝軟體進行分析，描述性統計包括:人數ヽ百分比ヽ平均數ヽ標準差，分析研究個案人口學資料分佈;推論性統計包括;獨立樣本T檢定(Independent samples T-test)ヽ相依樣本T檢定(Paired samples T-test)ヽ皮爾森相關(Pearson correation)ヽ單因子變異數分析(One way ANOVA)ヽ一般線性迴歸(Liner regression)ヽ廣義估計式(Generalized estimating equation, GEE)，分析椅子肌力訓練運動方案及搭配營養指導介入成效。結果: 收集60位受試者，以對照組33位實驗組27位完成研究計畫。人口學資料，性別:對照組男性15位(45.5%)ヽ女性18位(54.5%)，實驗組男性10位(37%)ヽ女性17位(63%)。年齡:對照組平均年齡69.39歲(SD = 11.99)，實驗組平均年齡66.07歲(SD = 9.28)。透析年數:對照組平均透析5.45年(SD = 4.66)，實驗組平均透析7.66年(SD = 6.13)。運動前：對照組組整體衰弱與實驗組無顯著差異。針對對照組與實驗組的總體，生活品質ヽ憂鬱ヽ營養的解釋力以迴歸分析發現：步行與生活品質負相關性(β = -0.268，ρ = 0.041)、寂寞與生活品質負相關性(β = -0.402，ρ= 0.003)、步行與憂鬱正相關性(β = 0.458，ρ = 0.002)、生活品質-活動能力與憂鬱負相關性(β = -0.362，ρ= 0.005)、白蛋白與營養正相關性(β = 0.702，ρ < 0.001)。運動後：對照組整體衰弱與實驗組無顯著差異，然而手握力方面實驗組第三ヽ四次有顯著差異(p = 0.012，p = 0.002)，步行方面第四次測驗實驗組有顯著差異(p = 0.034)。生活品質方面：分析結果顯示日常生活能力有顯著差異(p = 0.031)。憂鬱方面：分析結果顯示心情ヽ寂寞ヽ失敗有顯著差異(p = 0.036，p = 0.044，p = 0.020)。營養方面：分析結果顯示皮下脂肪喪失與肌肉耗損有顯著差異(p = 0.046，p = 0.031)。結論:本研究結果顯示實驗組整體衰弱無顯著差異，然而手握力ヽ步行增加有顯著差異。生活品質、憂鬱及營養之間具有相關因此護理人員照護血液透析病患，也需重視衰弱症廣泛、嚴重性，提供預防及減緩衰弱ヽ低生活品質ヽ憂鬱ヽ營養不良的護理指導。

關鍵字

衰弱；血液透析；椅子；運動

並列摘要

Background: Taiwan has the highest incidence and prevalence rate of end-stage kidney disease worldwide. The total number of dialysis patients in Taiwan is 90,000 as of 2018. The domestic dialysis quality mortality rate of 11% prolongs patients’ life, but hemodialysis patients have many health problems, including decreased physical function, fatigue, decreased muscle mass, physical inactivity, and weight loss. Dialysis patients are at high risk, and attention to frailty issues can avoid or delay not only physical deterioration but also the beginning of a vicious circle. Objective: This study aimed to: (1) understand the extent of frailty in patients undergoing hemodialysis due to kidney disease, (2) use the chair muscle-training program as an interventional measure and nutritional guidance to explore the effects of improving patient frailty, and (3) understand the factors related to quality of life, depression, and nutrition of the patients. Methods: The experiment and tracking research used the convenient sampling method to select hemodialysis patients in a clinic affiliated with a hospital located in the central part of Taiwan. Those in the experimental group underwent both the chair muscle training exercise program and nutrition guidance as interventional measures; both the experimental and control groups received routine dialysis care and answered the Quality of Life Scale, the Depression Scale of the Epidemiology Research Center, Frailty Assessment Scale, and Subjective Overall Nutrition Assessment Scale to evaluate the effectiveness of the interventions. SPSS 22.0 software was used to analyze the percentage, mean, standard deviation, and demographic data distribution of the research case. The inferential statistics used to determine the effectiveness of the chair muscle training exercise program and nutrition guide interventions were the independent samples T-test, paired samples T-test, Pearson correlation, one-way ANOVA, linear regression, and generalized estimating equation. Results: Sixty subjects completed the research project, with 27 in the experimental group and 33 in the control group. The mean age of the experimental group was 66.07 years (SD = 9.28) and that of the control group was 69.39 years (SD = 11.99). The overall frailty of the experimental group was not significantly different from the control group after the intervention. However, the hand grip strength in the third and fourth tests of the experimental group was significantly higher than that of the control group (p = 0.012, p = 0.002). In addition, walking in the fourth test of the experimental group was also higher than that of the control group (p = 0.034). Overall, in both the control and experimental groups, the explanatory power of quality of life, depression, and nutrition was examined using regression analysis; the results of this are as follows: a negative correlation between walking and quality of life (β = -0.268, ρ = 0.041), a negative correlation between loneliness and quality of life (β = -0.402, ρ = 0.003), a positive correlation between walking and depression (β = 0.458, ρ = 0.002), a negative correlation between quality of life and depression (β = -0.362, ρ = 0.005), and a positive correlation between albumin and nutrition (β = 0.702, ρ < 0.001). Conclusion: There was no significant difference in overall frailty in the experimental group, but there was a significant difference in the increase in hand grip and walking. A correlation among quality of life, depression, and nutrition was also identified. Therefore, when caring for future hemodialysis patients, the nursing staff will need to pay attention to the effects of debilitating diseases and provide nursing care in order to address and alleviate frailty, low quality of life, depression, and malnutrition.