Palo Alto Health Care System Department of Veterans Affairs Palo Alto Health Care System 晚期失智症和 阿茲海默症病人的照護 Caregiving for patients with late-stage dementia or Alzheimer's disease  趙壯志 醫學博士 Steven Chao, MD, PhD.  Staff neurologist VA Palo Alto HCS Clinical Assistant Professor Neurology and Neurological Science Stanford University School of Medicine   http://memory.ucsf.edu/chinese.html www.youtube.com/ucsfmemoryandaging

Outline 什麼是老年失智症 Late stage dementia 晚期失智症 Definition Sub-types AD, VasD, LBD Treatments 治療 Late stage dementia 晚期失智症 Clinical 症狀 Medical complication Treatment 治療 / Care 照護

什麼是老年失智症？ 以前又稱老年癡呆症. 1. 記憶力下降 2. 至少影響到一個其他的認知領域 : 語言，執行功能，運動功能，行為人格 1. 記憶力下降 2. 至少影響到一個其他的認知領域 : 語言，執行功能，運動功能，行為人格 3. 嚴重的足以干預日常功能和獨立性 記憶和其它認知的功能逐漸下降

老年失智不是正常老化 為什麼年老的搖滾明星最後退休了 不再記得歌詞了 “啦 啦 啦.. 啦” 電力琴聲造成助聽器反饋 不再記得歌詞了 “啦 啦 啦.. 啦” 電力琴聲造成助聽器反饋 厭倦了非法藥物成癮,準備開始對處方藥成癮

失智症 血管性失智症 (Vascular Dementia - VaD) 路易氏體型失智症 阿滋海默症(Alzheimer Dementia –AD)是老年人最普遍的致病因素 其他導致失智症的病症包括 血管性失智症 (Vascular Dementia - VaD) 路易氏體型失智症 (Dementia with Lewy Bodies - DLB) 額顳葉型失智症 (Frontotemporal Dementia - FTD) 以上每一種病症都可以從它對認知和行動特殊的影響分辨出來。 AD

Chinese patients at San Francisco (UCSF-2010) 阿滋海默症(Alzheimer Dementia) 57% 血管性失智症 (Vascular Dementia) 19% 路易氏體型失智症 (Dementia with Lewy Bodies) 8% 額顳葉型失智症(Frontotemporal Dementia) 3% 其他 (other) 14% 以上每一種病症都可以從它對認知和行動特殊的影響分辨出來。

阿滋海默症 神經纖維纏結體 Neurofibrillary tangles 澱粉體斑塊 Amyloid plaques

阿滋海默症的早期症狀 記憶功能衰退 執行功能衰退 空間功能衰退 算數能力衰退 生活不能自理 再三問同樣的問題, 重複同樣的故事 忘了如何做以前所做的事情 - 烹調，修理，或如何打牌等活動 依靠他人，如配偶，作出決定或回答以前他們會自己處理的問題 空間功能衰退 在熟悉的環境裏迷路，或無法找到家庭裏常用的東西 算數能力衰退 失去一個人支付帳單或平衡個人支票簿的能力 生活不能自理 忽略洗澡或穿著同樣的衣服，而且堅持說他們已洗過澡了或他們的衣服仍然是清潔 一而再再而三, 逐字逐句地

阿滋海默症(AD)的臨床诊断 Clinical Diagnosis 沒有一個實驗或者放射學的測試能夠提供一個肯定的診斷 最準確的AD診斷是要通過專業的醫生仔細的評估 一個評估應該包括跟患者和一個合作人﹐例如親人﹐配偶和好朋友的面試 神經科專科醫生提供的一個身體檢查 神經心理學測試提供認知功能的測試 大腦的電腦斷層掃描(CT)或者核磁共振成像 (MRI) The Gold Standard for a diagnosis of dementia is by looking at a brain under the microscope (Pathology) With current methods, most experienced clinicians are ~90% accurate when making a diagnosis of probable Alzheimer’s disease.

核磁共振成像 (MRI) Normal AD Hippocampus

功能性核醫學(FDG-PET) Massachusetts General Hospital Radiology Positron emission tomography PET scanning with the tracer fluorine-18 (F-18) fluorodeoxyglucose (FDG), called FDG-PET Functional nuclear medicine – PET fluorodeoxyglucose (FDG-PET) One of the best FDA approved imaging tools Approved for differential diagnosis, i.e. AD vs FTD Massachusetts General Hospital Radiology

AD Biomarker - Amyloid- PET Rabinovici et al., Neurology 2007

血管性失智症(VasD) 腦血管梗塞和慢性缺血導致認知功能下降 早期臨床癥狀 Stepwise progression (may be gradual and either slow or fast in decline) Sign of focal neurological deficits suggestive of prior strokes Frontal executive deficits Increased prevalence of vascular dementia in Japan: a community-based epidemiological study. AUIkeda M; Hokoishi K; Maki N; Nebu A; Tachibana N; Komori K; Shigenobu K; Fukuhara R; Tanabe H SONeurology 2001 Sep 11;57(5):839-44.   BACKGROUND AND OBJECTIVE: It has been suggested that there is a major difference in the ratio of AD to vascular dementia (VaD) between Japan and Western countries. To determine the type-specific prevalence of dementia in community-dwelling elderly from the Japanese community of Nakayama, all patients with dementing illness underwent a CT scan. METHODS: A door-to-door three-phase population survey was carried out on all persons aged 65 years and older residing at home on the prevalence day (January 1, 1997). The ascertainment of cases was made between January 1997 and March 1998. The study included a psychiatric interview; physical, neurologic, and neuropsychologic examinations; comprehensive laboratory tests; and cranial CT. A public health nurse also interviewed a person close to each subject. Dementia was defined according to the Diagnostic and Statistical Manual of Mental Disorders, third edition-revised, criteria, AD according to the National Institute of Neurological and Communicative Disorders and Stroke-Alzheimer's Disease and Related Disorders Association, and VaD according to Diagnostic and Statistical Manual of Mental Disorders, fourth edition, combined with information from the patient's neurologic history and CT scanning. RESULTS: Of 1438 inhabitants, 1162 (81.0%) completed the protocol. The prevalence of dementia was 4.8%. Of the 60 subjects with dementia, 35% had AD, 47% had VaD, and 17% had dementia resulting from other causes. CONCLUSIONS: The prevalence of dementia was similar to previous reports, but, contrary to results of virtually all studies conducted in developed countries and those recently conducted in Japan, almost half of the cases in the present study appeared to have VaD with neuroradiologic confirmation.

血管性失智症(VasD)臨床診斷 Clinical Diagnosis Evidence of dementia or cognitive impairment Evidence of vascular brain injury Presumptive evidence of a causal relationship between cognitive impairment and Vascular Brain Injury.

路易氏體型失智症 (Dementia with Lewy Bodies) Lewy Body

路易氏體型失智症 (Dementia with Lewy Bodies) 早期臨床症狀 Progressive dementia Visual hallucinations Parkinsonism Cognitive fluctuations Dysautonomia REM sleep behavior disorder Neuroleptic sensitivity

治療 I 有氧和負重的運動可以減緩腦萎縮和改善健康 因為AD患者通常會沒有積極性﹐個人教練會幫助患者更有效的做運動 治療精神症狀 煩躁, 憂鬱症 降低心血管危險因素 高血壓, 糖尿病,高血脂 盡量減少其他影響中樞神經系統的藥物 酒精，睡眠藥物，止痛藥

治療 II 現有幾種FDA批准的藥物用來治療AD 其他的藥物正在研究發展中 這些藥物抑制乙醯膽素的分解來減慢記憶力下降的速度 Acetylcholinesterase inhibitor (Aricept®, Exelon® or Razadyne®) Memantine (Namenda®) 一些患者在開始藥物之後不久就可能會感到暫時輕微的認知改進 其他的藥物正在研究發展中

Outline 什麼是老年失智症 Late stage dementia 晚期失智症 Definition Sub-types AD, VasD, LBD Treatments 治療 Late stage dementia 晚期失智症 Clinical 症狀 Medical complication Treatment 治療 / Care 照護

失智症 progression Mild Moderated Severe Medical complication

iADL Financial decision Medical decision Family/social Investment, Banking, Shopping Medical decision Treatment choices, level of care, goal of treatment. Family/social Cleaning, cooking, laundry shopping, travel.

bADL Feeding Cleaning Dressing Toileting Sleeping Transportation

失智症 progression Mild Moderated Severe Most bADL, lmited iADL No iADL, some bADL Severe No iADL, limited/No bADL

Medical complication Pneumonia UTI Bed sore Fall Others Seizure, DM, CAD, Resp, Renal failure.

Medical complication Pneumonia UTI Aspiration precaution Swallow evaluation Primary care evaluation/followup UTI Regular cleaning Incontinent care

Medical complication Bed sore Fall Blood clot Others pneumonia UTI Bed sore Freq turning in bed Cushion for wheelchair/Chair Regular Skin care Fall Home safety eval Assisted ambulation 24 hr supervision Blood clot Others DM, CAD, Resp, Renal failure, Seizure.

Medical complication Others Seizure, DM, CAD, Resp, Renal failure. Pneumonia UTI Bed sore Fall Others Seizure, DM, CAD, Resp, Renal failure.

Medical/Psych complication II Mood Depression, anxiety, irritability Sleep Reverse cycle, insomnia, day time sleepiness/Sundowning Behavior issues Impulsiveness, stubbiness, paranoia

Medical/Psych complication II Mood-Depression, anxiety, irritability Social activities Physical activities Behavior therapy Structured routine Case depend investigation Medication

Medical/Psych complication II Mood Sleep- Reverse cycle, insomnia, day time sleepiness/Sun downing Social activities Physical activities Light management Day time scheduled nap Evaluation for medication/side effect Medication/supplyment

Medical/Psych complication II Mood Sleep Behavior issues- Impulsiveness, stubbiness, paranoia Avoid stressful satiation/triggers Gentle/calm redirection/distraction Relative Autonomy with safety in mind

Conclusion Dementia is complicated Physical, mental, psychical, financial stress Initial diagnosis Medical management High demand for care taker Psychical-social complication

Thank You!!

Alzheimer Dementia in the U.S. Alzheimer's Association 2010 Alzheimer's Disease Facts and Figures

Leading Cause of Death in the U.S. Alzheimer's Association 2010 Alzheimer's Disease Facts and Figures

Life expectancy of Chinese Since age was the most important risk factor for most of the disease, We had some excuses that we are a later comer to the game. Since the life expectancy was only in the 40’s for majority of the Chinese people in the world in 1950, so we could expect not than mant people would die from these dieases. However thanks for the hard work of other specialties, now the bruned is back on to neurologist again. As people ages the incident of dementia and movement disorder inches up. Almost forgot to mention that Chinese living in America has their life expectancy in the mid 80’s. so we had no excuses here. But since the data was so limited, I will be talking mostly the data we know from Chinese not living in the U.S. However, I will mention briefly on what we found here in CA at the end.