沒有照片 作者: 張育誠
班別: 碩士班
畢業年度: 100
指導老師: 胡淑貞
論文題目: 藍空下的夕陽—社區老人憂鬱程度、身體功能與生活品質的關係,及其運動介入模式探討

[ 摘要 ]
介紹: 憂鬱是全球領先的疾病負擔之一,與社區老人的生活品質有密切的關連。然而,憂鬱是如何影響社區老人的生活品質,依然缺乏足夠的研究。進一步而言,身體功能、憂鬱症狀以及生活品質的每個構面的關係,也仍不清楚;關於老人運動對憂鬱的影響也仍缺乏有力的研究支持。 對成人雖然有許多種推薦的運動模式來促進身體健康,但是可以提升身心健康的高齡友善的運動模式仍然缺乏。
方法: 這個系列的研究分為四個部分。Study 1-1和1-2訪問了共490位社區居住的高齡者,用世界衛生組織的生活品質簡表(the brief version of the World Health Organisation Quality of Life instrument (WHOQOL-BREF)來評量生活品質,並且使用巴氏量表(the Modified Barthel Index (MBI)、15分老年憂鬱量表(the 15-item Geriatric Depression Scale (GDS-15)、迷你智能量表(the Mini-Mental State Examination (MMSE)來評量心智狀態。憂鬱症狀的程度分為三類,無憂鬱症狀(no depressive symptoms, NDS)表示GDS-15=0, 較低程度憂鬱症狀(lower level of depressive symptoms, LLDS) 表示1≦GDS-15≦5, 而較高程度憂鬱症狀(higher level of depressive symptoms, HLDS)表示5Study 2-1 and 2-2 是使用國民健康數的台灣高齡長期追蹤資料庫(Taiwan Longitudinal Survey on Ageing (TLSA)進行分析。 總共有1996, 1999, 2003 and 2007四個年份蒐集的資料被納入分析。有2673位在1996年已經是65歲以上的高齡者被納入本長期追蹤的研究,所有觀察數共有8397個。憂鬱症狀是以 Center for Epidemiologic Studies Depression Scale (CES-D)來衡量。憂鬱症狀的程度分為三類,無憂鬱症狀(no depressive symptoms, NDS)表示CES-D=0, 較低程度憂鬱症狀(lower level of depressive symptoms, LLDS) 表示1≦CES-D≦9, 而較高程度憂鬱症狀(higher level of depressive symptoms, HLDS)表示10≦CES-D≦30。運動狀態的衡量包含頻率(0, ≦2, 3-5, ≧6 次/週),以及運動長度(<15 分, 15-30 分, >30 分),而定義運動的最低強度是以運動後覺得會有點喘、以及流點汗作為達到中級強度運動的依據。運動模式分為四種,分別為EM1,表示每週至少三次,每次最少15分鐘的中級強度運動;EM2代表每週至少三次,每次至少30分鐘的中級強度運動;EM3代表每週至少6次,每次15分鐘的中級強度運動;EM4代表每週至少6次,每次至少30分鐘的中級強度運動。分析中也包含身體活動功能、情緒與社會支持、性別、年齡、婚姻、教育、經濟滿意度以及工作狀態。使用廣義線性混合模型(generalized linear mixed models, GLMM) 來分析前一波與當波的個別運動模式是否會影響當波的憂鬱症狀;Study 2-2 同樣以GLMM模式來探討個別運動模式的過渡狀態(transitional patterns)是否對憂鬱症狀造成影響。
結果: 在Study 1-1中,GDS-15的分數可以預測WHOQOL-BREF的四個構面以及26個項目。MBI的分數本來可以預測26個項目中的15項,但在納入GDS-15分析後只剩下3個項目仍然可以被預測。憂鬱分數也滿足身體功能與生活品質的生理、心理、環境三個構面的中介模型的理論要求。在Study 1-2中,GDS-15和MBI的分數在較低程度憂鬱症狀(LLDS)族群中,明顯影響了WHOQOL-BREF的生理與心理兩個構面;性別會影響無憂鬱症狀(NDS)族群的整體生活品質,而年齡增加似乎對高程度憂鬱症狀(HLDS)族群的生活品質的三個構面有保護作用。此外,在不同程度的憂鬱症狀中,生活品質的因子也都表現不同的影響程度。
在Study 2-1中,較低程度憂鬱症狀(LLDS)與較高程度憂鬱症狀(HLDS)的族群分別占總高齡人口的24.2%與23.4%。有38.6%的高齡者符合EM1,32.1%符合EM2,34.5%符合EM3,以及28.0% 符合EM4。同時期的EM4對較高程度憂鬱症狀(HLDS)的勝算比(odds ratio, OR)為0.80 (0.66-0.95);身體活動功能、感情社會支持、自我評量的健康程度、經濟滿意度與前一波調查的憂鬱症狀程度均對憂鬱症狀有顯著影響,但是前一波調查的運動狀況並沒有對後來的憂鬱有顯著影響。Study 2-2 顯示四種運動模式的持續狀態(persistent patterns)均對產生較高程度憂鬱症狀(HLDS)有保護作用,但是效果可能會隨時間減少,因為運動的過渡狀態與時間有交互作用。進一步對時間與年齡做分層分析後,發現EM3與EM4在1996-1999的持續(persistent)運動狀態(EM3與EM4的OR (95% C.I.)分別為0.66 (0.45-0.98)與0.58 (0.36-0.93)),以及1999-2003的新增(increasing)運動狀態均對於產生高程度憂鬱症狀(HLDS)有保護作用(EM3與EM4的OR (95% C.I.)分別為0.52 (0.35-0.79)與0.49 (0.31-0.76));這兩者運動模式的新增(increasing)狀態對於65-74歲的族群產生高程度憂鬱症狀(HLDS)有顯著保護作用(EM3與EM4的OR (95% C.I.)分別為0.66 (0.45-0.97) and 0.63 (0.42-0.95)),對於75-84歲的族群雖也有保護的傾向,但未達統計上的顯著程度。
結論: 對身體功能相對較佳的社區高齡者來說,憂鬱症狀可能影響生活品質的每個面向,也可能影響中介身體功能對生活品質的影響。較低程度憂鬱症狀(lower level of depressive symptoms)可能修飾生活品質影響因子的表現,這也表示生活品質可能在低程度憂鬱症狀時,會對憂鬱症狀或是身體功能的變化有較明顯的反應。
對高齡者較友善的低量運動模式(low-volume exercise),就是一周五次或以上、每次至少15分鐘中強度運動模式已經被證實對全死因與癌症有保護作用。我們的研究顯示持續的低量運動對於憂鬱症狀也有保護作用。我們建議在評量社區老人的生活品質時,也要同時評估憂鬱症狀,並且推廣低量運動模式,以有助於老人的身心健康。
 
[ 英文摘要 ]
INTRODUCTION: Depression is a leading disease burden worldwide and associated with several health conditions. It is closely associated with quality of life in community-dwelling older adults. However, how depressive symptoms affect each facets of quality of life in community-dwelling older adults is still unclear. Furthermore, the relationship among physical function, depressive symptoms and the respective domains of quality of life also requires further investigation. Moreover, the robust evidence regarding the effects of exercise on depressive symptoms is lacking. Although there are several exercise models recommended for adults’ physical health, there are still lacking age-friendly exercise models in considering physical and psychological benefits for older adults.
METHODS: This series of studies were divided into four parts. For study 1-1 and 1-2, a total of 490 ambulatory community-dwelling older adults aged 65 years or above were interviewed using the brief version of the World Health Organisation Quality of Life instrument (WHOQOL-BREF), the Modified Barthel Index (MBI), the 15-item Geriatric Depression Scale (GDS-15), and the Mini-Mental State Examination (MMSE). Depressive symptoms were divided into no depressive symptoms (NDS), which means GDS-15=0; lower level of depressive symptoms (LLDS), 1≦GDS-15≦5; and higher level of depressive symptoms, 5Study 2-1 and 2-2 used the Taiwan Longitudinal Survey on Ageing (TLSA) undertaken by the Health Promotion Administration, Ministry of Health and Welfare, Taiwan. Four waves of survey in 1996, 1999, 2003 and 2007 were included in the analysis. The 2673 participants who were 65 years or older in 1996 were selected, with the total number of 8397 observations. Depressive symptoms were measured with the Center for Epidemiologic Studies Depression Scale (CES-D). Depressive symptoms were divided into no depressive symptoms (NDS), which means CES-D=0; lower level of depressive symptoms (LLDS), 030 min), and moderate intensity of exercise, which required at least a little sweating and panting after exercise. The four exercise models were classified as EM1 as the exercise of at least moderate intensity was performed ≧3 times/week, ≧15 min/time; EM2, ≧3 times/week, >30 min/time; EM3, ≧6 times/week, ≧15 min/time; EM4, ≧6 times/week, >30 min/time. Physical activity function, emotional social support, and socio-demographic variants including included gender, age, marital status, education, economic satisfaction and employment were controlled during the analysis. Study 2-1 applied the generalized linear mixed models (GLMM) via PROC GLIMMIX to estimate how respective exercise models in the present and previous survey affect the current depressive symptoms. Study 2-2 further analyzed the effects of transitional patterns of respective exercise models on depressive symptoms with GLMM models.
RESULTS: In study 1.1, the GDS-15 score was predictive of the scores of the four domains and all 26 facets of the WHOQOL-BREF. The significant predictive effects of the MBI score on 15 of the 26 facets of the WHOQOL-BREF were reduced to three after the adjustment for the GDS-15 score. Depression (as assessed by the GDS-15) is a mediator of the relationship between MBI and the physical, psychological and environmental domains of the WHOQOL-BREF. In Study 1.2, the GDS-15 and MBI scores significantly affected the WHOQOL-BREF physical and psychological domain scores in the LLDS group. Gender influenced the WHOQOL-BREF scores in the NDS group, and increased age demonstrated protective effects on the three domains in the HLDS group. Moreover, the association between the WHOQOL-BREF and its covariates varied for different levels of depressive symptoms.
In Study 2-1, the LLDS and HLDS prevalence was 24.2% and 23.4% respectively. 38.6% of the population met the criteria of EM1; 32.1%, EM2 ; 34.5%, EM3; and 28.0%, EM4. The present practice of EM4 had a significant odds ratio of 0.80 (0.66-0.95) for HLDS. The previous level of depressive symptoms, physical activity function, emotional social support, self-assessed health and economic satisfaction were all positively predictive to HLDS. However, none of the practices of exercise models in the previous survey can predict the present HLDS. Study 2-2 showed that all the persistent patterns of exercise transitions reveal a significantly protective effect for HLDS, though the effects may be decreased over time because of the significant effects of interaction between time and transitional patterns of exercise. After stratified by time and age, the analysis showed that the persistent pattern of both EM3 and EM4 in the transitional period of 1996-1999 (OR (95% C.I.)=0.66 (0.45-0.98) and 0.58 (0.36-0.93) for EM3 and EM4 respectively) and the increasing pattern in the transitional period of 1999-2003 showed significantly protective effects for HLDS (OR (95% C.I.)=0.52 (0.35-0.79) and 0.49 (0.31-0.76) for EM3 and EM4 respectively). Furthermore, the increasing patterns of both EM3 and EM4 had protective effects for HLDS, though the effects were statistically significant in the age of 65-74 (OR (95% C.I.)=0.66 (0.45-0.97) and 0.63 (0.42-0.95) for EM3 and EM4 respectively), but not in the age of 75-84.
CONCLUSION: Depressive symptoms may affect each facets of WHOQOL-BREF and may mediate the relationship between physical function and quality of life in apparently healthy community-dwelling older adults. Furthermore, the lower level depressive symptoms may modify the manifestations of determining factors for quality of life, which indicated that quality of life may be more sensitive to the changes of depressive symptoms or physical function in the lower level of depressive symptoms.
An age-friendly exercise model, which is also known as the low-volume exercise, i.e. moderate exercise lasting more than 15 minutes each time and as frequent as five or more times a week, has shown the benefits for all-cause mortality and cancer rate. Our study showed that persistent low-volume exercise may be also protective for depressive symptoms. We recommend taking depressive symptoms into consideration when measuring QOL and promoting low-volume exercise for the physical and psychological health of community-dwelling older adults.
 
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