臺灣博碩士論文加值系統

背景與目的：衰弱(Frailty)容易發生失能、住院、死亡等負面結果。許多研究指出，身體活動介入對於預防或延緩老年人之衰弱與失能是有助益的。台灣人口急遽老化，衰弱問題成為重要議題；為了預防或延緩老年人的衰弱或失能，政府開辦許多長者預防及延緩衰弱失能課程。然而有部分長者因生理、心理或環境因素導致無法走出家門，其有潛在體能促進及防跌需求，卻又未必符合長照2.0復能服務對象；或是雖符合長照復能服務對象，卻因個人或家庭因素導致接受復能服務的意願不高。這些長者的長期坐式生活型態及多重慢性疾病影響，將加速退化過程，未來將造成家庭及社會沉重的負擔。透過陽明大學社會責任計畫「培力社區發展在地安老整合型服務計畫」之推動，結合跨校、跨科系資源，並與在地社區資源連結，以發展社區在地自主健康促進及長期照護服務網絡為目標。本研究透過社區夥伴關係的建立，探討居家型式體能促進及預防延緩失能活動對於社區衰弱長者的介入成效。
方法：本研究屬類實驗型研究設計(Quasi-experimental study design)。研究者搭配陽明大學社會責任計畫”照顧關懷小組”之任務執行，自2017年9月起陸續與新北市三芝區後厝里及台北市北投區數個里開始接觸與連結、與社區里長及志工建立夥伴關係。從2018年6月開始實地走訪北投社區，找出具有衰弱風險或輕度失能的個案。於2019年2月開始招募符合收案標準、年齡≥65歲的居家衰弱長者，依據其配合意願分配為運動介入組或控制組；預計招募20位運動介入組與20位控制組。考量居家運動介入計畫之可行性與顧及受試者權益，運動介入組大多從北投社區招募；控制組除為北投社區無意願接受運動介入者之外，不足人數則由新北市三芝區後厝里社區關懷據點進行招募。本研究結合物理治療師、社區志工及高齡照顧學系學生合作形成居家訪視小組，並開設培育課程來訓練社區志工及學生簡要的運動介入措施及照顧技能。由物理治療師評估長者在介入前之身體功能、環境障礙及生活照顧問題，形成個人化運動計畫；由社區志工陪同治療師及學生進行居家關懷訪視，執行每週2次、每次40~50分鐘、為期3個月之居家型體能促進及預防延緩失能活動介入。運動內容包含暖身運動、有氧運動、肌力運動、平衡與柔軟度運動。成效評量工具包括：基本生理資料（身高、體重、身體質量指數）、體適能檢測（握力、2.44公尺起身繞行測驗、2分鐘踏步測驗和單腳站平衡測試）、衰弱指標（體重減輕、身體耗弱程度、低身體活動量、步速緩慢和握力較弱）、身體活動量及日常生活活動功能 (ADLs)、The de Morton Mobility Index (DEMMI)量表、Short Physical Performance Battery (SPPB)簡短身體功能量表和Modified Barthel Index修正式巴氏量表。於12週介入後進行檢測來比較兩組介入效果。統計分析方法使用SPSS 24.0版本進行統計分析，顯著水準訂為0.05。
結果：共有40位衰弱長者參與此項研究，介入組20位，控制組20位。這些長者的平均年齡為82.7歲，80歲以上長者佔大多數，有75%的長者為女性。在經過12週的運動介入後，介入組相較於控制組在多數成效評量項目，呈現較明顯的進步情形，兩組前、後測變化趨勢達到組間顯著差異（組別*時間交互作用p值<0.05），包含：在體重(介入組60.2±11.1→59.25±13.1公斤，控制組61.8±10.21→62.35±9.57公斤，p=0.004)、BMI(介入組23.9±3.9→23.64±4.07kg/m2，控制組25.2±4.1→25.50±3.92 kg/m2，p=0.005)、收縮壓(介入組131.15±6.79→129.10±7.58 mmHg，控制組131.5±7.09→131.30±6.22 mmHg，p=0.028)、握力(介入組16.68±5.36→17.40±5.46公斤，控制組17.75±5.12→16.72±5.18公斤，p＜0.001)、3公尺行走速度(介入組9.33±3.63→8.29±3.13秒，控制組8.64±1.68→8.86±1.63秒，p<0.001)、兩分鐘踏步測驗(59.27±13.86→76.55±14.06下，控制組64.33±15.58→68.67±13.71下，p=0.018)、身體活動量(介入組361.29±194.79→459.42±205.75大卡，控制組394.25±164.86→369.02±127.54大卡，p=0.001)、DEMMI量表(介入組66.20±10.99→68.10±8.82分，控制組70.20±9.63→64.40±6.19分，p<0.001)、SPPB量表(介入組6.20±2.09→7.6±1.35分，控制組7.10±2.02→6.75±1.88分，p<0.001)和修正式巴氏量表分數(介入組84.10±7.01→89.40±6.02分，控制組88.10±6.34→87.90±5.47分，p<0.001)等。
結論與建議：本研究針對衰弱長者進行12週的居家型體能促進與延緩失能活動，由物理治療師進行初評、訂定目標與設立運動計畫，再交由社區志工及高齡照護系學生執行運動介入；與現今復能服務之治療師與居服員共同進入家中，為個案討論及相關介入計畫，再由居服員進行介入的模式相似。運動訓練對衰弱長者在身體組成、身體適能、活動變化量、身體功能表現和日常生活活動均有顯著改善。未來需要再更多的研究去探討這樣的居家介入模式是否可以複製到別的社區，未來也需要更長期的介入研究做更深入的探討。

BACKGROUND: Population of Taiwan is rapidly aging. Frailty could lead to adverse results such as disability, hospitalization, death, etc. Recent studies indicate that physical activity has a beneficial effect on the prevention of frailty or delay of disability in the elderly. The government has launched many disability prevention programs in the community activity center to promote physical fitness and prevent disability for the elderly. Nevertheless, some elders cannot get out of their homes to participate in the community activities due to physical, psychological or environmental factors, but not being disabled enough to be eligible for the provisions of reablement services in the long-term care plan 2.0. The sedentary lifestyle and the impact of chronic diseases will accelerate the process of degeneration and become the burden of family and society. Through the development of the Community Empowerment - Developing an Aging in Place Integrated Services Project of National Yang-Ming University, the research team aimed to collaborate with the local community, and to establish their own health promotion and long-term care service network. The purpose of the study is to develop a home-based transdisciplinary visiting team to promotion physical function and prevent disability for the community-dwelling elderly with frailty.

METHOUD: This study is a Quasi-experimental study design. From June 2018, we began to screen the Beitou and community, and to find out the potential cases at risk of frailty. In February 2019, 40 frail elders aged 65 years and over were recruited and assigned into the exercise intervention group and the control group according to their willingness to exercise and feasibility. We organized physical therapists, volunteers and students who major in Gerontological health Care to form a home-based transdisciplinary visiting team. The physical therapist assessed the physical function, environmental barriers and life care of the elderly before the intervention, and set up a personalized exercise prescription plan. The volunteer accompanied the physical therapists and students to conduct a home-based physical fitness training program which lasted for 12-week, twice a week, 40-50 minutes for each visit. The exercise included warm-up exercise, aerobic exercise, muscle strengthening exercise, balance and stretching exercise. A series of outcome measurements were conducted before and after the 12-week intervention period to examine the intervention effect. Those measurements included: demographic data (height, weight, body mass index, blood pressure), physical fitness testing (grip strength, timed up and go test, 2-minute step test and one-leg standing test), frailty index (unintentional weight loss, exhaustion, physically inactive, slowness and weak grip strength), physical activity level (IPAQ), physical function (SPPB & DEMMI), as well as activities of daily living (Modified Barthel Index). Statistical analysis was performed using SPSS version 24.0 with a significant level of 0.05.

RESULTS: A total of 40 frail elders participated in the study with 20 subjects in each group. The average age of these elders is 82.7±5.53 years old, with most elders over 80 years old and 75% of elders are women. After 12 weeks of exercise intervention, the intervention group showed greater improvement than the control group on the following outcome measures, including: body weight (60.2±11.1→59.25±13.1kg，p=0.004), BMI (23.9±3.9→23.64±4.07kg/m2，p=0.005), Systolic pressure (131.15±6.79→129.10±7.58 mmHg，p=0.028), grip strength (16.68±5.36→17.40±5.46 kg, p<0.001), 3m speed test (9.33±3.63→8.29±3.13 seconds，p<0.001), two-minute step test (59.27±13.86→76.55±14.06 times, p=0.018), IPAQ (361.29±194.79→459.42±205.75 kcal, p=0.001), DEMMI (66.20±10.99→68.10±8.82 point，p<0.001), SPPB scale (6.20±2.09→7.6±1.35, p<0.001), Modified Barthel Index scores (84.10±7.01→88.10±6.34 points, p<0.001), and etc

CONCLUSION: The community partnership model incorporating physical therapist, volunteers and students who major in Gerontological health Care, seems to work to help the community-dwelling elderly with frailty. The frail elders participated in an individualized physical fitness training program for 12 weeks under the instruction and supervision of physical therapist, volunteers and gerontological health care students. It is similar to the Reablement services in the Long-term Care plan 2.0 nowadays, which therapists and home-care attendants worked harmoniously to deliver the reablement plan at the old client’s home. Home-based physical fitness training program significantly improved the physical composition, physical fitness, physical activity, physical function performance and activities of daily living for those frail elders living at home. It is anticipatory that more research is undergone to explore whether such a transdisciplinary model of home-based physical-fitness intervention program could be replicated to other communities. In addition, longer-term intervention study with larger sample size are required to formulate a more in-depth policy or clinical implications.

目錄
致謝 I
中文摘要 III
英文摘要 VIII
目錄 IX
表目錄 XI
圖目錄 XII
附錄 XIII
第一章 緒論 1
第一節 研究背景與動機 1
第二節 研究目的 3
第二章 文獻回顧 4
第一節 社區長者身體適能狀況與失能的相關性 4
第二節　社區衰弱長者與失能及其他不良健康結果的相關性 7
第三節 身體活動介入對於衰弱長者身體功能促進之成效 13
第四節 社區夥伴關係建立之因素及影響 19
第三章 研究方法 22
第一節 研究設計與研究流程 22
第二節 研究對象 24
第三節 研究測量工具 25
第四節 運動介入 28
第五節 資料處理與統計分析方法 30
第四章 研究結果 31
第一節 研究對象基本資料 32
第二節 運動介入對於社區衰弱長者之介入成效 36
第五章 研究討論 41
第一節 研究對象的基本屬性及各項研究變項之討論 41
第二節 為運動介入內容之探討 42
第三節 為運動介入各項效果之探討 43
第三節 為介入模式執行之探討 44
第四節 研究限制 46
第六章 結論與未來研究建議 47
參考文獻 48

表目錄
（表一）運動介入組與控制組之基本特質比較 54
（表二）運動介入組與控制組之疾病史比較 55
（表三）運動介入組與控制組之身體組成基測值比較 56
（表四）運動介入組與控制組之體適能基測值比較 57
（表五）運動介入組與控制組之衰弱指標基測值比較 58
（表六）運動介入組與控制組之DEMMI與SPPB基測值比較 59
（表七）運動介入組與控制組之修正式巴氏量表基測值比較 60
（表八）運動介入組與控制組介入前後之身體組成比較 61
（表九）運動介入組與控制組介入前後之體適能比較 62
（表十）運動介入組與控制組介入前後之衰弱指標比較 63
（表十一）運動介入組與控制組介入前後DEMMI與SPPB比較 64
（表十二）運動介入組與控制組介入前後之修正式巴氏量表比較 65

圖目錄
圖4-1研究流程圖 66
圖4-2 運動介入組與控制組介入前後之身體組成的比較 67
圖4-3 運動介入組與控制組介入前後之血壓的比較 68
圖4-4-1 運動介入組與控制組介入前後之體適能的比較 69
圖4-4-2 運動介入組與控制組介入前後之體適能的比較 70
圖4-5-1 運動介入組與控制組介入前後之DEMMI & SPPB比較 71
圖4-5-2 運動介入組與控制組介入前後之DEMMI & SPPB比較(續) 72
圖4-6 運動介入組與控制組介入前後之衰弱人數比較 73
圖4-7 兩分鐘踏步測試施行狀況 73

附錄
附錄一、人體試驗委員會核准函 74
附錄二、受試者同意書 75
附錄三、評估量表 82
附錄四、檢測照片活動剪輯 99
附錄五、介入照片活動剪輯 100
附錄六、居家運動紀錄單張 101
附錄七、志工招募簡報 105
附錄八、學生運動介入前訓練與流程簡報 108

1.衛生福利部. 老人狀況調查報告2017 2017 [cited 2018 June 6]. Available from: URL: https://dep.mohw.gov.tw/DOS/cp-1767-38429-113.html.
2.Rockwood K, Howlett SE, MacKnight C, Beattie BL, Bergman H, Hebert R ,et al. Prevalence, attributes, and outcomes of fitness and frailty in community-dwelling older adults: report from the Canadian study of health and aging. J Gerontol A Biol Sci Med Sci. 2004;59(12):1310-7.
3.Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J ,et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146-56.
4.衛生福利部. 長照復能服務操作指引 2019 2019 [cited 2019 July.17]. Available from: URL: https://1966.gov.tw/LTC/cp-4444-47438-201.html.
5.Tak E, Kuiper R, Chorus A, Hopman-Rock M. Prevention of onset and progression of basic ADL disability by physical activity in community dwelling older adults: a meta-analysis. Ageing Res Rev. 2013;12(1):329-38.
6.WHO. Active ageing: a policy framework.Geneva:World Health Organization. 2002.
7.Puts MT, Lips P, Deeg DJ. Sex differences in the risk of frailty for mortality independent of disability and chronic diseases. J Am Geriatr Soc. 2005;53(1):40-7.
8.王秀華、李淑芳. 老年人功能性體適能之運動處方. 大專體育. 2009;101:164-71.
9.Zamboni M, Zoico E, Scartezzini T, Mazzali G, Tosoni P, Zivelonghi A ,et al. Body composition changes in stable-weight elderly subjects: The effect of sex. Aging Clinical and Experimental Research. 2013;15(4):321-7.
10.Roberts HC, Dodds R, Sayer AA. Current clinical care of older adults with sarcopenia. J Clin Densitom. 2015;18(4):493-8.
11.Jennifer S Brach JMV. Physical Impairment and Disability: Relationship to Performance of Activities of Daily Living in Community-Dwelling Older Men. Physical Therapy. 2002;82(8):752-61.
12.Takata Y, Ansai T, Soh I, Awano S, Yoshitake Y, Kimura Y ,et al. Physical fitness and 6.5-year mortality in an 85-year-old community-dwelling population. Arch Gerontol Geriatr. 2012;54(1):28-33.
13.Warren M, Ganley KJ, Pohl PS. The association between social participation and lower extremity muscle strength, balance, and gait speed in US adults. Prev Med Rep. 2016;4:142-7.
14.Rockwood K, Song X, MacKnight C, Bergman H, Hogan DB, McDowell I ,et al. A global clinical measure of fitness and frailty in elderly people. CMAJ. 2005;173(5):489-95.
15.Gobbens RJ, Luijkx KG, Wijnen-Sponselee MT, Schols JM. Toward a conceptual definition of frail community dwelling older people. Nurs Outlook. 2010;58(2):76-86.
16.Tom SE, Adachi JD, Anderson FA, Jr., Boonen S, Chapurlat RD, Compston JE ,et al. Frailty and fracture, disability, and falls: a multiple country study from the global longitudinal study of osteoporosis in women. J Am Geriatr Soc. 2013;61(3):327-34.
17.Ensrud KE, Ewing SK, Taylor BC, Fink HA, Cawthon PM, Stone KL ,et al. Comparison of 2 frailty indexes for prediction of falls, disability, fractures, and death in older women. Arch Intern Med. 2008;168(4):382-9.
18.Sanchez-Garcia S, Garcia-Pena C, Salva A, Sanchez-Arenas R, Granados-Garcia V, Cuadros-Moreno J ,et al. Frailty in community-dwelling older adults: association with adverse outcomes. Clin Interv Aging. 2017;12:1003-11.
19.Provencher V, Beland F, Demers L, Desrosiers J, Bier N, Avila-Funes JA ,et al. Are frailty components associated with disability in specific activities of daily living in community-dwelling older adults? A multicenter Canadian study. Arch Gerontol Geriatr. 2017;73:187-94.
20.Chainani V, Shaharyar S, Dave K, Choksi V, Ravindranathan S, Hanno R ,et al. Objective measures of the frailty syndrome (hand grip strength and gait speed) and cardiovascular mortality: A systematic review. Int J Cardiol. 2016;215:487-93.
21.Gill TM. Transitions between frailty states among community-living older persons. Archives of Internal Medicine, . 2006;166:418-23.
22.Chodzko-Zajko WJ, Proctor DN, Fiatarone Singh MA, Minson CT, Nigg CR, Salem GJ ,et al. Exercise and physical activity for older adults. Medicine & Science in Sports & Exercise. 2009;41(7):1510-30.
23.de Labra C, Guimaraes-Pinheiro C, Maseda A, Lorenzo T, Millan-Calenti JC. Effects of physical exercise interventions in frail older adults: a systematic review of randomized controlled trials. BMC Geriatr. 2015;15:154.
24.Fairhall N, Sherrington C, Lord SR, Kurrle SE, Langron C, Lockwood K ,et al. Effect of a multifactorial, interdisciplinary intervention on risk factors for falls and fall rate in frail older people: a randomised controlled trial. Age Ageing. 2014;43(5):616-22.
25.Tarazona-Santabalbina FJ, Gomez-Cabrera MC, Perez-Ros P, Martinez-Arnau FM, Cabo H, Tsaparas K ,et al. A multicomponent exercise intervention that reverses frailty and improves cognition, emotion, and social networking in the community-dwelling frail elderly: A randomized clinical trial. J Am Med Dir Assoc. 2016;17(5):426-33.
26.Giné-Garriga M, Guerra, M., Pagès, E.,Manini, T. M., Jiménez, R., & Unnithan, V. B. The effect of functional circuit training on physical frailty in frail older adults: A randomized controlled trial. Journal of Aging and Physical Activity. 2010;18:401-24.
27.Bray NW, Smart RR, Jakobi JM, Jones GR. Exercise prescription to reverse frailty. Appl Physiol Nutr Metab. 2016;41(10):1112-6.
28.Zech A, Drey M, Freiberger E, Hentschke C, Bauer JM, Sieber CC ,et al. Residual effects of muscle strength and muscle power training and detraining on physical function in community-dwelling prefrail older adults: a randomized controlled trial. BMC Geriatr. 2012;12:68.
29.Gill TM, Gahbauer, E. A., Allore, H. G., & Han, L. . Long-term benefits of a lifestyle exercise program for older people
receiving a restorative home care Service: A pragmatic randomized controlled
trial. Healthy Aging & Clinical Care in the Elderly. 2014;6:1-9.
30.Luger E, Dorner TE, Haider S, Kapan A, Lackinger C, Schindler K. Effects of a home-based and volunteer-administered physical training, nutritional, and social support program on malnutrition and frailty in older persons: A randomized controlled trial. J Am Med Dir Assoc. 2016;17(7):671 e9- e16.
31.陸玓玲、李蘭. 世界衛生組織與健康促進. 健康促進通訊.1998;3:17-22.
32.于漱、楊桂鳳. 在地化：社區健康營造永續發展的策略.7.2003;1:132-6.
33.陳柏宗 陳. 社區組織參與老人社區照顧之研究：以台南市長榮社區為例. 社會政策與社會工作學刊. 2006;10(1):49-113.
34.Kegler MC, Twiss JM, Look V. Assessing community change at multiple levels: the genesis of an evaluation framework for the California Healthy Cities Project. Health Educ Behav. 2000;27(6):760-79.
35.Parker G. Effectiveness of alliances and partnerships for health promotion. HEALTH PROMOTION INTERNATIONAL. 1998;3(2):99-120.
36.Labonté R. Community, community development, and the forming of authentic partnerships. Community Organizing and Community Building for Health: Rutgers University Press; 1997.
37.王珮如、胡淑貞. 健康社區夥伴關係的影響因素. 健康城市學刊.2004;2:24-32.
38.Healey WE, Reed M, Huber G. Creating a community-physical therapy partnership to increase physical activity in urban African-American adults. Prog Community Health Partnersh. 2013;7(3):255-62.
39.Thompson C, Fahs B, Kell C. A Nurse-Led Collaborative Linking Medical Center with Community Partners Transforms Patient Care and Reduces Readmissions. Heart & Lung. 2016;45(4).
40.Rikli RE, Jones CJ. Functional Fitness Normative Scores for Community-Residing Older Adults, Ages 60-94. Journal of Aging and Physical Activity. 1999;7(2):162-81.
41.CJ Jones RR. Senior fitness test. The Journal on Active Aging 2002:24-30.
42.教育部體育署. 一 O 四年度臺灣年長者功能性體適能現況評估研究結案報告書2015[cited 2019 June 12]. Available from: URL:https://www.sa.gov.tw/Resource/Attachment/f1474259369474.pdf.
43.Wu IC, Lin CC, Hsiung CA, Wang CY, Wu CH, Chan DC ,et al. Epidemiology of sarcopenia among community-dwelling older adults in Taiwan: a pooled analysis for a broader adoption of sarcopenia assessments. Geriatr Gerontol Int. 2014;14 Suppl 1:52-60.
44.Chen LK, Liu LK, Woo J, Assantachai P, Auyeung TW, Bahyah KS ,et al. Sarcopenia in Asia: consensus report of the Asian Working Group for Sarcopenia. J Am Med Dir Assoc. 2014;15(2):95-101.
45.劉影梅. 國際身體活動量表台灣中文版之發展與信效度驗證. 臺灣大學護理學研究所學位論文. 2004:1-463.
46.de Morton NA, Davidson M, Keating JL. The de Morton Mobility Index (DEMMI): an essential health index for an ageing world. Health Qual Life Outcomes. 2008;6:63.
47.Davenport SJ, de Morton NA. Clinimetric properties of the de Morton Mobility Index in healthy, community-dwelling older adults. Arch Phys Med Rehabil. 2011;92(1):51-8.
48.Wennie Huang WN, Perera S, VanSwearingen J, Studenski S. Performance measures predict onset of activity of daily living difficulty in community-dwelling older adults. J Am Geriatr Soc. 2010;58(5):844-52.
49.Gómez JF CC-L, Alvarado B, Zunzunegui MV, Guralnik J. Validity and reliability of the Short Physical Performance Battery (SPPB): a pilot study on mobility in the Colombian Andes. Colomb Med. 2013;44(3):165-71.
50.Shah S VF, Cooper B. Improving the sensitivity of the Barthel Index for stroke rehabilitation. J Clin Epidemiol. 1989;42(8):703-9.
51.Hocking C, Williams M, Broad J, Baskett J. Sensitivity of Shah, Vanclay and Cooper's modified Barthel Index. Clin Rehabil. 1999;13(2):141-7.
52.Cadore EL, Rodriguez-Manas L, Sinclair A, Izquierdo M. Effects of different exercise interventions on risk of falls, gait ability, and balance in physically frail older adults: a systematic review. Rejuvenation Res. 2013;16(2):105-14.
53.Fritz S, & Lusardi, M. White Paper: “Walking Speed: the Sixth Vital Sign”. Journal of Geriatric Physical Therapy. 2009;32(2):3-5.
54.Donoghue OA, Savva GM, Cronin H, Kenny RA, Horgan NF. Using timed up and go and usual gait speed to predict incident disability in daily activities among community-dwelling adults aged 65 and older. Arch Phys Med Rehabil. 2014;95(10):1954-61.
55.Shumway-Cook A, Brauer S, M. W. Predicting the Probability for Falls in Community-Dwelling Older Adults Using the Timed Up & Go Test. Physical Therapy. 2000.
56.Martin KA, Sinden AR. Who Will Stay and Who Will Go? A Review of Older Adults’ Adherence to Randomized Controlled Trials of Exercise. . Journal of Aging and Physical Activity. 2001;9(2):91-114.