DSM-5 中有關 ” 失智症 ”( 認知症 ) 的新觀念 New concepts of major neurocognitive disorder in DSM-5 歐陽文貞, M.D., M.P.H., Ph.D. 彰基體系精神科主任及鹿東醫院院長 台灣老年精神醫學會常務理事, 台灣精神醫學會常務監事.

Presentation on theme: "DSM-5 中有關 ” 失智症 ”( 認知症 ) 的新觀念 New concepts of major neurocognitive disorder in DSM-5 歐陽文貞, M.D., M.P.H., Ph.D. 彰基體系精神科主任及鹿東醫院院長 台灣老年精神醫學會常務理事, 台灣精神醫學會常務監事."— Presentation transcript:

1 DSM-5 中有關 ” 失智症 ”( 認知症 ) 的新觀念 New concepts of major neurocognitive disorder in DSM-5 歐陽文貞, M.D., M.P.H., Ph.D. 彰基體系精神科主任及鹿東醫院院長 台灣老年精神醫學會常務理事, 台灣精神醫學會常務監事 台灣臨床失智症學會理事 台灣失智症協會理事 1

2 大綱 前言 : 失智症 (dementia) 還有汙名化嗎 ? 介紹 ICD-9, ICD-10, DSM-IV-TR 的失智症及公 共衛生的議題 與家屬的負擔 DSM-5 的神經認知症 2

3 3 老人人口 總人口 老人 (%) 2000 2011 2025 2060 大陸 13 億多 6.8 8.9 13.2 台灣 0.23 億 8.6 11% 19.8% 39.6% 美 3 億 12.5 18.8 日本 1 億 17.1 22 26.7

4 4 失智症是什麼 ? 失智症是一腦部的慢性 / 持續退化疾病。 高級大腦皮質的功能障礙 -- 包括記憶、思 考、定向感、理解能力、規劃、學習、 語言、判斷能力。 意識狀態沒有混淆。 認知功能合併出現，而且在情緒控制、 社會行為與動機功能退化之前。 ICD-10 以前叫癡呆症或老番顛

5 5 失智症的認知缺損症狀有哪些 ? 多重認知缺限 ( 同時有 2 項 ) 1. 記憶損傷 (amnesia) – 近期或遠期記憶 ( 和心 症狀, 此症狀一定要有 ) 2. 認識不能 (agnosia)— 認物品、地、認人 3. 失語症狀 (aphasia) 、 4. 操作不能 (apraxia)- 穿衣 、洗澡、如廁、進 食、移動 ( 肌肉無力、無法協調 ) 5. 計算, 判斷, 規劃, 執行功能障礙 APA 1994 DSM-IV

6 老人就會 ” 記憶力 ” 不好 ?? 甚麼樣的記憶力不好可能是失智症 ?” – 發生記憶力不好的頻率高 : 忘記拔 key, – 已持續時間長 – 發生不好的 ( 嚴重的 ) 後果 貴人多忘事 ”( 舌尖現象 )? 忘得一乾二淨 ? 6

7 聯合晚報 2013.07.28 更早期預防或偵測失智症 失智症盛行率約 5%( 社區及機構的個案 ) – 只有認知方面症狀 MMSE<24 – 已出現 BPSD( 行為及其情緒問題 ) – 已出現大小便失禁及洗澡更衣等日常生活問題 極早期失智症 (minimal cortical impairment) – CDR=0.5?, MMSE 24-26? – Prodromal stage of dementia 輕微認知功能障礙 ( 失智症前期 ) – Pre-prodromal stage, MMSE 27-29, 正常老化如何分 ? 7

8 8 失智症盛行與對公共衛生的影響 失智症至少在美國 65 歲以上佔 10% （ McDowell2001 Aging13(3)143-62 ） 。 90% 的失智症會出現精神行為問題 ( 英 guide 2011) 失智症 10% - 30% 需機構或護理之家 2 。 其中輕到中度至少佔 2/3-3/4 。 存活時間 5-12 年。國外診斷後的 5 年內, 約有 3/4 病人需要送入看護所照護。 增加家屬的身心經濟與社會負擔。

9 9 失智症帶來的困擾 D 容易合併身體疾病或譫妄 (delirium) C 常出現包括失去記憶力及認知功能退化的 困擾（迷路走失、不認識家屬、錯認、忘 記關水或火、法律困擾或糾紛） B 行為及精神症狀（人格改變、幻覺、妄想、 憂鬱、傷人、激動、行為干擾） A 生活自理能力、

10 10 失智症不是精神病, 但是 失智症有精神行為症狀 -BPSD A— 憂鬱 ( 達重鬱症否 ), 焦慮, 輕躁或躁症, 易怒 B— 自言自語, 反覆衝動或持續行為, 遊走, 不適切行為, 坐立不安, 傷人或自傷, C— 被偷妄想, 錯認妄想, 忌妒妄想, 被害妄想, 宗教妄想 (?), 反覆固著的想法 ( 不尋常內容的 想法或妄想 ), 虛談現象, 答非所問, 聽幻覺, 視幻覺, 觸幻覺, 嗅幻覺, 4A D— 不想動或低動機, 失眠或嗜睡, 暴食, 厭食或 胃口差 ( 食慾高或低 ), 體重減輕, 性慾過高或 不適切性行為

11 哪些疾病或原因會造成失智症 ? 原發性退化失智症 : AD( 阿茲海默氏症 ), DLB( 路易士 體失智症 ), FTD( 額顳葉失智症 )( 共 60-70%) 血管性失智症 ( 約 15%) – AD/VaD 在南美高, 在亞洲低 (Marcos A Lopes2002 Arq. Neuro-Psiquiatr60(1)Mar ) 續發性失智症 (10-15%) 包含可逆性失智症 (10%) 酒精性失智症及藥物 ( 如 BZD) 或成癮物質引起失智症 其他病因引起的失智症

12 可以治療之續發性失智症 愛滋病造成失智症梅毒引起失智症 常壓性水腦症慢性硬腦膜下出血 慢速成長之腦腫瘤後天性甲狀腺功能過低 缺乏維他命 B1 缺乏維他命 B12 缺乏葉酸 (folic acid, B9) 維他命 B6 憂鬱症造成假性癡呆症 ?

13 續發性失智症 血管性失智症（最多）低血糖或其他休克造成 之腦病變 酒精性或物質使用失智 症（如強力膠） 克斐 - 雅各病之失智症（ CJD ） 巴金森氏病合併失智症其他大腦脂代謝障礙 放射線治療合併失智症一氧化碳中毒 杭亭頓病之失智症其他原因

14 14 Classification of mental disorders & diagnostic criteria 1952 DSM-I (ISO 成立 1947 於日內瓦 ) 1968 DSM-II & ICD-8 1977(79) ICD-9(ICD-9-CM) 1980 DSM-III, NINCDS-ADRDA (1984) 1987 DSM-IIIR 1992 ICD-10 1994 DSM-IV 2000 DSM-IV-TR NIA-AA(2011) 2013 DSM-5 2014 ICD-11(revision from 2007)

15 Changing Year from 1980- bio-psycho-social model 1980 Medical model to Holistic model, consultation, B_P_S model (Chong MY, et l 高醫醫誌 1998) 維基百科 1960-1998 美國 : 從敵對到和解 ICD-9CM (1977, 中文 1981) 1980 DSM-III not only psychosocial theory 1981 Diagnostic Interview Schedule (DIS) – First psychiatric diagnostic interview (Endicott J 1981; Bland et al. 1988) ( 可評估認知障礙盛行率 ) 1987-1988: Composite International Diagnostic Interview (CIDI) by WHO ( 沒有評估失智症 ?? 需確認 ) SCAN 有 MMSE, aphasia 及認知功能評估 15

16 from ICD-9 to ICD-10 1.ICD-9 (1977) 290-299 Psychosis ( 精神病 ) – Dementia and organic psychotic condition(290-294) 290 老年期及初老期器質性精神病狀態 (senile & pre-senile organic psychotic condition) 290.0 senile dementia, simple type 290.1 pre-senile dementia 290.2 senile dementia, depressed(290.21) or paranoid type(290.20) 290.3 senile dementia with acute confusional state 290.4 artheriosclerotic dementia (290.5 mixed dementia) – Other psychosis 294.1 續發性失智症, 295 schizophrenia, 296 躁鬱症, 297 paranoid state 298 other psychosis 300-314 Neurosis ( 精神官能症 ) 2. ICD-10(1992) 10 categories F0 Organic, including symptomatic, mental disorder ( 包含失智症、失憶、譫妄及器質性精神病 ) F00 dementia in Alzheimer’s disease F01 vascular dementia F02 dementia in other disease classified elsewhere (Pick’s disease, CJD, Huntington’s disease, Parkinson’s disease, HIV, other specified disease) F2 schizophrenia, schizotypal, delusional disorder, F3 情感性疾病, F4 –F6 焦慮疾病 … 16

17 ICD-9 290-294: organic psychotic condition 之一 dementia 290 老年期及初老期器質性精神病狀態 (senile & pre-senile organic psychotic condition) – 290.0 senile dementia, simple type – 290.1 pre-senile dementia – 290.2 senile dementia, depressed(290.21) or paranoid type(290.20) – 290.3 senile dementia with acute confusional state – 290.4 artheriosclerotic dementia – (290.5 mixed dementia) 17

18 ICD-10 organic, including symptomatic, mental disorder F00 dementia in Alzheimer’s disease F01 vascular dementia F02 dementia in other disease classified elsewhere F03 unspecified dementia F04 organic amnesic syndrome, not induced by alcohol and other psychoactive substance F05 delirium, not induced by alcohol and other psychoactive substance F06 other mental disorder due to brain damage and dysfunction and to physical disease F07 personality and behavior disorder due to brain damage and dysfunction and to physical disease F09 unspecified organic or symptomatic mental disorder 18

19 ICD-10 dementia F00.0 dementia in AD with early onset, F00.1 dementia in AD with late onset F01.0 vascular dementia of acute onset F01.1 multi-infarct dementia F01.2 subcortical vascular dementia F01.3 mixed cortical and subcortical dementia F02.x Pick’s disease, CJD, Huntington’s disease, Parkinson’s disease, HIV, other specified disease 19

20 ICD-10-DCR for dementia -1992 G1 evidence of each of the following: – (1) decline in memory(mild, moderate, severe) – (2)decline in other cognitive abilities: 特徵為判斷 力、思考能力及資訊處理能力下降。 必須要有客觀的資料 提供者，如果能夠，需以神經心理測驗或量化的客觀評估來補強。由先前較好的表現功能應該 被建立。下降的程度藉由以下評估判定，只要是輕度就符合診斷。 G2 awareness of the environment is preserved G3 decline in emotional control or motivation, or a change in social behavior – (1)emotional lability, (2)irritability – (3)apathy (4)corasening of social behavior G4 present for at least 6 months 20

21 From DSM-III to DSM-IV DSM-III (1980), DSM-IV (1994) DSM-IV-TR (2000): delirium, dementia, and amnesic and other cognitive disorders – Delirium – Substance-induced delirium – Dementia : AD(290.0-.3), VaD(290.4), 續發性失智症 (294) – Amnesic disorder – Amnesic disorder NOS – Other cognitive disorder NOS – Mental disorder due to a general medical condition 21

22 DSM-IV-TR: dementia syndrome 294.1x Dementia of the Alzheimer’s type ( 原 DSM-IV coding 及 ICD-9 及健保局 290.0, 290.1x, 290.2x) 290.4x Vascular dementia (formerly multi-infarct dementia) 294.1x Dementia due to other general medical condition, head injury, Pick’s disease,,,,, 292.8x, 291.2x Substance-induced persisting dementia Dementia due to multiple etiologies 294.8 Dementia NOS 22

23 DSM-IV-TR dementia of Alzheimer’s type A. both – (1)memory impairment, – (2)aphasia, agnosia, apraxia, disturbing in executive function B. significant impairment in ….. C. Gradual onset D. not due to other causes E. not occur exclusively during the course of a delirium F. not better accounted for by anther Axis I diagnosis, MDD or schizophrenia 23

24 NINCDS-ADRDA Alzheimer's Criteria proposed in 1984 by the National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer's Disease and Related Disorders Association (now known as the Alzheimer's Association)National Institute of Neurological and Communicative Disorders and StrokeAlzheimer's Disease and Related Disorders Association are among the most used in the diagnosis of Alzheimer's disease (AD). [1 (McKhann G, et al. Neurology. 1984 Jul;34(7):939-44.) Alzheimer's disease [1 24

25 NINCDS-ADRDA Definite Alzheimer's disease: The patient meets the criteria for probable Alzheimer's disease and has histopathologic evidence of AD via autopsy or biopsy.histopathologicautopsybiopsy Probable Alzheimer's disease: Dementia has been established by clinical and neuropsychological examination. Cognitive impairments also have to be progressive and be present in two or more areas of cognition. The onset of the deficits has been between the ages of 40 and 90 years and finally there must be an absence of other diseases capable of producing a dementia syndrome. Possible Alzheimer's disease: There is a dementia syndrome with an atypical onset, presentation or progression; and without a known etiology; but no co-morbid diseases capable of producing dementia are believed to be in the origin of it. Unlikely Alzheimer's disease: The patient presents a dementia syndrome with a sudden onset, focal neurologic signs, or seizures or gait disturbance early in the course of the illness.focal neurologic signsseizures gait 25

26 NINCDS-ADRDA 的 AD-1984 The NINCDS-ADRDA Alzheimer's Criteria specify 8 cognitive domains that may be impaired in AD: – memory, memory – language, language – perceptual skills, perceptual skills – constructive abilities, – orientation, (DSM-5 沒有此名詞 ) orientation – Attention, Attention – problem solving and functional abilities(DSM-5 沒有此名詞, 但是 DSM -5 多了 social cognition ). problem solving NIA-AA (National Institute of Aging/Alzheimer Association, 2011 文 獻 ) 失智症新標準除原本 DSM-IV 外, 2 domain 有問題 --domain 中 去除 apraxia 、加入 ” 行為或人格改變 ”(5. Changes in personality, behavior, or comportment) 也放在認知領域中但不一定要 amnesia 26

27 27 省思 --Nosology of AD 失智症名稱與定義會影響盛行率及發生率的計算 1950s Martin Roth 定義失智症為「記憶的嚴重退 化並伴隨時間與地點的定向感退化」 APA DSM-IIIR 及 -IV 以記憶受損為主及其他智能受 損 （ high cortical function ） 。 DSM-IIIR 記憶受損必需短期及 長期記憶均受損， DSM-IV 則無此規定 ( 其中之一即 可 ) 。 DSM-IV 只強調 Aphasia, Agnosia, Apraxia 或執行功 能, 比起 DSM-IIIR 及 ICD-10 較不強調思考與 judgement 的受損 NINCDS-ADRDA 強調 40-90 歲, 未強調功能受損

28 28 省思 --Nosology of dementia WHO ICD-10(DCR 研究用 ) impairment of high cortical function ，記憶受損不一定必然存在或被發 現。但是認知功能受損需超過 6 個月。 DSM-IIIR,DSM-IV 及 ICD-10 均強調社會功能受損, 但 是正常到失智症屬於一個連續性變化，很難切分。 Normal aging–MCI—mild dementia 3--64%?? ，所以 在 ICD-10 及 DSM- 均用社會職業功能受影響來切分 常引起誤差。 目前 DSM-IV 的診斷標準沒有提到病程或預後 --- 會 持續、不變、起伏或可逆性。

29 DSM-5: Neurocognitive disorder S 00 - 02 Delirium – S 00 Delirium S 00 Delirium – S 01 Substance-Induced Delirium S 01 Substance-Induced Delirium – S 02 Delirium Not Elsewhere Classified S 02 Delirium Not Elsewhere Classified S 03 Mild Neurocognitive Disorder S 04 Major Neurocognitive Disorder Subtypes of Major and Mild Neurocognitive Disorders 29

30 DSM-5 草稿 : neurocognitive disorder S XX.01 Neurocognitive Disorder due to Alzheimer's Disease S XX.02 Vascular Neurocognitive Disorder S XX.03 Frontotemporal Neurocognitive Disorder S XX.04 Neurocogntive Disorder due to Traumatic Brain Injury S XX.05 Neurocognitive Disorder due to Lewy Body Dementia S XX.06 Neurocognitive Disorder due to Parkinson's Disease S XX.07 Neurocognitive Disorder due to HIV Infection S XX.08 Substance-Induced Neurocognitive Disorder S XX.09 Neurocognitive Disorder due to Huntington's Disease S XX.10 Neurocognitive Disorder due to Prion Disease S XX.11 Neurocognitive Disorder due to Another Medical Condition S XX.11 Neurocognitive Disorder due to Another Medical Condition S XX.12 Neurocognitive Disorder Not Elsewhere Classified 30

31 何謂 DSM-5 的 Neurocognitive domain? Complex attention: sustained attention, selective attention- 同時許多刺激 但不分心 (focus?), 如聽數字且讀字 母, 只算字母. Divided attention : 同時做兩件事 ( 又 讀又聽又打字 ). processing speed: 量化時間內完成的任務. Major: 已經有專注困難, 易分心 ( 如看電視 ), 記不住 電話號碼, 無法心算. Mild: 例行任務 (task) 開始 出錯, 需 double-checked, 單純刺激時思考較容易 ( 看電視時會干擾思考 ) Executive function Planning; decision making; feedback/ error utilization( 反思及修 正力 : 因回饋而容易解決問題 ); overriding habit/inhibition( 逆向思考, 克服原本思考習慣 ); mental/cognitive flexibility( 有能力在 兩觀念、任務或原則中改變 ) Major: 複雜的案子有困難 完成 ; 需依靠他人做決定. mild: 需用力 (increased effort required to complete …) 才可完成複 雜任務. Learning and memory Immediate memory span; recent memory; Very long term memory, Implicit learning major: 及事情需提醒 Mild: 回想近期的事困難, 借助日曆紀事增加. 31

32 何謂 DSM-5 的 Neurocognitive domain? languageexpressive language; grammar and syntax( 語法 ); receptive language major: 語言困難. Mild: 找字困難, 避免使用 特殊名詞. Perceptual - motor >visual perception( 視覺認知 ); >visuoconstructional( 如手眼協調 ); >perceptual-motor(integrating perception with purposeful movement, 如釘木板 ); >praxis( 已學會動作的整合, 如揮手再見 ); >gnosis( 認識的整合 ? Perceptual integrity of awareness and recognition) Major: 開車困難, 騎車困難 Mild: 需要依賴地圖找方 向, 停車較不精準 (less precise in parking) Social cognition Recognition of emotion; theory of mind( 有辦法了解別人心裡的 想法 ); Major: 對社會穿著的禮儀 困難. Mild: 態度或行為上 細微變化, 如較無法認清 表情的含意 32

33 何謂 major 及 mild ( 非 minor) NCD? Major NCDMild NCD A 在六大認知領域中至少有一項 ( 或以上 ) 功能顯著下降 (significant decline) 的證據 ( 以下兩者都要 ): 1. 病人, 有見識的資訊 提供者或醫師認定病人認知下降, 2. 量 化的臨床評估或標準化神經心理測驗. A 在六大認知領域中至少有一項 ( 或以上 ) 功能不太大的下降 (modest decline) 的證 據 ( 以下兩者都要 ): 1. 病人, 有見識的資 訊提供者或醫師認定病人認知下降, 2. 量化的臨床評估或標準化神經心理測驗. B 認知缺損干擾日常生活的獨立性.B 認知缺損不干擾日常生活的獨立性. C 認知缺損不僅在 delirium 時發生.C 和 major NCD 條文相同 D 認知缺損無法以精神疾病做更好的解 釋, 如重鬱症或精神分裂病. ( 即上述疾 病也可以有 NCD) Specify: 無 / 有行為困擾 ( 情緒, 焦躁, 精神 病, 淡漠, 其他 ) 分輕 - 中 - 重三個嚴重程度 ( 輕 : 輕微影響 ADL) D 和 major NCD 條文相同 Specify: 無 / 有行為困擾 ( 情緒, 焦躁, 精神 病, 淡漠, 其他 ) 沒有分輕 - 中 - 重三個嚴重程度 33

34 DSM-5 定案 : major neurocognitive disorder A. Evidence of significant cognitive decline from a previous level of performance in one or more of the domains outlined above based on: 1. Concerns of the individual, a knowledgeable informant, or the clinician that there has been a significant decline in cognitive function; and 2. A substantial decline in cognitive performance, preferably documented by standardized neuropsychological testing, or in its absence, another qualified clinical asessment. ( 太寬了 ??) B. The cognitive deficits interfere with independence in everyday activies (i.e., at a minimum, requiring assistance with complex instrumental activities of daily living [more complex tasks such as paying bills or managing medications]). C. The cognitive deficits do not occur exclusively in the context of a Delirium. D. The cognitive deficits are not better explained by another mental disorder (e.g., Major Depressive Disorder, Schizophrenia). 34

35 DSM-5 Major neurocognitive disorder 去除 amnesiac disorder 12 個病因造成 MND: 增加 DLB, FTD 診斷, 維持 MND due to Traumatic brain injury AD 仍保有以記憶力早期受影響的症狀, 緩慢 發病 VaD 不強調 focal neurological sign, sudden onset, stepwise course 35

36 DSM-5 vascular MNCD A,D 相同, C 有腦血管疾病證據 B. The clinical features are consistent with a vascular etiology as suggested by one of the following: – 1. The onset of the cognitive deficits is temporally related to one or more vascular events – 2. Evidence for decline is prominent in complex attention( including speed processing), and/or frontal-executive functioning 36

37 DSM-5 vascular MNCD, specify if 1. Probable: Vascular Neurocognitive Disorder is considered probable if: – a) Clinical criteria are supported by neuroimaging evidence of significant parenchymal injury due to cerebrovascular disease (neuroimaging-supported) – b) The neurocognitive syndrome is temporally related to one or more cerebrovascular events and there is documented evidence of these events – c) If both clinical and genetic (e.g. cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy, CADASIL) evidence of cerebrovascular disease are present. 37

38 Major Frontotemporal NCD A.B.E. 同 MNCD with Lewy Body, D. 記憶學習及 pereptual- motor 功能, C.(1) behavior variant. (a)>=3 項 – i. behavior inhibitio, – ii. apathy or inertia, – iii. loss of sympathy or empathy, – iv. perseveration, stereotyped or compulsive/ritualistic behavior – v. 明顯退化 social cognitin and /or executive abilities. (2) language variant Causative FT NCD gentic mutation by family Hx or genetic testing; neuroimaging 看到額或顳葉不合比例萎縮. 38

39 MNCD with Lewy Body A 符合 MNCD, B. 緩慢發病, 持續惡化, C 核心 2 項或 “1+1” 叫 probable, 1 核 心或 1 建議 s/s 則為 possible, D 不是其他疾病做最佳解釋 C. Core Diagnostic Features of Lewy Body Disease include the following: – a) Fluctuating cognition with pronounced variations in attention and alertness. – b) Recurrent visual hallucinations that are typically well-formed and detailed. – c) Spontaneous features of parkinsonism with onset at least 1 year later than the cognitive impairment. Suggestive Diagnostic Features of Lewy Body Disease include the following:a) REM sleep behavior disorder, b) Severe neuroleptic sensitivity ( Low dopamine transporter uptake in basal ganglia demonstrated by SPECT or PET imaging. 本條文在 DSM-5 正式版本時 被刪除 ) 39

40 DSM-5 修改的理由 1.Major Neurocognitive Disorder (including what was formerly known as Dementia) is a disorder with greater cognitive deficits in at least one (typically two or more) of the following domains: Complex attention (sustained attention, divided attention, selective attention, processing speed), Executive ability (planning, decision-making, working memory, responding to feedback/error correction, overriding habits, mental flexibility), Learning and memory(immediate memory, recent memory [including free recall, cued recall, and recognition memory]) Language(expressive language [including naming, fluency, grammar and syntax] and receptive language), Visuoconstructional-perceptual ability (construction and visual perception),and Social cognition (recognition of emotions, theory of mind, behavioral regulation). 2.The cognitive deficits must be sufficient to interfere with functional independence. Important changes from the DSM-IV criteria include: change in nomenclature (MNCD or Dementia), not necessarily requiring memory to be one of the impaired domains, allowing cognitive deficit limited to one domain. 40

41 DSM-5 修改的理由 2 3.The term “dementia” is replaced by Major Neurocognitive Disorder, which is conceptualized as including what was formerly known as dementia as well as entities like amnestic disorder. “Dementia” is an accepted term for older adults (e.g., with Alzheimer’s disease)—although even in this setting it has acquired a pejorative or stigmatizing connotation, it is less well accepted among younger adults with deficits related to e.g., HIV or head injury. ( 去汙名化 ) 4.This rewording focuses on decline (rather than deficit—consistent with the requirement in the basic definition of an acquired disorder) from a previous level of performance. ( 和 ICD-10 一致, 變寬 ) 5.The previous criteria for dementia used Alzheimer’s disease as their prototype and thus required memory impairment as a criterion for all dementias. There is growing recognition that, in other neurocognitive disorders (e.g., HIV-related cognitive decline, cerebrovascular disease, frontotemporal degeneration, traumatic brain injury, etc.), other domains such as language or executive functions may be impaired first, or exclusively, depending on the part of the brain affected and the natural history of the disease. 6. The terminology for the cognitive domains has been updated to reflect current usage in neuropsychology and neurology. 41

42 修改的理由 3 7.The new definition, consistent with DSM-wide changes, focuses first on performance rather than disability. In the introductory table, we provide for each domain examples of specific symptoms or observations consistent with the Major level of decline and objective assessments. This encourages the use of objective measures, including formal neuropsychological testing where feasible with lesser exclusive reliance on individual judgment. 8.The presence of both symptoms/observations and objective assessment is included to ensure specificity. This is a larger issue for Minor Neurocognitive Disorder but included here for parallel structure of the criteria. NOTE: …. refining criteria A1 and A2 to achieve a balance between preferred formal neuropsychological test 及臨床判斷 ….. 9. The new language preserves the traditional function-based threshold for dementia but tries to operationalize it more clearly as a loss of independence. NOTE: The committee is still refining criterion D and discussing to what extent Major Neurocognitive Disorder should be diagnosed in the setting of disorders like schizophrenia and depression (although this concern applies primarily to Minor Neurocognitive Disorder). ( 不排斥精神分裂病 可以有 ” 重大認知障礙症 ”) 42

43 43 精神健康 (mental health) www.mhf.org.tw 精神健康基金會 www.mhf.org.tw 腦 心 智慧

44 診斷標準寬鬆及嚴格的影響 臨床服務 : 疾病的診斷成立與否 – 醫師診斷步驟改變, – 影響藥品或處置的給予與否 – 影響保險給付或相關福利領取 – 影響民眾求醫行為或接受度 行政 : 疾病盛行率的改變 – 影響醫療人力需求 – 影響醫療政策 研究教學 : 研究方法或流程的改變 – 影響部分研究結果或結果的詮釋 – 教學資料的改變 44

45 45 Nosology of dementia Reidel-Heller SG(2001)DSM-IIIR 及 ICD-10 診斷標準研 究 75 歲以上的 1692 人失智症盛行率 以 DSM-IIIR 的盛行率為 17.4% (95%CI =15.9-19.5) 以 ICD-10 的盛行率為 12.4%(95%CI= 10.6-14.2), 兩者 有明顯差異,ICD-10 threshold 較高, 越老差異越明顯. Br J psychiatry 2001 Sep;179:250-4

46 46 失智症盛行率 美國老人失智症盛行率 7-16%(71 歲以上者 13.9%, Plassman BL, et al 2007) 台灣的老人失智症盛行率 1.9-4.4%( 1982 to 1994) 跨國或同一區研究顯是失智症盛行性差異很大, 原 因很多, 在研究方法學中診斷標準寬嚴不一是其中 的一項。 目前失智症 ( 過去癡呆症 ) 仍有 stigmatization, unerdiagnosed and undertreatment

47 Prevalence of dementia in Latin America, India & China: population-based survey. The prevalence of DSM-IV dementia varied widely, from 0.3% in rural India to 6.3% in Cuba. After standardisation for age and sex, DSM-IV prevalence in urban Latin American sites was four- fifths of that in Europe, but in China the prevalence was only half, and in India and rural Latin America a quarter or less of the European prevalence. 10/66 dementia prevalence was higher than that of DSM-IV dementia, and more consistent across sites, varying between 5.6% (95% CI 4.2-7.0) in rural China and 11.7% (10.3-13.1) in the Dominican Republic. (Libre Rodriguez JJ, et al. Lancet 2008). 47

48 How to cope 早期發現的技巧 – 醫療人員了解疾病 – 全民了解 早期介入的方法 – evidence 48

49 Take home message DSM-5 中 dementia 已改名 (major neurocognitive disorder) 何謂 major 及 mild neurocognitive disorder – Neurocognive domain 6 大項 : “complex attention, executive function, learning and memory, language, perception-motor, social cognition” 和 DSM-IV 不同 (amnesia, aphasia, agnosia, apraxia, executive function) – 1 or more domain 且 memory 非唯一的核心症狀 加入 FTD and DLB 49

50 50 WPA/WHO 1st 共同宣言 1st 強調老人精神醫學的主要目標是 恢復健康 (restoration of health) 促進生活品質 (improvement of quality of life) 減少殘障 (minimization of disabilities) 自主性 (preservation of autonomy) 注重病患的家人及照顧者 (addressing the needs of family and other carers as well as those of the individual patient) Ref WHO Psychiatry of the elderly: a consensus statement. Document No. WHO/WMH/MND/96.7. Geneva:WHO,1996

51 51 WPA/WHO 2 nd 共同宣言 2 nd 宣言強調好的專業老人精神醫學服務的原則 健康及生活品質是老人及精神病患的基本人權 所有人有權容易得到適當的醫療服務 在資源有限的情況下, 病患的需求應該備適當且合乎倫理的 滿足 透過醫療衛生及社會措施來滿足各地的老人精神醫療需求 照顧者及精神疾病的老人都應該在照顧計劃中 政府應認清 NGO 的重要角色, 並和他們一起服務老人 Ref WHO. Organization of care in psychiatry of the elderly: a technical consensus statement. Document No. WHO/WMH/MND/97. Geneva:WHO,1997

52 52 WPA/WHO 3rd 宣言 3rd 宣言針對教育 - 好的專業老人精神醫學教育 醫學院學生及畢業後教育, 專業繼續教育 健康衛生及社會服務管理人員 -- 衛生所及基層開業 人員 其他照顧工作者 -- 機構人員 家庭及非正式照顧者 公共政策制定者 一般大眾 Ref WHO. Education in psychiatry of the elderly : a technical consensus statement. Document No. WHO/WMH/MND/98.4. Geneva:WHO,1998

53 神經心理測驗 深化教學及研究 : – 腦科學與神經心理測驗常模或本土化 服務 : 持續創新 – 我媽媽 ” 忘記 ” 打電話給我是哪裡出問題 ? Amnesia? 社會關懷及精神健康促進 (mental health ptomotion) 如此 : 專業就無法被取代 53

54 Thank you for your attention 54