社區腦中風患者復健照護情形之探討

Investigation of the Rehabilitation Care for Community-dwelling Stroke Patients

賴佐君(Tso-Chun LAI)

指導教授 ： 魏大森

亞洲大學/健康學院/長期照護研究所在職專班/碩士(2011年)

摘要

前言：近年來因腦中風治療與照護的進步，使得腦中風死亡人數及死
亡率均有下降趨勢，由83年13,658人(每十萬人口死亡率64.77)降至97年10,663人(每十萬人口死亡率46.4)；但因台灣社會快速高齡化，腦中風的盛行率並未隨之下降，醫療服務與社會福利之需求大增。
本研究目的有二：(1)了解腦中風患者從急性發病期至發病六個月期間之機能損傷程度、活動功能及心理社會層面之情形。(2)探討腦中風失能者生活功能獨立程度、憂鬱情形、跌倒與否之預測因子，及衝擊主要照顧者的相關因素，以為醫療照護及衛生政策制定之參考。
研究方法：本研究之患者資料由【彰化縣─腦中風個案服務照護網】提供。評估變項包括(1)機能損傷程度：含美國國衛院腦中風評估表(National Institute of Health Stroke Scale, NIHSS)、運動功能評估(Fugl-Meyer Score, FMS)及埃許瓦斯張力評估表(Modified Ashworth Scale, MAS)，(2)活動功能：含計時起身行走測試法(Timed Up and Go Test, TUGT)、腦中風病人姿勢評估量表(Postural Assessment Scale for Stroke Patient, PASS)、平衡及步態評分(Tinetti assessment tool：balance & gait)、跌倒信心評估表(Fall Efficacy scale, FES)與生活功能獨立程度量表(Functional Independence Measurement, FIM)，(3)社會心理層面：簡易智能評估量表(Mini Mental Scale Examination, MMSE)、老人憂鬱量表(Geriatric Depression Scale, GDS)與主要照顧者衝擊指數(Caregiver Strain Index, CSI)。上述量表，得分愈高，患者之損傷或失能愈明顯者包括NIHSS、MAS、TUGT及GDS。
研究結果：完訪樣本數為116人，年齡為71.3±10.4歲。雙變項分析顯示FIM與PASS、Tinetti score及FES呈高度正相關(r≧0.8)，而與NIHSS呈高度負相關(r≦-0.8)；PASS與FMS、MMSE及CSI變項間有中度正相關(r=0.6~0.8)，而與NIHSS、Tinetti score、FES、FMS及CSI呈現中度負相關(r=-0.6~-0.8)；身高與其他變項間無顯著相關性，年齡與PASS、Tinetti score、FES、NIHSS、MMSE及FIM呈現低度相關性(r≧-0.6或≦0.6)。多變項邏輯式迴歸分析患者復健照護情形，以生活功能獨立程度、患者的憂鬱情形、照顧者衝擊指數及跌倒與否當依變數，發現(1) Tinetti score及NIHSS為生活功能獨立量表之獨立預測因子，Tinetti score每增加一分FIM之調整後勝算比(adjusted odd’s ratio, AOR)為1.17(1.01~1.34)，即生活獨立性增加17%；NIHSS每增加一分則FIM之AOR為0.76(0.58~0.99)，即生活獨立性降低25%；(2)患者之PASS得分較高者，其憂鬱程度較低，每增加一分PASS，GDS之AOR為0.38(0.03~0.41)；(3)腦中風患者的失能程度對照顧者的衝擊具預測意義，每增加一個標準差(FMS為16分，FIM為26分)，CSI之AOR分別為1.12(1.04~1.21)與5.66(1.39~23.09)；(4)跌倒與否與NIHSS及GDS有顯著相關性，每增加一分NIHSS或GDS，則患者跌倒之AOR分別為1.64(1.20~2.25)與1.23(1.01~1.49)。
結論：本研究結果顯示腦中風失能者之後續相關問題相當嚴重，居家復健確有其重要性與急迫性，亦顯示目前彰化縣衛生局腦中風患者社區健康照護計畫之必要性，而政府推動十年大溫暖居家復健與長照保險等方案均為正確方向並值得大力支持。

關鍵字：腦中風(cerebrovascular accident)、復健照護(rehabilitation care)、功能獨立程度評量(Functional Independence Measure)、老人憂鬱量表(Geriatric Depression Scale)、照顧者衝擊指數(Caregiver Strain Index)、意外跌倒(accidental falls)

關鍵字

腦中風 ； 復健照護 ； 功能獨立程度評量 ； 老人憂鬱量表 ； 照顧者衝擊指數 ； 意外跌倒

並列摘要

Introduction：Owing to the improvement of healthcare, the number and rate of death in stroke patients had been decreased in recent years, from 13,680 strokes in 1994 (64.8 per hundred thousand people) to 10,663 in 2008 (46.4 per hundred thousand). Nevertheless, the prevalence is not correspondingly reduced due to fast aging of population which results huge needs of service in medical and long-term care.
Purpose：The aims of this study were (1) to evaluate the impairments, functional ability, and psycho-social status in stroke patients with onset-of-lesion within 6 months; (2) to investigate predictors of functional independence, depression, fall incidence and impacts of care-giver. The result could be a valuable reference for government blue-print of medical service and health-policy making.
Method：The research data were retrieved from Stroke-care network of the bureau of public health in Changhua County. Variables assessed included (1) Impairments: National Institute of Health Stroke Scale (NIHSS), Motor function (Fugl-Meyer Score, FMS), Muscle tone (Modified Ashworth Scale, MAS). (2) Functional ability: Timed Up and Go Test (TUGT), posture (Postural Assessment Scale for Stroke Patient, PASS), balance & gait (Tinetti assessment tool : balance & gait), Fall Efficacy scale (FES), Functional Independence Measurement (FIM), and (3) psycho-social status: mental (Mini Mental Scale Examination, MMSE), depression (Geriatric Depression Scale, GDS), impacts of caregiver (Caregiver Strain Index, CSI). Parameters with a higer score indicated more severe impairments or disability in NIHSS, MAS, TUGT, and GDS.
Result: A total of 116 subjects were collected with mean age 71.3  10.4. Bivariate analysis showed (1) FIM had a highly positive correlation with PASS, Tinetti score and FES (r  0.8), but highly negative correlation with NIHSS (r  -0.8). (2) PASS had a moderately positive correlation with FMS, MMSE and CSI (r = 0.6 ~ 0.8), but moderately negative correlated with NIHSS, Tinetti score, FES, FMS and CSI (r = -0.6 ~ -0.8). (3) Age was low correlated with PASS, Tinetti score, FES, NIHSS, MMSE, and FMS, whereas body height was not correlated with any other variables. In multivariate logistic regression analysis, functional independence, depression, impact of care-giver and falls were set as independent (outcome) variables. We found that (1) Tinetti score and NIHSS were independent predictors for FIM and NIHSS with adjusted odd’s ratio (AOR) of 1.17 (1.01~1.34) and 0.76 (0.58~0.99), respectively. Every increase in Tinetti score had the chance of 17% increase in functional independence and in NIHSS had a 25% decrease in functional independence. (2) The higher PASS, the lower chance of patient’s depression with an AOR of 0.38 (0.03~0.41). (3) FMS and FIM were significantly correlated with care-giver strain. An increment of 1SD (FMS=16, FIM=26), AOR of CSI were 1.12 (1.04~1.21) and 5.66 (1.39~23.09), respectively. (4) Falls could be predicted by NIHSS and GDS with AOR 1.64 (1.20~2.25) in NIHSS and 1.23 (1.01~1.49) in GDS.
Conclusion: The results show that continous care of disablement in stroke patients is a critical issue which indicates domiciliary rehabilitation program provided by Changhua health bureau is crucial and urgent for the community-dwelling strokes. Furthermore, the 10 years domiciliary-rehabilitation project and long-term care program directed by government are heading in right way and worthy to be fully supported.

Key words: cerebrovascular accident, rehabilitation care, Functional Independence

Measure, Geriatric Depression Scale, Caregiver Strain Index, accidental falls

並列關鍵字

cerebrovascular accident ； rehabilitation care ； Functional Independence Measure ； Geriatric Depression Scale ； Caregiver Strain Index ； accidental falls

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