老人失智症的藥物治療及其重要課題

Current Opinions and Topics in Pharmacotherapies of Elderly Dementia

歐陽文貞(Wen-Chen Ouyang)

《中南盟研究年刊》 4卷1期 (2011/09) Pp. 49-71

https://doi.org/10.6850/JCSMA.201109_4(1).0005

摘要

前言：失智症是老人常見的神經精神疾病，其症狀包括認知功能問題、行為精神問題(behavior and psychological symptoms of dementia, BPSD)及日常生活(activity of daily life, ADL)問題；其慢性化病程導致身體疾病罹患率(morbidity)與譫妄(delirium)發生率高，而且造成病患生活品質差、家屬、醫療經濟(economy of medicine)及社會的嚴重負擔；所以，積極了解失智症的藥物治療是刻不容緩的課題。方法：本文以文獻回顧的方式評述有關老人失智症的藥物治療。成果：近十年餘的文獻中，以乙醯膽鹼代謝酶拮抗劑(ChEI)對輕中度阿茲海默失智症最具共識，對中重度阿茲海默失智症則以NMDA接受體拮抗劑及memantin的資料最多實證，但上述藥物都只有延緩病程的效果，無法中止疾病或治療此疾病。其次如巴金森氏症合併失智症、路易氏體失智症及血管性失智症，乙醯膽鹼代謝酶拮抗劑對其認知功能的療效實證逐漸增加。在失智症合併行為精神問題方面，整體治療策略為D-C-B-A，即「應優先鑑別診斷或治療身體疾病(disease)或譫妄(delirium)」、其次為「維持或改善認知功能(cognitive function)」－阿茲海默失智症患者須儘早使用ChEI藥物、「再其次才處理行為精神問題(BPSD)」、「最後才設法改善日常生活問題(ADL)」：其中除了須儘可能改善造成譫妄的身體疾病外，以新一代抗精神病藥治療BPSD中激躁攻擊的實證最多，除必須「起始劑量低、緩慢增加劑量」外，更需注意監測及跟照顧者說明「新一代抗精神病藥可能會增加中風及死亡的風險」，謹慎使用；新一代抗精神病藥合併ChEI藥物與抗精神病藥一起使用，可能會減少抗精神病藥劑量及加強對BPSD的治療效果。結論，老人失智症的藥物治療在ChEI延緩認知功能退化及新一代抗精神病藥治療激躁攻擊有最多的實證文獻。未來有關失智症合併憂鬱、不適切性行為睡眠及反覆行為的藥物治療、阿茲海默失智症新的認知治療藥物與預防失智症的長期研發都是重要課題。

關鍵字

失智症 ； 乙醯膽鹼代謝酶抑制劑 ； 失智症合併行為精神症狀 ； 抗精神病藥

並列摘要

Objectives. Dementia, whose symptoms include cognitive impairment, behavior and psychological symptoms of dementia (BPSD), and problems in activity of daily life (ADE) is one of the most common neuropsychiatric disorders in the elderly. The chronicity, high morbidity, high incidence of delirium during the course of dementia result in deterioration of patient's quality of life and increment of family, medical economic and social burden. Therefore, how to treat the dementia is an pretty important issue.Methods. Article review.Results. The current issue of pharmacological treatment of dementia during the past decade is the antidementia drugs-acetylcholine esterase inhibitors (AChET or ChET) for improving the cognitive function in dementia of Alzheimer's type (DAT). The most persistent consensus among these drugs are effectiveness of ChEIs to mild and moderate DAT and memantine to moderate and severe DAT. However, the above drugs only slow the rate of deterioration but cannot stop the courses of this disorder. The secondly prominent and increasing evident data are ChEIs effect to dementia of Lewy's body (DLB) or dementia due to Parkinson's disease. The strategies of management of BPSD are ”D-C-B-A”. e.g. ”Delirium or physical disease (s) should be diagnosed and managed first”, ”Cognition maintenance using by ChETs or memantine as soon as possible”, ”Behavior and psychotic symptoms should be controlled by drugs rapidly”, and ”ADL training or alternative intervention are worth trying after initial control or improvement of cognition”. The most evident treatment is the second generation of antipsychotics for agitation or violence in dementia patients. However, the principle of geriatric psychopharmacology, ”start low and go slow”, should be followed and despite the modest efficacy in using second generation of antipsychotics in elderly dementia patients, the significant increase in adverse events such as cerebral vascular attack or increasing risk of death needs to be monitored. Besides, ChETs combined with antipsychotics may augment the effect and lower the dosage of antispychotics for treating BPSD.Conclusions. Current issues which should be concerned and worth further studying are pharmacological treatment for depression, inappropriate sexual behavior, sleep cycle or related problems, and repetitive behavior in patients with dementia. Besides, studies of new antidementia drugs and the preventive strategies for Alzheimer's dementia or vascular dementia are also another important issues in the future.

並列關鍵字

dementia ； Cholinergic esterase inhibitor ChEI ； behavior and psychological symptoms of dementia BPSD ； antipsychotics