The expert consensus guideline series. Treatment of dementia and its behavioral disturbances. Introduction: methods, commentary, and summary.
The expert consensus guideline series. Treatment of dementia and its behavioral disturbances. Introduction: methods, commentary, and summary.
复制标题
专家共识指南系列。
作者：
G. Alexopoulos;D. Jeste;Henry Chung;D. Carpenter;R. Ross;J. Docherty
目标
自1998年，痴呆症的新老年人的躁动疗法以来，对痴呆症及其行为障碍的新治疗选择已成为可用的。虽然只有2种胆碱酯酶抑制剂，Donepezil和artarine，1998年提供了3个新认知的认知能力自那时以来，已经引入了增强剂，以及几种新的非典型抗精神病药和抗抑郁药。但是，来自对照研究的数据仍然有限，可以指导临床医生在这些药物中进行选择以及测序和结合处理。因此，我们对专家意见进行了一项新的调查研究，以治疗与痴呆症相关的认知障碍和行为障碍。
方法
根据文献综述，开发了61个问题的调查，其中有1,225个选项。大多数选项是使用RAND 9点量表的修改版本进行评分的，以评估医疗决策的适当性。对于其他选择，要求专家写答案。该调查被发送给50名北美痴呆症专家，其中100％完成了痴呆症。在分析对以9分量表评级的项目的响应时，共识被定义为通过卡方的“拟合度”测试的分数非随机分布。根据均值围绕平均值的95％置信区间，我们为每个选项分配了一个分类等级（第一行/优先，第二行/替代，第三行/通常不合适）。然后为选定的临床情况制定了表明首选治疗策略的指南。
结果
对于有痴呆症风险的患者，专家建议控制高血压和糖尿病。他们还建议使用阿司匹林，并考虑有血管痴呆症风险的患者中降脂剂。胆碱酯酶抑制剂是轻度认知障碍患者的一种选择（即，阿尔茨海默氏症患者的痴呆症[AD]）。为了减慢轻度/中度AD的认知障碍，专家建议仅使用胆碱酯酶抑制剂或与维生素E.多己酮和甘氨酸结合使用，是首选的胆碱酯酶抑制剂。专家建议将胆碱酯酶抑制剂与N-甲基-D-天冬氨酸（NMDA）拮抗剂（例如，美容）相结合，如果患有轻度/中度痴呆的患者对单一疗法的反应不足。在轻度/中度血管或混合AD/血管痴呆的患者中，对高血压和糖尿病的控制是选择的治疗方法，阿司匹林另一种一线选择。胆碱酯酶抑制剂也是轻度/中度混合AD/血管痴呆的一线选择。在轻度/中度痴呆症的非药理学干预措施中，专家建议护理人员教育，护理人员的支持疗法，转介到日间治疗，运动计划和喘息护理。对于中等/重度AD或混合AD/血管痴呆，专家建议将NMDA拮抗剂与胆碱酯酶抑制剂组合。对于中度/重度血管或混合AD/血管痴呆，他们建议控制高血压和糖尿病。专家的评级强调了旨在减轻更严重痴呆症的护理人员负担的非药理策略的重要性。躁动和其他行为干扰的管理是本研究的另一个重点。专家建议使用非典型抗精神病药对del妄，精神病，侵略或愤怒而进行搅动。他们还将考虑以身体侵略的危险来管理愤怒。建议选择性羟色胺再摄取抑制剂治疗痴呆症患者的抑郁或焦虑症。苯二氮卓类药物或非典型抗精神病药被视为急性焦虑的短期选择。推荐曲唑酮用于失眠。专家还提出了有关剂量水平，治疗持续时间以及为患有不同复杂状况的患者选择的建议。
结论
专家就治疗痴呆症和相关行为障碍的关键步骤达成了高度共识。在专家意见的范围内，并期望新的研究数据将优先考虑，这些准则可能会为临床医生提供指导，为痴呆症患者提供护理。
OBJECTIVES
New treatment options for dementia and its behavioral disturbances have become available since publication of The Expert Consensus Guidelines on the Treatment of Agitation in Older Persons with Dementia in 1998. While only 2 cholinesterase inhibitors, donepezil and tacrine, were available in 1998, 3 new cognitive-enhancing agents have been introduced since that time as well as several new atypical antipsychotics and antidepressants. However, there are still limited data from controlled studies to guide clinicians in choosing among these agents and sequencing and combining treatments. We therefore conducted a new survey study of expert opinion on the treatment of cognitive impairment and behavioral disturbances associated with dementia.
METHODS
Based on a literature review, a 61-question survey was developed with 1,225 options. Most options were scored using a modified version of the RAND 9-point scale for rating appropriateness of medical decisions. For other options, the experts were asked to write in answers. The survey was sent to 50 North American experts on dementia, 100% of whom completed it. In analyzing responses to items rated on the 9-point scale, consensus was defined as a nonrandom distribution of scores by chi-square "goodness-of-fit" test. Based on the 95% confidence interval around the mean, we assigned a categorical rank (first line/preferred, second line/alternate, third line/usually inappropriate) to each option. Guidelines indicating preferred treatment strategies were then developed for selected clinical situations.
RESULTS
For patients at risk for dementia, the experts recommended control of hypertension and diabetes. They also recommended aspirin and would consider a lipid-lowering agent in patients at risk for vascular dementia. Cholinesterase inhibitors were an option for patients with mild cognitive impairment (i.e., at risk for Alzheimer's dementia [AD]). To slow cognitive impairment in mild/moderate AD, the experts recommended a cholinesterase inhibitor alone or combined with vitamin E. Donepezil and galantamine were the preferred cholinesterase inhibitors. The experts recommended combining a cholinesterase inhibitor with a N-methyl-D-aspartate (NMDA) antagonist (e.g., memantine) if a patient with mild/moderate dementia has an inadequate response to monotherapy. Control of hypertension and diabetes was the treatment of choice, in patients with mild/moderate vascular or mixed AD/vascular dementia, with aspirin another first-line option. Cholinesterase inhibitors were also a first-line option for mild/moderate mixed AD/vascular dementia. Among nonpharmacological interventions for mild/moderate dementia, the experts recommended caregiver education, supportive therapy for caregivers, referral to day treatment, exercise programs, and respite care. For moderate/severe AD or mixed AD/vascular dementia, the experts recommended combining an NMDA antagonist with a cholinesterase inhibitor. For moderate/severe vascular or mixed AD/vascular dementia, they recommended control of hypertension and diabetes. The experts' ratings underscore the importance of nonpharmacological strategies aimed at reducing caregiver burden in more severe dementia. Management of agitation and other behavioral disturbances was another focus of this study. The experts recommended using an atypical antipsychotic for agitation associated with delirium, psychosis, aggression, or anger. They would also consider divalproex to manage anger with a risk of physical aggression. Selective serotonin reuptake inhibitors were recommended for the treatment of depression or anxiety in patients with dementia. Benzodiazepines or atypical antipsychotics were viewed as short-term options for acute anxiety. Trazodone was recommended for insomnia. The experts also gave recommendations concerning dosage levels, duration of treatment, and choice of medications for patients with different complicating conditions.
CONCLUSIONS
The experts reached high levels of consensus on key steps in treating dementia and associated behavioral disturbances. Within the limits of expert opinion and with the expectation that new research data will take precedence, these guidelines may provide direction for clinicians offering care to patients with dementia.