老年憂鬱症患者之工具性日常生活活動表現

Abstract

背景: 老年憂鬱症是老年人最常見的心智障礙問題之一，患者除了受憂鬱症狀影響外亦伴隨輕微認知損傷以及工具性日常生活活動(instrumental activities of daily living, IADL)失能。IADL表現困難或減少參與，可能加重憂鬱等負面情緒、造成更嚴重的認知損傷以及影響其生活滿意度，因此IADL的評估與介入是老年憂鬱症臨床實務上相當重要的一環。然而目前針對老年憂鬱症IADL功能探討的文獻不足，現有研究評量失能的方式多侷限於針對其實際表現之問卷，而缺乏其自覺困難程度及操作表現之瞭解，並未比較其是否有所不同。另針對晚發型及復發型老年憂鬱症，由於病因、臨床表徵有所不同，其在IADL上的失能樣態或失能機轉等尚不清楚。 目的: 探討老年憂鬱症患者於IADL之操作能力、實際表現以及自覺困難程度等面向整體功能及IADL個別項目失能之情形，進一步比較晚發型、復發型憂鬱症於IADL功能表現之異同，並探討認知功能、憂鬱程度於IADL功能之關聯。 研究方法: 採橫斷面描述性研究，由北部一醫學中心轉介診斷為罹患重型憂鬱症之老年憂鬱患者，並於社區招募沒有明顯憂鬱和認知損傷之健康長者作為對照組。受試者將進行認知功能(蒙特利爾認知評估、史楚普色字測驗)、憂鬱症狀嚴重度(簡式老人憂鬱量表)等評量，IADL之操作能力、實際表現以及自覺困難程度分別以簡短式技能表現評量繁體中文版、失智症功能障礙評估量，及依該量表之各項自覺困難程度評量之。使用複迴歸分析法於控制人口學變項下，進行老年憂鬱症與健康對照組、晚發型與復發型憂鬱症之IADL整體功能及各子項目功能狀態比較；使用偏相關分析認知、憂鬱程度與IADL功能之關聯程度，以及使用複迴歸分析法比較認知、憂鬱程度於解釋IADL功能程度之重要性，並進一步進行調節和中介分析。 結果: 本研究共納入63名老年憂鬱症者(38名晚發型、25名復發型)及42名健康長者，復發型組平均年齡(59±5.9歲)顯著低於晚發型組(68±7.8歲)和健康組(67±9.0歲)，於性別和教育年數則沒有顯著差異(P性別=.541、P教育=.152)。兩類型老年憂鬱症於IADL整體功能之操作能力、實際表現以及自覺困難度皆顯著較健康組差(能力: P晚=.000、P復=.001 表現: P晚=.000、P復=.002 自覺: P晚=.000、P復=.000)；晚發型和復發型間於各面向IADL功能則皆沒有顯著差異(P能力=.653、P表現=.964、P自覺=.777)。兩類型老年憂鬱症於娛樂(P晚=.000、P復=.001)、外出(P晚=.004、P復=.015)、家務處理(P晚=.007、P復=.018)等IADL項目之實際表現顯著較健康組差，晚發型於財務處理較復發型差(P=.015)、復發型則於準備飯餐顯著較健康組差(P=.031)、於通電話顯著較晚發型差(P=.032)；兩類型老年憂鬱症於各IADL項目之自覺困難度則皆顯著較健康組感到困難(P晚=.000~.005、P復=.000~.034)。控制憂鬱影響下，晚發型憂鬱症之整體認知功能與三面向IADL功能呈現低度至中度相關(r=.222~.545)，復發型則皆為低度相關(r=.385~.393)；控制認知影響下，兩類型老年憂鬱症其憂鬱症狀與IADL操作能力幾乎無相關或僅低度相關(r晚=.032 r復=.208)，於IADL實際表現(r晚=.439 r復=.618)和自覺困難度層面(r晚=.456 r復=.569)則皆可達中度相關。 結論: 老年憂鬱症者面臨IADL操作能力損傷、主觀感受顯著困難，並且較未能實際參與在IADL中。而晚發型及復發型患者雖然各樣態整體IADL總分沒有顯著差異，但其困難項目有所不同。老年憂鬱症於解釋IADL操作能力部分以認知功能較為重要，於解釋IADL實際表現和自覺困難度部分則以憂鬱程度較為重要；而認知功能或憂鬱程度於解釋三面向IADL功能程度過程中並未存在顯著調節或是中介作用。此結果初步了解老年憂鬱症患者IADL失能情形和機轉，並提供臨床工作者進行整合性評估以及為老年憂鬱症者個別化規劃促進其IADL實際參與表現計畫時的參考依據。

Background: Geriatric Depression (GD) is the most common mental health disorder among older adults. Patients with GD may suffer from depression symptoms, mild cognitive dysfunction and impairment in instrumental activities of daily living (IADL). Poor IADL performance or decreased IADL participation may worsen their depression symptoms, lead to advanced cognitive impairment, and have an impact on quality of life. Hence, how to assess and improve IADL performance of GD patients is important for healthcare providers. However, there was limited number of studies about IADL performance of GD patients. Previous research mainly focused on IADL performance measured by self-report scales instead of the self-perceived difficulties or capacity in performing IADL. Also, there was a lack of comparison between the self-reported IADL performance and the self-perceived difficulty or capacity in performing IADL. Furthermore, growing evidence suggests that late-onset depression (LOD) differs from recurrent depression (RD) in terms of clinical features and etiology. Nonetheless, the IADL profile and mechanisms of IADL disabilities remain to be clarified. Aims: The purpose of this study is threefold: (1) To examine the differences between IADL capacity, actual performance of IADL and perceived difficulties when performing IADL among patients with GD and healthy controls (HCs), LOD and RD, (2) to investigate the performance of distinct IADL items in GD, and (3) to evaluate the correlation of depression and cognitive deficits to IADL function. Methods: A cross-sectional descriptive research design was employed. The GD patients with a diagnosis of major depressive disorder were recruited from psychiatric clinics in a medical center while those community-dwelling older adults without obvious cognitive and mood problems were recruited as the HCs. All participants were administered a series of tests on cognitive function (Montreal Cognitive Assessment, Stroop Color and Word Test), depression severity (Geriatric depression scale-Short Form) and triple-dimensional IADL function (The UCSD Performance-Based Skills Assessment, The Disability Assessment for Dementia-IADL scale). The authors compared the IADL performance between GD and HC, LOD and RD through multiple regression analysis. In addition, we used partial correlation and multiple regression analysis to evaluate the relationship of depression severity and cognitive deficits to IADL function. Results: There were 105 older adults (38 LOD, 25RD, 42 HC) recruited in this study, with matched gender and educational level (Pgender=.541, Pedu=.152) among the three groups. However, the average age of RD group(59±5.9) is younger than the other groups (LOD:68±7.8, HC:69±9.0). Both of the LOD and RD group were significantly worse than HCs in terms of general IADL capacity (PLOD=.000, PRD=.001), performance (PLOD=.000, PRD=.002) and perceived difficulties (PLOD=.000, PRD=.000). Compared with the RD group, the LOD group performed significantly worse on financial management (P=.015) while performing significantly better on telephoning (P=.032) and preparing meals (P=.031). Both groups were significantly interfered with the performance on leisure (PLOD=.000, PRD=.001), going on an outing (PLOD=.004, PRD=.015) and housework (PLOD=.007, PRD=.018), but not on medications. The results of partial correlation analysis revealed a low to moderate correlation between general cognition and varied dimension of IADL assessments (rLOD=.222~.545, rRD=.385~.393). Nevertheless, depression demonstrated moderate correlations with IADL performance (rLOD=.439, rRD=.618), perceived difficulties (rLOD=.456, rRD=.569) but rare to low correlation with IADL capacity (rLOD=.032, rRD=.208). Conclusions: This study showed that patients with GD had deficits in IADL capacity, performance and perceived difficulties. Although there were no significant differences between the LOD group and RD group on the triple-dimensional IADL function, they showed certain degree of diversity to distinct IADL items. Cognitive impairment had a prominent effect on IADL capacity of GD group, while depression is the key factor that affects actual performance of IADL and perceived difficulties in performing IADL. Besides, neither cognition nor depression serves as a mediator or mediating variable to IADL function. The results indicate the underlying IADL profile and mechanism of IADL dysfunction among GD patients. Moreover, they may help clinicians to develop an integrative evaluation and customized interventions targeting IADL dysfunction caused by GD.