老年癡呆癥的評(píng)估與認(rèn)知康復(fù)治療

1、老年癡呆癥的評(píng)估與認(rèn)知康復(fù)治療(Assessment and Cognitive Rehabilitation on Dementia)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(jì)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(zhǎng)至11.9%，及至2031年則會(huì)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(zhǎng)者約有4%患有老年癡呆癥，70歲或以上的長(zhǎng)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(zhǎng)者約有20%患老年癡呆癥，病發(fā)比率隨年齡增長(zhǎng)而增加。香港社會(huì)服務(wù)聯(lián)會(huì)于1997年在護(hù)

2、理安老院進(jìn)行研究，結(jié)果發(fā)現(xiàn)約37%的長(zhǎng)者患有老年癡呆癥。因此，及早對(duì)老年癡呆癥病者進(jìn)行評(píng)估及訂定適切的認(rèn)知訓(xùn)練是對(duì)老年癡呆癥病者很重要的。技術(shù)分享: 評(píng)估老年癡呆癥長(zhǎng)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(jì)等。作業(yè)治療師會(huì)因應(yīng)老年癡呆癥患者的能力，選擇合適的標(biāo)準(zhǔn)的評(píng)估工具。常用的認(rèn)知能力評(píng)估工具包括Mini-Mental State Examination(MMSE), Mattis Dementia Rating Scale(DRS), Kendrick Cognitive Tests for the Elderly, FULD Object Memory Eva

3、luation, Clifton Assessment Procedures of the Elderly, Rivermead Behavioural Memory Test, Hierarchial Dementia Rating Scale, Severe Impairment Battery, Ellens Diagnostic Module, Clock Drawing Test , Silvers Test等。評(píng)估情緒方面，我們會(huì)采用老人憂(yōu)郁癥短量表Chinese Version Geriatric Depression Short Form。日常生活評(píng)估工具包括Modified

4、Barthel Index, Lawton IADL Scale, Chinese Disability Assessment for Dementia , Assessment Motor & Process Scale等。 評(píng)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(píng)估工具包括WHOQOL (Bref) & QOL in Alzheimers Disease (QOL-AD), General Health Questionnaire (GHQ), Relatives Stress Scale, Zari

5、t Carer Stress Index 及Safety Assessment of Function & the Environment for Rehabilitation(SAFER)等。評(píng)估癡呆癥患者的發(fā)展階段，我們會(huì)使用Global Deterioration Scale (GDS) 及Functional Assessment Staging Test (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(gè)疑問(wèn)。認(rèn)知?dú)堈夏Ｊ?COGNITIVE DISABILITY MODEL, K

6、atz, 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(zhǎng)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(huì)因應(yīng)患者個(gè)別的需要， 訂定有系統(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(lèi)法、聯(lián)想法及善用記憶輔助工具等。英國(guó)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(dòng)現(xiàn)實(shí)導(dǎo)向訓(xùn)練、懷緬治療、記憶訓(xùn)練、計(jì)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(cè)驗(yàn)(RCT)研究顯示(Spector, 2003)，201位

7、在小區(qū)的長(zhǎng)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(gè)隨機(jī)臨床測(cè)驗(yàn)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(yàn)組，58人在非實(shí)驗(yàn)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(wèn)題 。=記憶訓(xùn)練包括打麻將、配對(duì)游戲、骨排游戲、賓哥游戲、拼圖活動(dòng)、問(wèn)答活動(dòng)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(bào)告顯示，三十位居住老人院的長(zhǎng)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(guó)文化的認(rèn)知訓(xùn)練活動(dòng)。因應(yīng)癡呆癥患者

8、的教育背景，治療師可編寫(xiě)閱讀及書(shū)寫(xiě)的認(rèn)知訓(xùn)練活動(dòng)。作業(yè)治療師可與家人商討家居認(rèn)知訓(xùn)練計(jì)劃，定期檢討復(fù)康計(jì)劃，以切合患者的情況。結(jié)論 作業(yè)治療師會(huì)因應(yīng)個(gè)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)脑u(píng)估及認(rèn)知復(fù)康訓(xùn)練。治療師會(huì)定期與家人一起檢討復(fù)康計(jì)劃，以協(xié)助癡呆癥之長(zhǎng)者能夠活得精采，長(zhǎng)者及其家人會(huì)有較佳的生活質(zhì)素。老年癡呆癥的評(píng)估與認(rèn)知康復(fù)治療(Assessment and Cognitive Rehabilitation on Dementia)李月英 (香港) 葵涌醫(yī)院Backgraound: In HK, the population is ageing rapidly. A

9、ccording to data of HK Census & Statistic Dept., there was about 8.7 %, 11.9% and would be increased to about 25% of the elderly are of age 65 or above in 1991, 2004 and 2031 respectively. Local prevalence study in dementia showed that about 4% of elderly persons of age 65 or above and increased

10、 to 6% and those of age 70 or above were suffered from moderate to severe dementia in HK (Chiu, H, 1988). Overseas studies reported that about 20% of elderly persons aged 80 or above had dementia and the prevalence of dementia increases with age. Studies of HK Council of Social Services showed that

11、above 37% of elderly persons living in Care & Attention Home had dementia. Early assessment and provision of appropriate cognitive training are important in the rehabilitation of the dementia persons. From overseas data, about 50% of carers of clients of dementia have symptoms of dementia (Alzhe

12、imers Association, 2005)Experience Sharing: Assessment on dementia clients include the following aspects: mental, cognitive, physical, ADL, social support and home environment. Different validated standardized assessment tools are employed with reference to the functioning of the dementia clients. C

13、ommonly used cognitive screening & assessment tools are: Mini-Mental State Examination(MMSE) Chinese ver., Mattis Dementia Rating Scale(DRS), Alzheimers Disease Assessment Scale (Cognitive) ADAS-Cog, Kendrick Cognitive Tests for the Elderly, FULD Object Memory Evaluation, Clifton Assessment Proc

14、edures of the Elderly, Rivermead Behavioural Memory Test, Hierarchial Dementia Rating Scale, Severe Impairment Battery, Ellens Diagnostic Module, Clock Drawing Test and Silvers Test etc. For mood assessment, Chinese version Geriatric Depression Scale Short Form is used. ADL assessment tools include

15、Modified Barthel Index, Lawton IADL Scale, Chinese Disability Assessment for Dementia and Assessment Motor Process Scale. Assessment of QOL among dementia clients & their carer stress and their home environmental (including physical & human) are important in the rehabilitation of the elderly

16、: WHOQOL (Bref) & QOL in Alzheimers Disease (QOL-AD), General Health Questionnaire (GHQ), Relatives Stress Scale, Zarit Carer Stress Index and Safety Assessment of Function & the Environment for Rehabilitation(SAFER) will be employed. To assess the stages of development of dementia illness,

17、the Global Deterioration Scale (GDS) and the Functional Assessment Staging Test (FAST) are used. People with dementia suffered from cognitive impairment. They have very poor short term memory, attention/concentration problem and with deficits in executive functions. Thus, they have difficulties in p

18、lanning and initiating and manage their basic self-care and the instrumental ADL and with problems in living safely in the community. Cognitive Disability Model (Katz, 2004) is adopted with the goals to reduce disability and enhance the functioning of dementia clients. Training in task performance b

19、y adapting task to clients capacity & enable independence at dementia clients cognitive functioning level. Structured cognitive and memory training will be planned & adaptive device will be used with reference to the cognitive deficits so that clients will live in their own environment safel

20、y with community support and lead the life of better QOL. Memory strategies include techniques of Organization, Repetition, Categorization, Association etc. Use of memory aids (mnemonic devices) in daily life are also integrated into the memory strategies. “Systematic memory training can help some p

21、eople with early-stage Alzheimer's disease (AD) to sharpen their memories and reduce disability” British researchers stated.Cognitive training activities cover a wide range of activities: RO, Reminiscence Activities, memory training programmes, computer programme, cognitive stimulation programme

22、 etc. Overseas RCT study in London among 201 elderly persons (Spector, 2003) showed that cognitive stimulation therapy (including RO, Reminiscence & cognitive stimulation) improved the cognition and QOL of older people with dementia. Cochrane review in application of Reality Orientation (classro

23、om RO) indicated that RO has benefits on both cognition and behaviour for dementia suffers (Spector et al, 2005). Memory training programmes included playing mah-jong or pokers, matching game, playing dominoes, bingo games, constructing puzzles or participating in quiz and application of memory stra

24、tegies. Mahjong Therapy Study implemented in the Home for the Elderly in HK reported that pre & post assessment of 30 clients showed improvement in cognitive function, emotion and ability to calculate and the clients progressed from moderate stage of dementia to mild stage of dementia (Chan & Yu, 2005). Actually, playing mah-jong is also one of the activities that can be used in cognitive training with cultural relevancy to the Chinese.Reading or simple paper and pencils might be planned for some selected dementia clients, with reference to their education background