近年來，失智盛行率愈來愈高，但失智者的自立生活照顧環境品質顯然也應相對地提高，因此本研究將聚焦於如何降低失智者照顧環境之困難度以提升失智者生活自立及照顧環境之品質，鼓勵失智者維繫人際互動並與社會連結，以延緩其認知能力的衰退及失智症狀的惡化。
本研究以歐、美及日本等國的概念為基礎，藉由文獻回顧法，擬定「失智者生活自立照顧環境」的3個層面、7個指標、21個評估因子及對應的125條規範。初期擬定準則四個層級的各個要項，在架構的建構上，本研究嘗試從物理環境層面、法規制度層面及營運管理層面去探討如何提升失智症者生活自立照顧能力，從而建立以環境改善為基礎的失智者生活自立照顧環境的評估因子與規範。
本指引之「物理環境層面」共有101條規範，著重於以失智者為中心，並配合失智者認知能力的衰退去做物理環境，即聲、光、熱、氣及標示應有的改善; 在加強交流互動與社區連結方面，思考如何凝聚單元照顧的家庭氛圍，延續原有的生活及社區連結等，不但可紓緩症狀，尚可提升社區的支持度。在安全方面，因失智者之認知能力衰退故自救能力較差，乃建立14則安全規範以避免失智者受到不必要的傷害。「法規制度層面」有9條規範，著重於符合法規要求與專業人員的證照與訓練。「營運管理層面」有15條規範，著重於從失智者的角度去解決問題，包含失智者的心理支持、生活照護的營運以及照護機構的行政管理等。
本研究邀請6位不同領域之專家，藉由修正型德菲法（Modified Delphi method）專家問卷之效度檢定進行評估因子與規範內容之修正，並執行各評估規範「適當性」的4分法評分，再根據專家之意見，刪除或修改評估規範之內容。
本研究在權重分析方面，採用層級分析法（Analytic Hierarchy Process, AHP）之專家問卷調查法，並根據11位不同領域學者、專家評估之原始資料進行層級分析以評定各層面、指標、評估因子及規範之權重。
為測試本準則的實用性，研究人員以所建立的評估量表分別至四家榮民之家的失智症專區實地試評，發現4家榮家分別有20、27、19及24項待改善事項。經分析評比之所有的89件待改善事項，本研究提出榮家間可互相標竿學習的32個圖例解說，以利榮家採取改善對策。
本研究為驗證專家的觀點與榮家現況之差異，遂進行專家權重與現況達成率的差異性分析，各有一致及不一致的驗證結果及其原因分析。
本研究已如預期建立一套具有良好效度的失智者生活自立照顧環境指引; 希望將來各失智症照護機構主管能以此指引為參考去擬定日後的改善計畫，以提供失智者優良的生活自立照顧環境及服務品質。

SUMMARY
With an aim to set up technical standards, this study utilizes the concepts brewed by several organizations from Europe, America and Japan as the basis to establish a guideline of 3 levels, 7 indicators, 21 assessment factors and 125 quality essentials for dementia self-reliance living environments in Taiwan. We have adopted 3 first-level of "physical environment", "regulations" and "operations management" to encompass the upgrades of the dementia self-reliance environment so as to induce a set of assessment factors and quality essentials.
Literature review, modified Delphi assay, the analytic hierarchy process (AHP) questionnaire and field survey were methods used in this study.
In order to check the effectiveness of this guideline and the quality of care environment, we perform on-site visits to dementia care units of four veteran’s homes in Taiwan by the guideline we established. We found 20, 27, 19 and 24 nonconformities respectively for the 4 veterans homes. After carefully evaluated all their 89 nonconformities, we proposed 32 benchmarking examples by photo illustration to show how to take corrective actions. We encourage them to take corrective actions to ensure all the quality essentials of this guideline are obeyed.
Key words: dementia; modified Delphi method; analytic hierarchy process (AHP); dementia self-reliance living environment

INTRODUCTION

The prevalence of dementia keeps on increasing recently, but on the other hand, the dementia self-reliance care environments have not been greatly improved accordingly. This study will focus on how to reduce the difficulties of care environment for dementia persons in order to encourage their independence which may alleviate the deterioration of cognitive ability and slow down the progression of dementia symptoms.
MATERIALS AND METHODS

We utilized the 4 point questionnaire of modified Delphi assay to check the validity of this guideline, and the analytic hierarchy process (AHP) questionnaire to evaluate the weighting and priority among levels, indicators, assessment factors and quality essentials respectively in this guideline.
To evaluate the quality of dementia care environments, we perform on-site assessment of dementia care units of four veteran’s homes by guidelines we established in this study.

RESULTS AND DISCUSSIONS

In this guideline, the 101 quality essentials of "Physical environment" level includes sound, light, heat, air, sign, security, family atmosphere and community link improvements. The 9 quality essentials of "Regulatory" level focuses on compliance with the licensing policy and the need of professional training. The 15 quality essentials of "Operational management" level focus on solving problem from dementia person’s perspective, including mental support of dementia persons, management of living care services, and administrative management of the organization.
To check the effectiveness, we send this guideline to six experts of different expertise for the 4 point questionnaire of modified Delphi assay to check the validity. As per their comments, we deleted quality essentials of CVI below 0.8 and modified some quality essentials as advised. Then we got a guideline of CVI 0.99. The guideline established was send to 11 experts of different expertise for analytic hierarchy process (AHP) questionnaire to evaluate the weighting and priority among levels, indicators, assessment factors and quality essentials respectively.
To evaluate dementia care units of four veteran’s homes, we found 20, 27, 19 and 24 nonconformities respectively for the 4 veterans homes. After carefully evaluated all their 89 nonconformities, we proposed 32 benchmarking examples by photo illustration to show how to take corrective actions.
We conducted the deviation analysis between experts’ weighing and the achieving rate of veteran’s homes for each assessment factors. Some consistent and inconsistent items were found.

CONCLUSION

To ensure that dementia elderlies are well protected when any nonconformity of care environment is identified whereby corrective action can be taken, we have established a guideline of fair validity as expected. We hope that in the near future, directors of dementia care facilities can utilize this guideline as a checklist to upgrade their facilities and assure the premium quality of dementia care environments and services.

一、英文文獻
Arai Y., et al., (2013), Functional status, morbidity, and mortality of centenarians, Clin Calcium. pmid:23268301.
Bonder B. R., et. Al., 2009 Functional performance of older adults, p.218, F.A. Davis Company.
Cohen, U., & Weisman, G. D., (1991), Holding on to home: Designing environments for people with dementia. Baltimore: Johns Hopkins University Press.
Dapp, U., et al. ( 2015), Dtsch Med Wochenschrift; 140(20):1495-1498.
Day, K., Carreon, D., & Stump, C. (2000), The therapeutic design of environment for people with dementia: A review of the empirical research, The Gerontologist, 40(40),397-416.
Droes, R. et al. (2006), Quality of Life in Dementia in Perspective: An Explorative Study of Variations in Opinions Among People with Dementia and their Professional Caregivers, and in Literature” , Dementia 5(4), pp.533-558.
FERMA (2017) , Risk Management Standard, Federation of European Risk Management Associations website.
Hampel H, et al., (2016) Precision medicine - Detection, Treatment and Prevention of Alzheimer's Disease. J Prev Alzheimers Dis. 3(4):243-259.
Hikichi H. et. al.,(2016), Increased risk of dementia in the aftermath of the 2011 Great East Japan Earthquake and Tsunami, Proc Natl Acad Sci U S A. pmid: 27791093
Hirakawa Y. et al. ( 2017), A qualitative study on barriers to achieving high-quality, community-based integrated dementia care. J Rural Med. May;12(1):28-32.
Chang K-W., Hsu Y-L., (2016),"Development of a Smart Living Space Platform Based on Motion Sensing Carpet," The 10th World Conference of the International Society for Gerontechnology, Nice, France. Gerontechnology 2016; 15(suppl.):8 .
Kodama K., (2004), Journal of Japanese Society for Dementia Care 3(2): 239 - 248.
Lawton MP et al., (2000), Professional environmental assessment procedure for
special care units for elders with dementing illness and its relationship to the
therapeutic environment screening schedule. Alzheimer Dis Assoc
Disord.;14(1):28-38.
Lesley Palmer, (2017), Best practice in the design of residential environments
for people living with dementia and sight loss, Proceedings of ADI
conference 2017.
Liapis J, Harding KE., ( 2017), Meaningful use of computers has a potential therapeutic and preventative role in dementia care: A systematic review. Australas J Ageing.
Lynn MR (1986), Determination and quantification of content validity. Nurs Res 35: 382–385. pmid:3640358 View Article PubMed/NCBI Google Scholar.
Ozaki, et al. (2007), The Japanese Centenarian Study: autonomy was associated with health practices as well as physical status. J Am Geriatic Society Jan;55(1):95-101, pmid:17233691.
Pascoal TA et al., (2017), Amyloid-β and hyperphosphorylated tau synergy drives metabolic decline in preclinical Alzheimer's disease. Mol Psychiatry. 2017 Feb;22(2):306-311.
Pascoal TA et al., (2017) Synergistic interaction between amyloid and tau predicts the progression to dementia. Alzheimers Dement. 2017 Jun;13(6):644-653.
Paraskevi Zafeiridi(2017), Usability study of a web-based intervention to support people living with dementia and their caregivers, Proceedings of ADI conference 2017.
Polit DF, Beck CT, Owen SV (2007), Is the CVI an acceptable indicator of content validity, Appraisal and recommendations. Res Nurs Health 30: 459– 467. pmid:17654487.
Verbeek, H. et al., (2009), Small, homelike care environments for older people with dementia: a literature review. International Psychogeriatrics, 21, 252–264.
Waleed Al-Faisal, ( 2006), Falls Prevention for Older Persons Eastern Mediterranean Regional Review, 2006.
OECD, (2015), Dimentia receives the worst care in the developed world.
Romedi Passini et al, (2000), Wayfinding in a Nursing Home for Advanced Dementia of the Alzheimer’s Type, Environment and Behavior 32: 684.
Satty T.L., (1980), The Analytic Hierarchy Process, McGraw Hill inc New York.
Yoon J. et al.( 2013) ,The effects of cognitive activity combined with active extremity exercise on balance, walking activity, memory level and quality of life of an older adult sample with dementia. J Phys Ther Sci. Dec; 25(12):1601-4.
Colindres Y.Y., Hsu Y-L., (2016 ), "Social media technology to reduce social isolation and provide care for older adults," The 10th World Conference of the International Society for Gerontechnology, Nice, France. Gerontechnology; 15(suppl.):11.
二、中文文獻
王詩涵(2017)，「以社會生態學理論探討影響高齡者功能表現的相關因素 ─ 以台南地區養護機構為例」，國立成功大學建築研究所碩士論文。
朱為民 、唐憶淨 (2017)，台灣老年學暨老年醫學會website 。
李梅英(2017)，高齡者社區照顧環境規劃95-96, 103。
邱慈云(2013)，「高齡日間照顧中心光環境心理影響之調查研究」，國立成功 大學建築研究所碩士論文。
邱銘章、湯麗玉(2009)，失智症照護指南，原水文化。
吳孟珊(2012)，以日本「認知症高齡者環境設施評估尺度」運用在台灣失智症 單元照顧環境評估尺度之初探，國立成功大學建築研究所碩士論文。
周世鑫(2013) ，「以日誌分析試探高齡者的生活模式-失智長者生活模式與生 活環境之改善」，國立成功大學建築研究所碩士論文。
黃喜男(2010)，老年人髖部骨折手術前後的考量，台灣老年醫學暨老年學雜誌 5(1)：p. 22。
陳柏宗 (2011)，複合式老人福利建築規劃設計與營運特質之研究，台灣健康 照顧研究學刊 第 10期， pp.37-56。
陳柏宗(2012)，日間照顧中心空間規劃設計手冊，台北：中華民國老人福利推 動聯盟。
陳柏宗 (2015) 公費安養機構無障礙環境之研究與探討，建築學報2015 (94 期)129-150。
陳柏宗(2017)，老人居住環境規劃與實務，國立成功大學老年學研究所。
陳政雄 (2009)，高齡社會失智症老人的新居住型態-團體家屋，台灣老人保健 學刊，5(1)，pp.17-35。
張祐瑞(2004)，照顧環境設計對失智症問題行為改善之影響研究-以失智症
照護示範中心為例，國立雲林科技大學空間設計系研究所碩士論文。
楊榮深(2008)，老年人的跌倒與骨折預防，台灣老年醫學暨老年學雜誌3(2)： pp.78-90。
蔡佳芬(2002 )，造成行為精神症狀的因素:台灣失智症協會。
蔡佳芬(2002 ) ，BPSD的類別及發生頻率:台灣失智症協會。
梁家欣等(2014)，內科學誌：25：pp.151-157。
廖家琪(2011)，「老人社區照顧關懷據點規劃設置準則之研究--以台南市為 例」，國立成功大學建築研究所碩士論文。
薛承泰(1995)，三十年來臺灣人口與家庭的變遷，中華民國世界和平教授學會。
薛承泰 (2007)，2030年的台灣–少子化的挑戰，主計月刊。
關華山（2007），瑞典失智者團體家屋的發展歷程與型態分析，東海學報47， pp.31-50。
簡禎富 (2005) ，決策分析與管理，雙葉書局。