比較遠距實體複合型式與實體型式多領域介入對於主觀認知衰退個案日常生活功能之成效

Abstract

背景：主觀認知衰退（subjective cognitive decline, SCD）是目前所知失智症光譜最早的症狀表現，也是近年來研究中主要關注的族群。非藥物治療是現階段對於SCD個案較可行的介入方式，特別是多領域介入被認為較有效。然而SCD的多領域介入如果要具成效，通常實體介入頻率要較高，所需成本大而難以廣為推行；採用遠距的方式可行，但需留意與個案互動的即時性與提供個別化的協助。因此發展適合SCD個案的多領域介入型式有其必要性。

目的：本研究使用多領域介入，比較遠距實體複合型式與傳統實體型式，對於SCD個案的客觀及主觀日常生活功能、認知活動參與、情緒與認知功能之成效。希望能提供SCD個案一有效且兼具成本效益的多領域介入。

方法：本研究為單盲、隨機分配試驗。受試者經神經內科醫師診斷SCD後轉介，或社區招募經醫師診斷後納入。兩組均為16周的多領域介入，包含認知、運動、飲食/營養，及其他失智症預防相關內容、回家作業與反思日誌，和個人目標設定及其他有助於失智症預防之策略。 本研究依據介入型式分為兩組：1.遠距實體複合組（簡稱複合組）─ 使用實體課程搭配通訊軟體（非同步遠距）方式進行，期間帶領者與團體成員間可透過通訊軟體進行相關問題的分享與討論；另有推薦受試者手機認知應用程式，鼓勵在家自行使用。另有實體介入每個月1次，共4次。2.實體組─ 全部採用傳統實體介入型式，每周1次，內容有針對認知的各向度做更深入的課程設計。兩組個案於介入前、介入後及介入結束後16週追蹤期，共接受三次評估，主要成效指標為客觀日常生活功能表現，次要成效指標為主觀日常生活功能、認知活動參與、情緒與認知功能。 介入成效統計方式以重複測量的單因子變異數分析（one-way repeated measurement ANOVA，one-way RM ANOVA）進行組內三個時間點（前測、後測、追蹤）差異檢定，使用邦佛洛尼校正（Bonferroni correction）進行兩兩時間點之間的顯著性確認；以獨立樣本t檢定，進行兩組別間成效差異的比較，並計算實驗效果量Cohen’s d。針對組間比較結果達中度效果量（d≧ 0.5）以上項目，採用多重線性回歸（multiple linear regression）進一步分析影響成效因子，納入分析因子包含年齡、MoCA（Montreal Cognitive Assessment）前測分數與組別。

結果：最終兩梯次共納入30人，其中複合組11人，實體組19人。基本資料與基準評估（前測）兩組間沒有顯著差異。 組內成效：複合型式多領域介入有助於SCD個案客觀日常生活功能的進步（簡短版加州大學聖地牙哥分校表現技巧評量〔The Brief University of California San Diego Performance-Based Skills Assessment, UPSAB〕）之溝通次量表，前測-追蹤p= 0.043）。實體型式多領域介入顯著提升SCD個案的認知活動參與（佛羅里達認知活動量表〔Florida Cognitive Activities Scale, FCAS〕，前測-後測p= 0.013，前測-追蹤p= 0.005）、降低焦慮情緒（貝氏焦慮量表〔Beck Anxiety Inventory, BAI〕，前測-後測p= 0.003；前測-追蹤p= 0.008）、增進語言記憶能力（字詞次序學習測驗〔The Word Sequence Learning Test, WS〕回憶，前測-後測p= 0.006；WS提示，前測-後測p= 0.021，前測-追蹤p= 0.036；WS再認，前測-追蹤p= 0.043）、提升視覺記憶能力（家庭圖片測驗〔Family Pictures subset, FP〕立即，前測-後測p= 0.009，前測-追蹤p= 0.002；延遲，前測-後測p= 0.004，前測-追蹤p< 0.001）。 組間成效：實體組比起複合組在認知活動參與實體組相較於複合組進步達顯著差異，且具高度效果量（FCAS，追蹤減前測p= 0.007，d= 0.93）。視覺記憶能力實體組較顯著差異，且具高度效果量（FP立即，後測減前測p= 0.038，d= 0.83，追蹤減前測p= 0.026，d= 0.89；延遲，後測減前測p= 0.044，d= 0.80，追蹤減前測p= 0.015，d= 0.98）。客觀日常生活功能、主觀日常生活功能、情緒、前瞻性記憶、語言學習能力、注意力與執行功能等，兩組表現未有明顯差異。

結論：使用遠距結合實體複合型式之多領域介入，有助於改善SCD個案的客觀日常生活功能，雖在整體介入成效不如實體組，但在未來應用上，若能採同步視訊的方式，確保足夠的介入劑量，強化即時互動及討論等，仍具備潛力，有助於SCD多領域介入的成本效益與便利性。

Background: Subjective cognitive decline (SCD) is considered the earliest symptom of the dementia spectrum and has been a primary focus of research in recent years. Non-pharmacological treatment is a feasible intervention method for SCD, and multi-domain intervention is proposed to be more effective than others. However, if multi-domain intervention for SCD is to be effective, the frequency of physical courses should usually be higher, and the cost required is too high to be widely implemented. Remote delivery is feasible, but assisting in real-time and individualized should be considered. Therefore, developing suitable forms of multi-domain intervention for SCD is necessary.

Objective: This study aims to compare the effectiveness of remote physical composite intervention with traditional physical intervention in improving objective and subjective daily functioning, cognitive activity participation, and emotional and cognitive functions in SCD. The goal is to provide effective and cost-effective multi-domain interventions for SCD.

Methods: This study is a single-blind, randomized controlled trial. Participants with SCD are referred by neurologists or communities. Both groups underwent a 16-week multi-domain intervention consisting of cognitive, exercise, diet/nutrition, and other dementia prevention-related content, along with home assignments, reflective journals, individual goal setting, and other strategies for dementia prevention. All participants were randomly assigned to two groups: 1. Remote physical composite group (composite group) - using physical courses with communication software (asynchronous remote), during which the leader and group members can share and discuss relevant issues through communication software. Participants were also recommended to use cognitive apps on their phones at home. Physical interventions occurred once a month for a total of four sessions. 2. Physical group - all sessions were conducted in a traditional physical format once a week, with more in-depth course designs for each dimension of cognition. All participants underwent assessments before, after, and 16 weeks after the intervention, with the primary outcome being objective daily functioning and secondary outcomes including subjective daily functioning, cognitive activity participation, and emotional and cognitive functions. The intervention's effectiveness was analyzed using one-way repeated measurement ANOVA within groups across three time points (baseline, post-intervention, follow-up) with Bonferroni correction for pairwise comparisons. Independent sample t-tests were used to compare the intervention effects between the two groups, and Cohen’s d was calculated as the effect size. For items with moderate effect sizes (d ≧0.5) in inter-group comparisons, multiple linear regression was used to analyze factors influencing effectiveness, including age, baseline Montreal Cognitive Assessment (MoCA) scores, and group assignment.

Results: Thirty participants were included in two batches, 11 in the composite group and 19 in the physical group. The two groups had no significant differences in characteristics and baseline assessments. Intra-group: Composite multi-domain intervention improved objective daily functioning in SCD clients (UPSAB communication, baseline to follow-up p= 0.043). Physical multi-domain intervention led to improvements in cognitive activity participation (FCAS, baseline to post-test p= 0.013, baseline to follow-up p= 0.005), anxiety (BAI, baseline to post-test p= 0.003, baseline to follow-up p= 0.008), verbal learning abilities (WS recall, baseline to post-test p= 0.006; WS cueing, baseline to post-test p= 0.021, baseline to follow-up p= 0.036; WS recognition, baseline to follow-up p= 0.043), and visual memory (FP immediate recall, baseline to post-test p= 0.009, baseline to follow-up p= 0.002; delayed recall, baseline to post-test p= 0.004, baseline to follow-up p< 0.001). Inter-group: The physical group showed significant improvements in cognitive activity participation compared to the composite group, with a high effect size (FCAS, post-test minus baseline p= 0.007, d= 0.93). The visual memory ability of the physical group improved more significantly, and it also had a high effect size (FP immediate recall, post-test minus baseline p= 0.038, d= 0.83, follow-up minus baseline p= 0.026, d= 0.89; delayed recall, post-test minus baseline p= 0.044, d= 0.80, follow-up minus baseline p= 0.015, d= 0.98). There were no significant differences between the two groups in objective daily functioning, subjective daily functioning, emotions, prospective memory, verbal learning abilities, attention, and executive functions.

Conclusion: Using remote combined with physical composite multi-domain intervention helps improve objective daily functioning in SCD. Although the overall intervention effect is not as good as that of the physical group, real-time interaction and discussion can be strengthened via adapting synchronized video methods to ensure the intervention effects. There is still potential to contribute to the cost-effectiveness and convenience of multi-domain intervention for SCD.