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系統識別號 U0026-3006201821225600
論文名稱(中文) 步行對社區阿茲海默氏症者日落症候群與睡眠品質之成效探討
論文名稱(英文) Effects of Walking on Sundown Syndrome and Sleep Quality in community dwelling people with Alzheimer’s disease
校院名稱 成功大學
系所名稱(中) 護理學系
系所名稱(英) Department of Nursing
學年度 106
學期 2
出版年 107
研究生(中文) 施燕華
研究生(英文) Yen-Hua Shih
電子信箱 yasshih@gmail.com
學號 TA8011020
學位類別 博士
語文別 英文
論文頁數 188頁
口試委員 指導教授-王靜枝
共同指導教授-白明奇
召集委員-陳清惠
口試委員-洪菁霞
口試委員-林惠賢
中文關鍵字 步行  日落症候群  睡眠品質  阿茲海默氏症 
英文關鍵字 walking  sundown syndrome  sleep quality  Alzheimer’s disease 
學科別分類
中文摘要 研究背景:晝夜與醒覺節律的改變常發生於阿茲海默氏症者,並與日落症候群及睡眠品質有關。此不僅困擾病人本身,更挑戰著照顧者面對與處理精神行為症狀。許多研究提到身體活動有助於調節晝夜與醒覺節律,因而可減緩病人的激躁行為與促進睡眠品質。而步行是多數失智症者安全又簡易可行的身體活動。然而,尚未有研究提到長期的步行介入措施對於日落症候群與睡眠品質之成效為何。
研究目的:本研究欲探討步行對社區阿茲海默氏症者日落症候群與睡眠品質之成效;同時欲了解不同步行時段對於社區阿茲海默氏者之日落症候群與睡眠品質之成效差異為何。
研究設計:採類實驗與縱貫性研究設計;招募60位符合收案標準之病人,依其意願選擇進入控制組、上午步行組或下午步行組,平均每組為20位病人;介入措施為24週,共有四次測量。研究結束後,計有46位病人進入資料分析。研究結果以中文版柯恩-曼斯菲爾德激動情緒行為量表(CMAI-C)與中文版匹茲堡睡眠品質量表(CPSQI)分別進行前測與第8、16及24週之三次後測。人口學資料以費雪精確檢定(Fisher exact test)與單因子變異數分析(ANOVA)來檢視三組間的差異顯著性;四次重複測量資料之組內與組間差異以廣義估計方程式(GEE)進行分析。
研究結果:整體研究參與完成率為90.2%。上午步行組在經過八週步行後,其日落症候群的改善與前測比較是顯著改善的(Wald X2= 7.91, p= .048)。在組別差異上,下午步行組在經過16週後(Wald X2= 14.64, p= .001)及上午或下午步行組在經過24週後(Wald X2= 15.08, p= .001),其日落症候群的改善成效顯著優於控制組。然而,在第24週之步行措施後,上午與下午步行之間並無顯著差異。在睡眠品質成效方面,下午步行組在第16週之成效顯著優於組內其他測量時間點(Wald X2= 11.03, p= .012),不過控制組在16週之睡眠品質竟也顯著優於前測值(Wald X2= 14.91, p= .02)。在組別差異上,步行8週後,上午步行組的睡眠品質較控制組與下午組為佳(Wald X2= 11.33, p= .003)。然而,對於睡眠品質之成效,上午組與下午組之間亦無顯著差異。
結論:本研究發現經過16週與24週的步行對改善失智症個案的日落症候群具有成效;經過16週下午組步行後,日落症候群可獲得減緩且繼續步行24週後,日落症候群仍然可獲得持續的改善。而上午組經過較長的24週步行時間後,日落症候群亦能獲得到改善,但不同的步行時段對日落症候群的改善並無顯著差別。此說明上午或下午步行對於改善日落症候群皆具有成效,且步行時間愈久,愈有持續的改善效果。步行對於促進睡眠品質的部分,短期8週後的步行,上午步行之睡眠品質明顯比下午步行與未步行者佳。本研究建議持續上午或下午步行對日落症候群有其助益,而短期上午步行能促進睡眠品質。此外,本研究中兩組步行組之研究參與度佳,此更加說明步行對於改善日落症候群與促進睡眠品質是一個安全、具體、可行且具有成效之介入措施。
英文摘要 Background: Sundown syndrome and sleep quality are important care issues for both people with dementia (PwD) and caregivers. Studies have indicated that disturbances of the circadian rhythm and sleep-wake rhythm a common occurrence in PwD and related to sundown syndrome and sleep quality. Walking is a safe and simple physical activity for most PwD. Many studies illustrated that physical exercise could affect agitation and sleep quality due to the regulation of circadian rhythm and sleep-wake rhythm, yet no research has ever explored the different effect of different long-term walking periods on sundown syndrome and sleep quality.
Purposes: The aims of this study were thus to examine the effects of walking on sundown syndrome and sleep quality in community dwelling people with Alzheimer’s disease, and determine whether different walking time periods show different effects on sundown syndrome and sleep quality in community dwelling people with Alzheimer’s disease.
Design: A quasi-experimental and longitudinal study design with four measurements were conducted.
Methods: 60 PwD who were recruited from dementia out-patient clinics of several hospitals and long-term care resource management centers in southern Taiwan, were equally assigned to either the control, morning or afternoon walking group according to their wishes for a six month intervention consisting of an average of 120 minutes walking per week, accompanied by their caregivers. 46 PwD completed the study at the end point. The Chinese version of the Cohen-Mansfield Agitation Inventory, Community form (CMAI-C) was used to assess sundown syndrome and the Chinese version of the Pittsburgh Sleep Quality Index (CPSQI) was used to measure sleep quality. Four measurements were conducted at the pre-test and three post-tests at 8th, 16th and 24th week. The Generalized estimating equation (GEE) was mainly performed for the longitudinal data analysis.
Results: An average 90.2% of the three groups finished the intervention with four adverse events reported in PwD. After walking for 8 weeks, the scores of the CMAI decreased significantly in the morning walking group (Wald X2= 7.91, p= .048) compared to the pre-test. Different groups presented different effects. The CMAI scores significantly decreased after 16 weeks walking in the afternoon (Wald X2=14.64, p=0.001) and after 24 weeks in the morning and afternoon walking groups (Wald X2= 15.08, p= .001) compared to the control group. However, there was no significant group difference between the morning and afternoon walking groups during the 24-week walking intervention. Regarding sleep quality, there was a significant effect on the CPSQI score after walking for 16 weeks in the afternoon walking group (Wald X2= 11.03, p= .012). Surprisingly, there was a significant difference in the sleep quality at 16 weeks in the control group compared to the pre-test (Wald X2= 14.91, p= .02). The group difference after 8 weeks walking in sleep quality improved significantly in the morning walking group than in the control and afternoon walking groups (Wald X2=11.33, p=0.003). However, no difference in sleep quality was found between the morning and afternoon walking groups.
Conclusions: The different effects between the three groups showed at 16-week and 24-week measurements. After 16 weeks walking in the afternoon group, sundown syndrome improved and after continuously walking for 24 weeks, sundown syndrome improved continually. Sundown syndrome also gradually improved after a longer walking time in the morning group; however there was no different effect between the two walking groups. The results indicated that either morning or afternoon walking was effective for improving sundown syndrome, and the longer the walking time was, the more sundown syndrome improved. Regarding sleep quality, only at 8 weeks did the significant difference among groups show that sleep quality in the morning walking group was better than in the afternoon walking and non-walking group. This study suggests that continued morning or afternoon walking could have a beneficial effect on sundown syndrome; shorter morning walking could improve sleep quality. In addition, the participation rate in the two walking groups was good in this study, this further indicates that walking is a concrete, feasible and effective intervention to improve sundown syndrome and promote sleep quality.
論文目次 中文摘要 ……………………………………………………………………... I

致 謝 ……………………………………………………………………... III
Abstract ………………………………………………………………………... IV
List of Contents ………………………………………………………………... VIII
List of Tables ………………………………………………………………….. XII
List of Figures ………………………………………………………………… XIII
Appendix ………………………………………………………………………. XIV
Chapter 1. Introduction ……………………………………………………... 1
1.1 Study background …………………………………………………… 2
1.2 Research purposes …………………………………………………. 6
1.3 Research questions …………………………………………………… 7
1.4 Definition of variables …………………………………… 8
1.4.1 Sundown syndrome ………………………………… 8
1.4.2 Sleep quality ………………………………………… 10
Chapter 2. Literature Review ……………………………………………….. 11
2.1 Dementia and behavior and psychological symptoms (BPSD) ……… 12
2.2 Sundown syndrome and sleep quality in people with Alzheimer’s dementia ………………………………………………………… 15
2.3 Sundown syndrome and sleep quality related to circadian rhythm and physical activity in people with Alzheimer’s disease ………………... 17
2.4 Pharmacological treatment and non-pharmacological interventions of sundown syndrome in people with dementia ………………………… 23
2.5 The benefit of walking among older adults ………………………….. 26
2.6 Exercise and physical activity in people with dementia ……………... 28
2.7 Effects and condition of walking on health outcomes for people with dementia ………………………………………………….................... 32
Chapter 3. Methodology ……………………………………………………... 37
3.1 Study design ………………………………………………………….. 38
3.2 Settings and Sampling …………………………………………… 39
3.2.1 Sample size ……………………………………………… 41
3.3 Walking intervention ……………………………………………… 42
3.3.1 Walking adherence ………………………………… 44
3.4 Data collection and procedure ……………………… 45
3.5 Ethical considerations ………………………………………. 50
3.6 Instruments …………………………………………………………… 51
3.6.1 Demographic data …………………………………… 51
3.6.2 Walking logs ……………………………………………… 52
3.6.3 Chinese version of the Cohen-Mansfield Agitation Inventory, Community form (CMAI-C) 53
3.6.4 Chinese version of the Pittsburgh Sleep Quality Index (CPSQI) ………………………………………………………. 54
3.7 Data analysis …………………………………………………………. 55
Chapter 4. Results ……………………………………………………………. 57
4.1 Demographic characteristics in people with dementia ……………….. 59
4.1.1 Demographic characteristics of people with dementia in the drop-out and participating groups ……………………………. 62
4.1.2 Difference in demographic characteristics between the drop-out group and participating groups in people with dementia ………………….. 64
4.2 Difference in the pre-test of sundown syndrome and sleep quality ….. 67
4.3 Demographic characteristics in caregivers of people with dementia … 68
4.3.1 Caregivers’ demographic characteristics between the drop-out and participating groups ………...... 68
4.3.2 Difference in caregivers’ demographic characteristics between the drop-out and participating groups ………………………. 69
4.4 Demographic characteristics of people with dementia among the three groups ………………………………………………… 71
4.4.1 Descriptive data of demographic characteristics of people with dementia …………………………………… 72
4.4.2 Differences in demographic characteristics of people with dementia ……………………………………… 74
4.5 Participating caregivers’ demographic characteristics among the control, morning walking and afternoon walking groups ……………. 77
4.5.1 Descriptive data of caregivers’ demographic characteristics … 77
4.5.2 Difference in caregivers’ demographic characteristics ………. 78
4.6 Participation rate among the control, morning walking and afternoon walking groups …………………… 80
4.7 The effectiveness of walking on sundown syndrome and sleep quality among the control, morning walking and afternoon walking groups ... 82
4.7.1 Difference in the pre-test among the three groups …………… 82
4.7.1.1 Difference in the pre-test of sundown syndrome among the three groups ……………………………. 83
4.7.1.2 Difference in the pre-test of sleep quality among the three groups …………………………………… 84
4.7.2 The effectiveness of walking on sundown syndrome ………... 86
4.7.2.1 Descriptive data of sundown syndrome throughout the study period ……………………………………. 87
4.7.2.2 The time effect of walking on sundown syndrome in each of the three groups …………….. 89
4.7.2.3 The group effect of walking on sundown syndrome in each time point ………………………………….. 91
4.7.3 The effectiveness of walking on sleep quality ……………….. 94
4.7.3.1 Descriptive data of sleep quality throughout the study period ……………………………………….. 95
4.7.3.2 The time effect of walking on sleep quality in each of the three groups ………………………… 96
4.7.3.3 The group effect of walking on sleep quality in each time point ………………………………………….. 98
4.8 Adverse events ……………………………………………………….. 101
Chapter 5. Discussion ………………………………………………………... 103
5.1 Demographic characteristics of people with dementia in the drop-out and participating groups …………… 105
5.2 Demographic characteristics of caregivers in the drop-out and participating groups ………………………………… 107
5.3 Pre-test of sundown syndrome and sleep quality among the control, morning walking and afternoon walking group ……………………… 108
5.4 The effectiveness of walking on sundown syndrome ………………... 109
5.4.1 The time effect of walking on sundown syndrome within group ………………………………………………………….. 109
5.4.2 The group effect of walking on sundown syndrome among the three groups …………………………………… 112
5.5 The effectiveness of walking on sleep quality …………………… 116
5.5.1 The time effect of walking on sleep quality within group …… 116
5.5.2 The group effect of walking on sleep quality among the three groups …………………………………………… 118
5.6 Adverse events in people with dementia 121
5.7 Limitations and further research ……………… 122
5.8 Implications for health ……………………………………… 125
5.8.1 Health education and clinical practice ..... 125
5.8.2 Policy on dementia care in the community …………………... 126
5.9 Conclusion …………………………………………………………… 127
Reference ……………………………………………………………………… 129
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