团体怀旧治疗对社区老年人抑郁症状的干预效果研究
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摘要
目的
了解社区老年人的怀旧功能(Reminiscence Function),探索老年人怀旧功能的影响因素；评价团体怀旧治疗(Group reminiscence therapy)对于减轻老年抑郁症状,提高抑郁症状缓解率、自尊水平、情感平衡能力以及生活质量的效果,以探索性地制定适合我国社会文化背景的团体怀旧治疗干预内容和实施方案,为社区老年抑郁的综合防治提供依据。
方法
第一部分采用多点横断面的现场流行病学研究方法,对长沙市社区老年人的怀旧功能以及抑郁症状的发生率进行调查,并对老年人怀旧功能的影响因素进行分析。本研究采用分层随机整群抽样的方法,于2008年1月-5月在长沙市5个行政区随机抽取3个行政区,每个行政区各随机抽取1-2个街道办事处,每个街道办事处再随机抽取2-4个社区,共8个社区。再分别以性别、年龄分层,抽取年龄≥60岁且无且无严重认知、听力障碍、躯体疾病及精神障碍的老年人600名进行调查,最终顺利调查并成功记录有效问卷455份,问卷有效率为75.83%。其中男197例(43.3%),女258例(56.7%)；年龄60-95岁,平均年龄为69.88±7.48。使用的调查问卷包括：自编的社会人口资料调查表、怀旧功能量表(R F S)中文版、老年抑郁量表(GDS)中文版。
第二部分在现况调查的研究基础上,运用团体怀旧治疗对符合入选标准的研究对象进行完全随机对照试验研究,探讨团体怀旧治疗对减轻社区老年人的抑郁症状,增加抑郁缓解率,提高自尊、情感平衡能力及晚年生活质量的效果。本部分实施时间为2008年6月-2009年5月。在8个进行基线调查的社区中,采取单纯随机抽样的方法,随机抽取四个社区设立4个干预小组,其余四个社区设立4个对照小组。将现场调查中所有筛查出患有轻、中度抑郁症状,并符合本研究入选标准的老年人,每个社区随机抽取15-20人,取得知情同意后纳入研究对象。8个社区共计129名,其中干预组共计62名,对照组共计67名。对照组给予健康教育,干预组除了接受健康教育外,同时接受团体怀旧治疗。分别在干预前及干预后两个时间点,以心理测评量表：老年抑郁量表(GDS)中文版、自尊量表中文版、情感平衡量表中文版和健康状况调查问卷(SF-36)中文版进行测评,以比较干预治疗的效果。
本研究所有资料以Epidata3.0统计软件建立数据库,并进行数据录入。采用SPSS13.0统计软件处理,统计方法包括描述性的分析、x2检验、t检验,重复测量方差分析、多元逐步回归分析等。a值取0.05作为检验水准,p值均为双侧概率。
结果
1.老年人的怀旧功能及其影响因素分析结果
(1)老年人的怀旧功能现状
455例老年人的怀旧功能调查结果显示怀旧功能总分为144±35.64。在8个维度中,按其标准分从高到低依次为维系亲密关系(15.38±3.76)、自我认同(21.85±6.08)、教育(17.90±4.98)、交际沟通(17.81±5.50)、减轻厌烦情绪(19.20±5.98)、重现痛苦(14.98±5.62)、对死亡的准备(17.38±6.24)和解决问题(14.52±6.35)。其中,怀旧功能总分、以及维持亲密关系、教育、自我认同、交际沟通、减轻厌烦情绪5个维度的得分均超过其理论最高分的平均水平。而对死亡的准备、解决问题和重现痛苦三个维度得分却低于其理论最高分的平均水平。
(2)老年人怀旧功能的影响因素
老年人的社会人口学因素及自我状况的主观评价对总体怀旧功能及其各个维度功能有影响。在单因素分析中,女性在自我认同、交际沟通和重现痛苦三个维度的得分较男性高(p<0.05)。各年龄组怀旧功能总的得分无差别,在各维度得分中,随年龄增加对死亡的准备维度得分有而呈上升的趋势(p<0.05)。离异或丧偶者在自我认同和重现痛苦两个维度得分均较在婚者高(p<0.05)。不同文化程度在怀旧功能总分及减轻厌烦情绪、对死亡的准备、自我认同、解决问题、交际沟通、重现痛苦、教育7个维度的得分差别均有统计学意义(p<0.05)。小学及以下文化程度组老年人在减轻厌烦情绪、对死亡的准备、交际沟通、重现痛苦四个维度的得分高于其他组老年人。职业对怀旧功能的影响,主要表现为农民在减轻厌烦情绪、对死亡的准备维度得分较其他组要高。高收入老年人在减轻厌烦情绪和重现痛苦两个维度得分要均低于其他组老年人(p<0.05)。不同居住方式对怀旧功能总分以及减轻厌烦情绪、对死亡的准备、自我认同、维系亲密关系、重现痛苦5个维度得分差别有统计学意义(p<0.05),其中,独居者在怀旧功能总得分以及对死亡的准备、自我认同和重现痛苦3个维度得分均高于其他居住方式者。过去一年经历过配偶或亲友去世的老年人在交际沟通、维系亲密关系和重现痛苦三个维度的得分也要高于没有经历过配偶或亲友去世者。健康状况非常差和有慢性病的老年人主要表现在减轻厌烦情绪、对死亡的准备、重现痛苦维度上得分比其他老年人高(p<0.05)。抑郁症状筛查阳性的老年人在减轻厌烦情绪,对死亡的准备,重现痛苦3个维度的得分也要高于没有抑郁症状者,而且其得分随抑郁症状的加重而增加(p<0.05)。
以总体怀旧功能及怀旧功能各维度为因变量,以老年人的一般资料、抑郁情绪等为自变量进行逐步回归分析发现：是否有慢性疾病、健康状况自评、抑郁情绪、居住方式、过去一年是否经历配偶或亲友去世、性别和经济状况是总体怀旧功能的主要影响因素；文化程度、居住方式、是否有慢性病、健康状况自评、抑郁情绪、经济状况是维度“减轻厌烦情绪”的主要影响因素；抑郁情绪、过去一年是否经历过配偶或亲友去世、是否有慢性病、健康状况自评、年龄、60岁前职业是维度“对死亡的准备”的主要影响因素；健康状况自评、过去一年是否经历过配偶或亲友去世、居住方式和性别是维度“自我认同”的主要影响因素；是否有慢性病和居住方式是维度“解决问题”的主要影响因素；健康状况自评、居住方式、经济状况和性别是维度“交际沟通”的主要影响因素；过去一年是否经历配偶或亲友去世、性别和是否有慢性病是维度“维系亲密关系”的主要影响因素；抑郁情绪、过去一年是否经历配偶或亲友去世、是否有慢性病、文化程度、居住方式是维度“重现痛苦”的主要影响因素。过去一年是否经历配偶或亲友去世、60岁以前职业、性别和健康状况自评是维度“教育”的主要影响因素。
(3)社区老年人抑郁症状发生率较高,455名被试老年人中,GDS平均分为8.78±6.44,有165人有不同程度的抑郁症状(GDS≥11分),总的筛查阳性率为36.26%,其中轻度抑郁症状者138人,占总体被试老年人的30.33%,中重度抑郁症状者27人,占总被试老年人的5.93%。
2.团体怀旧治疗对老年抑郁症状的干预效果分析
(1)运用团体怀旧治疗干预后,干预组的GDS分值相对于干预前有显著下降,经t检验,其差异有统计学意义(t=4.61,p=0.00)。对照组GDS分值在六周后也有所降低,差异有统计学意义(t=12.75,p=0.00)。经方差分析,干预组与对照组的GDS分值差异有统计学意义,(F=50.81,p=0.00)。经过六周的团体怀旧治疗后,干预组老年人抑郁症状的缓解程度显著高于对照组的老年人,(x2=18.49,p=0.00)。(3)干预组和对照组在进行了六周的团体怀旧治疗后自尊分值相对于干预前没有显著上升,经t检验,其差异无统计学意义。经方差分析,干预组与对照组的自尊分值差异也无统计学意义(F=3.33,p=0.07)。
(4)经过六周的团体怀旧治疗,干预组治疗后积极情感和情感平衡分值相对于干预前有显著升高,经t检验,其差异有统计学意义,而消极情感相对于干预前有明显下降,其差异也有统计学意义(t=10.74,p=0.00)。对照组在接受健康教育后,积极情感和情感平衡分值相对于干预前有所提高,消极情感较干预前有所下降,但差异均无统计学意义。经方差分析,干预组与对照组在积极情感、消极情感和情感平衡分值差异上均有统计学意义(F=49.84,p-0.00)。
(5)经过六周的团体怀旧治疗,干预组健康相关生活质量的各个维度相对于干预前都有所升高,t检验表明除生理机能(PF)和生理职能(RP)两个维度外,躯体疼痛(BP)、一般健康状况(GH)、精力(VT)、社会功能(SF)、情感职能(RE)、精神健康(MH)维度的得分差异有统计学意义。对照组在接受健康教育后,健康相关生活质量只有躯体疼痛(BP)维度相对于干预前有显著提高,经t检验其差异有统计学意义(t=2.69,p=0.01)外,其余各个维度干预前后的得分差异均无统计学意义。干预后干预组与对照组健康相关生活质量各个维度均分的比较中,经方差分析,在生理职能(RP)、躯体疼痛(BP)、一般健康状况(GH)、精力(VT)、社会功能(SF)、情感职能(RE)、精神健康(MH)维度上,干预组的得分显著高于对照组,其差异有统计学意义。
结论
1.老年人的总体怀旧功能较好,怀旧的目的主要表现为减轻厌烦情绪、提高自我认同感,促进交流沟通、维持亲密关系和教育。
2.居住方式、性别、是否有慢性疾病、健康状况自评、过去一年是否经历亲人或朋友的去世、经济状况、抑郁情绪是影响老年人总体怀旧功能的主要因素。自评健康状况非常差的老年人主要表现在重现痛苦维度得分比其他老年人高,而有慢性病的老年人在对死亡准备,重现痛苦等维度的得分也高于没有慢性病者；独居老年人在怀旧功能总得分以及对死亡的准备、自我认同和重现痛苦3个维度得分均高于其他组老年人；随着文化程度的增高,本科及以上文化程度的老年人总体怀旧功能却下降,而小学及以下文化程度老年人在减轻厌烦情绪、对死亡的准备、重现痛苦三个维度的得分高于其他组老年人；抑郁情绪对减轻厌烦情绪、对死亡的准备和重现痛苦有显著影响；过去一年是否经历过配偶或亲友去世对维系亲密关系、重现痛苦和对死亡的准备也有显著影响；随着年龄增长,对死亡的准备的得分呈上升趋势。此外,性别、婚姻状态、职业等因素对不同维度怀旧功能均存在显著影响。
3.社区老年人抑郁症状筛查阳性率较高,被识别率却很低,抑郁已成为老年人的主要心理健康问题。
4.在社区实施团体怀旧治疗有助于改善老年人的抑郁症状,缓解抑郁发生率,提高老年人群的总体心理健康水平及晚年生活质量,对促进社会的健康老龄化具有重要意义。
5.团体怀旧治疗的实施方案应根据现实环境并结合所处社会文化背景等实际情况进行选择。实施团体治疗过程中应遵循循序渐进、由浅入深、逐步引导的原则,注意各种技巧(如关怀性聆听、正向回馈、接纳、经验分享等)的运用,及时发现老年人情感的变化,疏导因不良经历引起的负性情绪,合理应用引导物,以达到事半功倍的效果。
6.团体怀旧治疗方法简便易行、经济实用,具有较大的社会经济效益,适合于在社区由护理人员推广实施。
Objectives:
To investigate the reminiscence functions and depression of elderly in community and to find out the factors which influence remininscenc functions of elderly. To explore the effectiveness of the group reminiscence therapy for reducing the depressive symptoms, increasing recovery rate of depression, and improving the self-esteem level, affect balance competence and quality of life of the depressed elderly. Results from this study will provide data for management of the depressed elderly in community by using reminiscence, and to conduct a larger study in the future.
Methods:
In first part, we applied an epidemiological method combining cross-sectional study in multi-sites to investigate the reminiscence functions and depression of elderly in community of Changsha city and analyze the factors which influence the reminiscence fuctions.Through Jaunary,2008 to May,2008, we applied the stratified cluster randomized sampling method for the screening. At first, we randomly chose eight communities for screening in five districts of Changsha city. According to gender and age stratification, a total of 600 cases of elderly at the age of 60 years or more from communities in Changsha city were investigated. Interview with the smooth and successful record of 455 valid questionnaires, the questionnaire efficiency is 75.83%. Male 197 (43.3%) and 258 women (56.7%),60-95 years of age, the average are is 69.88±7.48. The questionnaires used in this study include self social-demographic information questionnaire, reminiscence function scale and Geriatric Depression Scale (GDS).
At the second part of the study, we applied a randomized controlled trial study to explore the effectiveness of group reminiscence therapy for reducing the depressive symptoms, increasing recovery rate of depression, and improving the self-esteem, affect balance competence and quality of late-life of the depressed elderly. This part of the study lasted from June, 2008 to May,2009. Among the eight communities, we applied the simple random sampling method and randomly selected four communities for establishing four intervention groups, and the other four communities for establishing four control groups. Based on the screening results, the eligible depressed elderly who consented to participate were randomly recruited into the study. The sample size was 10-15 subjects in each community. Totally we recruited 129 study subjects (62 in intervention groups and 67 in control groups). Control group received health education, apart from the intervention group received health education, but also accepted group reminiscence therapy, before and after the intervention, we used psychological assessment scales including Geriatric Depression Scale (GDS) Chinese version, Chinese version of Self-Esteem Scale, Affect Balance Scale and SF-36 Chinese version to compare the therapeutic effect.
The database was established by Epidata3.0 and statistic analysis were performed using SPSS (version 13.0). Statistical methods included descriptive analysis, Chi-square test, t test, analysis of variance (ANOVA) and regression analysis. Level of significance of this study was set at.05.
Results:
1. The reminiscence functions of the community elderly and the analysis of the influencing factors
(1) The present situation of the reminiscence functions of the community elderly:The study of 455 cases of the reminiscence functions of the community elderly shows that the total score of the reminiscence functions is 144±35.64. Within the 8 domains, the scores from high to low level are:Identity (21.85±6.08), Boredom Reduction (19.20±5.98), Education (17.90±4.98), Conversation (17.81±5.50), Death Preparation (17.38±6.24), Intimacy maintenance (15.38±3.76), Bitterness Revival (14.98±5.62) and Problem Solving (14.52±6.35). Among them the scores of 5 domains including total score of the Reminiscence functions, Identity, Conversation, Intimacy Maintenance and Education all exceed the average value, while 3 domains including Death Preparation, Problem Solving and Bitterness Revival are lower than the average value.
(2) The influent factors of the reminiscence functions of the community elderly:Social demography and self-status subjective assessment have a certain influence on the overall reminiscence functions and each domain of the community elderly. The scores of the 3 domains of Identity, Conversation and Bitterness Revival among the females are higher than the males (p<0.05) in the single factor analysis. There are no differences among the overall scores of the reminiscence functions in each age group. The score of Death Preparation shows an ascending trend with the age increase in each domain. The scores of Identity and Bitterness Revival in the divorced and the widowed are both higher than that in the non-divorced (p <0.05). The score differences on the total score of the reminiscence functions and the 7 domains of Boredom reduction, Death preparation, Identity, Problem solving, Conversation, Bitterness Revival and Education due to different education level have statistical significance (p<0.05). In the education level of the elementary school and below, the scores of the elderly on Boredom Reduction, Death Preparation, Conversation and Bitterness Revival are higher than other groups. The influence of vocation on the reminiscence functions mainly shows in the higher scores of Boredom Reduction and Death Preparation in the peasant group as compared to other groups, while the other vocations show higher scores of Bitterness Revival than other groups (p<0.05). The scores of Boredom Reduction and Bitterness Revival in high-income elderly are lower than that in the other groups (p<0.05). Different living styles affect the overall scores of the elderly reminiscence functions and also 5 domains of Boredom Reduction, Death Preparation, Identity, Intimacy Maintenance and Bitterness Revival, and the score differences have statistical significance (p <0.05). Among them, the individuals living alone have higher overall scores of reminiscence functions and 3 domains of Death Preparation, Identity and Bitterness Revival than other living styles. The elderly who have undergone the death of spouses and relatives in the past 1 year have higher scores in the 3 domains of Conversation, Intimacy Maintenance and Bitterness Revival than those who haven't. Among them, the elderly with extreme poor health status and chronic diseases have higher scores on Boredom Reduction, Death Preparation and Bitterness Revival than others (p<0.05). The scores of the elderly with depression screening test positive on 3 domains of Boredom Reduction, Death Preparation and Bitterness Revival are higher than those without, and increase with the aggravation of depression symptoms (p<0.05).
The multiple stepwise regression analysis with overall reminiscence functions plus each domains of reminiscence functions as dependent variables and the general information, depression, etc as independent variables shows that:with/ without chronic diseases, self-assessment of health status, depression, living styles, experiencing the death of spouses and relatives in the past 1 year or not, sex, economic status are the factors affecting the overall reminiscence functions; education level, living styles, with/without chronic diseases, self-assessment of health status, depression and economic status are the factors affecting the domain "Boredom reduction"; depression, experiencing the death of spouses and relatives in the past 1 year or not, with/without chronic diseases and self-assessment of health status, age and vocation are the factors affecting the domain "Death preparation"; self-assessment of health status, experiencing the death of spouses and relatives in the past 1 year or not, living styles, and sex are the factors affecting the domain "Identity"; with/without chronic diseases and living styles are the factors affecting the domain "Problem solving"; self-assessment of health status, living styles, economic status and sex have prediction on domain "Conversation"; experiencing the death of spouses and relatives in the past 1 year or not, sex and with/without chronic diseases are the factors affecting the domain "Intimacy maintenance"; Depression, experiencing the death of spouses and relatives in the past 1 year or not, with/without chronic diseases, education level and living styles are the factors affecting the domain "Bitterness revival"; experiencing the death of spouses and relatives in the past 1 year or not, vocation, sex and self-assessment of health status are the factors affecting the domain "Teach".
2. Analysis of the effectiveness of group reminiscence therapy for depressive symptoms of elderly
(1) The incidence rate of depressive symptoms of elderly was higher in community.455 samples were tested in the sudy. The average score was 8.78±6.44. Among them,165 elderly had different levels of depressive symptoms (GDS≥11), the total rate was 36.26%.138 elderly had mild depression, accounting for 30.33% of total,27 elderly had moderate to severe depression, and accounting for the overall trail was 5.93%.
(2) After six week group reminiscence therapy intervention, the GDS score of intervention group declined remarkably compare with the beginning (t=4.61, p=0.00), while the GDS score of control group also change significantly (t=12.75, p=0.00). By covariance analysis, the intervention group and control group GDS scores were significantly different (F=50.81,P=0.00). The recovery rate of intervention group was higher than that of control group (x2= 18.49, p=0.00).
(3) After six week intervention, the self-esteem scores of intervention group and control group were no significant increased (p>0.05). By covariance analysis, the difference of self-esteem scores between intervention group and control group also wasn't statistically significant (F= 3.33, p= 0.07).
(4) After six-week group reminiscence therapy, the positive affect and affect balance scores of intervention group had increased significantly than that of the beginning(p< 0.01),and the negative affect score had dropped significantly(t=10.74, p=0.00).In control group, after receiving health education, the positive affect and affect balance scores had improved than that of the beginning and the score of negative affect also decreased compared with that before the intervention, but the differences were not statistically significant (p>0.05). By covariance analysis, the intervention group and control group's positive affect, negative affect and affect balance scores were significantly different(F= 49.84, p= 0.00).
(5) All subscales of SF-36 were improved to some extent after receiving six week intervention in the intervention group. T test showed that there were significant differences in subscales of bodily pain (BR)、general health (GH)、vitality (VT)、social functioning (SF)、role limitation due to emotional problems (RE)、mental health (MH),and no significant difference was found in subscales of physical function (PF) and role limitation due to physical problems (RP). In control group, only score of bodily pain (BP) was increased significantly (t=2.69, p=0.01) When compared with the scores of all subscales of SF-36 between the intervention group and control group after six week intervention, the scores of role limitation due to physical problems (RP)、bodily pain (BP)、general health (GH)、vitality (VT)、social functioning (SF)、role limitation due to emotional problems (RE)、mental health (MH) of intervention group were significantly higher than those of control group and the differences are statistically significant, while there was no difference in the scores of BF between the two groups.
Conclusion:
1. The overall reminiscence functions of elderly in community are optimistic. The major reminiscence functions of the elderly demonstrate as alleviating boredom mood, self-identity, communication, maintaining intimate relationships and education.
2. The factors of living styles, self-assessment of health status, with/without chronic diseases, experiencing the death of spouses and relatives in the past 1 year or not, economic status and depression are the related factors that influenced the overall reminiscence functions of the community elderly. The factors of self-assessment of health status and with/without chronic diseases also have great influence on the fuctions of boredom reduction, death preparation, identity, conversation, and bitterness revival. The fuction of death preparation was increasing with age increasing. The fuctions of boredom reduction, death preparation and bitterness revival are influenced by the factor of depression. The factor of experiencing the death of spouses and relatives in the past 1 year or not has the influence on fuctions of intimacy maintenance, bitterness revival and death preparation. Furthermore, the factors of sex, economical status and vacation etc. also have significant influences on different reminiscence functions of elderly.
3. The prevalence of depression among the community elderly was high. However, the recognition of the elderly depression is very low.Depression has become main psychological problem of them.
4. Since the implementation of group reminiscence therapy in the community can reduce the depressive symptoms, increase recovery rate of depression and improve the quality of life of the community depressed elderly effectively, so it has great significance for improving mental health of elderly and promoting successful aging for them.
5. Group reminiscence therapy should be based on the reality of social and cultural background. Implementation of the group therapy process should be followed progressive approach and gradually guide. And also should use a variety of skills (such as caring, listening, positive feedback, accept, and experience sharing, etc.). During the group intervention process, the emotional changes in the elderly should be timely detected and the negative emotions which caused by adverse experiences should be diverted immediately. The rational application of materials for guiding specific memory can also help to achieve the therapeutic effects.
6. Group reminiscence therapy is simple, economical and practical, and with the larger socio-economic benefits. So it is feasible and suitable for nursing staffs to carry out in the community.
了解社区老年人的怀旧功能(Reminiscence Function),探索老年人怀旧功能的影响因素；评价团体怀旧治疗(Group reminiscence therapy)对于减轻老年抑郁症状,提高抑郁症状缓解率、自尊水平、情感平衡能力以及生活质量的效果,以探索性地制定适合我国社会文化背景的团体怀旧治疗干预内容和实施方案,为社区老年抑郁的综合防治提供依据。
方法
第一部分采用多点横断面的现场流行病学研究方法,对长沙市社区老年人的怀旧功能以及抑郁症状的发生率进行调查,并对老年人怀旧功能的影响因素进行分析。本研究采用分层随机整群抽样的方法,于2008年1月-5月在长沙市5个行政区随机抽取3个行政区,每个行政区各随机抽取1-2个街道办事处,每个街道办事处再随机抽取2-4个社区,共8个社区。再分别以性别、年龄分层,抽取年龄≥60岁且无且无严重认知、听力障碍、躯体疾病及精神障碍的老年人600名进行调查,最终顺利调查并成功记录有效问卷455份,问卷有效率为75.83%。其中男197例(43.3%),女258例(56.7%)；年龄60-95岁,平均年龄为69.88±7.48。使用的调查问卷包括：自编的社会人口资料调查表、怀旧功能量表(R F S)中文版、老年抑郁量表(GDS)中文版。
第二部分在现况调查的研究基础上,运用团体怀旧治疗对符合入选标准的研究对象进行完全随机对照试验研究,探讨团体怀旧治疗对减轻社区老年人的抑郁症状,增加抑郁缓解率,提高自尊、情感平衡能力及晚年生活质量的效果。本部分实施时间为2008年6月-2009年5月。在8个进行基线调查的社区中,采取单纯随机抽样的方法,随机抽取四个社区设立4个干预小组,其余四个社区设立4个对照小组。将现场调查中所有筛查出患有轻、中度抑郁症状,并符合本研究入选标准的老年人,每个社区随机抽取15-20人,取得知情同意后纳入研究对象。8个社区共计129名,其中干预组共计62名,对照组共计67名。对照组给予健康教育,干预组除了接受健康教育外,同时接受团体怀旧治疗。分别在干预前及干预后两个时间点,以心理测评量表：老年抑郁量表(GDS)中文版、自尊量表中文版、情感平衡量表中文版和健康状况调查问卷(SF-36)中文版进行测评,以比较干预治疗的效果。
本研究所有资料以Epidata3.0统计软件建立数据库,并进行数据录入。采用SPSS13.0统计软件处理,统计方法包括描述性的分析、x2检验、t检验,重复测量方差分析、多元逐步回归分析等。a值取0.05作为检验水准,p值均为双侧概率。
结果
1.老年人的怀旧功能及其影响因素分析结果
(1)老年人的怀旧功能现状
455例老年人的怀旧功能调查结果显示怀旧功能总分为144±35.64。在8个维度中,按其标准分从高到低依次为维系亲密关系(15.38±3.76)、自我认同(21.85±6.08)、教育(17.90±4.98)、交际沟通(17.81±5.50)、减轻厌烦情绪(19.20±5.98)、重现痛苦(14.98±5.62)、对死亡的准备(17.38±6.24)和解决问题(14.52±6.35)。其中,怀旧功能总分、以及维持亲密关系、教育、自我认同、交际沟通、减轻厌烦情绪5个维度的得分均超过其理论最高分的平均水平。而对死亡的准备、解决问题和重现痛苦三个维度得分却低于其理论最高分的平均水平。
(2)老年人怀旧功能的影响因素
老年人的社会人口学因素及自我状况的主观评价对总体怀旧功能及其各个维度功能有影响。在单因素分析中,女性在自我认同、交际沟通和重现痛苦三个维度的得分较男性高(p<0.05)。各年龄组怀旧功能总的得分无差别,在各维度得分中,随年龄增加对死亡的准备维度得分有而呈上升的趋势(p<0.05)。离异或丧偶者在自我认同和重现痛苦两个维度得分均较在婚者高(p<0.05)。不同文化程度在怀旧功能总分及减轻厌烦情绪、对死亡的准备、自我认同、解决问题、交际沟通、重现痛苦、教育7个维度的得分差别均有统计学意义(p<0.05)。小学及以下文化程度组老年人在减轻厌烦情绪、对死亡的准备、交际沟通、重现痛苦四个维度的得分高于其他组老年人。职业对怀旧功能的影响,主要表现为农民在减轻厌烦情绪、对死亡的准备维度得分较其他组要高。高收入老年人在减轻厌烦情绪和重现痛苦两个维度得分要均低于其他组老年人(p<0.05)。不同居住方式对怀旧功能总分以及减轻厌烦情绪、对死亡的准备、自我认同、维系亲密关系、重现痛苦5个维度得分差别有统计学意义(p<0.05),其中,独居者在怀旧功能总得分以及对死亡的准备、自我认同和重现痛苦3个维度得分均高于其他居住方式者。过去一年经历过配偶或亲友去世的老年人在交际沟通、维系亲密关系和重现痛苦三个维度的得分也要高于没有经历过配偶或亲友去世者。健康状况非常差和有慢性病的老年人主要表现在减轻厌烦情绪、对死亡的准备、重现痛苦维度上得分比其他老年人高(p<0.05)。抑郁症状筛查阳性的老年人在减轻厌烦情绪,对死亡的准备,重现痛苦3个维度的得分也要高于没有抑郁症状者,而且其得分随抑郁症状的加重而增加(p<0.05)。
以总体怀旧功能及怀旧功能各维度为因变量,以老年人的一般资料、抑郁情绪等为自变量进行逐步回归分析发现：是否有慢性疾病、健康状况自评、抑郁情绪、居住方式、过去一年是否经历配偶或亲友去世、性别和经济状况是总体怀旧功能的主要影响因素；文化程度、居住方式、是否有慢性病、健康状况自评、抑郁情绪、经济状况是维度“减轻厌烦情绪”的主要影响因素；抑郁情绪、过去一年是否经历过配偶或亲友去世、是否有慢性病、健康状况自评、年龄、60岁前职业是维度“对死亡的准备”的主要影响因素；健康状况自评、过去一年是否经历过配偶或亲友去世、居住方式和性别是维度“自我认同”的主要影响因素；是否有慢性病和居住方式是维度“解决问题”的主要影响因素；健康状况自评、居住方式、经济状况和性别是维度“交际沟通”的主要影响因素；过去一年是否经历配偶或亲友去世、性别和是否有慢性病是维度“维系亲密关系”的主要影响因素；抑郁情绪、过去一年是否经历配偶或亲友去世、是否有慢性病、文化程度、居住方式是维度“重现痛苦”的主要影响因素。过去一年是否经历配偶或亲友去世、60岁以前职业、性别和健康状况自评是维度“教育”的主要影响因素。
(3)社区老年人抑郁症状发生率较高,455名被试老年人中,GDS平均分为8.78±6.44,有165人有不同程度的抑郁症状(GDS≥11分),总的筛查阳性率为36.26%,其中轻度抑郁症状者138人,占总体被试老年人的30.33%,中重度抑郁症状者27人,占总被试老年人的5.93%。
2.团体怀旧治疗对老年抑郁症状的干预效果分析
(1)运用团体怀旧治疗干预后,干预组的GDS分值相对于干预前有显著下降,经t检验,其差异有统计学意义(t=4.61,p=0.00)。对照组GDS分值在六周后也有所降低,差异有统计学意义(t=12.75,p=0.00)。经方差分析,干预组与对照组的GDS分值差异有统计学意义,(F=50.81,p=0.00)。经过六周的团体怀旧治疗后,干预组老年人抑郁症状的缓解程度显著高于对照组的老年人,(x2=18.49,p=0.00)。(3)干预组和对照组在进行了六周的团体怀旧治疗后自尊分值相对于干预前没有显著上升,经t检验,其差异无统计学意义。经方差分析,干预组与对照组的自尊分值差异也无统计学意义(F=3.33,p=0.07)。
(4)经过六周的团体怀旧治疗,干预组治疗后积极情感和情感平衡分值相对于干预前有显著升高,经t检验,其差异有统计学意义,而消极情感相对于干预前有明显下降,其差异也有统计学意义(t=10.74,p=0.00)。对照组在接受健康教育后,积极情感和情感平衡分值相对于干预前有所提高,消极情感较干预前有所下降,但差异均无统计学意义。经方差分析,干预组与对照组在积极情感、消极情感和情感平衡分值差异上均有统计学意义(F=49.84,p-0.00)。
(5)经过六周的团体怀旧治疗,干预组健康相关生活质量的各个维度相对于干预前都有所升高,t检验表明除生理机能(PF)和生理职能(RP)两个维度外,躯体疼痛(BP)、一般健康状况(GH)、精力(VT)、社会功能(SF)、情感职能(RE)、精神健康(MH)维度的得分差异有统计学意义。对照组在接受健康教育后,健康相关生活质量只有躯体疼痛(BP)维度相对于干预前有显著提高,经t检验其差异有统计学意义(t=2.69,p=0.01)外,其余各个维度干预前后的得分差异均无统计学意义。干预后干预组与对照组健康相关生活质量各个维度均分的比较中,经方差分析,在生理职能(RP)、躯体疼痛(BP)、一般健康状况(GH)、精力(VT)、社会功能(SF)、情感职能(RE)、精神健康(MH)维度上,干预组的得分显著高于对照组,其差异有统计学意义。
结论
1.老年人的总体怀旧功能较好,怀旧的目的主要表现为减轻厌烦情绪、提高自我认同感,促进交流沟通、维持亲密关系和教育。
2.居住方式、性别、是否有慢性疾病、健康状况自评、过去一年是否经历亲人或朋友的去世、经济状况、抑郁情绪是影响老年人总体怀旧功能的主要因素。自评健康状况非常差的老年人主要表现在重现痛苦维度得分比其他老年人高,而有慢性病的老年人在对死亡准备,重现痛苦等维度的得分也高于没有慢性病者；独居老年人在怀旧功能总得分以及对死亡的准备、自我认同和重现痛苦3个维度得分均高于其他组老年人；随着文化程度的增高,本科及以上文化程度的老年人总体怀旧功能却下降,而小学及以下文化程度老年人在减轻厌烦情绪、对死亡的准备、重现痛苦三个维度的得分高于其他组老年人；抑郁情绪对减轻厌烦情绪、对死亡的准备和重现痛苦有显著影响；过去一年是否经历过配偶或亲友去世对维系亲密关系、重现痛苦和对死亡的准备也有显著影响；随着年龄增长,对死亡的准备的得分呈上升趋势。此外,性别、婚姻状态、职业等因素对不同维度怀旧功能均存在显著影响。
3.社区老年人抑郁症状筛查阳性率较高,被识别率却很低,抑郁已成为老年人的主要心理健康问题。
4.在社区实施团体怀旧治疗有助于改善老年人的抑郁症状,缓解抑郁发生率,提高老年人群的总体心理健康水平及晚年生活质量,对促进社会的健康老龄化具有重要意义。
5.团体怀旧治疗的实施方案应根据现实环境并结合所处社会文化背景等实际情况进行选择。实施团体治疗过程中应遵循循序渐进、由浅入深、逐步引导的原则,注意各种技巧(如关怀性聆听、正向回馈、接纳、经验分享等)的运用,及时发现老年人情感的变化,疏导因不良经历引起的负性情绪,合理应用引导物,以达到事半功倍的效果。
6.团体怀旧治疗方法简便易行、经济实用,具有较大的社会经济效益,适合于在社区由护理人员推广实施。
Objectives:
To investigate the reminiscence functions and depression of elderly in community and to find out the factors which influence remininscenc functions of elderly. To explore the effectiveness of the group reminiscence therapy for reducing the depressive symptoms, increasing recovery rate of depression, and improving the self-esteem level, affect balance competence and quality of life of the depressed elderly. Results from this study will provide data for management of the depressed elderly in community by using reminiscence, and to conduct a larger study in the future.
Methods:
In first part, we applied an epidemiological method combining cross-sectional study in multi-sites to investigate the reminiscence functions and depression of elderly in community of Changsha city and analyze the factors which influence the reminiscence fuctions.Through Jaunary,2008 to May,2008, we applied the stratified cluster randomized sampling method for the screening. At first, we randomly chose eight communities for screening in five districts of Changsha city. According to gender and age stratification, a total of 600 cases of elderly at the age of 60 years or more from communities in Changsha city were investigated. Interview with the smooth and successful record of 455 valid questionnaires, the questionnaire efficiency is 75.83%. Male 197 (43.3%) and 258 women (56.7%),60-95 years of age, the average are is 69.88±7.48. The questionnaires used in this study include self social-demographic information questionnaire, reminiscence function scale and Geriatric Depression Scale (GDS).
At the second part of the study, we applied a randomized controlled trial study to explore the effectiveness of group reminiscence therapy for reducing the depressive symptoms, increasing recovery rate of depression, and improving the self-esteem, affect balance competence and quality of late-life of the depressed elderly. This part of the study lasted from June, 2008 to May,2009. Among the eight communities, we applied the simple random sampling method and randomly selected four communities for establishing four intervention groups, and the other four communities for establishing four control groups. Based on the screening results, the eligible depressed elderly who consented to participate were randomly recruited into the study. The sample size was 10-15 subjects in each community. Totally we recruited 129 study subjects (62 in intervention groups and 67 in control groups). Control group received health education, apart from the intervention group received health education, but also accepted group reminiscence therapy, before and after the intervention, we used psychological assessment scales including Geriatric Depression Scale (GDS) Chinese version, Chinese version of Self-Esteem Scale, Affect Balance Scale and SF-36 Chinese version to compare the therapeutic effect.
The database was established by Epidata3.0 and statistic analysis were performed using SPSS (version 13.0). Statistical methods included descriptive analysis, Chi-square test, t test, analysis of variance (ANOVA) and regression analysis. Level of significance of this study was set at.05.
Results:
1. The reminiscence functions of the community elderly and the analysis of the influencing factors
(1) The present situation of the reminiscence functions of the community elderly:The study of 455 cases of the reminiscence functions of the community elderly shows that the total score of the reminiscence functions is 144±35.64. Within the 8 domains, the scores from high to low level are:Identity (21.85±6.08), Boredom Reduction (19.20±5.98), Education (17.90±4.98), Conversation (17.81±5.50), Death Preparation (17.38±6.24), Intimacy maintenance (15.38±3.76), Bitterness Revival (14.98±5.62) and Problem Solving (14.52±6.35). Among them the scores of 5 domains including total score of the Reminiscence functions, Identity, Conversation, Intimacy Maintenance and Education all exceed the average value, while 3 domains including Death Preparation, Problem Solving and Bitterness Revival are lower than the average value.
(2) The influent factors of the reminiscence functions of the community elderly:Social demography and self-status subjective assessment have a certain influence on the overall reminiscence functions and each domain of the community elderly. The scores of the 3 domains of Identity, Conversation and Bitterness Revival among the females are higher than the males (p<0.05) in the single factor analysis. There are no differences among the overall scores of the reminiscence functions in each age group. The score of Death Preparation shows an ascending trend with the age increase in each domain. The scores of Identity and Bitterness Revival in the divorced and the widowed are both higher than that in the non-divorced (p <0.05). The score differences on the total score of the reminiscence functions and the 7 domains of Boredom reduction, Death preparation, Identity, Problem solving, Conversation, Bitterness Revival and Education due to different education level have statistical significance (p<0.05). In the education level of the elementary school and below, the scores of the elderly on Boredom Reduction, Death Preparation, Conversation and Bitterness Revival are higher than other groups. The influence of vocation on the reminiscence functions mainly shows in the higher scores of Boredom Reduction and Death Preparation in the peasant group as compared to other groups, while the other vocations show higher scores of Bitterness Revival than other groups (p<0.05). The scores of Boredom Reduction and Bitterness Revival in high-income elderly are lower than that in the other groups (p<0.05). Different living styles affect the overall scores of the elderly reminiscence functions and also 5 domains of Boredom Reduction, Death Preparation, Identity, Intimacy Maintenance and Bitterness Revival, and the score differences have statistical significance (p <0.05). Among them, the individuals living alone have higher overall scores of reminiscence functions and 3 domains of Death Preparation, Identity and Bitterness Revival than other living styles. The elderly who have undergone the death of spouses and relatives in the past 1 year have higher scores in the 3 domains of Conversation, Intimacy Maintenance and Bitterness Revival than those who haven't. Among them, the elderly with extreme poor health status and chronic diseases have higher scores on Boredom Reduction, Death Preparation and Bitterness Revival than others (p<0.05). The scores of the elderly with depression screening test positive on 3 domains of Boredom Reduction, Death Preparation and Bitterness Revival are higher than those without, and increase with the aggravation of depression symptoms (p<0.05).
The multiple stepwise regression analysis with overall reminiscence functions plus each domains of reminiscence functions as dependent variables and the general information, depression, etc as independent variables shows that:with/ without chronic diseases, self-assessment of health status, depression, living styles, experiencing the death of spouses and relatives in the past 1 year or not, sex, economic status are the factors affecting the overall reminiscence functions; education level, living styles, with/without chronic diseases, self-assessment of health status, depression and economic status are the factors affecting the domain "Boredom reduction"; depression, experiencing the death of spouses and relatives in the past 1 year or not, with/without chronic diseases and self-assessment of health status, age and vocation are the factors affecting the domain "Death preparation"; self-assessment of health status, experiencing the death of spouses and relatives in the past 1 year or not, living styles, and sex are the factors affecting the domain "Identity"; with/without chronic diseases and living styles are the factors affecting the domain "Problem solving"; self-assessment of health status, living styles, economic status and sex have prediction on domain "Conversation"; experiencing the death of spouses and relatives in the past 1 year or not, sex and with/without chronic diseases are the factors affecting the domain "Intimacy maintenance"; Depression, experiencing the death of spouses and relatives in the past 1 year or not, with/without chronic diseases, education level and living styles are the factors affecting the domain "Bitterness revival"; experiencing the death of spouses and relatives in the past 1 year or not, vocation, sex and self-assessment of health status are the factors affecting the domain "Teach".
2. Analysis of the effectiveness of group reminiscence therapy for depressive symptoms of elderly
(1) The incidence rate of depressive symptoms of elderly was higher in community.455 samples were tested in the sudy. The average score was 8.78±6.44. Among them,165 elderly had different levels of depressive symptoms (GDS≥11), the total rate was 36.26%.138 elderly had mild depression, accounting for 30.33% of total,27 elderly had moderate to severe depression, and accounting for the overall trail was 5.93%.
(2) After six week group reminiscence therapy intervention, the GDS score of intervention group declined remarkably compare with the beginning (t=4.61, p=0.00), while the GDS score of control group also change significantly (t=12.75, p=0.00). By covariance analysis, the intervention group and control group GDS scores were significantly different (F=50.81,P=0.00). The recovery rate of intervention group was higher than that of control group (x2= 18.49, p=0.00).
(3) After six week intervention, the self-esteem scores of intervention group and control group were no significant increased (p>0.05). By covariance analysis, the difference of self-esteem scores between intervention group and control group also wasn't statistically significant (F= 3.33, p= 0.07).
(4) After six-week group reminiscence therapy, the positive affect and affect balance scores of intervention group had increased significantly than that of the beginning(p< 0.01),and the negative affect score had dropped significantly(t=10.74, p=0.00).In control group, after receiving health education, the positive affect and affect balance scores had improved than that of the beginning and the score of negative affect also decreased compared with that before the intervention, but the differences were not statistically significant (p>0.05). By covariance analysis, the intervention group and control group's positive affect, negative affect and affect balance scores were significantly different(F= 49.84, p= 0.00).
(5) All subscales of SF-36 were improved to some extent after receiving six week intervention in the intervention group. T test showed that there were significant differences in subscales of bodily pain (BR)、general health (GH)、vitality (VT)、social functioning (SF)、role limitation due to emotional problems (RE)、mental health (MH),and no significant difference was found in subscales of physical function (PF) and role limitation due to physical problems (RP). In control group, only score of bodily pain (BP) was increased significantly (t=2.69, p=0.01) When compared with the scores of all subscales of SF-36 between the intervention group and control group after six week intervention, the scores of role limitation due to physical problems (RP)、bodily pain (BP)、general health (GH)、vitality (VT)、social functioning (SF)、role limitation due to emotional problems (RE)、mental health (MH) of intervention group were significantly higher than those of control group and the differences are statistically significant, while there was no difference in the scores of BF between the two groups.
Conclusion:
1. The overall reminiscence functions of elderly in community are optimistic. The major reminiscence functions of the elderly demonstrate as alleviating boredom mood, self-identity, communication, maintaining intimate relationships and education.
2. The factors of living styles, self-assessment of health status, with/without chronic diseases, experiencing the death of spouses and relatives in the past 1 year or not, economic status and depression are the related factors that influenced the overall reminiscence functions of the community elderly. The factors of self-assessment of health status and with/without chronic diseases also have great influence on the fuctions of boredom reduction, death preparation, identity, conversation, and bitterness revival. The fuction of death preparation was increasing with age increasing. The fuctions of boredom reduction, death preparation and bitterness revival are influenced by the factor of depression. The factor of experiencing the death of spouses and relatives in the past 1 year or not has the influence on fuctions of intimacy maintenance, bitterness revival and death preparation. Furthermore, the factors of sex, economical status and vacation etc. also have significant influences on different reminiscence functions of elderly.
3. The prevalence of depression among the community elderly was high. However, the recognition of the elderly depression is very low.Depression has become main psychological problem of them.
4. Since the implementation of group reminiscence therapy in the community can reduce the depressive symptoms, increase recovery rate of depression and improve the quality of life of the community depressed elderly effectively, so it has great significance for improving mental health of elderly and promoting successful aging for them.
5. Group reminiscence therapy should be based on the reality of social and cultural background. Implementation of the group therapy process should be followed progressive approach and gradually guide. And also should use a variety of skills (such as caring, listening, positive feedback, accept, and experience sharing, etc.). During the group intervention process, the emotional changes in the elderly should be timely detected and the negative emotions which caused by adverse experiences should be diverted immediately. The rational application of materials for guiding specific memory can also help to achieve the therapeutic effects.
6. Group reminiscence therapy is simple, economical and practical, and with the larger socio-economic benefits. So it is feasible and suitable for nursing staffs to carry out in the community.
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