全科医学中的心理健康病案研究 (十五)
——一位老人的抑郁（第二部分）

2013-01-26 17:31FionaJuddGrantBlashkiLeonPiterman

中国全科医学 2013年9期

Fiona Judd，Grant Blashki，Leon Piterman （著），杨辉（译）

作 (译)者单位:3010 澳大利亚维多利亚州，澳大利亚Melbourne大学(Fiona Judd，Grant Blashki);澳大利亚Monash 大学(Leon Piterman，杨辉)

Affiliation:Melbourne University，Victoria 3010，Australia (Fiona Judd，Grant Blashki);Monash University (Leon Piterman)

注:Fiona Judd、Grant Blashki 的作者简介见2012 年第1A 期，Leon Piterman 的作者简介见2012 年第2A 期，见中国全科医学杂志社官方网站(http://www. chinagp. net);文后附英文来稿原文

1 病史

琼第一次来看病是12 个月前（参见上期病案研究）。经过接下来6 个月内的数次就诊，你给他的诊断是抑郁，并开始采用氟西汀（百忧解）和人际关系治疗（ IPC）相结合的治疗措施。在第一次做出诊断的时候，你已经注意到琼的抑郁症状和记忆主诉是比较突出的。你给琼的解释是，这些问题是抑郁的表现，通过抗抑郁药的治疗就会得到解决。不过6 个月过去了，百忧解的药量加到了40 mg/d，琼的记忆问题一直没有好转。

2 进一步的病史

琼说他感到情绪好多了，只不过还是一直担心他的记忆问题。他的睡眠情况已经正常，食欲也恢复了正常。他说自己做事情的兴趣和动机也恢复到原来的状况。但是，他说自己总是忘事儿。他说自己记不清楚父亲最初患老年痴呆症的时候是什么样子，不过他能够生动地回忆起父亲患病晚期时候的样子。琼说现在自己很简单的事情都记不起来，比如记不住刚才把东西放在哪里了，跟人约好的事情转眼就忘了，他妻子跟他说他总是重复做某些事情。这让他很有挫败感。不过，他对很早以前发生的事情却记得很清楚。

3 体检

琼一如既往地穿戴整齐。不过很有意思的是，他穿了一双不成对的袜子。而且细心的你还发现，他的领带上沾了污迹，这与他的穿戴有些不协调。他看上去有些紧张，不过他否认自己焦虑，只是认为自己的记忆有问题。他也否认自己感到抑郁。他的情绪不像是忧郁的。没有抑郁的想法，也没有知觉障碍。他的注意力和集中力是受损的，而且正如以前诊断的那样，主要是瞬时和短期记忆受损。

4 提问

4.1 可能的诊断是什么?

4.2 需要做哪些进一步的评估?

4.3 怎样治疗琼的问题?

5 解答

5.1 可能的诊断可能的诊断是“老年痴呆症”。琼的抑郁问题已经通过以前的治疗得到了好转，而他的记忆问题却一直存在。虽然抗抑郁药能造成某些认知紊乱，但通常影响是很轻微的，而且选择性5 -羟色胺再摄取抑制剂(SSRI)所造成的影响要比其他抗抑郁药小得多。所以，不太可能是抗抑郁药造成琼的记忆问题。

重要的是，有些身体健康的老年人，特别是那些越来越担心自己患有老年痴呆症的老年人，也会总关注自己的记忆问题，而且会不断地寻求别人的慰藉，确认自己不是一步步地走向老年痴呆症。对于那些有辉煌过去的老年人来说，这种心情最为普遍，他们会认为随着衰老的过程，自己的认知速度、记忆和集中力也会衰退。所以现在要做的重要事情是给琼做全面的记忆测验，从而区分到底是真的记忆问题，还是他自己的过分担心［1］。

5.2 进一步的评估应该进一步采集病史，主要了解阿尔茨海默病(Alzheimer's disease)、血管性痴呆(vascular dementia)的危险因素以及其他可能的原因，如头部肿瘤和酒精滥用。所以，要进一步询问家族史、卒中史、高血压史、吸烟史、糖尿病史、高胆固醇血症史。

最有用的病史是来自最熟悉琼的人，比如他的妻子。要注意从他妻子那里了解琼记忆问题发生的时间和频率，以及她认为的任何认知和行为变化。

之前，琼做过一些检查和化验，排除了躯体疾病。但是这些检查还应该继续做，来发现任何可以降低老年痴呆症风险的原因。现在，应该给他做颅脑CT 检查及血液检查，包括人类免疫缺陷病毒(HIV)和梅毒血清学检查、代谢筛查以及营养缺乏的评估。明确和纠正器官疾病并不能逆转老年痴呆症的发生，但这可以改善患者的生活质量。

更进一步的认知测验是做好评估的必要步骤。除了你已经做过的各种测验外，一定要正式地给患者做认知测验。最常使用的测验工具是简易精神状态检查(mini mental state examination，MMSE)［2］。一般来说，MMSE 得分在23 分及以下，则提示明显的认知缺损。

5.3 怎样治疗如果你的进一步评估结果证实可能诊断为老年痴呆症，那么你的治疗计划取决于你对老年痴呆症原因的推定。老年痴呆症最常见的原因是阿尔茨海默病(60%)，其次为血管性痴呆和路易体痴呆(各占10%)。鉴于琼有阿尔茨海默病的家族史，而没有血管性痴呆的家族史，也没有任何幻视(visual hallucinations，见于路易体痴呆)，所以最可能的病因是阿尔茨海默病。

胆碱酯酶抑制剂(cholinesterase inhibitors)可以轻微地改善记忆、精力和情绪，值得一用。但要注意，这类药也有明显的不良反应，如恶心、腹泻、噩梦、腿部痉挛。在使用这些药物之前，应该把琼转诊给精神病学专家或老年精神病学专家，以便做进一步的评估。

对琼的长期管理包括发现和治疗共发的抑郁、谵妄或精神病症状;管理精神错乱的行为(随着老年痴呆症的发展进程，这些行为会越来越常见);对家庭和照顾者提供支持;对法律和伦理问题保持关注，如患者在什么情况下可以继续开车、患者的决策能力以及拟定遗嘱的能力［3］。

译者注:

简易精神状态检查 (mini mental state examination，MMSE):总分为30 分的建议测量量表，用于筛查认知损害。该工具于1980 年代引进中国，用于精神卫生研究和临床实践，关于中文版请参见张明园等［4］1995 年的报告。

胆碱酯酶抑制剂(cholinesterase inhibitors):常用药物有多奈哌齐(安理申)、利凡斯的明(艾斯能)、加兰他敏以及中国研制的双益平。

1 Conner DO，Piterman L，Darvall L. Common mental health problems in the elderly//Blashki G，Judd F，Piterman L. General practice psychiatry ［M］. McGraw Hill Medical，2007:257 -276.

2 Folstein M，Folstein S，McHugh P. The mini mental state:A practical method for grading the cognitive state of patients for the clinician ［J］.Journal of Psychiatric Research，1975，12:189 -198.

3 Therapeutic guidelines ［Z］. Psychotropics，2008.

4 张明园，Elena Yu，何燕玲. 痴呆的流行病学调查工具及其应用［J］. 上海精神医学，1995，7 (1):3 -5.

【Introduction of the Column】The Journal presents the Column of Case Studies of Mental Health in General Practice;with academic support from Australian experts in general practice，psychology and psychiatry from Monash University and the University of Melbourne. The Column's purpose is to respond to the increasing needs of mental health services in China. Through study and analysis of mental health cases，we hope to improve understanding of mental illnesses in Chinese primary health settings，and to build capacity of community health professional in managing of mental illnesses in general practice. Patient-centred and whole-person approach in general practice is the best way to maintain and improve the physical and mental health of residents. Our hope is that these case studies will lead new wave of general practice and mental health development both in practice and academic research. A number of Australian experts from the disciplines of general practice，mental health and psychiatry will contribute to the Column. You will find A/Professor Blashki，Professor Judd and Professor Piterman are authors of General Practice Psychiatry. The Journal cases are helping to prepare for the translation and publication of a Chinese version of the book in China. We believe Chinese mental health in primary health care will step up to a new level under this international cooperation.

Affiliation:Melbourne University，Victoria 3010，Australia (Fiona Judd，Grant Blashki);Monash University (Leon Piterman)

1 H istory

Jon first consulted you 12 months ago. After several visits over a 6 month period you made a diagnosis of depression and initiated treatment with Fluoxetine together with some interpersonal counselling (IPC). At the time of the initial diagnosis you had noted that amongst Jon' s depressive symptoms，memory complaints were prominent. You explained to Jon that you felt these complaints were part of his depression and would resolve with treatment with an antidepressant. However，after 6 months，the last 2 at a dose of 40 mg/day Fluoxetine，Jon's memory problems have persisted.

2 Further history

Jon reports that his mood feels good，other than his worries about his memory. His sleep is normal，his appetite is also normal，he has his interest and motivation back，but he forgets things. He indicates he does not know how his father's dementia first presented，but he vividly recalls the later stages of his father's illness. Jon reports he's frustrated as he can't remember simple things，where he's put things，has missed a couple of appointments，and his wife has told him he repeats things. By contrast，his memory for things in the past is as good as ever.

3 Exam ination

Jon presents as well dressed，but curiously he's wearing odd socks. And，again somewhat incongruently，he has a stain on his tie. He seems somewhat tense but denies feeling anxious，other than about his memory，and denies feeling depressed. His affect is not depressed. There is no depressive thought content and no perceptual disturbance. His attention and concentration are impaired，and as was the case when initially seen he has problems with immediate and short term memory.

4 Questions

4.1 What is your probability diagnosis?

4.2 What further assessment is required?

4.3 How should Jon be treated?

5 Answers

5.1 The probability diagnosis is possible dementia. Jon's depression has resolved with treatment，yet his memory problems persist. Whilst antidepressant medication can cause some disturbance of cognition，it is generally mild，and is more common with other classes of antidepressants than it is with the SSRI medications. Thus，this is not likely to be the cause of Jon's complaints.

Importantly，some normal older people，particularly those who are particularly concerned that they may be at increased risk of dementia may worry about and seek reassurance that they are not dementing. This is most common in high achievers who notice age related changes in cognitive speed，memory and concentration. It is important to carefully test Jon's memory to make this differentiation［1］.

5.2 Further history taking should focus on risk factors for Alzheimer's disease，vascular dementia，and other possible causes such as head trauma and alcohol abuse. Thus，ask about family history，history of stroke，hypertension，smoking，diabetes mellitus and hypercholesterolemia.

The most useful history will be obtained from someone who knows Jon well- his wife. It is important to check the duration and rate of onset of the memory problems，and have her account of any cognitive and behavioural change.

Jon has had some initial investigations to exclude physical problems but these need to be extended now to detect any potentially reversible cause of dementia. Investigations should include a CT head scan and blood tests including HIV and syphilis serology，metabolic screen， and assessment for nutritional deficiency. Identification and correction of organic problems may not necessarily reverse the dementia but will improve the patient's quality of life.

More extensive cognitive testing is an essential part of the assessment. In addition to any simple testing you have already done，it is important to formally test cognition，most often this is done using an instrument such as the Mini Mental State Examination(MMSE)［2］. Generally speaking，a score of 23 or less is suggestive of significant cognitive impairment.

5.3 If your further assessment confirms the likely diagnosis of dementia，further treatment will depend on the presumed cause of the dementia. Alzheimer's disease is the most common cause of dementia (60%)，followed by vascular disease and Lewy body dementia(each 10% of cases). Given Jon has a family history of Alzheimer's disease，no history of vascular problems and has not reported any visual hallucinations (seen in Lewy body dementia)the most likely cause is Alzheimer's disease.

The cholinesterase inhibitors may produce small but worthwhile improvements in memory，energy and mood. However，they have significant side effects including nausea，diarrhoea，vivid dreams and leg cramps. Jon should be referred to a psychiatrist or psychogeriatrician for further assessment before he is started on these medications.

Longer term management includes the detection and treatment of co - occurring depression，delirium or psychotic symptoms;management of disturbed behaviours which become more common as dementia worsens;support of family and carers;and attention to legal and ethical issues such as how long should the person continue to drive a car，capacity to make decisions and testamentary capacity［3］.

Notes:

Mini mental state examination (MMSE):It is a 30 - point questionnaire test which is used to screen for cognitive impairment. The tool was introduced into China in middle 1980s，and was used in mental health research and clinical practice. For more informationabout Chinese version MMSE，see Zhang 1995［4］.

Cholinesterase inhibitors: rivastigmine， donepezil， galantamine are used in Chinese healthcare system. Huperzine (a Chinese developed medicine)is also used.