全科醫(yī)學中的心理健康病案研究 (十五)
——一位老人的抑郁（第二部分）

2013-01-26 17:31:38FionaJuddGrantBlashkiLeonPiterman

中國全科醫(yī)學 2013年9期

關鍵詞：記憶

Fiona Judd，Grant Blashki，Leon Piterman （著），楊輝（譯）

作 (譯)者單位:3010 澳大利亞維多利亞州，澳大利亞Melbourne大學(Fiona Judd，Grant Blashki);澳大利亞Monash 大學(Leon Piterman，楊輝)

Affiliation:Melbourne University，Victoria 3010，Australia (Fiona Judd，Grant Blashki);Monash University (Leon Piterman)

注:Fiona Judd、Grant Blashki 的作者簡介見2012 年第1A 期，Leon Piterman 的作者簡介見2012 年第2A 期，見中國全科醫(yī)學雜志社官方網(wǎng)站(http://www. chinagp. net);文后附英文來稿原文

1 病史

瓊第一次來看病是12 個月前（參見上期病案研究）。經(jīng)過接下來6 個月內(nèi)的數(shù)次就診，你給他的診斷是抑郁，并開始采用氟西汀（百憂解）和人際關系治療（ IPC）相結合的治療措施。在第一次做出診斷的時候，你已經(jīng)注意到瓊的抑郁癥狀和記憶主訴是比較突出的。你給瓊的解釋是，這些問題是抑郁的表現(xiàn)，通過抗抑郁藥的治療就會得到解決。不過6 個月過去了，百憂解的藥量加到了40 mg/d，瓊的記憶問題一直沒有好轉。

2 進一步的病史

瓊說他感到情緒好多了，只不過還是一直擔心他的記憶問題。他的睡眠情況已經(jīng)正常，食欲也恢復了正常。他說自己做事情的興趣和動機也恢復到原來的狀況。但是，他說自己總是忘事兒。他說自己記不清楚父親最初患老年癡呆癥的時候是什么樣子，不過他能夠生動地回憶起父親患病晚期時候的樣子。瓊說現(xiàn)在自己很簡單的事情都記不起來，比如記不住剛才把東西放在哪里了，跟人約好的事情轉眼就忘了，他妻子跟他說他總是重復做某些事情。這讓他很有挫敗感。不過，他對很早以前發(fā)生的事情卻記得很清楚。

3 體檢

瓊一如既往地穿戴整齊。不過很有意思的是，他穿了一雙不成對的襪子。而且細心的你還發(fā)現(xiàn)，他的領帶上沾了污跡，這與他的穿戴有些不協(xié)調(diào)。他看上去有些緊張，不過他否認自己焦慮，只是認為自己的記憶有問題。他也否認自己感到抑郁。他的情緒不像是憂郁的。沒有抑郁的想法，也沒有知覺障礙。他的注意力和集中力是受損的，而且正如以前診斷的那樣，主要是瞬時和短期記憶受損。

4 提問

4.1 可能的診斷是什么?

4.2 需要做哪些進一步的評估?

4.3 怎樣治療瓊的問題?

5 解答

5.1 可能的診斷可能的診斷是“老年癡呆癥”。瓊的抑郁問題已經(jīng)通過以前的治療得到了好轉，而他的記憶問題卻一直存在。雖然抗抑郁藥能造成某些認知紊亂，但通常影響是很輕微的，而且選擇性5 -羥色胺再攝取抑制劑(SSRI)所造成的影響要比其他抗抑郁藥小得多。所以，不太可能是抗抑郁藥造成瓊的記憶問題。

重要的是，有些身體健康的老年人，特別是那些越來越擔心自己患有老年癡呆癥的老年人，也會總關注自己的記憶問題，而且會不斷地尋求別人的慰藉，確認自己不是一步步地走向老年癡呆癥。對于那些有輝煌過去的老年人來說，這種心情最為普遍，他們會認為隨著衰老的過程，自己的認知速度、記憶和集中力也會衰退。所以現(xiàn)在要做的重要事情是給瓊做全面的記憶測驗，從而區(qū)分到底是真的記憶問題，還是他自己的過分擔心［1］。

5.2 進一步的評估應該進一步采集病史，主要了解阿爾茨海默病(Alzheimer's disease)、血管性癡呆(vascular dementia)的危險因素以及其他可能的原因，如頭部腫瘤和酒精濫用。所以，要進一步詢問家族史、卒中史、高血壓史、吸煙史、糖尿病史、高膽固醇血癥史。

最有用的病史是來自最熟悉瓊的人，比如他的妻子。要注意從他妻子那里了解瓊記憶問題發(fā)生的時間和頻率，以及她認為的任何認知和行為變化。

之前，瓊做過一些檢查和化驗，排除了軀體疾病。但是這些檢查還應該繼續(xù)做，來發(fā)現(xiàn)任何可以降低老年癡呆癥風險的原因。現(xiàn)在，應該給他做顱腦CT 檢查及血液檢查，包括人類免疫缺陷病毒(HIV)和梅毒血清學檢查、代謝篩查以及營養(yǎng)缺乏的評估。明確和糾正器官疾病并不能逆轉老年癡呆癥的發(fā)生，但這可以改善患者的生活質(zhì)量。

更進一步的認知測驗是做好評估的必要步驟。除了你已經(jīng)做過的各種測驗外，一定要正式地給患者做認知測驗。最常使用的測驗工具是簡易精神狀態(tài)檢查(mini mental state examination，MMSE)［2］。一般來說，MMSE 得分在23 分及以下，則提示明顯的認知缺損。

5.3 怎樣治療如果你的進一步評估結果證實可能診斷為老年癡呆癥，那么你的治療計劃取決于你對老年癡呆癥原因的推定。老年癡呆癥最常見的原因是阿爾茨海默病(60%)，其次為血管性癡呆和路易體癡呆(各占10%)。鑒于瓊有阿爾茨海默病的家族史，而沒有血管性癡呆的家族史，也沒有任何幻視(visual hallucinations，見于路易體癡呆)，所以最可能的病因是阿爾茨海默病。

膽堿酯酶抑制劑(cholinesterase inhibitors)可以輕微地改善記憶、精力和情緒，值得一用。但要注意，這類藥也有明顯的不良反應，如惡心、腹瀉、噩夢、腿部痙攣。在使用這些藥物之前，應該把瓊轉診給精神病學專家或老年精神病學專家，以便做進一步的評估。

對瓊的長期管理包括發(fā)現(xiàn)和治療共發(fā)的抑郁、譫妄或精神病癥狀;管理精神錯亂的行為(隨著老年癡呆癥的發(fā)展進程，這些行為會越來越常見);對家庭和照顧者提供支持;對法律和倫理問題保持關注，如患者在什么情況下可以繼續(xù)開車、患者的決策能力以及擬定遺囑的能力［3］。

譯者注:

簡易精神狀態(tài)檢查 (mini mental state examination，MMSE):總分為30 分的建議測量量表，用于篩查認知損害。該工具于1980 年代引進中國，用于精神衛(wèi)生研究和臨床實踐，關于中文版請參見張明園等［4］1995 年的報告。

膽堿酯酶抑制劑(cholinesterase inhibitors):常用藥物有多奈哌齊(安理申)、利凡斯的明(艾斯能)、加蘭他敏以及中國研制的雙益平。

1 Conner DO，Piterman L，Darvall L. Common mental health problems in the elderly//Blashki G，Judd F，Piterman L. General practice psychiatry ［M］. McGraw Hill Medical，2007:257 -276.

2 Folstein M，F(xiàn)olstein S，McHugh P. The mini mental state:A practical method for grading the cognitive state of patients for the clinician ［J］.Journal of Psychiatric Research，1975，12:189 -198.

3 Therapeutic guidelines ［Z］. Psychotropics，2008.

4 張明園，Elena Yu，何燕玲. 癡呆的流行病學調(diào)查工具及其應用［J］. 上海精神醫(yī)學，1995，7 (1):3 -5.

【Introduction of the Column】The Journal presents the Column of Case Studies of Mental Health in General Practice;with academic support from Australian experts in general practice，psychology and psychiatry from Monash University and the University of Melbourne. The Column's purpose is to respond to the increasing needs of mental health services in China. Through study and analysis of mental health cases，we hope to improve understanding of mental illnesses in Chinese primary health settings，and to build capacity of community health professional in managing of mental illnesses in general practice. Patient-centred and whole-person approach in general practice is the best way to maintain and improve the physical and mental health of residents. Our hope is that these case studies will lead new wave of general practice and mental health development both in practice and academic research. A number of Australian experts from the disciplines of general practice，mental health and psychiatry will contribute to the Column. You will find A/Professor Blashki，Professor Judd and Professor Piterman are authors of General Practice Psychiatry. The Journal cases are helping to prepare for the translation and publication of a Chinese version of the book in China. We believe Chinese mental health in primary health care will step up to a new level under this international cooperation.

Affiliation:Melbourne University，Victoria 3010，Australia (Fiona Judd，Grant Blashki);Monash University (Leon Piterman)

1 H istory

Jon first consulted you 12 months ago. After several visits over a 6 month period you made a diagnosis of depression and initiated treatment with Fluoxetine together with some interpersonal counselling (IPC). At the time of the initial diagnosis you had noted that amongst Jon' s depressive symptoms，memory complaints were prominent. You explained to Jon that you felt these complaints were part of his depression and would resolve with treatment with an antidepressant. However，after 6 months，the last 2 at a dose of 40 mg/day Fluoxetine，Jon's memory problems have persisted.

2 Further history

Jon reports that his mood feels good，other than his worries about his memory. His sleep is normal，his appetite is also normal，he has his interest and motivation back，but he forgets things. He indicates he does not know how his father's dementia first presented，but he vividly recalls the later stages of his father's illness. Jon reports he's frustrated as he can't remember simple things，where he's put things，has missed a couple of appointments，and his wife has told him he repeats things. By contrast，his memory for things in the past is as good as ever.

3 Exam ination

Jon presents as well dressed，but curiously he's wearing odd socks. And，again somewhat incongruently，he has a stain on his tie. He seems somewhat tense but denies feeling anxious，other than about his memory，and denies feeling depressed. His affect is not depressed. There is no depressive thought content and no perceptual disturbance. His attention and concentration are impaired，and as was the case when initially seen he has problems with immediate and short term memory.

4 Questions

4.1 What is your probability diagnosis?

4.2 What further assessment is required?

4.3 How should Jon be treated?

5 Answers

5.1 The probability diagnosis is possible dementia. Jon's depression has resolved with treatment，yet his memory problems persist. Whilst antidepressant medication can cause some disturbance of cognition，it is generally mild，and is more common with other classes of antidepressants than it is with the SSRI medications. Thus，this is not likely to be the cause of Jon's complaints.

Importantly，some normal older people，particularly those who are particularly concerned that they may be at increased risk of dementia may worry about and seek reassurance that they are not dementing. This is most common in high achievers who notice age related changes in cognitive speed，memory and concentration. It is important to carefully test Jon's memory to make this differentiation［1］.

5.2 Further history taking should focus on risk factors for Alzheimer's disease，vascular dementia，and other possible causes such as head trauma and alcohol abuse. Thus，ask about family history，history of stroke，hypertension，smoking，diabetes mellitus and hypercholesterolemia.

The most useful history will be obtained from someone who knows Jon well- his wife. It is important to check the duration and rate of onset of the memory problems，and have her account of any cognitive and behavioural change.

Jon has had some initial investigations to exclude physical problems but these need to be extended now to detect any potentially reversible cause of dementia. Investigations should include a CT head scan and blood tests including HIV and syphilis serology，metabolic screen， and assessment for nutritional deficiency. Identification and correction of organic problems may not necessarily reverse the dementia but will improve the patient's quality of life.

More extensive cognitive testing is an essential part of the assessment. In addition to any simple testing you have already done，it is important to formally test cognition，most often this is done using an instrument such as the Mini Mental State Examination(MMSE)［2］. Generally speaking，a score of 23 or less is suggestive of significant cognitive impairment.

5.3 If your further assessment confirms the likely diagnosis of dementia，further treatment will depend on the presumed cause of the dementia. Alzheimer's disease is the most common cause of dementia (60%)，followed by vascular disease and Lewy body dementia(each 10% of cases). Given Jon has a family history of Alzheimer's disease，no history of vascular problems and has not reported any visual hallucinations (seen in Lewy body dementia)the most likely cause is Alzheimer's disease.

The cholinesterase inhibitors may produce small but worthwhile improvements in memory，energy and mood. However，they have significant side effects including nausea，diarrhoea，vivid dreams and leg cramps. Jon should be referred to a psychiatrist or psychogeriatrician for further assessment before he is started on these medications.

Longer term management includes the detection and treatment of co - occurring depression，delirium or psychotic symptoms;management of disturbed behaviours which become more common as dementia worsens;support of family and carers;and attention to legal and ethical issues such as how long should the person continue to drive a car，capacity to make decisions and testamentary capacity［3］.

Notes:

Mini mental state examination (MMSE):It is a 30 - point questionnaire test which is used to screen for cognitive impairment. The tool was introduced into China in middle 1980s，and was used in mental health research and clinical practice. For more informationabout Chinese version MMSE，see Zhang 1995［4］.

Cholinesterase inhibitors: rivastigmine， donepezil， galantamine are used in Chinese healthcare system. Huperzine (a Chinese developed medicine)is also used.