探討失智症患者家庭照顧者的壓力因應歷程對憂鬱程度之影響

Abstract

目的：家庭一直是照顧失智症親人的重要支柱。患者健康狀況與照顧需求的複雜性與多元化，長期的照顧任務將對家庭照顧者造成身體和情緒的困擾。本研究是以Lazarus和Folkman的壓力與因應互動理論為基礎，探討照顧者面對照顧工作的壓力因應歷程，最後對其憂鬱程度產生之影響。 方法：本研究採取橫斷性設計，以立意取樣方式針對失智症家庭的主要照顧者為對象，於北部和中部地區之醫學中心收案314人，經醫院倫理委員會審查通過後，並取得受訪者知情同意，以結構式問卷進行訪談與資料收集。問卷內容包括失智症患者及主要照顧者的基本屬性、神經精神量表（NPI）和日常生活活動功能（ADL）、評估家庭功能的家庭評估照顧者量表（UWFACS）、照顧者反應評估量表（CRA）、照顧者自我效能量表（RSCSE）、照顧者處理壓力的評估量表（CAMI）以及流行病學中心憂鬱量表（CES-D）。以SPSS 22.0、AMOS統計軟體進行描述性、推論性及結構方程模式統計分析。 結果：34.39%照顧者具有憂鬱傾向（CES-D總分16分以上）。照顧者為女性、小學畢業、配偶擔任照顧者，每日照顧16小時以上、因為照顧患者而改變工作、自覺目前健康不佳、與患者感情不佳、自覺經濟狀況不佳的照顧者，其整體憂鬱程度較高。經模式適配度檢定，所建立之失智症家庭照顧者「壓力因應歷程」整體模式適配度及內在結構適配度能符合標準（Chi-square=135.8, Chi-square/ DF=1.235, GFI=0.947, RMSEA=0.027, TLI=0.987, CFI=0.989, PGFI=0.633），假設理論模式可獲得部份支持。在結構模式中，照顧者的壓力源與家庭功能顯著影響負向照顧評價，家庭功能顯著影響照顧自我效能與因應策略，負向照顧評價、自我效能、因應策略的幫助程度可預測憂鬱程度。然而，負向照顧評價、自我效能與因應策略之間無影響關係。 結論：依據研究結果發現，自我效能和因應策略對照顧者的憂鬱程度有直接的影響，並且家庭功能是壓力因應模式中的重要影響因素。因此，建議衛生專業人員應制定以家庭為中心的介入措施，加強家庭成員之間的支持，提高照顧自我效能，使用積極有效的因應措施，以減輕照顧者的壓力和憂鬱程度。

Purpose: The families have always been the cornerstone of care for relatives with dementia. Caring for family members with dementia can be a long-term burden task resulting in physical and emotional distress. The purpose of this research was to examine the influence of stress and coping process on depression among family caregivers of relatives with dementia based on Lazarus and Folkman’s theory of stress appraisal and coping. Method: This study adopted a cross-sectional correlational design. Purposive sampling was used to recruit 314 dyads of dementia patients and family caregivers from the outpatient neurological clinics of hospitals in northern and central Taiwan. Approval for this study was obtained from the institutional review board of the medical center before collecting data. Data were gathered through interviews with a structured questionnaire, which includes demographic characteristics for caregivers and care receivers, Neuropsychiatric Inventory (NPI) and activities of daily living (ADL), University of Wisconsin family assessment caregiver scale (UWFACS) for family functioning, caregiver reaction assessment (CRA) for negative caregiving appraisals, the revised scale for caregiving self-efficacy (RSCSE), carers' assessments of managing index for coping strategies(CAMI), and center for epidemiological studies depression scale (CES-D). The statistics analysis methods included descriptive statistics, Pearson product-moment correlation, ANOVA, and the structure equation modeling by the AMOS software. Results: 34.39% of the dementia caregivers reported to be at risk of depression (CES-D≧16 points). Family caregivers with elementary education, female, spouse, above 16 hours of daily care, job changes, poor self-rated health, poor relationship with patient, and poor economic status had higher level of depression. The results showed that the established “stress and coping process” model for family caregivers of patients with dementia has indicated good model fit (Chi-square=135.8, Chi-square/ DF=1.235, GFI=0.947, RMSEA=0.027, TLI=0.987, CFI=0.989, PGFI=0.633). The overall model fit indicators revealed that the research hypotheses and empirical results were partly coincidence. Family functioning and NPI had a significant impact on negative caregiving appraisals. Family functioning had a positive and significant impact on both self-efficacy and coping strategies. Negative caregiving appraisals, self-efficacy, and coping strategies could predict caregiver depression. However, negative caregiving appraisals and self-efficacy had no effect on coping strategies. Conclusion: Findings from the present study, self-efficacy and coping strategies have direct impact on caregiver depression. Family functioning is an important influential factor in the stress coping model. Therefore, it is strongly suggested that health professionals should develop appropriate family-centered interventions that focus on strengthening inter-family support, promoting caregiving self-efficacy and using of proactive coping to alleviate caregiver stress and depression.