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研究生:唐元翎
研究生(外文):Yuan-Ling Tang
論文名稱:複合式認知介入對於主觀衰退患者之日常生活及認知功能促進效益之前導研究
論文名稱(外文):The Effects of a Multicomponent Cognitive Intervention Program on the Daily and Cognitive Function in Adults with Subjective Cognitive Decline: A Pilot Study
指導教授:毛慧芬毛慧芬引用關係
指導教授(外文):Hui-Fen Mao
口試委員:邱銘章吳建德
口試委員(外文):Ming-Jang ChiuChien-Te Wu
口試日期:2020-06-24
學位類別:碩士
校院名稱:國立臺灣大學
系所名稱:職能治療研究所
學門:醫藥衛生學門
學類:復健醫學學類
論文種類:學術論文
論文出版年:2020
畢業學年度:108
語文別:中文
論文頁數:124
中文關鍵詞:主觀認知衰退認知介入失智症日常生活活動
外文關鍵詞:subjective cognitive declinecognitive interventiondementiaactivities of daily living
DOI:10.6342/NTU202002406
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背景:主觀認知衰退(subjective cognitive decline, SCD)患者是指個體主觀感受到持續存在的認知減退,但客觀認知測驗表現仍屬於正常範圍,近年來被認為可能是失智症的早期危險因子,而引起學者關注,開始探討認知介入對於SCD患者的成效。然而過去研究多以認知功能表現為主要成效指標,對於介入是否能改善日常生活功能表現仍不清楚;此外過去亦發現單純認知訓練之效益較難類化至其他認知向度及日常生活功能,無論是針對輕度認知障礙患者的認知介入文獻,或目前針對SCD患者的幾項試驗都顯示複合式介入(結合認知訓練、認知復健、心理介入與生活型態介入等至少二種以上之介入)的成效可能較佳,有較高的機會產生類化效果。另文獻指出認知介入成效的個體差異性大,依據認知儲備理論,介入成效可能受到年齡、教育程度、基礎認知功能等因子影響,但目前尚未確認哪些是關鍵影響因子。 目的:本研究欲探討複合式認知介入對於SCD患者的主觀及客觀日常生活及認知功能表現是否具立即、持續或延遲效益;並進一步探討影響認知介入成效的相關因子,包含年齡、教育程度、基礎認知功能、焦慮程度等。
方法:本研究為單一組別前後測實驗設計,由北部醫學中心神經內科轉介經醫師確診之SCD患者。所有受試者共接受四次成效評估,第一次基礎評估後,進入16週無介入等待期作為歷史性對照,於二週內完成前測,並開始為期16週的複合式認知介入方案,結束後二週內完成後測,再經過16週後進行追蹤評估。介入頻率為每週一次,每次1.5小時,共16堂團體課。主要成效指標為主觀與客觀日常生活功能表現,次要成效指標為客觀認知測驗表現、焦慮及憂鬱程度。以單因子重複測量變異數分析(repeated measured ANOVA)檢定四個時間點間的差異,再以費雪最小顯著差異法(Fisher's LSD comparisons)進行事後檢定,但因本研究樣本量較小,故參考效果值(Cohen's d)來判斷療效大小;並進行相關性分析探討可能影響介入成效的因子。
結果:共13位患者完成介入而納入分析。本介入結束時,對於改善SCD患者的自陳日常生活功能(p =.16, Cohen's d = 0.42)、整體認知功能(p =.21, Cohen's d = 0.37)、降低憂鬱程度(p =.14, Cohen's d = 0.44)具有低度效果;對於改善長期日常視覺記憶力(p =.05, Cohen's d = 0.60)、降低焦慮程度(p =.08, Cohen's d = 0.53)具有中度效果,且顯著改善患者的立即與延遲視覺記憶(立即:p <.05, Cohen's d = 0.66 ~ 1.19;延遲:p = .03 ~ .07, Cohen's d = 0.56 ~ 0.69)。追蹤結果顯示介入結束後的效果皆可維持至16週時,僅降低憂鬱之成效消退。此外,患者的主觀認知表現及客觀日常生活表現則於追蹤期時產生延遲效益。相關性分析顯示年齡、教育程度及前測MoCA分數與各項成效指標的改變量無顯著相關,但焦慮程度與MoCA、延遲視覺內容記憶呈負相關,考量本研究樣本量偏小,尚無法推論認知儲備理論是否被支持。
結論:本研究初步支持對至臨床就醫的SCD患者採取複合式認知介入,可 改善患者的日常生活表現 、整體認知功能短期與長視覺記憶,以及降低焦 慮與憂鬱程度 ,並且效果可維持至少 四個月 。未來可進一步透過隨機對照試驗驗證複合式認知介入之療效,並提供神經影像學之佐證。
Background: Individuals with subjective cognitive decline (SCD) have greater risk of developing dementia. Cognitive intervention, which can be classified as cognitive stimulation, cognitive training, and cognitive rehabilitation, is a major non-pharmacological intervention for individuals at increased risk of cognitive impairment. What should be noticed is that most efficacy studies for individuals with SCD used neuropsychological cognitive measures as outcome assessments. The impact of cognitive interventions on daily functional performance among individuals with SCD were infrequently explored. In addition, cognitive training focusing on specific cognitive outcomes is suspected to have limited far transfer to everyday functioning. Some researches proposed that multicomponent interventions which integrates several types of intervention may have potential to reach the maximum impact on daily function.
Objectives: The purposes of this study are to examine the immediate, maintained and delayed (16 weeks) effect of a multicomponent cognitive intervention program on cognitive and daily function in individuals with SCD, and to investigate whether the demographic (e.g., age and educational level, etc.) and clinical variables (e.g., level of baseline cognitive function, etc.) would affect the effects of intervention.
Method: This study was a pretest-posttest design. The subjects with SCD diagnosed by physicians were recruited from the neurology outpatient clinic of NTU hospital. All participants had waited for 16 weeks as a historical control and received the multicomponent cognitive intervention. The program was composed of 16 weekly 1.5-hour group sessions in a 4-month period. The multicomponent cognitive intervention consisted of cognitive training, cognitive rehabilitation, psychoeducation intervention and lifestyle interventions. All participants were assessed at four time points: before waiting period, before the intervention, after the intervention, and 16-week follow-up. The primary outcomes were the subjective and objective ADL performance, and the secondary outcomes were the cognitive performance, level of anxiety and depression. A repeated-measures analysis of variance (ANOVA) with a Fisher's least significant difference (LSD) post hoc test was used for statistical analysis. Due to small sample size, effect sizes (Cohen's d) were reported for all results.
Results: Thirteen subjects have completed the intervention. Results showed small improvements after the intervention in ADL performance (p =.16, Cohen's d = 0.42), global cognitive performance (p =.21, Cohen's d = 0.37), level of depression (p =.14, Cohen's d = 0.44). There was a median beneficial effect on long-term everyday memory (p =.05, Cohen's d = 0.60), level of anxiety (p =.08, Cohen's d = 0.53). In addition, the intervention resulted in significant improvement in immediate and delay visual content and context memory (immediate: p <.05, Cohen's d = 0.66 ~ 1.19; delay: p = .03 ~ .07, Cohen's d = 0.56 ~ 0.69). All the effects remained on the 16-week follow-up except the effect of decreasing the level of depression. Demographic characteristics (age and education) and cognition (pretest MoCA score) did not affect the effects of intervention, however, the lower level of anxiety was associated with better improvements in MoCA and delayed visual content memory.
Conclusion: Our findings supported that applying multicomponent cognitive intervention to subjects with SCD in clinical setting. The intervention could lead to improvements in ADL performance, cognition and psychological well-being, breaking through the bottleneck of limited effects of traditional cognitive training on daily function. Most of those improvements were maintained at 4 months.
口試委員會審定書 ................................................................... i
誌謝.............................................................................. ii
中文摘要......................................................................... iii
英文摘要........................................................................... v
第一章 研究背景 .................................................................... 1
第二章 文獻回顧 .................................................................... 3
第一節 主觀認知衰退 ................................................................ 3
一、定義與診斷標準 ................................................................. 3
二、盛行率與病理 ................................................................... 4
三、臨床症狀表現及影響 .............................................................. 5
四、小結 .......................................................................... 9
第二節 針對主觀認知衰退患者之介入及成效 ............................................. 11
一、非藥物介入之類型、理論機制及療效實證 ............................................ 11
二、複合式認知介入的定義及應用於主觀認知衰退患者之成效 ................................ 15
三、小結 ......................................................................... 17
第三章 研究目的與假設 ............................................................. 20
第四章 研究方法 ................................................................... 21
第一節 研究設計 ................................................................... 21
第二節 研究對象 ................................................................... 22
一、取樣方式 ...................................................................... 22
二、樣本數估計 .................................................................... 23
第三節 評估工具 ................................................................... 24
一、基本人口學及臨床資料 ........................................................... 24
二、主要成效指標 .................................................................. 25
三、次要成效指標 .................................................................. 27
第四節 介入內容 ................................................................... 31
第五節 研究流程 ................................................................... 35
第六節 資料分析 ................................................................... 36
第五章 結果 ....................................................................... 37
第一節 樣本描述 ................................................................... 37
第二節 介入之主要成效 ............................................................. 39
第三節 介入之次要成效 ............................................................. 44
第四節 影響介入成效之相關因子 ...................................................... 52
第六章 討論 ....................................................................... 54
第一節 受試者之認知困擾與日常生活表現 ............................................... 55
第二節 介入對於日常生活功能之立即、持續或延遲效益探討 ................................ 56
第三節 介入對於客觀認知表現與心理安適感之立即、持續或延遲效益探討 ..................... 60
第四節 受試者之人口學與臨床特性對介入成效之影響 ...................................... 63
第五節 研究限制 ................................................................... 64
第六節 臨床應用與實務建議 .......................................................... 65
第七章 結論 ....................................................................... 66
參考文獻.......................................................................... 67
附錄一 臺大醫院研究倫理委員會—臨床試驗審查同意公文 ................................... 76
附錄二 ClinicalTrials.gov PRS Receipt............................................. 79
附錄三 受試者知情同意書 ............................................................ 84
附錄四 評估量表 ................................................................... 90
附錄五 SCD複合式認知介入文獻彙整表 ................................................ 118
附錄六 回家作業與反思日誌範例 ..................................................... 123
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