痴呆症患者三位一体干预模式的构建、评价及机制研究

Dementia is the leading factor contributing to disability in the elderly and it is not curable currently. Quality of care plays a significant role in dementia progression and quality of life for people with dementia. The applicant’s previous research indicated that more than 80% of people with dementia are cared for by their spouse at home, resulting in very low quality of care and extremely high prevalence of co-morbidities and complications. There are few components in the Chinese healthcare system targeting the family care and community management for people with dementia. Based on the applicant’s previous studies, this study aims at establishing an evidence-based hospital-community-family trinity model and evaluate its effects on the quality of life for people with dementia. The mechanism of the model will be analyzed based on the PRECEDE-PROCEED theoretical framework. The study comprises the following three phases. (1) The best available evidence regarding the existing dementia caregiver interventions will be identified through rigorous systematic review and Meta analysis; furthermore, the evidence level and recommendation grade will be clarified. (2) Based on the evidence identified from the first phase and guided by the PRECEDE-PROCEED theoretical framework, hospital-community-family trinity model will be established. Multidiscipline experts and stakeholders will be invited to review the model and structured intervention manual with matching discs will be developed for the implementation of this model in the third phase. (3) Randomized controlled trial will be used to test and evaluate the effects of the model on the quality of life of people with dementia. The mechanism of various mediator variables will be analyzed based on the PRECEDE-PROCEED theoretical framework. Findings from the study are expected to improve the quality of care and ultimately promote the quality of life of people with dementia, and provide robust evidence for better community management of dementia in a timely manner.

痴呆症是老年人失能的首要危险因素，尚无有效的治疗方法。照顾质量与患者疾病进展及生活质量密切相关。课题组前期研究发现，我国80%以上的痴呆症患者由老年配偶独自照顾，照顾质量低下、并发症频发，而医疗卫生体系中缺乏针对痴呆症家庭照护与社区管理的干预方案。本项目在前期研究基础上，以循证为基础，构建痴呆症患者医院-社区-家庭三位一体干预模式，并验证其效果、分析其作用机制。主要研究内容包括：(1)对国外相关干预措施及效果进行系统评价和Meta分析，明确其证据等级和推荐等级；(2)以PRECEDE-PROCEED模式为理论依据、以最可靠的研究证据为基础，构建医院为指导、社区为主体、家庭为落脚点的三位一体干预模式并进行论证，形成标准化的干预手册及配套光盘；(3)通过随机对照试验评价该模式对患者生活质量的干预效果，分析各中介变量的作用机制。本项目将为改善痴呆症患者照顾质量和生活质量、促进其社区管理提供依据。

痴呆症是导致老年人失智、失能的首要危险因素，尚无有效的治疗方法。照顾者身心状况、照顾质量和患者疾病进展及生活质量密切相关。课题组前期研究发现，我国80%以上的痴呆症患者由老年配偶独自照顾，照顾质量低下、并发症频发，而医疗卫生体系中缺乏针对痴呆症家庭照护与社区管理的干预方案。在已有研究基础上，本项目主要研究了以下几个内容：（1）对痴呆症患者家庭照顾者现有干预措施进行了系统文献回顾与证据质量评价，明确了干预效果确切的干预内容，构建了干预框架，包括痴呆症相关基本知识、痴呆症患者日常生活照顾技巧、痴呆症患者认知障碍的护理、痴呆症精神行为症状的预防与管理、照顾者的自我支持，形成了初版的干预内容与实施方案；（2）分别采用半结构式访谈和函评方式对初版干预内容进行利益相关者论证和专家论证，并据此修改干预方案，主要包括课程结构与内容的调整、语言表述的中国化和口语化、增加实用建议与资源链接内容等，制作标准化干预手册；（3）干预方案的预试验，共6例痴呆症患者家庭照顾者参加了预试验，完成了相应的量表测评和质性访谈，综合预试验发现的问题修改干预方案，修改主要包括分小组集中干预、增加同伴讨论、采用一对一方式收集测评指标等；（4）干预方案的随机对照试验，现阶段干预组49例家庭照顾者完成了所有干预以及评价指标测评，对照组43例家庭照顾者完成了相应指标测评，量性结果表明，干预方案对于改善痴呆症患者认知状况、精神行为症状与生活质量，缓解照顾者负担和负性情绪短期效果明确；质性访谈结果提示，照顾者与社区医务人员对于干预方案的总体满意度和接受度较好，将干预内容嵌入现有的社区基本公共卫生服务具有一定可行性；同时明确了干预方案中的核心要素。本研究结果对于发展痴呆症社区支持服务、改善家庭照顾者照顾质量和身心状况具有参考意义，且干预内容可作为培训素材，用于基层医务人员、养老机构护理人员的培训项目，提升痴呆症相关知识、技能与照护能力。