轉(zhuǎn)引文獻(xiàn)綜述: 癡呆患者的行為障礙--非藥物干與和精神藥物的應(yīng)用, 美國(guó)家庭醫(yī)生雜志, American Family Physician, 2016年8月15日。
這里摘錄用藥的部分。盡管 FDA警告精神藥物增加癡呆病人的死亡危險(xiǎn), 14%的老人院癡呆病人還是用了這類藥物。
約15%一75%的癡呆病人有妄想, 妄想性的自我定向障礙 (誤判自己的身份), 幻覺(jué)(常是幻視), 亂走, 激越, 攻擊性, 和其它精神行為異常。
FDA 不批準(zhǔn)抗精神藥物的使用是因?yàn)檎f(shuō)明有效的證據(jù)很差而對(duì)病人造成傷害的證據(jù)卻是高質(zhì)量的。所以, 醫(yī)生在開(kāi)始這項(xiàng)未得到批準(zhǔn)的治療時(shí), 要在病人承受的風(fēng)險(xiǎn)和得到好處間作出權(quán)衡。開(kāi)始用盡可能低的劑量, 再慢慢調(diào)節(jié)。晚間睡前服用。
有效性: 三個(gè)綜述關(guān)于非典型抗精神病藥物的報(bào)導(dǎo)一致地顯示了aripiprazole (Abilify) 有減輕癡呆病人行為和精神癥狀, 雖然這種減輕的程度是有限的, Abilify 的用量是2-10mg 每日, 是低量。
對(duì)olanzapine (Zyprexa) 5 mg/day, quetiapine (Seroquel) 50 mg/day, risperidone (Risperdal) 0.25--1.5 mg/day 的效果卻沒(méi)有得出一致的結(jié)論, 用量化方法(用數(shù)字給分) 去測(cè)定癥狀輕重的結(jié)果, Olanzapine 和quetiapine 效果最差。
沒(méi)有效的抗精神病學(xué)物有: ziprasidone (Geodon), paliperidone (Invega), clozapine (Clozaril), a senapine (Saphris), 還有iloperidone (Fanapt)。不過(guò)這些一般是精神科醫(yī)生才開(kāi)的藥, 用于治療精神分裂癥。
付作用: 抗多巴胺作用 antidopaminergic effects, 例如運(yùn)動(dòng)性障礙, 也可以出現(xiàn)在非典型抗精神病物治療中, 其它的付作用有抗膽堿作用, 錐體外系癥狀, 神經(jīng)惡性癥狀, 體位性低血壓, 過(guò)度鎮(zhèn)靜, 中風(fēng), 長(zhǎng)期應(yīng)用會(huì)增加發(fā)生下列情況的危險(xiǎn)性: 肥胖癥, 糖尿病, 高血壓, 血脂相異常。
令人關(guān)注更多的是有證據(jù)說(shuō)明這類藥物增加死亡率。在2015年, 一項(xiàng)回顧性的研究搜集了90000名患癡呆癥的復(fù)員軍人的病歷, 發(fā)現(xiàn)得到抗精神病藥物, 典型的藥物抑或不典型的, 比沒(méi)有得到這類藥物的有較高的死亡的危險(xiǎn)。這里引用了一個(gè)概念, 叫 NNH, a number needed to treat to harm, 治多少個(gè)病人會(huì)傷害病人? 具體數(shù)字如下: 對(duì)第一代抗精神病藥物, haloperidol 26, 第二代的, 死亡率增加最少的是 quetiapine NNH 50, 其次是olanzapine 40, riperidone 27。作為一個(gè)組, 用高劑量和低劑量相比, 用Olanzapine, quetiapine, risperidone 的病例死亡率有3.5%的增高。Aripiprazole 增大心血管的風(fēng)險(xiǎn), NNH 58, 但對(duì)死亡率的影響不明。
Lei Ding：This is complicated. Very D2 antagonist is still the best.Leaving sundowning alone without intervention is far worse than the risks they had claimed.
Lei Ding：Once you prescribe such a medication for a demented patient, sooner or later, a warning from the insurance company would come to you. In this dillema, we may not be sure how we are supposed to respond to them. Now, with this article, we at least have better idea to position ourselves.
Lei Ding：EMR gives you an option and you choose 'you are aware of the side effect' Then you will be ok. We treat the patient not insurance companies.
Lei Ding：大部分癡呆病人開(kāi)始被使用精神藥物源于護(hù)理人員的要求，病人不睡覺(jué)，試圖走動(dòng)，看到鬼怪等等；然后幻覺(jué)的診斷就來(lái)了。我個(gè)人覺(jué)得應(yīng)該像對(duì)待2，3歲的孩子那樣對(duì)待晚期癡呆的病人，照著教科書(shū)上做，護(hù)理人員應(yīng)該首先看病人是不是餓了，或是想大便，或是想小便，或者褲子濕了，或者白天被別護(hù)理指揮睡多了，或者只是想找個(gè)人說(shuō)說(shuō)話，記住他們只有幾歲的智力了。如果都不是，可以到下一步，是不是尿道感染，肺炎........ 精神藥物的作用應(yīng)該是臨時(shí)的，不應(yīng)該超過(guò)幾天
Lei Ding：說(shuō)的太好了。我覺(jué)得這是精神藥物濫用的重要因素之一。on the other hand, our doctors are at same positions. We don't want to spend too much time to explain the real situation or take responsibility if anything happens. JUST GIVE A PILL.
Lei Ding：I agree。Medications can make matters worse. However, doctors often prescribed medication to justify patient visit.
Lei Ding：是啊,人文關(guān)懷勝過(guò)藥物。病人也不想吃精神藥物。
Lei Ding：those patients may not be able to 'think '.
Lei Ding：這些病人在有語(yǔ)言表達(dá)錯(cuò)亂,行為異常的時(shí)候,不能立刻以為其語(yǔ)言理解能力也同等程度下降了。因?yàn)樗麄兛梢灾滥姆N藥是精神藥物,并且拒絕吃。
Lei Ding：另外這類藥太貴，藥廠起了不好的作用
Lei Ding：There should be a dementia specialist and insomnia specialist. It is hard to take care of these patients when patients don't want to see a psychiatrist and all these meds need to be metered. Home aids and family members usually have no skill to take care these patients. Every one around it is suffering, and we don't have much to offer.
Lei Ding：yes. It is complicated and time consuming issues. So far we don't have specialist on this field except psychiatrists.
Lei Ding：Neuropsychiatrist is a subspecialty is psychiatrist for dementia
Lei Ding：how can we find them? There are very few around with difficulty to make appointment and not accept most insurance.
Lei Ding：Geriatric psychiatrist Dr. Austria.
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