老年癡呆癥的評估與認(rèn)知康復(fù)治療

1、老年癡呆癥的評估與認(rèn)知康復(fù)治療(AssessmentandCognitiveRehabilitationonDementia)李月英(香港)葵涌醫(yī)院背景：香港人口有急劇老化的現(xiàn)象。根據(jù)香港統(tǒng)計處的數(shù)據(jù)顯示，于1991年的65歲或以上的老年人口占香港8.7%,于2004年增長至11.9%,及至2031年則會增加至約25%于1988年趙鳳琴教授于本港進(jìn)行的老年癡呆癥流行病率研究顯示，65歲或以上的長者約有4%患有老年癡呆癥,70歲或以上的長者則約有6%患有老年癡呆癥。海外研究顯示，80歲或以上的長者約有20%!老年癡呆癥，病發(fā)比率隨年齡增長而增加。香港社會服務(wù)聯(lián)會于1997年在護(hù)理安老院進(jìn)行研究，

2、結(jié)果發(fā)現(xiàn)約37%勺長者患有老年癡呆癥。因此，及早對老年癡呆癥病者進(jìn)行評估及訂定適切的認(rèn)知訓(xùn)練是對老年癡呆癥病者很重要的。技術(shù)分享：評估老年癡呆癥長者包括以下幾方面：精神狀況，身體功能，日常生活操作，家居支持及環(huán)境設(shè)計等。作業(yè)治療師會因應(yīng)老年癡呆癥患者的能力，選擇合適的標(biāo)準(zhǔn)的評估工具。常用的認(rèn)知能力評估工具包括：Mini-MentalStateExamination(MMSE),MattisDementiaRatingScale(DRS),KendrickCognitiveTestsfortheElderly,FULDObjectMemoryEvaluation,CliftonAssessmen

3、tProceduresoftheElderly,RivermeadBehaviouralMemoryTest,HierarchialDementiaRatingScale,SevereImpairmentBattery,Ellen'sDiagnosticModule,ClockDrawingTest,Silver'sTest等。評估情緒方面，我們會采用老人憂郁癥短量表ChineseVersionGeriatricDepressionShortForm。日常生活評估工具包括：ModifiedBarthelIndex,LawtonIADLScale,ChineseDisabilit

4、yAssessmentforDementia,AssessmentMotor&ProcessScale等。評估患者及其家人的生活質(zhì)素和生活壓力與及居住環(huán)境(包括實(shí)物環(huán)境及人物環(huán)境)是癡呆癥患者的康復(fù)中很重要的一環(huán)，評估工具包括：WHOQQBref)&QOLinAlzheimer'sDisease(QOL-AD),GeneralHealthQuestionnaire(GHQ),RelativesStressScale,ZaritCarerStressIndex及SafetyAssessmentofFunction&theEnvironmentforRehabili

5、tation(SAFER)等。評估癡呆癥患者的發(fā)展階段，我們會使用GlobalDeteriorationScale(GDS)及FunctionalAssessmentStagingTest(FAST)。癡呆癥患者有認(rèn)知缺損，他們的近期記憶較差，集中注意力也較弱。執(zhí)行及處理日常生活事情也有相當(dāng)?shù)睦щy，以致能否安全地在小區(qū)生活也是一個疑問。認(rèn)知?dú)堈夏Ｊ?COGNITIVEDISABILITYMODEL,Katz,2004)應(yīng)用于老年癡呆癥的復(fù)康，旨在增加患者的功能及減低他們的殘障。訓(xùn)練患者的策略是因應(yīng)長者的認(rèn)知能力而改變環(huán)境，以增強(qiáng)癡呆癥患者日常生活的適應(yīng)能力。作業(yè)治療師會因應(yīng)患者個別的需要，訂定

6、有系統(tǒng)的認(rèn)知及記憶訓(xùn)練，并提供一些記憶改善設(shè)施，以協(xié)助癡呆癥患者在小區(qū)生活，并改善生活質(zhì)素。記憶策略包括組織法、重復(fù)法、分類法、聯(lián)想法及善用記憶輔助工具等。英國的研究顯示，有系統(tǒng)的記憶訓(xùn)練可以改善早期癡呆癥患者的記憶及減少傷殘障礙。認(rèn)知訓(xùn)練包括不同的訓(xùn)練活動：現(xiàn)實(shí)導(dǎo)向訓(xùn)練、懷緬治療、記憶訓(xùn)練、計算機(jī)軟件訓(xùn)練、認(rèn)知剌激訓(xùn)練等。倫敦的隨機(jī)臨床測驗(RCT)研究顯示(Spector,2003),201位在小區(qū)的長者，參與認(rèn)知剌激治療后，在認(rèn)知能力及生活質(zhì)素兩方面都有改善。6個隨機(jī)臨床測驗現(xiàn)實(shí)導(dǎo)向訓(xùn)練的研究(RCT)顯示(Spector,2005),共125位癡呆癥患者，67人在實(shí)驗組，58人在非實(shí)驗

7、組，現(xiàn)實(shí)導(dǎo)向訓(xùn)練可幫助老年癡呆癥患者改善認(rèn)知能力和行為問題。=記憶訓(xùn)練包括打麻將、配對游戲、骨排游戲、賓哥游戲、拼圖活動、問答活動及教授記憶力策略等。陳章明教授及余枝勝醫(yī)生于2005年在香港發(fā)表的研究報告顯示，三十位居住老人院的長者，參與打麻將治療后，認(rèn)知、情緒及運(yùn)算能力方面也有改善。癡呆癥的情度則由中度癡呆癥進(jìn)展到輕度癡呆癥。其實(shí)打麻將治療也是一種切合中國文化的認(rèn)知訓(xùn)練活動。因應(yīng)癡呆癥患者的教育背景，治療師可編寫閱讀及書寫的認(rèn)知訓(xùn)練活動。作業(yè)治療師可與家人商討家居認(rèn)知訓(xùn)練計劃，定期檢討復(fù)康計劃，以切合患者的情況。結(jié)論作業(yè)治療師會因應(yīng)個別癡呆癥患者的能力和需要及癡呆癥患者的發(fā)展階段而提供適當(dāng)?shù)?/p>

8、評估及認(rèn)知復(fù)康訓(xùn)練。治療師會定期與家人一起檢討復(fù)康計劃，以協(xié)助癡呆癥之長者能夠活得精采，長者及其家人會有較佳的生活質(zhì)素。老年癡呆癥的評估與認(rèn)知康復(fù)治療(AssessmentandCognitiveRehabilitationonDementia)李月英(香港)葵涌醫(yī)院todataofHKCensus&StatisticBackgraound:InHK,thepopulationisageingrapidly.AccordingDept.,therewasabout8.7%,11.9%andwouldbeincreasedtoabout25%oftheelderlyareofage65o

9、rabovein1991,2004and2031respectively.Localprevalencestudyindementiashowedthatabout4%ofelderlypersonsofage65oraboveandincreasedto6%andthoseofage70oraboveweresufferedfrommoderatetoseveredementiainHK(Chiu,H,1988).Overseasstudiesreportedthatabout20%ofelderlypersonsaged80orabovehaddementiaandtheprevalenc

10、eofdementiaincreaseswithage.StudiesofHKCouncilofSocialServicesshowedthatabove37%ofelderlypersonslivinginCare&AttentionHomehaddementia.Earlyassessmentandprovisionofappropriatecognitivetrainingareimportantintherehabilitationofthedementiapersons.Fromoverseasdata,about50%ofcarersofclientsofdementiah

11、avesymptomsofdementia(AlzheimersAssociation,2005)ExperienceSharing:Assessmentondementiaclientsincludethefollowingaspects:mental,cognitive,physical,ADL,socialsupportandhomeenvironment.Differentvalidatedstandardizedassessmenttoolsareemployedwithreferencetothefunctioningofthedementiaclients.Commonlyuse

12、dcognitivescreening&assessmenttoolsare:Mini-MentalStateExamination(MMSE)Chinesever.,MattisDementiaRatingScale(DRS),Alzheimer'sDiseaseAssessmentScale(Cognitive)ADAS-Cog,KendrickCognitiveTestsfortheElderly,FULDObjectMemoryEvaluation,CliftonAssessmentProceduresoftheElderly,RivermeadBehaviouralM

13、emoryTest,HierarchialDementiaRatingScale,SevereImpairmentBattery,EllensDiagnosticModule,ClockDrawingTestandSilversTestetc.Formoodassessment,ChineseversionGeriatricDepressionScaleShortFormisused.ADLassessmenttoolsincludeModifiedBarthelIndex,LawtonIADLScale,ChineseDisabilityAssessmentforDementiaandAss

14、essmentMotorProcessScale.AssessmentofQOLamongdementiaclients&theircarerstressandtheirhomeenvironmental(includingphysical&human)areimportantintherehabilitationoftheelderly:WHOQOL(Bref)&QOLinAlzheimersDisease(QOL-AD),GeneralHealthQuestionnaire(GHQ),Relatives'StressScale,ZaritCarerStres

15、sIndexandSafetyAssessmentofFunction&theEnvironmentforRehabilitation(SAFER)willbeemployed.Toassessthestagesofdevelopmentofdementiaillness,theGlobalDeteriorationScale(GDS)andtheFunctionalAssessmentStagingTest(FAST)areused.Peoplewithdementiasufferedfromcognitiveimpairment.Theyhaveverypoorshorttermm

16、emory,attention/concentrationproblemandwithdeficitsinexecutivefunctions.Thus,theyhavedifficultiesinplanningandinitiatingandmanagetheirbasicself-careandtheinstrumentalADLandwithproblemsinlivingsafelyinthecommunity.CognitiveDisabilityModel(Katz,2004)isadoptedwiththegoalstoreducedisabilityandenhancethe

17、functioningofdementiaclients.Trainingintaskperformancebyadaptingtasktoclients'capacity&enableindependenceatdementiaclientscognitivefunctioninglevel.Structuredcognitiveandmemorytrainingwillbeplanned&adaptivedevicewillbeusedwithreferencetothecognitivedeficitssothatclientswillliveintheirown

18、environmentsafelywithcommunitysupportandleadthelifeofbetterQOL.MemorystrategiesincludetechniquesofOrganization,Repetition,Categorization,Associationetc.Useofmemoryaids(mnemonicdevices)indailylifearealsointegratedintothememorystrategies."Systematicmemorytrainingcanhelpsomepeoplewithearly-stageAl

19、zheimer'sdisease(AD)tosharpentheirmemoriesandreducedisability"Britishresearchersstated.Cognitivetrainingactivitiescoverawiderangeofactivities:RO,ReminiscenceActivities,memorytrainingprogrammes,computerprogramme,cognitivestimulationprogrammeetc.OverseasRCTstudyinLondonamong201elderlypersons(

20、Spector,2003)showedthatcognitivestimulationtherapy(includingRO,Reminiscence&cognitivestimulation)improvedthecognitionandQOLofolderpeoplewithdementia.CochranereviewinapplicationofRealityOrientation(classroomRO)indicatedthatROhasbenefitsonbothcognitionandbehaviourfordementiasuffers(Spectoretal,200

21、5).Memorytrainingprogrammesincludedplayingmah-jongorpokers,matchinggame,playingdominoes,bingogames,constructingpuzzlesorparticipatinginquizandapplicationofmemorystrategies.MahjongTherapyStudyimplementedintheHomefortheElderlyinHKreportedthatpre&postassessmentof30clientsshowedimprovementincognitiv

22、efunction,emotionandabilitytocalculateandtheclientsprogressedfrommoderatestageofdementiatomildstageofdementia(Chan&Yu,2005).Actually,playingmah-jongisalsooneoftheactivitiesthatcanbeusedincognitivetrainingwithculturalrelevancytotheChinese.Readingorsimplepaperandpencilsmightbeplannedforsomeselecteddementiaclients,withrefe