失智症患者的認知、動作、行為問題與日常生活功能之相關性探討

Association between Cognition, Physical Function, Behavioral Problem and Activities of Daily Living in People with Dementia

黃竑嘉(Hung-Chia Huang)

指導教授 ： 陳惠媚

高雄醫學大學/健康科學院/職能治療學系碩士班/碩士(2018年)

摘要

失智症患者的日常生活功能 (ADL) 量測方式包括問卷式及操作式，而不同失智症型態的臨床特徵（包括認知、動作及行為），對其ADL功能影響可能具差異性。但僅少數研究在探討兩種類型工具在不同失智症亞型的潛在差異與個別的重要預測因子。故本研究目的有三：(1) 探討三種失智組與健康對照組在日常生活功能、認知、動作及行為的表現差異。(2) 比較各類失智組在問卷式、操作式日常生活測驗與三種臨床（認知、動作及行為問題）測驗之相關。(3) 分析各類失智組的操作式與問卷式日常生活表現之臨床預測因子。本研究共招募30名健康長者、49名阿茲海默氏症患者 (AD)、17名血管性失智症患者 (VaD) 及14名路易氏體失智症患者 (DLB)。每位受試者均量測蒙特利爾認知測驗 (MoCA)、身體功能測驗 (PPT) 與臺灣版操作型工具性日常生活測驗 (TPIADL)，此外，健康長者還須受訪填答神經精神量表 (NPI) 及失智症功能障礙評估量表 (DAD)，失智受試者則由代理人受訪填寫這兩份量表。統計分析以相關性分析檢驗ADL工具與其他臨床測驗之關係，並以線性迴歸分析進一步檢視臨床變項在操作式及問卷式ADL工具的預測力。研究結果顯示：(1) 如預期，三種類型失智患者的 MoCA、PPT、NPI、TPIADL、DAD 與其工具性日常生活子測驗 (DAD-IADL) 及基礎性日常生活子測驗 (DAD-BADL) 均較健康對照組差，然而，三組的 TPIADL、DAD、DAD-IADL、DAD-BADL、 MoCA、PPT 及 NPI 則呈現無顯著差異。(2) 所有失智組的 TPIADL 與 DAD、MoCA、PPT 或 NPI 的分數均呈現中度相關性 (r=-.653, -.675, -.550, .330; p< .001)。(3) 在 AD 組的 TPIADL、DAD、DAD-IADL 或 DAD-BADL 之臨床變項解釋量範圍為 48.2-62.3%。TPIADL的顯著預測因子為MoCA (β= -.615, p< .001) 及 PPT (β= -.238, p= .046)；DAD-IADL的顯著預測因子為 MoCA (β= .563, p< .001) 及 NPI (β= -.252, p= .033)；DAD-BADL的顯著預測因子則是 MoCA (β= .473, p= .001) 及 PPT (β= .299, p= .024)。在 VaD 組僅發現 TPIADL 具有 MoCA (β= -.622, p= .008) 顯著預測因子。DLB組的兩種ADL工具則無發現顯著預測因子。AD 患者在操作式及問卷式 ADL 工具的表現一致受到認知衰退的影響。問卷式 IADL 工具比操作式IADL工具還會多受到行為問題的影響，顯示出選擇IADL測驗工具的重要性。操作式工具在了解失智患者在認知介入後的IADL改變可能比問卷式工具更敏感。然而，由於本研究之VaD或DLB樣本數較少，無法確定觀察的結果。根據上述結果討論，可提供臨床工作者選擇適當的ADL工具，並可提供失智患者更適切的介入策略。

關鍵字

日常生活功能 ； 失智症 ； 認知 ； 動作 ； 行為問題

並列摘要

Specific dementia may lead to different clinical features (cognition, physical decline, and behavioral disturbance). Both self-report and performance-based measures are often used in assessment pattern of everyday functioning for patients with dementia, few comparative studies by using two pattern measures in specific dementia were determined potential differences and its relative importance of factors. The purpose of this study was: (1) to investigate the differences of activities of daily living (ADL), cognition, physical function and behavioral problem (2) to determine the relationships of performance-based or informant-based ADL assessment and cognition, physical function or behavioral measurement. (3) to identify the predictors of performance-based and informant-based ADL assessments across three dementia types. Participants were 30 healthy elders, 49 outpatients with Alzheimer’s disease (AD), 17 outpatients with vascular dementia (VaD), and 14 outpatients with Lewy body dementia (DLB). Taiwan Performance-based Instrumental Activities of Daily Living (TPIADL), Disability Assessment for Dementia (DAD), Montreal Cognitive Assessment (MoCA), Physical Performance Test (PPT), and Neuropsychiatric Inventory (NPI) were administered. Correlation analyses were conducted to examine the relationships among the ADL measures and other clinical tests. Linear regression analyses further examined the amount of variability predicted in performance-based and informant rating ADL. The results indicated that: (1) As expected, patients with three dementia types had worse MoCA, PPT, NPI, TPIADL, DAD and its subscale of instrumental activities of daily living (DAD-IADL) and basic activities of daily living (DAD-BADL) than healthy control group. However, no significant differences in TPIADL, DAD, MoCA, PPT and NPI among three types of dementia groups. (2) The moderate and significant correlations (r= -.653, -.675, -.550, .330; p< .001) between TPIADL and DAD, MoCA, PPT or NPI scores in whole dementia samples. (3) For AD group, our regression analyses explained 48.2-62.3% of the variances in the TPIADL, DAD, DAD-IADL or DAD-BADL. In the TPIADL score, MoCA (β= -.615, p< .001) and PPT (β= -.238, p= .046) were significant predictors; In DAD-IADL score, MoCA (β= .563, p< .001) and NPI (β= -.252, p= .033) were significant predictors; In DAD-BADL score, MoCA (β= .473, p= .001) and PPT (β= .299, p= .024) were significant predictors. For VaD group, only MoCA (β= -.622, p= .008) predicted TPIADL score. For DLB group, there was no significant predictor for two pattern assessment. Our results suggest that performance-based and informant-rating assessments of IADL/BADL function are influenced by different clinical characteristics of patients with AD. Performance-based and informant rating IADL/BADL measures are consistently influenced by the AD patient’s cognitive deficit. In particular, informant-rating IADL appears to be more influenced by the patient’s behavioral status than performance-based ADL measure. This has important implications for IADL measure selection. Performance-based measure may be more sensitive to IADL functional change subsequent to treatments targeting cognition than informant-rating measure. However, fixed observation can't be asserted due to caveat of small sample size in patients with VaD or DLB. These results may guild clinical professionals to select appropriate ADL assessments and can be useful to healthcare providers in treatment planning for patients with dementia.

並列關鍵字

Activities of daily living ； Dementia ； Cognition ； Physical function ； Behavioral problem

參考文獻

內政部 (2016) 。105 年第 3 週內政統計通報 (104 年底人口結構分析)。內政部：統計處。民國 105 年 1 月 16 日。取自：http://www.moi.gov.tw/stat/news_content.aspx?sn=10225

Ahmed, R. M., Paterson, R. W., Warren, J. D., Zetterberg, H., O’Brien J. t., Fox, N. C., … Schott, J. M. (2014). Biomarkers in dementia: Clinical utility and new directions. Journal of Neurology, Neurosurgery, and Psychiatry, 85, 1426–1434.

Ahn, I. S., Kim, J. H., Kim, S., Chung, J. W., Kim, H., Kang, H. S., & Kim, D. K. (2009). Impairment of instrumental activities of daily living in patients with mild cognitive impairment. Psychiatry Investigation, 6, 180-184.

Albert, S. M., Bear-Lehman, J., Burkhardt, A., Merete-Roa, B., Noboa-Lemonier, R., & Teresi, J. (2006). Variation in sources of clinician-rated and self-rated instrumental activities of daily living disability. Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 61, 826-831.

Alexander, N. B., Mollo, J. M., Giordani, B., Ashton-Miller, J. A., Schultz, A. B., Grunawalt, J. A., & Foster, N. L. (1995). Maintenance of balance, gait patterns, and obstacle clearance in Alzheimer's disease. Neurology, 45, 908-914.