多元個案管理對失智者問題行為及家庭照顧者困擾、自我效能、憂鬱、負荷和健康促進行為之成效

Effects of Multicomponent Case Management on the Problem Behaviors of Patients With Dementia and Family Caregivers' Distress, Self-Efficacy, Depression, Burden and Health Promotion Behaviors

背景：失智家庭照護較缺少理論基礎及長期追蹤的多元個案管理。目的：以Pearlin照護壓力過程模式為基礎，探討早至中期失智家庭的多元個案管理對失智者問題行為、照顧者困擾、自我效能、憂鬱、負荷和健康促進行為之成效。方法：採雙組單盲隨機對照試驗，於北台灣3家地區醫院失智症門診收集76對失智者及照顧者，隨機分配至實驗組39對、對照組37對。實驗組接受4個月介入，包含2次家訪（或門診訪）及2次電訪，內容包含評估、衛教、諮商、支持、轉介、使用長照2.0資源。對照組接受常規照護和2次社交電訪。資料收集為前測（T0），介入後第4（T1）、6（T2）、12（T3）個月後測，以廣義估計方程式驗證成效。結果：以對照組前測結果為基準，並控制組別與時間交互作用，實驗組於T1、T2，在失智者問題行為中的情緒與精神症狀、社會參與及照顧者困擾、獲得喘息與控制沮喪想法的自我效能、憂鬱、負荷、健康促進行為等成果達顯著差異（p＜.05）；失智者精神動作調節、照顧者處理干擾行為的自我效能及健康促進行為的營養部分，只在T1達顯著差異（p＜.05）。所有的結果變項在T3均無顯著差異。結論／實務應用：本研究的個案管理介入成效可達6個月，能改善失智者的問題行為和照顧者憂鬱、負荷情形和對問題行為所產生的困擾並可提升照顧者的自我效能和健康促進行為，可作為失智症政策之參考。

Background: Few of the interventions currently available for family caregivers (FCGs) of persons with dementia (PWDs) with long-term follow-ups have a grounding in theory and incorporate multicomponent case management formats. Purpose: Based on Pearlin's Caregiving and Stress Process model, this study was developed to examine the effectiveness of a family-centered case management program for PWDs with early to moderate dementia in terms of reducing PWDs behavioral problems and improve FCG outcomes, including distress, self-efficacy, depression, caregiver burden, and health-promoting behaviors. Methods: This randomized, single-blind, parallel-controlled trial included 76 dyads of PWDs and their FCGs. The dyads were recruited from outpatient clinics at dementia centers in three district hospitals in northern Taiwan. The dyads were randomly assigned to the intervention group (IG, n = 39) and control group (CG, n = 37). The dyads in the IG received a four-month intervention with two home or clinic visits and two telephone interviews. The multi-component interventions provided assessment, education, consultations, support, and referrals to long-term care resources. The CG received routine care and two social phone calls. Data were collected upon enrollment (T0 = baseline) and at 4-,6-, and 12-months post-intervention (T1, T2, and T3, respectively). Generalized estimating equations were conducted to analyze the effects of the intervention. Results: By controlling for the interaction between group and time, we made a comparison between IG and the CG. The results showed significant improvements from baseline measures in behavioral problems in the PWDs for mood, psychosis, and social engagement, and improvements in the FCGs for distress and self-efficacy for obtaining respite as well as for better control of distressing thoughts, feelings of depression, caregiver burden, and overall health promoting behaviors at T1 and T2 (p ＜ 0.5). Significant improvements were also found in the IG for psychomotor regulation among PWDs and the self-efficacy of FCGs in managing the PWDs' disturbing behaviors and health promotion behaviors for nutrition at T1 (p ＜ 0.5). There were no significant improvements in the outcome variables at T3. Conclusions/Implications for Practice: Significant interactions between group and time were found at the 6-month assessment (T2) for improvements in problem behaviors of PWDs and depression, caregiver burden, and distress in the FCGs. Positive effects on self-efficacy and health promotion behaviors among the FCGs were also achieved. The results suggest that a multicomponent case management intervention should be referenced in dementia care policymaking for FCGs and PWDs.