老年痴呆症的评估与认知康复治疗

1、老年痴呆症的评估与认知康复治疗(AssessmentandCognitiveRehabilitationonDementia)李月英(香港)葵涌医院背景：香港人口有急剧老化的现象。根据香港统计处的数据显示，于1991年的65岁或以上的老年人口占香港8.7%,于2004年增长至11.9%,及至2031年则会增加至约25%于1988年赵凤琴教授于本港进行的老年痴呆症流行病率研究显示，65岁或以上的长者约有4%患有老年痴呆症,70岁或以上的长者则约有6%患有老年痴呆症。海外研究显示，80岁或以上的长者约有20%!老年痴呆症，病发比率随年龄增长而增加。香港社会服务联会于1997年在护理安老院进行研究，

2、结果发现约37%勺长者患有老年痴呆症。因此，及早对老年痴呆症病者进行评估及订定适切的认知训练是对老年痴呆症病者很重要的。技术分享：评估老年痴呆症长者包括以下几方面：精神状况，身体功能，日常生活操作，家居支持及环境设计等。作业治疗师会因应老年痴呆症患者的能力，选择合适的标准的评估工具。常用的认知能力评估工具包括：Mini-MentalStateExamination(MMSE),MattisDementiaRatingScale(DRS),KendrickCognitiveTestsfortheElderly,FULDObjectMemoryEvaluation,CliftonAssessmen

3、tProceduresoftheElderly,RivermeadBehaviouralMemoryTest,HierarchialDementiaRatingScale,SevereImpairmentBattery,Ellen'sDiagnosticModule,ClockDrawingTest,Silver'sTest等。评估情绪方面，我们会采用老人忧郁症短量表ChineseVersionGeriatricDepressionShortForm。日常生活评估工具包括：ModifiedBarthelIndex,LawtonIADLScale,ChineseDisabilit

4、yAssessmentforDementia,AssessmentMotor&ProcessScale等。评估患者及其家人的生活质素和生活压力与及居住环境(包括实物环境及人物环境)是痴呆症患者的康复中很重要的一环，评估工具包括：WHOQQBref)&QOLinAlzheimer'sDisease(QOL-AD),GeneralHealthQuestionnaire(GHQ),RelativesStressScale,ZaritCarerStressIndex及SafetyAssessmentofFunction&theEnvironmentforRehabili

5、tation(SAFER)等。评估痴呆症患者的发展阶段，我们会使用GlobalDeteriorationScale(GDS)及FunctionalAssessmentStagingTest(FAST)。痴呆症患者有认知缺损，他们的近期记忆较差，集中注意力也较弱。执行及处理日常生活事情也有相当的困难，以致能否安全地在小区生活也是一个疑问。认知残障模式(COGNITIVEDISABILITYMODEL,Katz,2004)应用于老年痴呆症的复康，旨在增加患者的功能及减低他们的残障。训练患者的策略是因应长者的认知能力而改变环境，以增强痴呆症患者日常生活的适应能力。作业治疗师会因应患者个别的需要，订定

6、有系统的认知及记忆训练，并提供一些记忆改善设施，以协助痴呆症患者在小区生活，并改善生活质素。记忆策略包括组织法、重复法、分类法、联想法及善用记忆辅助工具等。英国的研究显示，有系统的记忆训练可以改善早期痴呆症患者的记忆及减少伤残障碍。认知训练包括不同的训练活动：现实导向训练、怀缅治疗、记忆训练、计算机软件训练、认知剌激训练等。伦敦的随机临床测验(RCT)研究显示(Spector,2003),201位在小区的长者，参与认知剌激治疗后，在认知能力及生活质素两方面都有改善。6个随机临床测验现实导向训练的研究(RCT)显示(Spector,2005),共125位痴呆症患者，67人在实验组，58人在非实验

7、组，现实导向训练可帮助老年痴呆症患者改善认知能力和行为问题。=记忆训练包括打麻将、配对游戏、骨排游戏、宾哥游戏、拼图活动、问答活动及教授记忆力策略等。陈章明教授及余枝胜医生于2005年在香港发表的研究报告显示，三十位居住老人院的长者，参与打麻将治疗后，认知、情绪及运算能力方面也有改善。痴呆症的情度则由中度痴呆症进展到轻度痴呆症。其实打麻将治疗也是一种切合中国文化的认知训练活动。因应痴呆症患者的教育背景，治疗师可编写阅读及书写的认知训练活动。作业治疗师可与家人商讨家居认知训练计划，定期检讨复康计划，以切合患者的情况。结论作业治疗师会因应个别痴呆症患者的能力和需要及痴呆症患者的发展阶段而提供适当的

8、评估及认知复康训练。治疗师会定期与家人一起检讨复康计划，以协助痴呆症之长者能够活得精采，长者及其家人会有较佳的生活质素。老年痴呆症的评估与认知康复治疗(AssessmentandCognitiveRehabilitationonDementia)李月英(香港)葵涌医院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