以實證觀點探討失智症行為精神症狀之照護

Behavioral and Psychological Symptoms for Dementia: An Evidence-based Perspective

10.6386/CGN.202309_34(3).0004

陳秋月(Chiu-Yueh Chen)；簡淑慧(Sui-Whi Jane)

失智症 ； 失智症合併行精神症狀 ； 實證護理 ； dementia ； behavioral and psychological symptoms of dementia ； evidence-based nursing

長庚護理

34卷3期（2023 / 09 / 01）

36 - 45

繁體中文;英文

在台灣，失智症盛行率約1.35%，且近90%病患會合併出現行為精神症狀，激動易怒、言語及行為攻擊、失控行為、憂鬱、焦慮、妄想和幻覺等，且隨疾病惡化增加主要照顧者負荷或導致機構化照顧，也增加醫護人員照顧上的挑戰，本文透過實證文獻探討，失智症精神行為之生理病理機轉及臨床徵象、評估、處置及照護，以提升護理人員對於失智症行為精神症狀的生物心理社會照護認知，進而改善其照護品質。綜合本實證文獻發現，失智症精神行為症狀可透過及早評估其認知及生活功能，釐清是否進入精神行為症狀，根據其嚴重性提供適切的處置。當病患因出現急性症狀以精神科藥物治療時，須監控藥物所產生之副作用，以減少對病患日常生活安全性之衝擊。臨床上，建議透過全人照顧模式，結合在地化社區資源提供照顧者對失智症行為精神症狀及因應策略之教育訓練，並提供病患以功能性分析為基礎之行為治療介入處置、回憶治療或輔助治療，進而提升病患及其照顧者的照護品質。

The prevalence rate of dementia is around 1.35% in Taiwan, with nearly 90% of patients concurrently experiencing behavioral and psychological symptoms of dementia (BPSD). These symptoms include agitation, irritability, verbal and behavioral aggression, disruptive behavior, depression, anxiety, delusions, and hallucinations. The progression of dementia places a significant burden on caregivers and increases the likelihood of institutionalized care, presenting challenges for healthcare providers. The paper discussed the pathophysiological mechanisms, clinical symptoms and signs, assessment methods, treatment options, and care strategies related to BPSD. Results indicated that BPSD can be identified by early assessment of patients' cognitive and functional abilities, allowing clinicians to tailor appropriate treatment modalities based on the severity of BPSD. When patients are treated with antipsychotic medication during the acute stage of BPSD, clinicians must closely monitor potential side effects. In clinical practice, we recommend a holistic model that combines localized community resources. This approach includes providing training programs for caregivers on BPSD and related coping strategies, implementing functional analysis-based interventions, incorporating reminiscence therapy, and exploring complementary alternative medicine (CAM). These strategies can enhance the quality of care and alleviate the challenges faced by their caregivers.

1. 吳怡慧, Y. H.,林明憲, M. S.(2017)。失智照護。臨床醫學月刊，79(1)，19-25。
   連結：
2. 陳怡亨, Y. H.,溫美蓉, M. R.,林麗嬋, L. C.(2020)。失智症行為精神症狀的導因與治療。榮總護理，37(4)，352-359。
   連結：
3. 黃正平, J. P.(2006)。失智症之行為精神症狀。台灣精神醫學，20(1)，3-18。
   連結：
4. 賴怡伶, Y. L.,傅進華, C. H.,游雅貴, Y. K.,陳慶元, C. Y.,許齡尹(2020)。以「五全概念」發展失智照顧技巧課程可行性研究。身心障礙研究季刊，18(2)，97-107。
   連結：
5. 蘇億玲, Y. L.,曾旻, M.,賴嘉敏, C. M.,楊雅婷, Y.-T.(2022)。應用Natural Helper Model提升失智據點服務成效之推動經驗。長庚護理，33(1)，58-70。
   連結：
6. Aarsland, D.(2020).Epidemiology and pathophysiology of dementia-related psychosis.Journal of Clinical Psychiatry,81(5),AD19038BR1C.
7. Arvanitakis, Z.,Shah, R. C.,Bennett, D. A.(2019).Diagnosis and Management of Dementia: A Review.JAMA,322,1589-1599.
8. Ayers, C. R.,Davidson, E. J.,Dozier, M. E.,Twamley, E. W.(2020).Cognitive rehabilitation and exposure/sorting therapy for late-life hoarding: Effects on neuropsychological performance.The Journals of Gerontology: Series B, Psychological Sciences and Social Sciences,75(6),1193-1198.
9. Bessey, L. J.,Walaszek, A.(2019).Management of behavioral and psychological symptoms of dementia.Current Psychiatry Reports,21(8),66.
10. Breijyeh, Z.,Karaman, R.(2020).Comprehensive review on alzheimer's disease causes and treatment.Molecules,25(24),5789.
11. Calsolaro, V.,Femminella, G.D.,Rogani, S.,Esposito, S.,Franchi, R.,Okoye, C.,Rengo, G.,Monzani, F.(2021).Behavioral and psychological symptoms in dementia (BPSD) and the use of antipsychotics.Pharmaceuticals,14(3),246.
12. Cerejeira, J.,Lagarto, L.,Mukaetova-Ladinska, E. B.(2012).Behavioral and psychological symptoms of dementia.Frontiersin Neurology,3,1-21.
13. Chakraborty, S.,Lennon, J. C.,Malkaram, S. A.,Zeng, Y.,Fisher, D. W.,Dong, H.(2019).Serotonergic system, cognition, and BPSD in Alzheimer's disease.Neuroscience Letters,704,36-44.
14. Cipriani, G.,Vedovello, M.,Ulivi, M.,Lucetti, C.,Di Fiorino, A.,Nuti, A.(2013).Delusional misidentification syndromes and dementia: A border zone between neurology and psychiatry.American Journal of Alzheimer's Disease & Other Dementias,28(7),671-678.
15. Cloak, N.,Al Khalili, Y.(2020).Behavioral and psychological symptoms in dementia.StatPearls.
16. Cummings, J.,Pinto, L. C.,Cruz, M.,Fischer, C. E.,Gerritsen, D. L.,Grossberg, G. T.,Hwang, T. J.,Ismail, Z.,Jeste, D. V.,Koopmans, R.,Lanctot, K. L.,Mateos, R.,Peschin, S.,Sampaio, C.,Tsuang, D.,Wang, H.,Zhong, K.,Bain, L. J.,Sano, M.(2020).Criteria for psychosis in major and mild neurocognitive disorders: International psychogeriatric association (IPA) consensus clinical and research definition.The American Journal of Geriatric Psychiatry,28(12),1256-1269.
17. Cunningham, E. L.,McGuinness, B.,Herron, B.,Passmore, A. P.(2015).Dementia.The Ulster Medical Journal,84(2),79-87.
18. Dyer, S. M.,Harrison, S. L.,Laver, K.,Whitehead, C.,Crotty, M.(2018).An overview of systematic reviews of pharmacological and non-pharmacological interventions for the treatment of behavioral and psychological symptoms of dementia.International Psychogeriatrics,30(3),295-309.
19. El Haj, M.,Roche, J.,Jardri, R.,Kapogiannis, D.,Gallouj, K.,Antoine, P.(2017).Clinical and neurocognitive aspects of hallucinations in alzheimer's disease.Neuroscience and Biobehavioral Reviews,83,713-720.
20. Emmady, P.D.,Tadi, P.,Del Pozo, E.(2021).Dementia (Nursing).StatPearls.
21. Kales, H. C.,Gitlin, L. N.,Lyketsos, C. G.(2015).Assessment and management of behavioral and psychological symptoms of dementia.BMJ,350,h369.
22. Kales, H. C.,Lyketsos, C. G.,Miller, E. M.,Ballard, C.(2019).Management of behavioral and psychological symptoms in people with Alzheimer's disease: An international Delphi consensus.International Psychogeriatrics,31(1),83-90.
23. Kratz, T.(2017).The diagnosis and treatment of behavioral disorders in dementia.Deutsches Arzteblatt International,114(26),447-454.
24. Kupeli, N.,Vickerstaff, V.,White, N.,Lord, K.,Scott, S.,Jones, L.,Sampson, E. L.(2018).Psychometric evaluation of the Cohen Mansfield Agitation Inventory in an acute general hospital setting.International Journal of Geriatric Psychiatry,33(1),158-165.
25. Kwon, C. Y.,Lee, B.(2021).Acupuncture for behavioral and psychological symptoms of dementia: A protocol of systematic review.Medicine,100(6),e24341.
26. Lam, K.,Chan, W. S. Y.,Luk, J. K. H.,Leung, A. Y. M.(2019).Assessment and diagnosis of dementia: A review for primary healthcare professionals.Hong Kong Medical Journal,25(6),473-482.
27. Lane, C. A.,Hardy, J.,Schott, J. M.(2018).Alzheimer's disease.European Journal of Neurology,25(1),59-70.
28. Legere, L. E.,McNeill, S.,Schindel Martin, L.,Acorn, M.,An, D.(2018).Nonphar macological approaches for behavioural and psychological symptoms of dementia in older adults: A systematic review of reviews.Journal of Clinical Nursing,27(7–8),e1360-e1376.
29. Lei, P.,Ayton, S.,Bush, A. I.(2021).The essential elements of Alzheimer's disease.The Journal of Biological Chemistry,296,100105.
30. Leung, D. K.Y.,Chan, W. C.,Spector, A.,Wong, G. H. Y.(2021).Prevalence of depression, anxiety, and apathy symptoms across dementia stages: A systematic review and meta-analysis.International Journal of Geriatric Psychiatry,36(9),1330-1344.
31. Li, X. L.,Hu, N.,Tan, M. S.,Yu, J. T.,Tan, L.(2014).Behavioral and psychological symptoms in Alzheimer's disease.BioMed Research International,927804.
32. Linnemann, C.,Lang, U. E.(2020).Pathways connecting late-life eepression and dementia.Frontiers in Pharmacology,11,279.
33. Livingston, G.,Johnston, K.,Katona, C.(2015).Systematic review of psychological approaches to the management of neuropsychiatric symptoms of dementia.The American Journal of Psychiatry,162(11),1996-2021.
34. Lolk, A.,Andersen, K.(2017).Behavioural disturbances in dement patients.Ugeskr Laeger,179(12),V10160740.
35. Mahalingam, S.,Chen, M. K.(2019).Neuro imaging in dementias.Seminars in Neurology,39(2),188-199.
36. Mukku, S.,Dahale, A. B.,Muniswamy, N. R.,Muliyala, K. P.,Sivakumar, P. T.,Varghese, M.(2021).Geriatric depression and cognitive impairment-an update.Indian Journal of Psychological Medicine,43(4),286-293.
37. Pearce, D.,Gould, R.L.,Roughley, M.,Reynolds, G.,Ward, E.V.,Bhome, R.,Reeves, S.(2022).Paranoid and misidentification subtypes of psychosisindementia.Neuroscience & Biobehavioral Reviews,134,104529.
38. Pedersen、 D. D.,胡宗明（譯）, T, M.(Trans.)(2017).精神科口袋書臨床隨身手冊.合記=Ho-Chi Book Publishing.
39. Perini, G.,Cotta Ramusino, M.,Sinforiani, E.,Bernini, S.,Petrachi, R.,Costa, A.(2019).Cognitive impairment in depression: recent advances and novel treatments.Neuropsychiatric Disease and Treatment,15,1249-1258.
40. Raz, L.,Knoefel, J.,Bhaskar, K.(2016).The neuropathology and cerebrovascular mechanisms of dementia.Journal of Cerebral Blood Flow & Metabolism,36(1),172-186.
41. Rootes-Murdy, K.,Goldsmith, D. R.,Turner, J. A.(2022).Clinical and structural differences in delusions across diagnoses: a systematic review.Frontiers in Integrative Neuroscience,15,726321.
42. Scales, K.,Zimmerman, S.,Miller, S.J.(2018).Evidence-based nonpharmacological practices to address behavioral and psychological symptoms of dementia.The Gerontologist,58 1(suppl_1),S88-S102.
43. Sun, B.L.,Li, W. W.,Zhu, C.,Jin, W. S.,Zeng, F.,Liu, Y. H.,Bu, X. L.,Zhu, J.,Yao, X. Q.,Wang, Y. J.(2018).Clinical research on alzheimer's disease: Progress and perspectives.Neuroscience Bulletin,34(6),1111-1118.
44. Tible, O. P.,Riese, F.,Savaskan, E.,von Gunten, A.(2017).Best practice in the management of behavioural and psychological symptoms of dementia.Therapeutic Advances in Neurological Disorders,10(8),297-309.
45. Vuic, B.,Konjevod, M.,Tudor, L.,Milos, T.,Nikolac Perkovic, M.,Nedic Erjavec, G.,Pivac, N.,Uzun, S.,Mimica, N.,Svob Strac, D.(2022).Tailoring the therapeutic interventions for behavioral and psychological symptoms of dementia.Expert Review of Neurotherapeutics,22(8),707-720.
46. Zucchella, C.,Sinforiani, E.,Tamburin, S.,Federico, A.,Mantovani, E.,Bernini, S.,Casale, R.,Bartolo, M.(2018).The multidisciplinary approach to alzheimer's disease and dementia. A narrative review of non-pharmacological treatment.Frontiers in neurology,9,1058.
47. 社團法人台灣失智症協會 (2022 ， 4 月 1 9日)．台灣失智症人口推估 。http://www.tada2002.org.tw [Taiwan Alzheimer's Disease Association. (2022, April 19). Estimates of taiwan alzheimer's disease population. http://www.tada2002.org.tw]
48. 張可臻, K. C.,陳昭源, J. Y.,林忠順, T. S.(2008)。失智症合併精神行為症狀的診斷及治療照護。基層醫學，23(6)，153-157。
49. 郭純安, C. A.(2012)。國立臺灣大學=National Taiwan University。