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Clinical Practice Guideline for Dementia 2008

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แนวทางเวชปฏิบัติภาวะสมองเสื่อม
(Clinical Practice Guideline for Dementia),

http://www.neurothai.org/images/2012/download/dementia-2008.pdf

Published in: Health & Medicine
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Clinical Practice Guideline for Dementia 2008

  1. 1. ˈ F F F F ˆ F F F F F F F F F F F F F F F F ˈ
  2. 2. F F F ˈ F F F 20 F ʾ F F F F ˁ ˈ ˈ F ˆ F F F F F F F F ʾ F F ˈ F ˈ F F F F F F F ˁ F F F F F ˁ F F F ˁ F F F ˁ F F F ˁ F ˀˊ F ˁ F F F ˁ F F F F F F F ˈ F F ˁ F F F ˆ F F F F ˈ F F F ˁ ˈ F F F F F F ( F ) F
  3. 3. F 1 F F 3 4 4 F ˁ (strength of recommendation : + +) 9 F F ˁ (strength of recommendation : - -) 15 1 F 16 2 F 21 3 (general management) 28 3.1 (acitivities of daily living : ADL) 28 3.2 F (environment) 30 3.3 F (caregivers) 31 3.4 ˀˊ F ˁ (rehabilitation) 32 3.5 F ˁ F (palliative and end-of- life care) 41 3.6 ˆ F (legal issue) 42 4 Management of cognitive impairment 46 4.1 F F (non-pharmacological management) 46 4.2 F (pharmacological management) 50 5 ˆ 55 (management of behavior and psychological symptoms of dementia)
  4. 4. ( F ) F 1. F 71 • • F - F - F F - F F - F F - F F F F : 1 + 1 > 2 - F F - F F ˁ F - F • : a circular diagram • F MCI AD MMSE score • Activities of daily living : ADL 2. F ˁ F aphasia, apraxia, agnosia 82 3. Mild cognitive impairment 85 4. Neurodegenerative disorders 87 5. Reversible dementias 89 6. Diagnosis and Statistical Manual of Mental Disorders, 4th edition 91 (DSM IV TRTM ) 7. (strength of recommendation) 92 F 99 MMSE 105 TMSE 106 MMSE-Thai 2002 107 F F F 110 F 111
  5. 5. F 1 6 2 7 3 Management of hallucinations / delirium 8 4 ADL 78 5 F F MCI AD MMSE score 79
  6. 6. 1. . 2. . 3. . 4. . . 5. . F 6. . . 7. . . F 8. . 9. . . F F 10. . . F 11. . . F F 12. . . F 13. . . F 14. . . 15. . . F F 16. . F F 17. . 18. . 19. . 20. . 21. . . F 22. . . F 23. . 24. . F 25. . F F F 26. . . F F
  7. 7. 1 F F F F F ˈ ˆ F ˆ 50 ʾ F F 45-50 ʾ F F F F 4 23 F F F F F F ʾ 2543 37,157 F F 68.81 ʾ 68.67 ʾ F 11.4 F ˈ F F 13.9 F ˈ F 8.0 F F F F F F F F F F F 6,122 1 6 F F F F ˁ F ˈ F F F ʾ 2545 ˈ 69.9 ʾ 74.9 ʾ F F ˈ F ˁ F F F F F F ˆ F F F F F ˂ (Clinical Practice Guideline for Dementia : ) ˈ F F ˈ F F ˈ ˁ F F F ˁ F F ˁ
  8. 8. 2 F F F ˈ F 168 F F F F F F F F F 90 F F F F F 80 F ˈ F F F F F F F F F ˈ 5 ʾ F F F F F F F F F F F F F F F F ˆ F F F F F F F ˁ F ˁ F F F F F F ˈ F F F F F F F F F F F ˆ F F F F F ˀˊ F ˁ F F F ˁ F ˈ F F F ˁ F F F ˁ F F F
  9. 9. 3 F F CPG F F F CPG F F F F F F F CPG F F CPG 100% ˈ F F CPG F CPG F ˂ CPG F F CPG F ʽ F ˈ F F F F aphasia, apraxia, agnosia, neuropsychological tests F MMSE F F F CPG F F 2 F 1 ˈ F 2 ˈ F F F F F F ˆ 1 F CPG F ʽ F F F F F F F F 2 1,2 F F ˈ F F F F F F F F 3 F F F ʽ F F F F 4 F CPG F F F F F F
  10. 10. 4 (strength of recommendation) ++ F F F F F F F ˁ F F (cost effective) + F F F F F F ˁ F F F +/- F F F F F F F ˁ F F F F F F ˁ F F F F ˆ F - F F F F F F F ˁ F F F F ˈ F F - - F F F F F F F ˁ F (quality of evidence) 1 F (systematic review) F F F - (randomize-controlled clinical trials) F F F - F F 1 (a well-designed, randomize-controlled, clinical trial) 2 F F F F F (non-randomized, controlled, clinical trials) F F F F (well-designed, non-randomized, controlled clinical trial) F F F F ( F cohort study, case-control study) 3 F (descriptive studies) F (fair-designed, controlled clinical trial) 4 F (consensus) F F ˁ F F F F F F 2 7
  11. 11. 28 3 (general management) 3.1 (activities of daily living : ADL) F F F F • F F F F F • F • F F F F F F • F F • F F F • F F F F • • F • F ˂ F F F F F F F - F F F F F ˈ • F • F F • F F F F F • F • ʽ F F ˁ F F F F ˂ F F F F F • F F • F F F F F F • F F F ˁ • F ˆ F F F ˈ F F F ˆ
  12. 12. 29 F • • F F ˁ • F F • ʽ F F ˁ F F F F F F F F F F F F F F ˁ F F F F F F • F F F F F F ˁ F F F F ˁ F • ˈ F F F F F F F F F • F F F F F F ˈ F 1. F F F 5 F ˆ F F ˁ F serum albumin F F 3.6 mg% F F 3.0 mg% F ˁ F F F F F F F F F F F F F F F F F F ˈ F F ˁ 2. BMI 3. F F ˁ 4. F F ˁ ˈ F drug interaction F F ˁ Alzheimer 5. ˂ F ˆ 6. F ˈ F F F 7. F F 8. F F F ˁ F F
  13. 13. 30 3.2 F (environment) F • F F F F F • F • ˂ F F F F F F ˂ F F • F • F F F • F F F F ʾ ˂ F F F F F F F • F F F F • F F • F F ˈ F F mild to moderate dementia F F F F F F ˁ F F
  14. 14. 31 3.3 F (caregivers) • F F - - F - F ˁ - F F F F F F F F F F F F F • - F - F F F ˁ F F F ˁ - F F F F • F ˆ 1.3 - F F F ˈ - F F F F F F F F F ˁ F - F F F F F F F F - F F F F F F F F F - F ˆ F F F F F F - F F F F F F - F F F F F ˆ F F - F F F F F F F F F F F F F F
  15. 15. 32 3.4 ˀˊ F ˁ 3.4.1 ˀˊ F ˁ F (physical rehabilitation) ˀˊ (rehabilitation) F F ˁ F F ˁ F 4 F • (physical) • (mental) • (social) • (vocational) F F F F F F F F F ˀˊ F F ˀˊ F F F ˀˊ F F ˁ F F F F F F F ˁ F F ˂ F F F F ˁ F ˀˊ F F F F F ˀˊ F F ˁ F F ˁ F F F F ˀˊ F F ˈ (multidisciplinary team) F ˁ F F ˆ F F F F F F ˀˊ F ˁ F F ˆ ˈ F F F ˀˊ ˂ ˀˊ F F F F ˁ F F F F ˁ F 2 F F
  16. 16. 35 - F ˈ F F F ˁ F F F ˆ (hearing aid) - F F F F ˁ F F - F F F ˁ F F F F ˁ F F F ˁ F F ˈ F ʿ F ʿ F ˁ F 3. F F F F F 1. F (range of motion exercise) 2. F (strengthening exercise) 3. F (muscle endurance) 4. (cardiovascular endurance exercise) 5. F (balance exercise) F F ˀˊ F F F ˁ ˈ 6 F (occupational therapy) (physiotherapy) (speech therapy) F F F ˈ F F F ˁ ˈ F F F F F F F ˁ F (physical fitness) F F F ˁ F F F F ˁ F F ˁ F F ˁ F F F ˁ F F ˁ 2 ʾ ˀˊ F ˁ F F F F 3.1 (physical therapy) F F ˁ F F F F ˂ F (joint contracture) ʿ F F F F ʿ F F F F F F F (walker) F (hydrotherapy) F (traction) F F (sound diathermy) F F ˂ (transcutaneous electrical nerve stimulation)
  17. 17. 36 3.2 (occupational therapy) F F F ˁ F F ʿ F ʿ F F F F F F F F F ˁ F F F 3.3 (recreational therapy) F ˁ F F F ˈ F F ˁ F F F F F F ˈ F F F F F F F F 1. F (range of motion exercise) 2. F (strengthening exercise) 3. F (muscle endurance) 4. (cardiovascular endurance exercise) 5. F (balance exercise) 4. F ˈ F F F ˁ F F F F F F F F F F ʽ F F F F F ˈ F ˁ F F F F F ˁ F F F F F F F F F F F F F ˈ F F ˂ F F ˂ F F F ˁ F F F ˂ ʽ F ˂ F F F • ʽ F F • F F F ˈ F F F F F F F • F F F • F F ˁ F F F ˁ ˈ F F F
  18. 18. 42 3.6 ˆ F (legal issue) F ˁ F ˁ Alzheimer F ˆ ˁ F F F F F F F F F F F F ˁ F F F F F F ˁ F F F F F F F F ˈ F F ˈ F F F F F F F F F F F F F F F ˁ F F F F ˁ F * F F F F F F ˁ F ˈ F F ˈ F F ˁ ˈ F ˁ F F F ˁ F F F ˆ F F F ˁ ˆ F F F F F ˁ F F ˁ
  19. 19. 44 * F ˁ F F ˁ F orientation F delusive thought F F F F F F F ˁ F F F F F F F F F F ˁ F F F F F F F F F F F F F F F ˁ F F F ˁ F ˈ F F ˁ F F F F F F CPR F F F (tracheostomy) F F F F F F F F F F F ˁ F ˁ F F F ˁ F F ˈ F ** ˆ F F F F ˆ F F ˈ F ˁ ˈ F 29 30 *** ˆ ˈ ˆ F ˆ ˆ (BPSD) F F F F F F F F ˁ F F **** F F F F F F ˈ F F ˁ F F ˁ ˈ F F F ˁ F F ˁ F F • F F F F ˁ F F F F F F
  20. 20. 45 • F F F F ˁ F ˈ F • F F F F F ˂ ˆ F F ˁ F F F ***** F F F F ˁ ˈ F F
  21. 21. 57 - F F F ˈ F F - F F - F F F 1/3 ½ F F F F F F F ˆ F F ˁ F F F F ˁ - F F F F - F F F F ˁ F F F F F F F F ˁ F F F F F F F F F F ˈ F F F F ˈ ˈ F F F ˈ F F F F F F F F F F F ˈ ˈ ˆ ABCs F ˆ A. (antecedent) F F ˈ F B. C. (consequences) F F F ˁ F F F - ˆ F ˆ F F F ʾ F F ˁ F F ˈ F ˈ F F F F - F (delirium) F - F F F F ˁ - F F F ˁ F F F F F F F F F -
  22. 22. 58 - F F F F F F ˁ F F F F F F F F F F F F ˁ F F F F F F F ˁ F ˁ F F F F ˈ F F F F ˁ F F F F F F F ˁ F F F - F ˁ F F - F F F - F F F F F F ˁ F F F F F ˁ F F F F F F F F F - F F F F F ˁ F F F F F F F ˁ F F F ˈ F - F F F F F F F F F ˁ F F F F F F F ˈ F - F F F F ˁ F F F F F - F F ˁ F F ˈ F F F F - F - F F ˁ F F F F F F F ˁ F F F F F - F F F - F F ˁ F ˈ
  23. 23. 71 1 F F • • F - F - F F - F F - F F - F F F F : 1 + 1 > 2 - F F - F F ˁ F - F • : a circular diagram • F MCI AD MMSE score • Activities of daily living : ADL
  24. 24. 72 F F ˈ ˈ F ˆ F ˈ F 3-4 F F F ˈ F F F F ˈ F F F F F F F F F F ˆ F F ˈ F F F F F ˈ 5-6 ʾ ˈ ½- 2 ʾ F F 1-2 F F ˈ F ˈ Law of cerebral dissolution : In case of brain damage, loss of higher cerebral function will happen first and before primitive brain function cognitive function first and before motor control activity F F F F F F John Hughlings Jackson F F F F F ˁ F F ˈ F F ˈ F F F F F F F ˆ / F F F F F F ˁ F ˈ F F F F ˈ F F F F F ˈ F HIV/AIDS ʽ F F F F
  25. 25. 73 F F F ˈ F F ˈ F F F F F 5-6 ʾ F F F F F F ʽ F F F F F F F F F F F ˈ ʾ ˈ 5 ʾ 10 ʾ F F F 60 ʾ F 60 ʾ F 5 ʾ 80 90 ʾ F 60 - 64 ʾ 1-2% 1-2 100 F 70 - 74 ʾ 12% 1 8 F 80- 84 ʾ 31% 1 3 F F F F ˈ mongolian F ˈ caucasian F 60% 1 2 85 ʾ F F F F F F F F ˁ F F F ˈ 3 F F F F F 3 ˈ 5 7 F F : F F F F F F F F F
  26. 26. 74 : F F ˆ F F F : F F F F F ˈ ʾ F F F F F F F F F F ˆ F 2 F F cholinesterase inhibitors NMDA receptor antagonist F F F ˁ F F 5-6 ʾ F F ˈ 10 ʾ 15 ʾ F F ˁ F F F ˁ F F F F F F F F F F 2 F F F F F F ˁ F F F F ˈ F F F F F 10+ ʾ ˈ F F ˈ F F F F : 1+1 > 2 F F 2 F F F F F F 2 F F F F F F F F F 1+1 > 2 F F F F : F F F F ˆ F F F F 1500 . : F 5 F F F F F F F F F F F F F F
  27. 27. 75 : F F F F F F F F F F F F • : F F F F F F F F F F F 1-2 F F F F F F F F F F : : F : F F F 1-2 F F F F F ˈ F F F F F ˈ F F F ˈ F F F ˈ F F F F F ˁ F F F ˁ ˈ ˈ F F F F F ˂ F 2-3 ʾ F F F F 4-5 ʾ F F ˁ F ˈ F ˈ F F F F ˁ F (caregivers) F ˈ F F F F F F F
  28. 28. 76 F F F F F ˈ F F 1-2 F ˈ F F F F ˈ F F mental depression F F ˁ F F F F F F F F ˈ ˈ F F F F ˁ F : ˆ F F ˆ F 70 ʾ ˈ F (mean) ˈ F F F ˁ F F F F ˈ F ˆ ˈ F ˁ F F F ˈ F F F F F ˈ F F ˆ F F ˂ F F ˈ F ˈ F F F F F F F F F F ˈ F ˆ F ˈ F F F F F F F F F ˆ ˈ F ˁ F F F F F F F F F ˈ F F ˁ F F :- ˈ F F F F F F F F F ˈ F F F F F F ˈ ˈ F F F F F
  29. 29. 77 F ˈ F F F F F F F F ˆ F F F F F F F F F F Every home is a nursing home for ageing people & Alzheimer sdisease - F F F F / ˈ (city nursing home) (state/regional nursing home) ˈ F ˈ ˈ ˆ F ˆ F F F F F ˁ F F F F ˆ F F F F F F F ˈ F ˆ F F ˁ F F F F F F ˈ ˈ ʾ F F F F
  30. 30. 80 Activities of daily living (ADL) ADL ˈ F ADL F MMSE F ˈ F F ˈ F F F F F F ˈ F F F F ˆ F F F F F F F F F F F F memory circuits main minor satellite circuits F F • ADL F ! • MMSE F 15-30 F ADL F dementia ˈ F F ˈ ˈ 1. F F ADL F ˁ F F F F ˁ ˈ F ˆ F • F ˁ • F F F • ˁ 2. F ADL F ˁ ˈ F ˆ F F F 3 F F F ˁ • ADL F ˁ F / • ADL • F ˁ F F F ADL F ( F F F F F ) F F F ˁ F F F ADL F F F F F F ˈ F F F ADL ˈ 2 instrumental ADL (iADL) basic ADL (bADL)
  31. 31. 81 bADL ˈ personal care F ˆ F iADL ˈ F F F iADL F F dementia F bADL F Pseudodementia A reversible neuropsychological disorder : depression Aphasia Problem with language ( F F F / F receptive/ expressive, sensory/motor, fluent/non fluent, wermicke/broca) Apraxia Inability to carry out purposeful movements even though there is no motor and sensory paralysis or impairment Agnosia Failure to recognize, people, part of body, object, etc. Disturbance of executive function Impaired initiation, planning, reasoning, sequential organization, and judgement
  32. 32. 82 2 F ˁ F aphasia, apraxia, agnosia F ˁ F F F F ˈ F F F ˈ subtype CVA lesion F internal capsule F ˁ aphasia, apraxia, agnosia F F F F ˁ F F F 1 Motor aphasia (nonfluent, Broca s, anterior) 50 ʾ F F F F F ˆ F F F F F F F ˆ CT scan brain : Broca s area infarct 2 Sensory aphasia (fluent, Wernicke s, posterior) 60 ʾ F F ˆ F F F F F ˈ F F F F F F CT scan brain : lobar hemorrhage left cerebral hemisphere Wernicke s area 3 Conduction aphasia 55 ʾ F F F F F F ˈ F ˁ F F F F F F F F F F F F F F F F ˆ F F ˁ ˈ F F F F ˆ F CT scan brain: lesion arcuate fasciculus : fiber tract motor sensory speech centers (Broca Wernicke connecting tract) 4 Alexia without agraphia 59 ʾ ˈ F F F F F F ˈ F F F ˈ F F F F F ˆ F
  33. 33. 83 - F F F F ˈ - F F F F F F F F - F F F F F F ( ) F F - F F F F F F F ! CT scan : lesion splenium of corpus callosum hemisphere F F 5 Agraphia 58 ʾ ˈ F F F F F F F F F / F F ( ˈ ) F F F F ˆ - F F - F F F − F F ˈ F 2-3 F F ˈ - F F ( ) F F CT scan brain : small hematoma left frontoparietal area ˈ lobar hemorrhage 6 Apraxia F ˁ 51 ʾ F F F F F ˈ 2-3 F F F F F F ˈ ˈ - F - F : no weakness - Basic sensory perception : pain, touch, joint sense − - F F ˈ * : F F F F F * ˆ : ˆ F F F ˆ F F F F F ˆ CT scan : left parietal infarct
  34. 34. 84 7 Agnosia aphasia F ˁ 61 ʾ F F ˆ F ˈ 2 F F F F F ˆ ˈ F F - F F F F * F F F ˁ F F F F F F F F * F F F ˁ ˈ F F F F ˈ F F F * F F F F (right-left disorientation) * F ˁ F F F ˈ F ˁ F F F F F F * F F F F F 2-3 F F F CT scan : left parietal, angular gyrus F ˁ ˈ typical Gerstmann s syndrome - finger agnosia - nominal aphasia - right-left confusion - acalculia 8 Agnosia: prosopagnosia 80 ʾ ˈ F F F hip fracture F F 3 F ʽ F F F F F F F ˈ F F F F - F F F F F F F F ˈ F ˁ F F F F F prosopagnosia CT scan : right occipitotemporal infarct.
  35. 35. 85 3 Mild cognitive impairment F ˆ F F F F F cognitive function F F (mild cognitive impairment MCI) F F (dementia) (normal forgetfulness) F 10-15 F F MCI F ˁ F F F F F F F ˈ F F F F F F F F MCI F ˁ ˆ F F cognitive function F F F F F F F ˁ F F F F MCI ˈ F (syndrome) F F F ˁ MCI ˈ F F 10-15 F ʾ F F (amnestic MCI) F ˁ MCI F ˈ MCI F F F F ˈ MCI ʾ F F MCI of Alzheimer-type - ˆ F F ˁ - ˈ (progressive onset) - F F - Amnestic syndrome of the hippocampal type defined by: very poor free recall despite adequate (and controlled) encoding; decreased total recall because of insufficient effect of cueing or impaired recognition; numerous intrusions - F F cognitive function ˈ - F ˈ - F F F F
  36. 36. 86 ˆ F F MCI F F cognitive function ˈ ˂
  37. 37. 87 4 Neurodegenerative disorders F neurodegenerative disorders F ˁ F F F F F F F F F F ˁ F ˁ F F F F ˁ F F Alzheimer s disease ˈ F F neurodegenerative disorders F ˆ F F ˁ F ˁ F F 8 10 ʾ F F F F 20 ʾ F ˆ F ˁ 4 F 0.5% 65 ʾ ˈ F 5 ʾ 65 ʾ F 360,000 F ʾ F F ˁ F F F F F F ˁ F ʾ 18,408 F ˈ 30,096 36,132 F F ˁ F F F F F F F F F ˈ F F ˈ F F F ˆ F F F F ˆ F F 1. F F F F ˆ F F F F F F F ˁ F 2. F F F ˈ F F 3. F F F ˈ F F F 4. F F F F
  38. 38. 88 5. F F F F ˆ F F F F ˁ F F F F ˁ F F F ʿ F F F ˁ ˈ F F ˁ F Frontotemporal dementia ˈ ˆ F F F F F F F F F F ˁ F F ˈ F F ˈ F F ˁ F Dementia with Lewy bodies ˈ F Lewy bodies F F ˁ F F F ˁ parkinsonism F F ˁ F F F ˆ F F F F
  39. 39. 89 5 Reversible dementias Reversible dementias F 15.1%1 F ˁ F 1. Intoxication : F F F F anticholinergic, cardiovascular, antihypertensives, sedative-hypnotic F cognitive impairment F heroin, glue, carbon monoxide, carbon disulfide, lead, mercury, manganese intoxication F F irrevessible F 2. Central nervous infection : F leptomeningitis encephalitis bateria, fungus, protozoa, virus post infectious encephalomyelitis cranial examthem F F F reversible dementias F F F F tuberculous meningitis, cerebral cysticercosis, neurosyphitlis 3. Metabolic disorders : F F thyroid, parathyroid, adrenal, pituitary F hypoxemia hypercapnia F encephalopathy dehydration, electrolyte disturbances F F F F Wilson s diseases, metabolic leukodystrophy, adrenoleucodystrophy neuronal storage diseases 4. Nutritional disorders : thiamine F Wernicke-Korsakoff s encephalopathy folate B12 B6 5. Vascular dementia : F ischemia cardioembolic stroke ˈ vascular dementia ˈ reversible partially reversible F F F F F ˂ 6. Space occupying lesion : frontal lobe temporal lobe F F F F ˈ F metastatic malignant tumours F F F
  40. 40. 90 7. Normal pressure hydrocephalus : gait disturbance ˆ F F F ˁ F F F ventriculoperitoneal shunt F 8. Affective disorders : depression in late life F F F 2-3 ʾ F F F ˁ F F F F F F F F F F cognitive impairment ˁ deep white matter F F F ˈ F F F F F F ˈ F F
  41. 41. 91 6 Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM - IV TRTM ) Dementia* A : The development of multiple cognitive deficits manifested by both (1) Memory impairment (impaired ability to learn new information or to recall previously learned information) (2) one (or more) of the following cognitive disturbances: (a) Aphasia (language disturbance) (b) Apraxia (impaired ability to carry out motor activities despite intact motor function) (c) Agnosia (failure to recognize or identify objects despite intact sensory function) (d) Disturbance in executive functioning (i.e., planning, organizing, sequencing, abstracting) B: The cognitive deficits in Criteria A1 and A2 each cause significant impairment in social or occupational functioning and represent a significant decline from a previous level of functioning. C: The deficits do not occur exclusively during the course of a delirium. D: The deficits may be associated with mental disorders such as anxiety mood delusions, hallucinations, personality change wandering agitation. The cognition disturbance may be accompanied by a clinically significant behavior disturbance E: Dementia may be progressive, stable, remitting * American Psychiatry Association. Diagnostic and Statistic Manual of Mental Disorders.4th Edition Text Revision. (DSM-IV-TRTM ) Washington (DC): American Psychiatric Press.
  42. 42. 92 7 (strength of recommendation) ++ F F F F F F F ˁ F F (cost effective) + F F F F F F ˁ F F F +/- F F F F F F F ˁ F F F F F F ˁ F F F F ˆ F - F F F F F F F ˁ F F F F ˈ F F - - F F F F F F F ˁ F F F F F F F ˁ (anecdotal report) F F F F ˈ (quality of evidence) 1 F (systematic review) F F F - (randomize-controlled clinical trials) F F F - F F 1 (a well-designed, randomize-controlled, clinical trial) 2 F F F F F (non-randomized, controlled, clinical trials) F F F F (well-designed, non-randomized, controlled clinical trial) F F
  43. 43. 93 F F ( F cohort study, case-control study) 3 F (descriptive studies) F (fair-designed, controlled clinical trial) 4 F (consensus) F F ˁ F F F F F F 2 (strength of recommendation) ˈ ˂ F F ˁ ˈ F F (prolonged life) ˁ (decreased morbidity) F (improved quality of life) F F ˁ F F F F F F F F F F F ˂ F F ( F F F F F F ˁ ˁ F / F F ˁ ) F F F F F F F F F 1 F ˈ F F ++ ++ F ˈ F 1 F F F F F F F F F ( F F F F F 50 ʾ F +/- ) F F Papanicolaou F ++ ˆ 2 F F F F F F F ˈ F
  44. 44. 94 F F F F ˈ ˈ F ˈ F F F ˈ F ˈ F F F ˂ F F F F F F F F F F F F CT / MRI brain F ++ F F ˆ F F F F ˈ F F F ( +/- ) F F ˈ F F +/- F F:- 1. F ˆ F F F F F F F F ˈ F 2. F 3. F F F F 4. F F 5. F F F F ˆ F ˆ F F F 12 F ˁ F F F ˈ F F F F F ˁ F F F F F F F F F F F F ˆ F (systematic review and consensus of peer reviewers) F F F F F F F F F F F F F
  45. 45. 95 F F F ˆ ˆ / F F F F F F F F 5 F F 1. ˂ F F F F 2. ˂ F F F F F F F 3. ˂ / F ( F ) ˈ F F 5 F F (1) (safety) (2) F (efficacy) (3) (effectiveness) (4) F F (benefit of population and entire society) (5) (efficiency) F 1. (safety) F F ˂ ˁ F ˀˊ F ˆ F F F F (safety monitoring program: SMP) F F ( F NNH: number needed to harm) F F F F 2. F (efficacy) F ˈ F F F F F
  46. 46. 96 F F F ˆ / F F F F F F F ( F NNT: number needed to treat) F F F 3. (effectiveness) F F F F F F F F F F F F F / F F F / F F F F F F F F F F ˆ / F F F F F 3.1 F ˈ F 3.2 F F ˁ F F F F F 3.3 F F F F ˈ F 3.4 F F F F F ˈ F F 4. F F (benefit of population and the whole society) F F F F ˈ F F F / F F F F F (utility) ˆ F F F F F F F F F F F F F ˈ F F F F F F F F F F F F F F F F F F F ˁ F F F 5. (efficiency) F F F F F F F F ˂ F F F F F ˂ F F F F F F ˈ F F F F ˈ F
  47. 47. 97 F F 1. F ++ , -- F F F F F F F F F / F F F ˈ F ( F ˁ ) F F 2 F F :- 1.1 1 : F F F - (randomize-controlled, clinical trial) F F 1 1.2 2 : F F F F F (non-randomized, controlled, clinical trial) F F F F F F 2 F F 1.2.1 F (cohort) 1.2.2 (case-control) 1.2.3 (multiple-time series) F F adrenaline F ˂ F 2. F + , - F F F F F F F F F F F / F F F ( F ˁ ) F F F F F F ( ) F F F F / F F F / F F F F 1 F F:- 2.1 F 1 ( 1 F F 1 , 2 F F 2 ) F F F 2.2 3 / 4 3. F +/- F F F F F F F F ( F F F F F F F F) F :- 3.1 F ˆ ( F F F) F F F
  48. 48. 98 3.1.1 F 3.1.2 F ˈ 3.1.3 F (surrogated end-point) 3.1.4 F F (safety monitoring program : SMP) 3.1.5 F 3.2 ( 1 / 2) F 3.3 F F 3.4 F F (ultimate end points) F 3.5 F F F F F ˆ F F F
  49. 49. 99 F 2 F F 1. Prayurahong B, Chanjanakijskul S, Supawan P, et al. Vitamin B12, Folic Acid and Hematological status in elderly thais. J Med Assoc Thai 1993:76;71-78. 2. Assantachai P, Yamwong P, Chongsuphaijaisiddhi T. Relationship of vitamin B1, B12m Folate and the cognitive ability of the Thai rural elderly. J Med Assoc Thai 1997;80:700-705. 3.3 Management of caregivers 1. New Zealand Guidelines Group New Zealand Guidelines Completed: Guide.(1998- 2003),Site Development and Management by ENIGMA. 2. Brien J., Ames D,Burns A. eds. Dementia:Family Carers for People with Dementia.2nd ed. London:Arnold,2000. 3. . . : F F ,2537 4. . F : F F, ʾ 27, 3, 2537. 5. Alzheimer , Association . Alzheimer , s Disease Guidelines: A Summary for Patients,Family and Friends.American Academy of Neurology. 3.4 ˆ F 1. Mender MF. Cummings TL. Dementia: A Clinical Approach. Elsevier: Butterworth Heinemann, 2003 2. Spar TE, Rue AL. Clinical Mann cal of Geriatric Psychiatry. Washington, DC: A Mercian Psychiatric Publishing. Inc. 2006. 3. (Clinical Practice Guideline for Dementia). 1 4. http://www. Inet.nswo.moph.go.th. F 19-36, 420-437. F 29 . 2551.
  50. 50. 100 3.5 ˀˊ F ˁ F (Physical rehabilitation) 1. Teri L, Gibbons LE, McCurry SM, Logsdon RG, Buchner DM, Barlow WE, et al. Exercise plus behavioral management in patients with Alzheimer disease: a randomized controlled trial. JAMA. 2003 ; 290 :2015-22. 2. Arkin SM. Alzheimer rehabilitation by students: interventions and outcomes. Neuropsychol Rehab 2001; 11 : 273-317. 3. Josephsson S, Backman L, Borell L, Bernspang B, Nygard L, Ronnberg L. Supporting everyday activities in dementia: an intervention study. Int J Geriatr Psychia 1993; 8 : 395-400. 4. Farina E, Fioravanti R, Chiaveri L, Imbornone E, Alberoni M, Pomati S, et al. Comparing two programs of cognitive training in Alzheimer s disease: a pilot study Acta Neurol Scand 2002 ; 105: 365-371. 5. Woolham J, Frisby B, Quinn S, Smart W, Moore A. The Safe at Home Project: using technology to support the care of people with dementia in their own homes. London: Hawker Publications Ltd; 2002. 6. Bach D, Bach M, Bohmer F, Fruhwald T, Grilc B. Reactivating Occupational Therapy: A Method to improve Cognitive Performance in Geriatric Patients. Age and Ageing 1995 ; 24 : 222-226. 7. Gitlin LN, Corcoran M, Winter L, Boyce A, Hauck WW. A randomized, controlled trial of a home environmental intervention: effect on efficacy and upset in caregivers and on daily function of persons with dementia. Gerontologist 2001 ; 41 : 4-14. 3.6 F (end of life care) 1.World Health Organization. Definition of palliative care. Geneva: WHO, 2002. www.who.int/cancer/palliative/definition/en/ 2.Sachs GA, Shega JW, Cox-Hayley D. Barriers to excellent end-of-life care for patients with dementia. J Gen Intern Med 2004; 19: 1057-63 3.Monias A, Meier DE. Palliative care in early, moderate, and advanced dementia. In: Cassel CK, ed. Geriatric medicine: An evidenced-based approach. New York: Springer, 2003: 343-58 4.Lyness JM. End-of-life care: Issues relevant to the geriatric psychiatrists. Am J Geriatr Psychiatry 2004; 12: 457-72
  51. 51. 101 5. F. End-of-life care. : , F F, . F 3. : F , 2547: 575-601 6.Post SC, Whitehouse PJ. Fairhill guidelines on ethics of the care of people with Alzheimer s disease: a clinical summary. J Am Geriatr Soc 1995; 43: 1423-9 7.Kim KY, Yeaman PA, Keene RL. End-of-life care for persons with Alzheimer s disease. Psychiatric Services 2005; 56: 139-41 8.Volicer L. Care at the end of life in severe dementia. In: Vellas B, Winblad B, Grundman M, eds. Severe dementia. Paris: Serdi Publisher, 2003: 194-9 9.Reisberg G, Ferris S, DeLeon M, et al. The global deterioration scale for assessment of primary degenerative dementia. Am J Psychiatr 1982; 139: 1136-9 10. Brookmeyer R, Corrada MM, Curriero FC, et al. Survival following a diagnosis of Alzheimer s disease. Arch Neurol 2002; 59: 1764-7 11. Finucane TE, Christmas C, Travis K. Tube feeding in patients with advanced dementia: A review of the evidence. JAMA 1999; 282: 1365-70 4.1 F F (non-pharmacological management of cognitive function) 1. APA : Treating Alzheimer s Disease and Other Dementias of Late Life, a quick reference/guide, May 1997. 2. Brown E J: Sndezelen, in Enhancing the Quality of Life in Advanced Dementia. Edited by Volicer L., Bloom Charette L.Philadelphia, PA, Brunner /Mazel, 1999, pp 169-185. 3. Butler RN : The Life Review : An Interpretation of Reminiscence in Aged. Psychiatry 26 : 65-76 : 1963. 4. Butler RN : Successful Aging and the Role of Life Review. J Am Geriatr Soc 22 : 529- 532,1974 . 5. Feil N : The Validation Breakthrough. Baltimore, MD, Health Professions Press, 1993. 6. Hanser SB : Music Therapy with Individuals with Advanced Dementia, in Enhancing the Quality of Life in Advanced Dementia. Edited by Volicer L. Bloom-Charette L. Philadelphia, PA, Brunner / Mazel, 1999, pp 141-167. 7. Norton LE, Malloy PF, Salloway S : The Impact of Behavioral Symptoms on Activities of Daily Living in Patients with Dementia. Am J Geriatr Psychiatry 9 : 41-48, 2001.
  52. 52. 102 8. Patten BM : The Ancient Art of Memory usefulness in treatment. Arch Neurol 26:25-31, 1972. 9. Piaget J. The Construction of Reality in Child. New York, Basic Book, 1954. 10. Pinkney L, Sarker P : Snoezelen : an Evaluation of An Environment Used by, People Who Are Elderly and Confused , in Sensations and Disability. Edited by Hutchinson R, Kewin J. Chesterfield , UK, Robinson and Sons, 1994, pp 172-182. 11. Teri L. Uomoto J. Reducing excess Disability in Dementia Patients : Waiving caregivers to manage patient depression Clinical Genealogist 10 : 49-63, 1991. 12. Schoffer G, Poon L : Individual Variability in Memory Training with the Elderly. Educ Gerostol 8 :217-229, 1982. 4.2 F (pharmacological management) Rogers SL, Farlow MR, Doody RS, et al. A 24-week, double-blind, placebo-controlled trial of donepezil in patients with Alzheimer s disease. Neurology 1998;50:136-45. Rogers SL, FriedhoffLT, for the Donepezil Study Group. The efficacy and safety of donepezil in patients with Alzheimer's disease: results of a US multicentre, randomized, double-blind, placebo-controlled trial. Dementia 1996;7:293-303. Cummings JL, Donobue JA, Brooks RL. The relationship between donepezil and behavioral disturbances in patients with Alzheimer's disease. J geriatr Psychiatry 2000;8:134-140. Feldman H, Gauthier S, Hecker J, et al. A 24-week, randomized, double-blind study of donepezil in moderate to severe Alzheimer s disease. Neurology 2001;57:613-20. Corey-Bloom J, Anand R, Veach J. A randomized trial evaluating the efficacy and safety of ENA 713 (rivastigmine tartrate), a new acetylcholinesterase inhibitor, in patients with mild to moderately severe Alzheimer s disease. Int J Geriatr Psychopharmacol 1998;1:55-65. Rosler M, Anand R, Cicin-Sain A, et al. Efficacy and safety of rivastigmine in patients with Alzheimer s disease: international randomised controlled trial. BMJ1999;318:633-40. Rosler M, Retz W, Retz-Junginger P, Dennler HJ. Effects of two-year treatment with the cholinesterase inhibitors rivastigmine on behavioural symptoms in Alzheimer's disease. Behavioural neurology 1998/1999;11:211-6.
  53. 53. 103 Wilcock GK, Lilienfeld S, Geans E. Efficacy and safety of galantamine in patients with mild to moderate Alzheimer s disease: multicentre randomised controlled trial. BMJ 2000;321 : 1-7. Tariot PN, Solomon PR, Morris JC, et al. A 5-month, randomized, placebo-controlled trial of galantamine in AD. Neurology 2000;54:2269-76. Raskind MA, Peskind ER, Wessel T, et al. Galantamine in AD: A 6-month randomized, placebo- controlled trial with a 6-month extension. Neurology 2000;54:2261-8. Donepezil-Treated Patients with Probable Vascular Dementia Demonstrate Cognitive Benefits, Annals New York Academy of Sciences. 2002;977:513-22. Donepezil in Vascular Dementia : A randomizwd, placebo controlled study, Neurology. 2003 Aug 26;61(4):479-86. Efficacy and tolerability of donepezil in vascular dementia. Positive results of a 24-week, Multicenter, International, Randomized, Placebo-controlled Clinical Trial, Stroke. 2003 Sep 11. 5 ˆ (Management of behavior & psychological symptoms of dementia) Alistair Burns, Bengt Winblad, Wiley. Bright light therapy. severe dementia, John wiley & sons Ltd. Satlin A, Volicer L, Ross V, Herz L, Campbell S (1992): Bright light trial of Behavioral & sleep disturbance in patients with dementia ,Am J Psychiatry 149(8):1028-1032. Skjeerve A, Holstein F, Agrsland D, Improvement in behavioral symptoms and advance of activity acrophone acter short steam bright light treatment in severe dementia Small wood J, Brown R, Coulter F, Irvine E, copland C (2001) Aromatherapy and behavior disturbance in dementia; a randomized controlled trial Int J Geriatr psychiatry, 16 (10):1010-1013. Lord TR, Garner JE (1993) Effects of music therapy on Alzheimer patients Percept Mot skill, 76(2) : 451-455. # Schneider LS et al. Risk of death with atypical antipsychotic drug treatment for dementia: meta- analysis of randomized placebo-controlled trials. JAMA 2005 Oct 19;294(15):1934-43.
  54. 54. 104 1 Larrieu S, Letenneur L, Orgogozo JM. Et al. Incidence and outcome of mild cognitive impairment in a population based propective cohort. Neurology 2002; 59:1594-9. 4 Reversible dementia Martyn C, Gale C: The British Medical Association.London: Dorling kindersley, 2002 5 Diagnostic and Statistical Manual of Mental Disorders,4th edition (DSM - IV TRTM ) American Psychiatry Association. Diagnostic and statistic manual of mental disorders. (DSM-IV-TRTM ) 4th edition. Washington (DC): American Psychiatric Press; 2000. 1. Folstein MF, Folstein SE, Mc Hugh PR. Mini Mental State: a practical method for grading the cognitive state of patient for the clinician. J Psychiatr Res 1975;12:189-98. 2. ( F F ). Train the Brain Forum (Thailand). Thai Mini Mental State Examination (TMSE). Siriraj Hosp Gaz 1993;45:359-74. 3. F F F . F MMSE-Thai 2002. 4. , . F F: F F , F F ; 5(4)2-7,2545.
  55. 55. 107 MMSE Thai 20023 Mini - Mental State Examination : Thai version (MMSE Thai 2002) 1. Orientation for time (5 ) ( F 1 ) 1.1 F .. 1.2 .. 1.3 .. 1.4 ʾ ʾ .. 1.5 .. 2. Orientation for place (5 ) ( F F F ) ( F 1 ) 2.1 F 2.1.1 F F ... .. 2.1.2 F F ... . 2.1.3 F - .. .. 2.1.4 . 2.2.5 .. .. 3. Registration (3 ) F ˈ 3 F ( , , ) ˆ F F ( ) F ( , , ) F F 3 F F F * F F F F F F ( 1 F 1 ) F F .. 2 F F F F F F . 4. Attention/Calculation (5 ) ( F F F ) F ˈ ( , ) ˈ ? F ˈ F F 4.1 F F ˈ F F F 4.2 4.1 " F 100 7 F F F .......... .......... .......... ........ F ( ) 5 F F 1,2, 3 F F F F F F F F F 4.2 F ( )
  56. 56. 108 4.2 " ( ) F F ( , ) ˆ F F ( , ) F F F - - - - ( , ) F ˆ " .......... .......... .......... .......... . 5. Recall (3 ) F F 3 F F F ( 1 F 1 ) F F 2 F F F F F F 6. Naming (2 ) 6.1 F F F F .. ... ...... 6.2 F F F F .. ... F 7. Repetition (1 ) ( F F F 1 ) " ˆ ( ) ( ) F F F ( , ) ( ) " " F F F" 8. Verbal command ( 3 ) F ˈ " ˆ ( ) F F F F ( , ) F F F ................"( , F , ) F F -4 F F F F F ( , F , ) 9. Written command (1 ) F ˈ ˈ F F ( , ) F F ( , ) F F F F F F .. 10. Writing (1 ) F ˈ " F ( , ) F F F F F 1 ................................ ..
  57. 57. 109 11.Visuoconstruction (1 ) F ˈ " F F ( F F F ) .. 30 • ≤ 22 MMSE-Thai 2002* Sensitivity Specificity Positive predictive value Negative predictive value efficiency F F ( F F F F) < 14 23 35.4 76.8 64.5 50.0 54.3 < 17 30 56.6 93.8 88.9 71.0 76.3 F < 22 30 92.0 92.6 91.2 93.3 92.4
  58. 58. 110 F F F 4 F F F ( F) F ( F F) 1. ( ) ( ) 2. F ˆ F ( ) ( ) 3. F F ˈ ( ) ( ) 4. F F ( ) ( ) 5. F F F F F ( ) ( ) 6. F ( ) ( ) 7. F F ( ) ( ) 8. F F F ( ) ( ) 9. F F F F F ˈ ( ) ( ) 10. ˆ ( F F F F F ) ( ) ( ) 11. F F F F ( ) ( ) < 4 F F F F > 4
  59. 59. 111 F ACh = Acetylcholine AChE = Acetylcholine esterase AD = Alzheimer s disease ADL = Activities of daily living APP = Amyloid precursor protein BuChE = Butyrylcholine esterase CADASIL = Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy CAG = Cytosine arginine - guanine ChEIs = Cholineesterase inhibitors CJD = Creutzfeldt Jakob disease CNS = Central nervous system CPG = Clinical practice guideline CVD = Cerebrovascular disease CYP = Cytochrome DLB = Dementia with Lewy bodies DRPLA = Dentatorubropallidoluysian atrophy EEG = Electroencephalography EPS = Extrapyramidal side effects fMRI = functional Magnetic resonance imaging FTD = Frontotemporal dementia LP = Lumbar puncture MCI = Mild cognitive impairment MMSE Thai 2002 = Mini - Mental State Examination : Thai version 2002 MMSE = Mini - Mental State Examination : Folstien et al 1975 MOCA = Montreal cognitive assessment MRI = Magnetic resonance imaging NPH = Normal pressure hydrocephalus NC = Negative correlation
  60. 60. 112 PC = Postive correlation PDD = Parkinson s disease dementia PET = Position emission tomography SCA = Spinocerebellar ataxia SPECT = Single photon emission computed tomography TMSE = Thai Mental State Examination : Train the Brain Forum VaD = Vascular dementia
  61. 61. 113 F F F F / F F F F 24 - 25 2551 1. . F F . . 2. . F 54 F 3. . F 66 F 4 4. . F F F 42 5. . ˂ F 57 6. F 65 7. . F F F 21 8. F F F F 13 9. . . F F 55 F 10. . F F 63 F F 11. F 63 F F 12. F F 23 13. . F F . . F 14. F F 15. . F . . 16. . ˈ . . 17. . F F . . F F 18. . F . . F 19. . F F . . F 20. . F F . .
  62. 62. 114 21. . F . . F F 22. . F . . F 23. . . . F F 24. . . . 25. . . . F - 26. . F . . 27. . F . . 28. . . . 29. . ʽ F . . 30. . ʽ . . 31. . F . . F

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