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  • 學位論文

症狀群集與皮質醇、生物節律之關係

The relationship between symptom clusters and cortisol circadian rhythm

指導教授 : 林佳靜
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摘要


子計畫ㄧ: 肝癌是台灣癌症死亡原因的第二位,本篇研究的目的是為了了解肝癌病患的症狀問題,包括 (a) 睡眠障礙、疲憊及憂鬱間之關係; (b) 並探討憂鬱問題在睡眠障礙與疲憊間是否為中介關係。本研究為橫斷性研究,共收集77名肝癌病患,所有病患皆完成問卷的訪問,問卷包括:簡明疲憊量表-台灣版(the Brief Fatigue Inventory-Taiwan Form)、匹茲堡睡眠品質量表-台灣版(the Pittsburgh Sleep Quality Index-Taiwan Form)、及醫院焦慮憂鬱量表-憂鬱次量表-台灣版(the Depression subscale of the Taiwanese version of the Hospital Depression and Anxiety Scale),並利用路徑分析的統計方法來測試憂鬱的中介角色。研究結果發現:肝癌病患的疲憊、睡眠障礙及憂鬱症狀間呈現顯著正相關,且這些症狀會同時發生,本研究亦發現憂鬱在睡眠困擾與疲憊間為一個完全中介的角色,亦即本研究結果發現肝癌病患的憂鬱症狀在睡眠障礙與疲憊關係中佔有一個非常重要的機轉,而本研究是第一個討論肝癌病患的睡眠障礙、疲憊及憂鬱等三個症狀群集現象的研究,並進ㄧ步指出憂鬱在睡眠障礙與疲憊間的中介角色。本研究提供臨床上的醫護人員非常重要的訊息,憂鬱在這之中扮演極重要角色,醫護人員在照護這類病患時,必須同時提供睡眠障礙、疲憊及憂鬱的護理措施,才能真正解決病患之不適情形。 子計畫二: 本篇文章的目的主要是要探討肝癌病患的憂鬱情形、睡眠品質與生活品質間之關係,並測試憂鬱在睡眠障礙與生活品質間的角色。本研究利用橫斷性設計,共收集73位肝癌病患,所有病患皆完成下列問卷,包括:歐洲生活品質量表(European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core-30, EORTC QLQ C-30)、匹茲堡睡眠品質量表(the Pittsburgh Sleep Quality Index-Taiwan Form, PSQI- Taiwan Form),及醫院焦慮憂鬱量表—憂鬱次量表( Depression subscale of the Taiwanese version of the Hospital Depression and Anxiety Scale, HADS),資料統計分析方法包括:平均數、標準差及迴歸分析。 研究結果發現:(1)睡眠障礙和憂鬱間呈現統計上顯著正相關(r=0.48, p=0.000),而睡眠障礙與憂鬱程度皆與肝癌病患之生活品質呈現顯著負相關(r=-0.310, p=0.008; r=-0.367, p=0.001);(2) 另外,憂鬱在睡眠障礙與生活品質間為完全中介的角色。 這個研究結果可以了解,肝癌病患的憂鬱情形、睡眠障礙與生活品質間之關係,並進ㄧ步得知憂鬱在睡眠障礙與生活品質間所扮演的重要角色。總結來說,本研究探討肝癌病患的憂鬱及睡眠障礙症狀與生活品質間關係,且發現憂鬱症狀在睡眠障礙與生活品質間為完全中介的角色,亦即在肝癌病患治療過程中,心理因素之影響佔很重要的成分,在護理措施中是不可被忽視的一部分。 子計畫三: 肝癌病患在罹病及治療過程中,經歷許多症狀之困擾,其中疼痛、疲憊、憂鬱及睡眠障礙是癌症患者不論是在治療期或罹病期間經常抱怨的症狀,且經常干擾病患的生活,甚至會讓人失去治療或活下去的信心。在健康個體中,皮質醇值通常在清晨剛醒時為最高點,之後隨著一天時間的進行而逐漸下降(Posener, et al., 1996)。生物節律的規則性是下視丘軸系統是否平衡的重要指標,睡醒皮質醇反應(CAR)被視為HPA活性的新指標,在剛睡醒的30分鐘內,平均皮質醇濃度會上升50∼100%,且延續至少1小時(Pruessner etal,1997)。這個反應在75%的健康人身上發現,而且隨著時間仍維持高度的穩定性(Wust etal.,2000)。 本研究案主要針對肝癌病人其生物節律中皮質醇之變化與疼痛、疲憊、憂鬱及睡眠障礙間之關係,在病患起床時、及起床後半小時收集個案唾液中之皮質醇,連續三天,並利用問卷收集病患之疼痛、疲憊、憂鬱及睡眠品質,利用SPSS15.0處理資料。共收集約95名肝癌病患進行此項研究。另外,利用性別及年齡配對方式,收集30位控制組個案。 結果發現,肝癌病患之疼痛、疲憊、憂鬱及睡眠障礙彼此間皆呈現顯著正相關(r=0.24-0.64);肝癌病患之疼痛、疲憊、憂鬱及睡眠障礙皆較控制組個案嚴重,達統計上顯著差異;肝癌病患之皮質醇值在清晨剛睡醒(11.68 vs. 6.61, p=0.000)、睡醒30分之皮質醇(11.79 vs. 7.52, p=0.013)、AUC值(365.36 vs. 262.96, p=0.028)皆較控制組高,達統計上顯著差異;肝癌病患中,有疼痛者、有疲憊者、有憂鬱者、睡眠品質較差者,其平均皮質醇濃度及CAR 之AUC值皆較無疼痛者、無疲憊者、無憂鬱者、睡眠品質較好者之濃度高,但未達統計上顯著差異;且無疼痛者、無疲憊者、無憂鬱者、睡眠品質較好者之CAR增加量皆較有疼痛者、有疲憊者、有憂鬱者、睡眠品質較差者高。 另外,利用actigraphy收集病患之睡眠休息型態,並計算出病患之生物節律值(r24及I0.48)的病患,其疼痛、疲憊、憂鬱及睡眠障礙程度比較差之生物節律(r24<0.2)者低,達到統計上顯著差異;而在代表皮質醇之生物節律性與actigraphy之生物節律性之比較上,利用r24或I0.48),其平均皮質醇值、CAR增加量及AUC值皆較差的生物節律低,並達到統計上顯著差異,顯示肝癌病患當有過高的皮質醇濃度時,是處於較差的生物節律狀態。 本研究是第一個針對肝癌病患並利用唾液皮質醇值來計算皮質醇清醒反應(CAR)之生物節律,並與actigraphy之生物節律比較來了解肝癌病患之生物節律情形,並進ㄧ步了解疼痛、疲憊、憂鬱及睡眠障礙與生物節律間之關係。本研究能協助醫護人員了解肝癌病患在接受治療期間生物節律皮質醇之變化及與疼痛、疲憊、憂鬱及睡眠障礙間的關係,並可進ㄧ步推估生物節律與生活品質及預後間之關係,藉此可協助醫護人員找出合宜之處理方式,並提升病患在治療期間之生活品質。

並列摘要


Project 1: The purposes of this study were to (a) explore the relationships among sleep disturbances, fatigue, and depression and (b) to test whether depression mediates the effect of sleep disturbances on fatigue in patients with hepatocellular carcinoma (HCC). A cross-sectional study was conducted with a total of 77 patients with HCC. All participants completed questionnaires that included the Brief Fatigue Inventory-Taiwan Form, the Pittsburgh Sleep Quality Index-Taiwan Form, and the Depression subscale of the Taiwanese version of the Hospital Depression and Anxiety Scale. Path analysis was used to test the mediation role of depression. The major results were as follows: Fatigue, sleep disturbances, and depression are positively interrelated and co-occur in patients with HCC. Moreover, depression completely mediates the effects of sleep disturbances on fatigue. These findings suggest that depression is an important mechanism underlying the relationship between sleep disturbances and fatigue for patients with HCC. In conclusion, this is the first study exploring the phenomenon of symptom clustering in sleep disturbance, fatigue, and depression in patients with HCC and investigating the mediating role of depression that underlies the relationship between sleep disturbances and fatigue. The current findings could be of clinical importance and imply a need to consider management of sleep disturbances, fatigue, and depression simultaneously. Project 2: The purposes of this study were to (a) explore the relationships among sleep disturbance, depression, and quality of life and (b) to test whether depression mediates the effect of sleep disturbance on quality of life in patients with hepatocellular carcinoma (HCC). A cross-sectional study was conducted with a total of 73 patients with HCC. All participants completed questionnaires that included the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core-30 (EORTC QLQ C-30), the Pittsburgh Sleep Quality Index-Taiwan Form, and the Depression subscale of the Taiwanese version of the Hospital Depression and Anxiety Scale. Path analysis was used to test the mediation role of depression. The major results were as follows: Sleep disturbance is positively related to depression(r=0.48, p=0.000), sleep disturbance and depression are negatively interrelated with quality of life(r=-0.310, p=0.008; r=-0.367, p=0.001) in patients with HCC. Moreover, depression completely mediates the effects of sleep disturbance on quality of life. These findings suggest that depression is an important mechanism underlying the relationship between sleep disturbance and quality of life for patients with HCC. In conclusion, this is the first study exploring the phenomenon of symptoms (sleep disturbance and depression) affects quality of life in patients with HCC and investigating the mediating role of depression that underlies the relationship between sleep disturbance and quality of life. The current findings could be of clinical importance and imply a need to consider management of sleep disturbance and depression simultaneously. Project 3: Hepatocellular carcinoma patients are often diagnosed at advanced stages with poor prognosis and frequently are coupled with severe symptom occurrence, including pain, fatigue, depression and sleep disturbance. Multiple symptoms occurrence result in a decline in patients’ function and quality of life. Cortisol exhibits diurnal variations peaking in the early morning hours (about 30 minutes after waking), declining rapidly in the morning, with a slower decrease in the afternoon, and reaching its lowest level in the evening. This diurnal rhythm is thought to be an important indicator of hypothalamic- pituitary- adrenal (HPA) axis competence. The Cortisol Awakening Response (CAR) is an important marker for HPA axis. In a normal CAR, cortisol concentrations reach their nadir during the early morning hours and the initial 30-45 min post-awakening mark the steepest increase in cortisol. Cortisol levels rapidly increase after awakening by around 50-100% and remain elevated for at least 60 min. The response to awakening reported about 75% in healthy people. The aim of the present study was to investigate the relationship between CAR and pain, fatigue, depression and sleep disturbance in hepatocellular carcinoma patients. We measured salivary cortisol upon awakening and 30 min after on three consecutive days. All participants fill out four questionnaires about pain, fatigue, depression and sleep disturbance. There are 95 patients and 30 control group participants matched with sex and age in the study. Pain, fatigue, sleep disturbances, and depression are positively interrelated and co-occur in patients with HCC (r=0.24-0.64, p<0.05). HCC patients have more severe pain, fatigue, depression and sleep disturbance than control group. The cortisol level on awakening (11.68 vs. 6.61, p=0.000) 、awakening after 30 min (11.79 vs. 7.52, p=0.013) 、AUC (365.36 vs. 262.96, p=0.028) in HCC patients higher than control group. HCC patients with pain, fatigue, depression, and sleep disturbance have higher mean cortisol level and AUC level than those without symptoms. The rest- activity circadian rhythm was characterized by autocorrelation coefficient at 24h (r24), and the dichotomy index (I0.48) have lower symptoms than the dampened patients (r24<0.2). Finally, the good circadian rhythm (r24>0.48) have lower mean cortisol level, CAR increasing level and AUC level than dampened rhythm patients. These findings suggest a sustained activation of the HPA axis among HCC patients. In conclusion, the results of the present study indicate a dysregulation in HPA axis activity, characterized by elevated morning salivary cortisol levels among HCC patients. The exact mechanisms by which these stress-induced changes in HPA function occur require further investigation.

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被引用紀錄


巫秀鳳(2011)。笑笑功對於長期照護機構住民心理健康促進的實證研究〔碩士論文,臺北醫學大學〕。華藝線上圖書館。https://doi.org/10.6831%2fTMU.2011.00152

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