桌遊作為輕度認知障礙患者認知訓練之療效初探

Abstract

背景：輕度認知障礙患者為失智症高危險群，發展適當處置避免其惡化為失智症是臨床努力的目標，其中以認知為基礎的非藥物介入是重點。遊戲式認知訓練是老人研究和實務上常應用的介入形式，然應用於輕度認知障礙患者之療效仍不明確，另目前也尚未釐清以團體或個別形式介入之效益是否有所差異。 目的：本研究以桌遊活動作為認知介入媒介，針對老年輕度認知障礙患者進行認知訓練，探討其對記憶力、注意力及執行功能等認知功能之效益。並進一步比較團體及個別兩種不同介入形式之效益。 研究方法：為單盲準實驗設計研究，由醫院神經內科轉介18位老年輕度認知障礙患者參與本研究，患者被分派至團體組(5-8人一組)及個別組(一對一)，兩組均接受12次經職能治療師調整規則以強化特定認知功能之桌遊訓練課程(每週進行2次，每次1.5小時)，並於介入前後完成下列各項成效評估，包含：(1)整體認知功能(蒙特利爾認知評估-台灣版)、(2)選擇性及分散性注意力(日常注意力測驗)、(3)立即性及延遲性視覺記憶(情境記憶測驗)、(4)立即性及延遲性語言記憶(行為記憶測驗)、(5)訊息處理速度(符號數字轉換測驗)、(6)控制/抑制能力(色字測驗)、(7)視覺空間工作記憶(劍橋神經認知測驗-中文版)，以及(8)情緒(老年憂鬱量表)等。以無母數統計進行資料分析，探討組內介入前後、及組間成效是否達顯著差異(p<.05)。 研究結果：介入後全體受試者在整體認知功能、選擇性注意力、延遲視覺記憶、立即與延遲語言記憶方面均有顯著改善。個別介入組在整體認知功能、延遲性語言記憶、控制/抑制及視覺空間工作記憶達顯著改善，然而，團體組僅在延遲性語言記憶有顯著改善。進一步比較團體及個別兩組組間各認知項目改善的差異，均未達顯著，顯示二種介入方式差異不大；然而低功能(臨床失智評定量表-加總計分[Clinical Dementia Rating – Sum of Boxes, CDR-SOB]≧3分)接受個別訓練者，執行功能會在視覺空間工作記憶較團體組進步顯著，而高功能(CDR-SOB≦2.5分)接受團體訓練者，情緒改善程度較個別組顯著。 結論：桌遊認知訓練對老年輕度認知障礙患者認知功能具有正面療效，特別在整體認知功能、延遲性視覺記憶、立即和延遲性語言記憶能力。此外，個別訓練在組內有較多認知項目改善，但與團體組間未達顯著差異，顯示團體式的桌遊介入並不會比個別形式更具成效；反之，個別形式則可能因訓練強度較高及可顧及個別化難度調整，成效更為良好，然此結果尚須增加樣本數進一步驗證之。

Backgrounds: Persons with mild cognitive impairment (MCI) are at high risk for dementia. Cognitive-based intervention, such as game-based cognitive training for persons with MCI to prevent their further deterioration, is crucial in clinical practice. However, there was no sufficient evidence to support the efficacy of game-based cognitive training for persons with MCI. There was also no study to compare the effects of cognitive training between different formats of the intervention, individual and group. Aims: The purpose of this study was to investigate the efficacy of a board game-based cognitive training program on the enhancement of cognitive functions, namely attention, memory and executive function. We also compared the efficacy between group versus individual format. Methods：This was a single-blind, quasi-experimental study. The subjects included 18 older adults with a confirmed MCI from a neurologist. The participants were assigned either a group- or individual-based intervention. Both groups received a 12-session cognitive training program (1.5 hours for each session, twice a week). The primary outcomes included the general cognitive function (Montreal Cognitive Assessment-Taiwan Version), selective/divided attention (Test of Everyday Attention), immediate/delayed visual memory(Contextual Memory Test), immediate/delayed verbal memory (The Rivermead Behavior Memory Test-Third Edition), processing speed (Symbol Digit Modalities Test), inhibition (Stroop Color and Word Test), visual spatial working memory (Cambridge Neuropsychological Test Automated Battery-Spatial working memory), and emotional state(Geriatric Depression Scale). Outcomes were assessed pre- and post-test. The nonparametric statistics were used by Wilcoxon Signed Ranked Test (within group analysis) and Mann-Whitney U Test or Chi-Squared (between group analysis). Results：The results showed significant improvement for all subjects in overall cognitive function, selective attention, delayed visual memory and immediate/delayed verbal memory after the intervention. Subjects in individual format showed significant within-group improvement in overall cognitive function, delayed verbal memory, inhibition, and visual space working memory. While subjects in group format improved significantly only in visual spatial working memory. However, there was no significant between-group difference of the changes on all outcome measures. Furthermore, subjects with low cognitive function (Clinical Dementia Rating – Sum of Boxes≧3) had significantly improved visual space working memory after training in individual training format , whereas subjects with high cognitive function has only significant improvement in the emotional state after the group training. Conclusions：The present study showed that applying a 12-session board-game cognitive training for older adults with MCI had positive effects on cognitive function enhancement, especially in general cognition and memory. With equal time of intervention, compared with group format, the individual format provide more opportunities for practices, can be more tailored to individuals’ needs, and might result in better outcomes. Future studies need larger samples to validate this.