腦中風患者心理困擾與功能恢復相關之系列性研究

腦中風患者具有生理及心理問題，在生理功能方面，中風患者功能恢復時間缺乏一致性且少有研究探討個體間功能恢復差異；在心理問題方面，中風患者面臨許多心理困擾，然而缺乏合適評量工具無法瞭解中風患者多面向心理困擾，且多面向心理困擾對功能恢復之影響仍少有研究探討。因此本研究目的為：(1)探討中風後功能恢復變化趨勢及影響因素；(2)發展情緒與社會功能障礙中文版量表及建立信、效度；(3)探討中風患者心理困擾變化趨勢、影響因素，及釐清心理困擾與功能恢復之相關性。研究結果詳述如下：階段一：以腦中風登錄資料庫共367位患者為主，探討入院時至出院後一年內的功能恢復軌跡及影響因子；結果顯示，腦中風患者功能恢復共有五種軌跡變化，族群一及族群二(佔18%)於中風後呈現功能依賴；族群三、四及五(佔82%)於中風後三個月可呈現不同程度之功能恢復；功能恢復影響因子包含：年齡、住院天數、症狀分類(OCSP)、身體質量指數及血清白蛋白(p<0.05)，其中血清白蛋白愈高者，功能恢復顯著較佳(trend effect: 25.83 p<0.001)。階段二：情緒與社會功能障礙中文版量表總量表及次量表內在一致性為0.96及0.79-0.91；驗證性因素分析確立，中文版量表具有六個因素結構：生氣、無助感、情緒無法控制、淡漠、懶散及心情愉悅，且呈現合適建構效度 (RMSEA=0.071, SRMR=0.05; CFI=0.98, NNFI=0.98)、同時效度和已知族群效度。階段三：研究結果顯示：1. 初次腦中風患者出院後三個月內呈現多面向心理困擾，心理困擾在出院後一至二個月最顯著；2.中風後多面向心理困擾顯著為疾病嚴重度與功能恢復之中介因子(Indirect effect: 0.28, p<0.05)，中風嚴重度會引發多面向心理困擾而導致功能依賴；3.廣義估計方程式確立中風後多面向心理困擾對功能恢復具短期及動態性影響效應，中風後五天的整體心理困擾及隨著時間歷程不同時間點的心理困擾，顯著影響中風患者功能恢復。本研究確立情緒與社會功能障礙中文版量表具有合適信、效度，此量表的發展將有助於臨床實務更詳實評估中風患者多面向心理困擾；由於中風後功能恢復具不同軌跡趨勢，中風後多面向心理困擾顯著影響功能恢復，因此針對中風患者於急性期即應給予多面向心理困擾評估及研擬合適介入策略，以期改善心理困擾及達到提昇功能恢復之成效。

關鍵字

腦中風；心理困擾；功能恢復；情緒與社會功能障礙量表

並列摘要

Stroke survivors can experience a decline in physical and mental function. Regarding physical problems, stroke patients have demonstrated a variety of functional recovery trends and inconsistent recovery times ranging from several weeks to 1 year; however, few studies have explored individual differences in functional recovery. Regarding mental problems, stroke patients experience various forms of psychological distress, but researchers have not used an appropriate instrument to evaluate psychological distress. Furthermore, few studies have explored the effects of the various forms of psychological distress on the prognostic outcomes of stroke patients. Therefore, this study had 3 purposes: (1) to explore the trajectory groups and determinants of functional recovery for ischemic stroke patients 1 year after stroke; (2) to develop and validate a modified Chinese version of the Emotional and Social Dysfunction Questionnaire (ESDQ_C) for evaluating stroke patients; and (3) to describe the complexity and trajectory of psychological distress among stroke survivors, as well as explore the relationship between psychological distress and functional recovery. Results in the first study found that five trajectory clusters of functional recovery were identified. Nearly 18% of stroke patients（cluster 1 and 2）maintained functional dependence, whereas 82% of stroke patients （cluster 3, 4 and 5）demonstrated functional recovery, requiring 3 months of recovery. Determinants for various trajectory clusters of functional recovery were age, duration of disease, symptoms classification, body mass index and serum albumin level. A higher concentration of serum albumin generally predicted a more favorable functional recovery. In the second study, the results of confirmatory factor analysis confirmed that the ESDQ_C, based on a 6-factor model, exhibited satisfactory construct validity, and appropriately represented the emotional and social distress including anger, emotional dyscontrol, helplessness, inertia, indifference, and euphoria. Satisfactory validities including concurrent validity and known-group validity were also evident. Cronbach’s α coefficient for the total scale and subscales of ESDQ_C were 0.96 and 0.79-0.91, respectively. In the third study, results included: 1. Stroke patients experienced various forms of psychological distress, and that psychological distress significantly increased between time of admission and 2 months after discharge. 2. The various forms of psychological distress significantly mediated the effect of severe stroke syndromes on functional dependence. 3. The various forms of psychological distress exert a short-term, dynamic effect on functional recovery. The trajectory of various forms of psychological distress exerted significant negative effects on functional recovery. Our study confirmed that the ESDQ_C questionnaire is reliable, valid, and effective for assessing various types of emotional and social distress among Chinese stroke patients. Moreover differential trajectory of functional recovery persisted in stroke patient and various forms of psychological distress significantly inhibited functional recovery. By understanding the nature and effect of various forms of psychological distress, healthcare professionals can appropriate evaluate and design effective interventions to help improve mental and physical function in stroke patients.

並列關鍵字

Stroke ； psychological distress ； functional recovery ； Emotional and Social Dysfunction Questionnaire (ESDQ)

參考文獻

Okazaki, S. (2002). Influences of culture on Asian Americans' sexuality. Journal of Sex Research, 39(1), 34-41. doi: 10.1080/00224490209552117

Polit, D. F., Beck, C. T., & Owen, S. V. (2007). Is the CVI an acceptable indicator of content validity? Appraisal and recommendations. Research in Nursing and Health, 30(4), 459-467. doi: 10.1002/nur.20199

參考文獻