認知矯正治療於中年慢性思覺失調症病人的認知功能成效The Efficacy of Cognitive Remediation Therapy on Cognitive Functionsin Middle-Aged Inpatients with Chronic Schizophrenia

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2019-05-20 已刊登
新刊登 綜 整 預防/治療/介入類型

作  者

許瓊華 陳姿廷* 陳其嶸 林美蓮 李宜玟 金玉華

實證知識類別

B 類:實證健康照護應用

PICO

治療/預防性問題

治療/介入措施

精神醫學 Psychiatry

科別

  • 精神衛生 Mental health
  • 臨床指引/實證照護成效 Clinical Guidelines/Evidence Based Outcomes

中文關鍵詞

中年慢性思覺失調症 認知矯正治療 認知功能

英文關鍵詞

middle-aged patients with chronic schizophrenia cognitive remediation therapy cognitive function

機構名稱

長庚醫療財團法人高雄長庚紀念醫院

申請單位

護理部

中文摘要

形成臨床提問:
思覺失調症病人常伴隨認知功能障礙,進而影響日常生活、工作與社會功能,藥物雖能減輕症狀,卻無法完全改善認知功能。台灣目前正面臨高齡化問題,過去研究多採用認知矯正治療(Cognitive Remediation Therapy, CRT)來改善年輕思覺失調症病人認知功能,於中年病人的文獻數較少,因此成效仍待進一步確認。本研究目的採取實證護理方式,探討認知矯正治療於中年慢性思覺失調症病人的認知功能成效。PICO-P:慢性思覺失調症病人、I:認知矯正治療、C:常規治療、O:認知功能。
文獻搜尋的方法與分析:
將P、I、C、O轉換為搜尋關鍵字、標準語彙(MeSH Term);並使用布林邏輯及限定欄位等策略,搜尋Cochrane Library、UpToDate、PubMed、CINAHL、華藝線上圖書館等資料庫。
文獻的品質評讀:
搜尋5個中英文文獻資料庫共50篇文獻,經篩選後只有一篇RCT文獻符合本文PICO,並對此篇文獻採用PEDro Scale進行評讀。評讀採VIP步驟:有效性(validity)、重要性(importance)、應用性(practicability)分析。評析結果:PEDro Scale為5分,即文獻具有尚可接受的有效性;Effect Size: 0.68-0.71(中-高)、Odds Ratio: 3.50-7.45、NNT : 4-6,即研究結果具有一定的重要性;病人屬性與本院相似,治療非侵入性,不需額外費用,因此CRT為一安全有效、低成本且效益高的治療方式。
證據之臨床應用:
研究設計為單一組別前後研究(Single group before-and-after study ),對象為南部某醫學中心10位病人。CRT介入由護理師與職能治療師使用Lumosity認知訓練軟體與紙筆益智學習單進行,時間為每週兩次,包含一次個別化電腦訓練及一次紙筆團體治療,每次各一小時,持續三個月。活動流程依序為:說明益智活動規則與電腦操作10分鐘;依病人認知功能提供適當認知層面與難度的活動,過程給予提示與教導認知策略40分鐘;討論表現與策略10分鐘。
成效評值:
結果顯示CRT介入三個月後,病人於簡易心智量表(Mini-Mental State Examination, MMSE)所有分測驗(定向感、注意力及計算能力、記憶力、語言、口語理解及行為能力、建構力)與總分皆有進步,但未達統計顯著差異(ps> 0.05);於職能治療綜合評量表(The Comprehensive Occupation Threapy Evaluation Scale, COTES)專注度、學習能力、問題解決能力分數及認知相關項目總分有顯著進步(ps< 0.05),其餘認知項目(現實定向力、遵循指令、組織及計畫能力)雖有進步,但未達統計顯著差異(ps> 0.05)。
結論與建議:
初步顯示CRT可提升中年慢性思覺失調症病人的專注度、學習能力、問題解決能力等認知功能。本研究考量中年病人因老化影響視力與精細動作,建議操作電腦時外接大型、簡化的鍵盤及放大視窗,將使病人更容易操作。

英文摘要

Ask an answerable question (PICO):
Cognitive impairment is common among patients with Schizophrenia, and it affects their daily life and social relationship. Although medication helps to control clinical symptoms, yet it fails to completelyimprove cognitive functionin patients with schizophrenia. Aginghas become a critical issue in Taiwan.Multiple studies have demonstrated the benefits of cognitive remediation therapy (CRT) for younger patients with schizophrenia, but a few studies reported that CRT has benefits for middle-aged patients. It is unclear whether CRT is effective in middle-aged patients with schizophrenia. The purpose of our study is to understand whether CRT is effective for improving cognitive functionsin middle-agedpatients with chronic schizophrenia. We used the evidence-based nursing practice to investigate the efficacy of CRT on middle-agedpatients with chronic schizophrenia. PICO-P refers to chronic schizophrenia patients, I for CRT, C for regular care, and O for cognitive functions.
The Method and Analysis of Literature Review:
We transformed PICO into Keywords and MeSH Term, and used the combination of the Boolean logicand limit as the strategies to research databases including Cochrane Library, UpToDate, PubMed, CINAHL, and Airiti Library.
Critical Appraisal:
Search result: In total, there are 50 articles searched in the 5 databases. After screening, only one RCT paper with the higher level of evidencewas identified to match our PICO question. Literature appraisal was used with PEDro scale and followingthe VIP steps: validity, importance, and practicability.We identified the paper with5 points on the PEDro scaleas acceptable validity. Effect size was 0.68-0.71 as medium to high level. Odds ratio was 3.50-7.45. Number needed to treat was 4-6. To sum up, CRT is abeneficial intervention for patients. The paper was identifiedthe similar attributes of patientsas ours.CRT is a non-invasive treatment and convenient without extra cost. Hence, it issafe, effective, affordable and efficient to patients and clients.
Clinical Application of Evidence:
The study design was a single group before-and-after study. The trial recruited 10 chronic schizophrenia patients to receive CRT. Nurses and occupational therapists appliedcomputerized and paper-and-pencil tasks. Lumosity cognitive trainingprogramsand self-designed worksheets were used toconduct the CRT programs twice per week, including one computerizedsession and one paper-and-pencilsession. In each session, 10 minutes for the description of activities rules or computer operations, 40 minutes for practicingcognitive activities with cuing and teaching of cognitive strategies, and 10 minutes to discuss functional performance and cognitive strategies. The total duration of the intervention was 3 months.
Evaluation of Effectiveness:
Results indicatedthat after three months intervention of CRT, patients with schizophrenia made progress in total score and 6 subscores of the Mini-Mental State Examination (MMSE), but the change did not reach statistical significance(ps> 0.05).Comprehensive Occupational Therapy Evaluation Scale(COTES) indicated significant improvements in the scores ofconcentration, learning, problem solving and general cognition-related items (ps< 0.05), but the other 3 scores were no significant changes(ps> 0.05).
Conclusions and Recommendations:
Preliminary results revealed that CRT improvedconcentration, learning, problem solving of middle-aged schizophrenic patients. Due to the vision loss andthe fine motor skills degradation of aging, we suggested that computer interface should consistedlargerkeyboard and monitorfor the convenience of the middle-agedgroup.