失智症與呼吸困難：生活規劃及醫療建議-神經內科

洪煒斌 醫師回覆-神經內科

您好:失智症除了藥物治療之外，還有非藥物介入，包括職能治療、認知訓練、懷舊、藝術、社交…等等。
可以聯繫媽媽生活的縣市失智症共同照護中心或是長照服務管理中心，詢問相關的服務提供者。
病程的進展不同的失智症進展速度不同，以阿滋海默症為例，在輕度失智症階段，病人通常可在協助下獨立自主生活，有些人仍然可以開車、工作和參加社交活動，但是時常有記憶失誤，例如忘記熟悉的單詞或日常物品的位置，通常有2年左右。
中期通常有4年左右，症狀更為明顯，病人可能會出現語言障礙、感到沮喪或生氣，並以意想不到的方式行事，例如拒絕洗澡，在沒有幫助的情況下難以表達思想和執行日常任務。
在失智症的末期，通常有7年左右，病人無法對環境做出適當反應、嚴重的語言障礙、運動障礙等，完全失去生活自主能力，需要旁人全面照顧。
但是每個階段的時間只能做為參考，會有個別化差異，若是好好照顧可以延緩。
失智症各個階段可參考Global deterioration scale for assessment of primary degenerative dementia (GDS) [1]，如下表。
喘的症狀大多是心臟或是肺部問題，若是已經排除這方面的疾病，則心因性因素也必須考慮。
失智症病人也常會伴隨有憂鬱或是焦慮等症狀，也可能用喘的方式來表現。
可請神經科或是精神科醫師協助評估轉介。
GDS Clinical characteristics Yrs[2]1 No cognitive decline No subjective complaints of memory deficit. No memory deficit evident on clinical interview.2 Very mild cognitive decline. Subjective complaints of memory deficit, most frequently in following areas: (a) forgetting where one has placed familiar objects; (b) forgetting names one formerly knew well. No objective evidence of memory deficit on clinical interview. No objective deficits in employment or social situations. Appropriate concern with respect to symptomatology. 153 Mild cognitive decline. Earliest clear-cut deficits. Manifestations in more than one of the following areas: (a) patient may have gotten lost when traveling to an unfamiliar location; (b) coworkers become aware of patient's relatively poor performance; (c) word and name finding deficit becomes evident to intimates; (d) patient may read a passage or a book and retain relatively little material; (e) patient may demonstrate decreased facility in remembering names upon introduction to new people; (f) patient may have lost or misplaced an object of value; (g) concentration deficit may be evident on clinical testing. Objective evidence of memory deficit obtained only with an intensive interview. Decreased performance in demanding employment and social settings. Denial begins to become manifest in patient. Mild to moderate anxiety accompanies symptoms. 74 Moderate cognitive decline. Mild dementia. Clear-cut deficit on careful clinical interview. Deficit manifest in following areas: (a) decreased knowledge of current and recent events; (b) may exhibit some deficit in memory of ones personal history; (c) concentration deficit elicited on serial subtractions; (d) decreased ability to travel, handle finances, etc. Frequently no deficit in following areas: (a) orientation to time and place; (b) recognition of familiar persons and faces; (c) ability to travel to familiar locations. Inability to perform complex tasks. Denial is dominant defense mechanism. Flattening of affect and withdrawal from challenging situations frequently occur. 25 Moderately severe cognitive decline. Moderate dementia. Patient can no longer survive without some assistance. Patient is unable during interview to recall a major relevant aspect of their current lives, e.g., an address or telephone number of many years, the names of close family members (such as grandchildren), the name of the high school or college from which they graduated. Frequently some disorientation to time (date, day of week, season, etc.) or to place. An educated person may have difficulty counting back from 40 by 4s or from 20 by 2s. Persons at this stage retain knowledge of many major facts regarding themselves and others. They invariably know their own names and generally know their spouses' and children's names. They require no assistance with toileting and eating, but may have some difficulty choosing the proper clothing to wear. 1.56 Severe cognitive decline. Moderately severe dementia. May occasionally forget the name of the spouse upon whom they are entirely dependent for survival. Will be largely unaware of all recent events and experiences in their lives. Retain some knowledge of their past lives but this is very sketchy. Generally unaware of their surroundings, the year, the season, etc. May have difficulty counting from 10, both backward and, sometimes, forward. Will require some assistance with activities of daily living, e.g., may become incontinent, will require travel assistance but occasionally will be able to travel to familiar locations. Diurnal rhythm frequently disturbed. Almost always recall their own name. Frequently continue to be able to distinguish familiar from unfamiliar persons in their environment. Personality and emotional changes occur. These are quite variable and include: (a) delusional behavior, e.g., patients may accuse their spouse of being an impostor, may talk to imaginary figures in the environment, or to their own reflection in the mirror; (b) obsessive symptoms, e.g., person may continually repeat simple cleaning activities; (c) anxiety symptoms, agitation, and even previously nonexistent violent behavior may occur; (d) cognitive abulla, i.e., loss of willpower because an individual cannot carry a thought long enough to determine a purposeful course of action. 2.57 Very severe cognitive decline. Severe dementia. All verbal abilities are lost over the course of this stage. Frequently there is no speech at all -only unintelligible utterances and rare emergence of seemingly forgotten words and phrases. Incontinent of urine, requires assistance toileting and feeding. Basic psychomotor skills, e.g., ability to walk, are lost with the progression of this stage. The brain appears to no longer be able to tell the body what to do. Generalized rigidity and developmental neurologic reflexes are frequently present. 7Ref:[1] Reisberg B, Ferris SH, de Leon MJ, Crook T. The Global Deterioration Scale for assessment of primary degenerative dementia. Am J Psychiatry. 1982 Sep;139(9):1136-9. doi: 10.1176/ajp.139.9.1136. PMID: 7114305.[2] Yrs*: 7 clinical stages of Alzheimer’s Brochure. Fisher center for Alzheimer’s research foundation.