第七章 討論與結論
7.7 結論
本研究首次以中風之住院復健期病人為對象，檢驗 MMSE 之區辨、
預測及療效評量三種實用功能。結果顯示 MMSE 對病人入院時認知功能 的區辨功能較出院時佳；相較於入院 MMSE 總分之預測功能，以出院時 MMSE 總分預測病人中風一年後的 BADL 獨立程度的預測功能較佳；此外，
MMSE 具有小到中度的內在反應性，可適當地反應病人住院期間認知功能 變化。
本研究結果支持 MMSE 具備認知評估工具之實用功能，且研究結果 顯示 MMSE 使用於復建住院期的中風病人有不同的實用功能：臨床人員 可應用 MMSE 於中風病人入住復健病房時區辨病人認知功能程度，協助 復健期間治療計畫與目標之擬定；MMSE 之預測功能則可應用於病人協助 出院安置及居家復健計畫之參考指標；此外，MMSE 亦可作為中風病人於 住院期間之認知功能療效評量指標。
45
46
表二、「中風住院病人復健資料庫之建置」計畫─受試者同意書內容節錄
研究計畫名稱：
中文：中風住院病人復健資料庫之建置
英文：Establishment of a databank for inpatients receiving stroke
rehabilitation
BI, Stroke Rehabilitation Assessment of Movement (STREAM ), Postural Assessment Scale for Stroke Patients (PASS), Functional Ambulatory Category (FAC)。情緒問卷 包含中文版 EQ5D 與簡明病人健康問卷(Patient Health Questionnaire, PHQ-9)。認 知測驗則包含視知覺忽略測驗、聽知覺忽略測驗、Point Digit Span (PDS)點式數 字廣度測驗, FDT 注意力測驗, Loewenstein Occupational Therapy Cognitive Assessment 幾何序列(GS of LOTCA)與動作運用(Praxis of LOTCA), Mini-Mental State Examination (MMSE), Boston Diagnostic Aphasia Examination (BDAE)、字卡 測試、認知功能評估、語言功能評估及 WCST。此一系列的動作與情緒、認知測 驗的評估，各約需花費 40 至 50 分鐘完成，每個測驗間的休息時間，將視受試者47
當時情況而有所增減。將分別於住院後與出院前 3 天進行上述測驗的住院評估與 出院評估，入院評估與出院評估的施測間隔至少為 7 天。 您的 CT 或 MRI 腦造 影資料，將由查閱病歷取得。作答結果將作為後續建置大樣本規模中風住院病人 全面性資料庫之基礎。
(2)追蹤電訪
將在此次中風後 1 年進行，內容為結合 BI、EQ5D 主要測驗項目、FAI(The Frenchay Activities Index)芙蘭切活動量表、PASIPD (Physical activity scale for individuals with physical disabilities) 身體失能者活動評量表、RMI (Rivermead Mobility Index)移動指數量表之複合式量表，作為評估 您日常生活能力、移動能 力、社交活動及情緒狀況等預後指標。
驗證程序：
(1)入出院評估
若 您符合收案標準，將由二至三位施測者協助 您以施測所有評估問卷及測 驗。若 您因生理限制或覺得疲累無法於同一時段完成所有項目評量，評量則予 以暫停，未完成部分由該名施測者於 3 日內再行完成。
(2)追蹤電訪
將在此次中風後 1 年進行，由一位施測者以電話訪問的方式，詢問 您相關 問卷題目。若 您因生理限制或覺得疲累無法於同一時段完成所有問卷，未完成 部分由該名施測者於 1 週內再行完成。
可能產生之副作用、發生率及處理方法：
完成相關評量約需 40 至 50 分鐘，可能會造成您生理上與心理上些微疲累，
因個人身心狀況而有所差異，發生危險的比率甚低。在訪問進行時，如您有身體 不適情形發生，會立即聯繫相關醫護人員處理，並立即停止訪問。
試驗預期效益：
提供未來研究者修訂或發展符合不同中風類型及受損腦區病人族群屬性的 動作能力、情緒感知與認知能力的臨床測驗，以及臨床實務者擬訂合適復健計畫 所需的關鍵資訊。並發展一系列快速且適用於中風住院病人的具有可接受心理計 量特性的動作、情緒與認知測驗評估工具，進而提升中風復健效能，促進病人福 祉。
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表三、樣本人口學特性
前後測皆完成 (n=168)
僅完成前測 (n=64)
p-value
性別
男/女, n 113/55 38/26 0.26
年齡(年), Mean ± SD 64.1±12.9 66.5±13.8 0.25 中風類型
出血型/阻塞型, n 57/111 15/49 0.12 腦傷側
右/左/雙側, n 73/88/7 32/29/3 0.84 發病到初評間隔(天), Median (min-max) 19 (5-111) 17 (4-61) 0.60 復健病房住院天數, Median (min-max) 33 (8-97) 31 (3-112) 0.29 前後測間隔(天), Median (min-max) 29 (7-89) - - 教育程度
小學以下/國高中/大專以上, n 36/80/52 27/18/19 0.05 入院 MMSE 分數, Median (min-max) 22 (0-30) 23 (1-30) 0.70 出院 MMSE 分數, Median (min-max) 25 (1-30) - - 入院 BI 分數, Median (min-max) 30 (0-90) 30 (0-90) 0.63 出院 BI 分數, Median (min-max) 75 (0-100) - - 中風一年後 BI 分數(n=124), Median
(min-max)
90 (0-100) -
-
* p<0.05
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表四、MMSE 單向度檢驗 (Mokken scale analysis)結果
項目 平均值 Hi
1 時間定向力(0-5 分) 2.93 0.67 2 空間定向力(0-5 分) 3.43 0.71 3 訊息登錄(0-3 分) 2.61 0.75 4 系列減七(0-5 分) 2.62 0.69 5 短期記憶(回憶, 0-3 分) 1.11 0.65 6 命名(0-2 分) 1.72 0.79 7 覆頌(0-1 分) 0.85 0.66 8 閱讀理解(0-1 分) 0.84 0.71 9 書寫造句(0-1 分) 0.64 0.64 10 口語理解及執行(0-3 分) 2.40 0.57 11 建構力(0-1 分) 0.54 0.41
Scale H=0.67
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表五、研究對象於 MMSE 與 BI 之地板／天花板效應 地板效應
n (%)
天花板效應 n (%) 入院 (n=168)
MMSE 3 (1.8) 9 (5.4) BI 12 (7.1) 0 (0.0) 出院 (n=168)
MMSE 0 (0.0) 17 (10.1*) BI 1 (0.6) 13 (7.7) 中風一年後 (n=124)
BI 7 (5.6) 52 (41.9*) * > 10%
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表六、MMSE 用於復健住院中風病人之預測效度
預測效度 出院 BI 分數 中風一年後 BI 總分 Spearman’s ρ
入院 MMSE 總分 0.40† (n=168)
0.45† (n=124)
出院 MMSE 總分 - 0.57†
(n=124) * p<0.05；† p<0.001
52
表七、MMSE 用於復健住院中風病人之內在與外在反應性 反應性 (Responsiveness) MMSE
內在反應性
Wilcoxon Z -7.95†
ES 0.33
SRM 0.66
外在反應性, ρ
入出院 BI 分數變化 0.26* (p=0.001)
Abbreviations: BI, Barthel Index; MMSE, Mini Mental State Examination; ES, effect size; SRM, standardized response mean.
* p<0.05 ; † p<0.001
53
圖
圖一、臨床評估中風病人認知功能之重要性
協助 診斷
臨床 決策
療效 指標 預測
預後
臨床 評估
54
：表示「中風病人資料庫建置」計畫收案時間，資料庫之資料收集分為兩個階 段，分別為「入出院評估」及「追蹤電訪」，病人於入院後及出院前三天內各接受 一次評估，於中風後一年接受一次電話訪問追蹤，共三次評估。詳細評估內容請 見附錄一。
中風發病
入復健病房 出院 中風一年後
圖二、「中風病人資料庫建置」計畫資料庫收案時間點
入出院評估 追蹤電訪
55
附註：本研究檢驗 MMSE 用於中風住院復健病人之預測效度。分別檢驗以病人入 院時之 MMSE 分數預測出院及中風一年後的 BI 分數，及以病人出院時之 MMSE
分數預測中風一年之 BI 分數，用以檢驗 MMSE 用於不同時間點之預測功能。
圖三、MMSE 之預測效度分析示意圖
2 3 4
MMSE MMSE
MMSE
BI
BI BI
1. 中風/發病 2. 入住復健病房 3. 出院
4. 中風後一年
1 2 3 4
56
57
58
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