Alzheimer's disease dementia

Introduction to Alzheimer's disease dementia Dementiain Alzheimer's disease is a progressive degenerative neurological degenerative disease with clinical memory impairment, aphasia, misuse, loss of recognition, visual space skills damage, and implementation. Functional dysfunction, as well as generalized dementia such as personality and behavioral changes, are characterized by etiology. In the past, people who were 65 years old were called preseniledementia; after 65 years old, they were called senile dementia (seniledementia). The main pathological changes of this disease are cerebral cortical atrophy, neurofibrosis and degeneration of cerebral nerve cells and senile plaques, which are common diseases in old age. basic knowledge Proportion of the disease: the probability of illness in the elderly is 0.7% Susceptible people: good for the elderly Mode of infection: non-infectious Complications: vascular dementia in the elderly, vascular dementia, paralytic dementia

Causes of Alzheimer's disease dementia

(1) Causes of the disease

Family history (15%):

Most epidemiological studies suggest that family history is a risk factor for AD. Some patients have members of the same family with higher disease than the general population. In addition, the risk of congenital disease is increased, further genetics. Studies have confirmed that the disease may be caused by autosomal dominant genes. Recently, through gene mapping studies, it was found that the pathological genes of amyloid in the brain are located on the 21st pair of chromosomes. It can be seen that dementia is genetically related, but genetic. It is difficult to be sure how much the effect is. Because the age of onset of AD is relatively late, there is no research report on twins based on the general population. The same disease rate reported by a few elderly single-ovary twins (MT) is not very high. The report suggests that there is a family aggregation phenomenon in AD. The relationship between AD and the positive family history of first-degree relatives is also quite positive. According to the available data, 8 case-control studies, AD has a significant association with the first-degree relatives of dementia history, and the other has not found two. Correlation, a reanalysis of 11 case-control studies in Europe showed that if at least one first-degree relative had dementia, the risk of dementia More than 3 times, the study of the distribution frequency of apolipoprotein E (Apo E) genotype in the population further supports the pathogenesis of genetic factors on AD. It has been proved that Apo E allele 4 is an important risk factor for AD, Apo The frequency of the E 4 gene was significantly increased in both familial and sporadic AD. The frequency of the Apo E 4 gene in autopsy-recognized AD patients was about 40%, compared with about 16% in the normal control population, with an 4. The risk of AD in alleles is 2 to 3 times higher than that in the general population, and the risk of carrying 2 4 alleles is about 8 times that of the general population. It is now clear that the Apo E4 allele is not a must in AD. Predictive factors, its predictive effect on the onset of AD remains to be confirmed by prospective studies. The authors may have late-onset AD with the collected cases, suggesting that family aggregation may be an important risk factor for early-onset AD, but The interpretation of positive results should be cautious, and family aggregation is not a true genetic factor. Thus, genetic factors are not the only factor in the pathogenesis of AD.

Physical illness (20%):

Such as thyroid disease, immune system diseases, epilepsy, migraine, etc., have been studied as a risk factor for AD, a history of hypothyroidism, the relative risk of AD is 2.3, there is a history of seizures before the onset of AD (relative The risk is 1.6). The history of migraine or severe headache has nothing to do with AD. Many studies have found that the history of depression, especially the history of depression in the elderly, is a risk factor for AD. A recent case-control study suggests that in addition to depression Other functional disorders such as schizophrenia and paranoid psychosis are also associated with a history of central nervous system infections such as encephalitis, meningitis, herpes virus infection, and history of exposure to livestock, and animal history of food animals fail to demonstrate these factors. Related to AD, the chemical substances that have been studied as risk factors for AD include heavy metal salts, organic solvents, pesticides, drugs, etc. The role of aluminum has been a concern because animal experiments have shown that aluminum salts have an impact on learning and memory; Studies suggest that the prevalence of dementia is related to the amount of aluminum in drinking water, and preliminary results of a study on the prevalence of dementia in France by Michel et al. Aluminium is a risk factor for AD, but further analysis has denied this result. Flaten et al. (1990) reported that aluminum in drinking water is associated with dementia, and several studies have failed to confirm that aluminum is a risk factor for AD. Case-control studies of people with exposure to heavy metals, including exposure to aluminum, have not found any heavy metals associated with AD. It may accelerate the aging process due to the accumulation of neurotoxins such as aluminum or silicon in the body, but aluminum is a nerve. Toxic substances, but as far as the existing research is concerned, it can not be used as a risk factor for AD. It has been reported that smoking is not a risk factor for AD, but instead it protects AD, and some authors have not found the relationship between them. People with less AD may be short-lived because of their short life expectancy.

Low education level (20%):

There are more and more reports about the low level of education and the prevalence of dementia. Shanghai reported that the prevalence of dementia and AD is 6.9%, and the school age is 1.2% more than 6 years. Recently, an epidemiological survey in Italy is similar. Found that, but a Japanese case-control study did not find a link between education levels and dementia and/or dementia subtypes, there is no reasonable explanation for this, some scholars believe that this is caused by systematic errors, due to most epidemiology The study uses a two-stage screening test to perform a diagnostic test on patients who are positive for screening. Such people with low illiteracy or low education may have low scores in the screening test during the screening stage, and are easy to enter the diagnostic test stage and diagnose For dementia, the prevalence rate is increased, and in fact these people may not have a decline in cognitive function at all. It is believed that this is due to the biological characteristics of illiterate itself, not educational issues, and education is related to socio-economic conditions, further This problem is complicated. However, Zhang Mingyuan et al. (1990) used different screening boundaries according to the cultural level of the screening subjects during screening. The value avoids this systematic error. As a result, the prevalence of dementia in low-educational people is still high. Several studies have confirmed this result. The low level of education and the etiology of AD are still unclear. The possible explanation is Early childhood education promoted the development of cortical synapses, increased the number of synapses and increased the "brain reserve", thus delaying the diagnosis of dementia. This hypothesis was supported by some clinical observations, for example, high AD-level patients with educational status can retain some cognitive functions even in the advanced stage. They have a relatively short course from the diagnosis to the death of the disease. The low level of education has a similar relationship with vascular dementia and other secondary dementia.

Head trauma (15%):

Head trauma refers to head trauma with conscious disturbance. Brain trauma has been reported as a risk factor for AD. In 12 case-control studies, 3 cases were found to be significantly associated; 4 AD had more traumatic history than the control group, but no Statistically significant, the other 5 did not find any correlation between the two, but a recent follow-up study of severe traumatic brain injury has attracted more people's interest. Robert et al. followed the average follow-up of severe traumatic brain injury for 25 years. The result was about 1 /3 patients with amyloid-like protein deposition similar to AD, clinical and epidemiological studies suggest that severe brain injury may be one of the causes of some AD, according to current data, head trauma may be AD A risk factor, but not sure.

Parental age is too high or too low (10%):

(greater than 40 years old or younger than 20 years old) Because Down's syndrome (DS) may be a risk factor for AD, and DS risk increases with the increase of maternal age, there are 9 case-control studies, some found to be related, and some Differences were found but not statistically significant, or no correlation was found at all, and some were considered to be only risk factors for some sporadic AD.

Other (10%):

Progressive failure of the immune system, weakening of the body's detoxification function and lentivirus infection, as well as social and psychological factors such as widowhood, living alone, financial difficulties, and life bumps can be the cause of the disease.

Alzheimer's disease dementia prevention

1. Pay attention to rice, flour, corn, millet, etc. as the main food to ensure the important heat energy source of brain cells.

2. Pay attention to the intake of fat, especially essential fatty acids.

3. A large intake of vitamin B12 and folic acid is beneficial to prevent senile dementia.

4. Free radicals are the bane of dementia.

Alzheimer's disease dementia complications Complications vascular dementia, vascular dementia, paralytic dementia

The disease causes declining quality of life due to dementia, so it is easy to suffer from various chronic physical diseases and secondary systemic infection or failure.

Symptoms of Alzheimer's disease dementia Common symptoms Eyes sluggish, angry face, disrespectful mental disorder, suspicious anxiety, restlessness, restlessness, expression, indifference, depression, muscle atrophy

The patient's appearance is old, the skin is dry and wrinkled, the pigmentation is white, the white teeth are off, the muscles are atrophy, and the performance may be too neat, organized, disciplined, and may be informal, expressive or violent or dull, behavioral and childish and stupid. When accompanied by memory loss, these appearance characteristics may indicate dementia. In the early stage, there are many mild forgetting and personality changes such as subjective self-willedness, stubborn relocation, selfishness and narrowness, etc., often not noticed by family members, and a small number of patients are indifferent to their habits. Stereotype, irritable emotions, easy to quarrel with people or entangled with family due to slight discomfort, and then the memory of recent events is obviously diminished, intelligent activities such as understanding, calculation, judgment and analysis are significantly reduced, mental function is declining, and it is difficult to do work or housework. Labor, even can not correctly answer the age of their own name, do not know how to eat, do not know how to eat, go home, go to the childish, collect waste paper, often accompanied by sleep rhythm upside down, bedtime during the day, night activities, visible depression, Xin Fast, indifferent or unstable, showing focal symptoms of parietal dysfunction such as Difficulties in words, can be persecuted by delusions, stolen or suspected delusions, some patients may have confusion or embarrassment in their disease course, called senile sputum, often caused by acute trauma, replacement of environmental or physical diseases The pain response disappeared in the body. There were no other obvious signs in the nervous system examination. The EEG showed a slowing of the rhythm. CT examination showed cerebral cortical atrophy and ventricular enlargement. The most characteristic clinical manifestation was the typical cortical dementia syndrome. The main symptoms are described as follows:

1. Memory disorder: It is an early prominent symptom or core symptom of AD. In the early stage, it mainly involves short-term memory, memory preservation (three irrelevant words cannot be remembered within 3 minutes), and it is difficult to learn new knowledge, and can not complete new tasks. Forget things, throw things down, when you are serious, just say something or just do something, just forget, just put down the tableware and ask for dinner, can't remember the name of the acquaintance, phone number, repeat the same words or ask the same question, the conversation begins I forgot what I said at the beginning, so it is difficult to communicate in language, things are often misplaced or lost, shopping forgot to pay or multiple payments, everything needs someone to remind or bring me a "memo", even if it is often wrong, often forgot Call back, forget to go to an important date, show social withdrawal, housewives forget to turn off the water tap or turn off the gas, causing security risks, can appear familiar and old things like new symptoms, such as the passers-by greet, like a loved one, but the acquaintance is familiar with the familiar Learning new knowledge early in the disease, the ability to master new skills is reduced, can only engage in simple stereotypes, as the disease progresses, far memory Gradually affected, I can't remember my birthday, family address and life experience. When I am serious, I can't even answer a few people at home. Their names, ages and occupations can't be answered accurately. There is only one mark of half-claw left in the memory of the river. Structure and fiction.

The general course of disease progresses slowly in the first two to four years. Some patients have some self-knowledge about their current status in the early stage of the disease. They know that their memory is not as good as before. Some try to cover up or try to make up for their memory defects, while others have a negative attitude or Blame others, "My memory is good, no problem", "I can remember the past years of the past", "Everyone else is tricking me, I want to belittle me, as long as they stay away from me, nothing will happen."

2. Visual space and disorientation: It is one of the early symptoms of AD. If you are familiar with the environment or lost your way at home, you can't find the toilet there, go to your own bedroom, go for a walk or go out and get lost in the streets, draw a picture test. Can not accurately copy simple stereograms, Webster adult intelligence scale inspection space skills (such as block modeling) scores lowest, time orientation is poor, do not know what year is today, He Yue, He Day, do not know whether it is morning or afternoon, So it may be late to get up in the middle of the night to go shopping.

3. Speech Disorder: The patient's speech disorder is in a specific pattern. The order is semantic disorder firstly. It is difficult to find words, improper words or Zhang Guan Li Dai, and there is no way to talk, and there may be pathological descriptions, reading and writing. Difficulties, followed by loss of naming ability or nomenclature aphasia (can recognize objects or can be used correctly, but can not be named exactly), initially limited to a few items, later extended to the common common object naming, there are reports of early AD patients Boston naming test ( Boston Naming Test) has more errors than MMSE, suggesting that naming difficulties may be earlier than memory loss. Neuropathological changes are mainly located in the posterior part of Wernicke. Cortical sensory aphasia is also common. Speech disorder further develops into grammatical errors. The word class, the statement is reversed, and the final phoneme is also destroyed and verbally pronounced, unintelligible, or silent.

4. Loss of recognition (feeling function is normal, but can not recognize or identify objects), misuse (understand and exercise function is normal, but can not perform exercise) is also quite common if the former can not identify the object, location and face (face loss, Prosopaghosia, Can't recognize the face), can't recognize the self in the mirror, and another kind of misuse: conceptual misuse, which can not be executed according to the instructions to complete the series of actions correctly, can be done spontaneously, such as dressing, inside and outside, before and after Do not wear the knife, fork, spoon or hand to eat or use the mouth to eat.

5. Mental retardation: Intelligence includes the acquired knowledge, experience, and ability to apply these knowledge and experience to solve new problems and form new concepts. Intelligence activities are closely related to thinking, memory and attention. Although memory itself is not intellectual, Severe memory impairment is often accompanied by intelligent impairment. AD patients are a kind of comprehensive mental decline, including cognitive functions such as understanding, reasoning, judgment, abstract generalization and calculation. AD patients' thinking ability is slow and slow, and they cannot be abstract logical thinking. The similarities and differences of things cannot be analyzed and summarized. The expression thinking lacks logic. The speech is often contradictory and cannot be perceived. For example, "I live with my mother." "How old is she?" "80s," "What about you?" "I am 82 years old." "Isn't that that you and your mother are older?" "Yes." Because of the decline in judgment, despite the snow flakes outside the window, they insisted that "it is midsummer now". Some people observe AD patients longitudinally. It was found that MMSE decreased by an average of about 3 points per year, and individual patients may have different rates of mental decline.

6. Personality changes: patients with a number of sacral leaves often show obvious personality changes, which can be the development of past personality characteristics, but also can deviate from the other extreme, such as patients lazy, retreating, self-centered, sensitive and suspicious, selfish Responsible, irresponsible, reprimanding others or deaf people, speech vulgar, behavior disregarding social norms, not trimming margins, not talking about hygiene, hiding items, smashing cigarettes, picking up bad rarities, can appear sexually depressive, shameless, publicly undress or publicly Masturbation, and two people before the illness, are very troublesome for the family, some of which are secondary to personality changes, and some are caused by cognitive defects. These symptoms often appear in the middle of the disease, but personality changes are not inevitable. Under careful care, the patient may be very gentle and docile, and personality changes may not be prominent.

7. Eating, sleep and behavioral disorders: The patient's appetite is often diminished. About half of the patients have normal sleep rhythm disorder or upside down, bedtime during the day, night activities, and harassment. EEG shows long REM sleep latency, slow wave sleep reduction, and patient's movements are repeated. Stereotype, stupid and clumsy, such as repeatedly closing the drawer, purposelessly put things in and out, repeatedly turn the door lock, play with clothes buckles or avoid contact, show retreat, weird, entangle the people around, do not let the family go away.

8. Catastrophic reaction: refers to the subjective realization of their intellectual impairment, but strongly denied, and then generate secondary agitation under stress, such as to cover up memory loss, patients use to change topics, jokes, etc. The attention of the other party, once it is seen, debunked or interfered with the patient's life mode, such as forcing the patient to go to the toilet, changing clothes, it is unbearable and induces a "disaster response", that is, sudden and strong speech or personal attack, the nursing staff often mistakes It is considered that the patient's ingratitude and ignorance make the family feel confused and frustrated. The termination and seizure of this reaction are often sudden.

9.Sundowner syndrome (Sundowner syndrome or Sundowning): In elderly people who are seen in excessive sedation, when infected with trauma, environmental changes or weakened external stimuli, such as in the dull light, when the scene of the character is not easily identifiable, it is characterized by lethargy and insanity. , ataxia or accidental fall, psychotropic drugs (such as sedative sleeping pills) can not tolerate, physical illness can also induce sunset syndrome, when dementia and sputum coexist, leading to a sharp decline in cognitive function, once the physical disease improves, cognitive The function has also gradually stabilized.

10. Klüver-Bucy Syndrome (KBS): The reported incidence can be as high as 70%. It is a behavioral abnormality related to temporal lobe function. It is similar to the KBS of animals who have bilateral temporal lobe resection. For example, visual recognition cannot and cannot be recognized. The face of a loved one or the self in the mirror, using the mouth to explore objects (mouth exploration), can also be expressed as compulsive chewing gum or smoking, as well as hand care, touching the eyes and excessive appetite, casually eat.

11.Capgras Syndrome: It is a special concept of delusion. If you don't know your loved ones, you think that it is a liar to replace impersonation. About 30% of delusions, mostly non-systematic theft, murder, poverty and embarrassment, can also continue. The system is delusional and thinks that the living room is not his own home. The family planning to abandon him often causes difficulties in family and nursing. It can be misidentified. The portraits, photos and people in the screen are mistaken for real people and talk to them, about 10%. The patient has an auditory hallucination. The patient hears the voice or talks with the "person". 13% have visual hallucinations. Most of them appear in the evening. They are often villains such as children, dwarves, and sometimes these villains come from TV screens. They should be alert to the possibility that the illusion may overlap. In the subacute sputum symptoms of dementia, apathy is a common early symptom. About 40% to 50% of patients may have a transient depression. After persuasion or improvement of the environment, remission is often achieved. Severe and persistent depression is rare. There may be euphoria, anxiety and irritation. The nervous system may be accompanied by extrapyramidal symptoms such as increased muscle tone and tremor. It may also appear to reach the toe, strong grip, sucking and so on. Reflex, epileptic seizures can be seen in the late stage.

12. Clinical manifestations of AD in each phase

(1) The first period or the early stage (1~3 years): difficulty in learning new things, mild damage to distant memory; spatial orientation disorder, complex structure depending on spatial skills; less vocabulary, loss of naming ability; Emotional sorrow, some patients have delusions; normal exercise system, EEG examination is normal; CT/MRI examination is normal; PET/SPECT shows low metabolism/low perfusion of posterior parietal lobe on both sides.

(2) Phase 2 or medium term (2 to 10 years): severe memory impairment in the near and far; simple structure depending on spatial skills, spatial orientation disorder; fluency aphasia; computational inability; conceptual motor disability; apathy or irritability; Some patients have delusions; irritability, sputum, EEG check background rhythm; CT/MRI examination normal or ventricle enlargement, sulcal widening; PET/SPECT showed double top and frontal lobe metabolism low / perfusion low.

(3) Stage 3 or late stage (8-12 years): severe mental decline; limb rigidity, flexion position; incontinence, EEG is diffuse slow wave; CT/MRI sees ventricle enlargement, sulcal widening; PET/ SPECT showed low topal and frontal lobe metabolism/low perfusion.

Because the etiology of AD is unknown, the clinical diagnosis is still based on medical history and symptoms, supplemented by mental, intellectual and neurological examinations. The gold standard for diagnosis is pathological diagnosis (including biopsy and autopsy). It should be noted that neither missed diagnosis nor misdiagnosis .

The clinical diagnosis of AD can be based on the following points: 1 progressive cognitive impairment in the elderly or pre-senile, 2 in memory, especially near memory impairment, the decline in learning new knowledge is the first symptom, followed by mental retardation, disorientation and Personality changes, 3 physical examination and neurological examination failed to find evidence of tumor, trauma and cerebrovascular disease, 4 blood, cerebrospinal fluid, EEG and brain imaging examination can not reveal a specific cause, 5 no material dependence or other mental history.

Middle-aged and elderly people with personality changes should carefully consider the possibility of dementia, such as patients complained of forgetting and mental activity decline should pay attention, avoiding the concealment of cognitive defects, denuders and defenders should also be highly vigilant.

The previous diagnosis of AD multi-use exclusion method, and now the improvement of diagnostic criteria, according to the family to provide detailed medical history and typical performance, the clinical diagnosis accuracy rate and pathological diagnosis can be as high as 85%, plus various psychological tests, laboratory tests, the correct rate can be Up to 90%.

Examination of Alzheimer's disease dementia

The development of molecular biology provides the possibility for the diagnosis of AD laboratory. Many scholars are striving to find the biomarker of AD in order to make a correct diagnosis of AD before birth. Although there is no breakthrough progress at present, the prospect is attractive, and the ideal biological marker should be More specific and sensitive than clinical diagnosis.

(1) Common Neuropsychological Rating Scale: Cognitive test is the Concise Mental State Scale (MMSE), the Mattis Dementia Rating Scale (DRS), the Alzheimer's Disease Assessment Scale (ADAS), and the CERAD Complete Set of AD Diagnostic Neurology The psychological test is an important method for diagnosing the severity of dementia and dementia. In recent years, many internationally simple and rapid screening tools have been introduced and revised in China, with high diagnostic validity, sensitivity and specificity. A brief overview is as follows:

1 Mini Mental State Examination (MMSE): Prepared by Folstein in 1975, MMSE has been the most popular and most commonly used screening marker for Alzheimer's disease at home and abroad, including time and location orientation (10 points). Language (spontaneous language 1 point, retelling 1 point, naming 2 points, understanding instruction 4 points, total 8 points), mental arithmetic (100 consecutive reductions of 7, 5 points), immediate and short-term auditory memory of 3 words (6 points) , structural imitation (cross pentagon, 1 point) and other projects, out of 30 points, time-consuming 5 to 10min, test-retest reliability 0.80 ~ 0.99, the reliability of the test between 0.95 ~ 1.0, the sensitivity of dementia diagnosis is mostly 80% to 90%, the specificity is mostly 70% to 80%, and the scoring standard is evaluated. If the answer or operation is correct, record "1", the error is "5", refuse to answer or say "9" or "7". ", the main statistics "1" project sum (MMSE total score), the range is 0 ~ 30, the international standard 24 is divided into cut-off values, 18 ~ 24 for mild dementia, 16 ~ 17 for moderate dementia, 15 Severe dementia, China found that the critical value of education is different, so the Chinese version of MMSE based on different levels of education demarcation points The domestic Zhangmingyuan demarcation according to the DSM-III-R diagnostic criteria is: illiterate group 17 points, primary school group 20 points, middle school or above group 24 points; Zhang Zhenxin, Hong Zhen according to the percentage distribution of community elderly population distribution The demarcation points are: illiterate group 19 points, primary school group 22 points, middle school or above group 26 points, lower than the demarcation is divided into cognitive function impairment, Zhang Mingyuan's 5-year follow-up for community elderly shows that normal aging MMSE Reduced by about 0.25 points per year, pathological aging is about 4 points per year.

Its advantages are high sensitivity, easy operation, easy to carry, and short time. It is widely used in large-scale community surveys and clinicians for preliminary examination of suspicious cases. The disadvantages are: A. The project is vulnerable to the test. The influence of education level is likely to have a ceiling effect on the elderly with higher education level, and there may be false negatives. For those who are illiterate or low-educated and speaking, there may be false positives. B. Only the total score can be used as an analytical indicator. Projects such as memory, structural imitation, etc. are not enough to reflect the corresponding cognitive domain performance, can not effectively map individual cognitive profiles, C. emphasize language function, non-verbal items are less; right hemisphere dysfunction and frontal lobe function The obstacles are not sensitive enough. D. Memory examination lacks recognition project; the naming project is too simple, E. There is no time limit, F. is more sensitive to cortical dysfunction than to subcortical dysfunction, and G. can not be used for differential diagnosis of dementia. As a follow-up tool for cognitive decline, it is not sensitive enough. For example, Clark and other 82 patients with AD were followed up for 4 years, and 16% of patients had no significant decrease in MMSE score. Knowing damage is often combined with a comprehensive cognitive test scale or a number of specific single test tools. With the development of the times, the age structure of the elderly population in China and the education level of the elderly are changing, and have received higher education. There will be more and more old people. The Chinese version of MMSE will be classified as a junior high school or above as a group. There is no distinction between the junior high school education level and the university education level. According to the current demarcation points, the high education seniors are slightly recognized. It is difficult to identify the damaged function.

2 The advantages and disadvantages of the Hasegawa Dementia Scale (HDS), Blessed Dementia Scale (BDS), Dementia Simple Screening Scale (BSSD) and 7-minute Neurocognitive Screening Scale (Solomon, 1998) are similar to those of MMSE. In 1987, MMSE increased the number of questions and items, revised to 3MS, and compiled the Cognitive Ability Screening Scale (CASI) based on the trial effect of 3MS, including orientation, attention, mental arithmetic, far-end memory, recent memory, structure. Imitation, language (name, understanding, writing), verbal fluency, concept judgment, etc. 9 factors, a total of 20 questions, 15 to 20 minutes, 15 months interval test reliability is 0.92, CASI total score 100 points, score can be Converted to MMSE, HDS-R scores, Chinese, English, Japanese, Western (Ban) and other language versions, can be used for comparison of different cultural backgrounds, has been applied in the United States, Japan, Hong Kong, China and Taiwan , Shanghai, Hangzhou, Chengdu have application reports, Hasegawa's Dementia Scale (HDS), a total of 11 projects, including orientation (2), memory (4), common sense (2), calculation (1 item), remembering the named memory (2 items), the scale uses positive score method The full score is 32.5 points, the original author's cut-off value is set as: dementia 10.5 points, suspicious dementia 10.5 ~ 21.5 points, edge state 22.0 ~ 30.5 points, normal 31.0 points, can also be divided according to educational level normal value: illiterate 16 points , elementary school <20 points, above secondary school <24 points.

3DRS: Prepared by Mattis in 1976, there are five factors: A. Note: including digital breadth, performing more complex verbal instructions, B. Startup and maintenance: including verbal fluency, alternating hands, C. Concept formation: Including word categorization and picture similarity, D. Structure: imitate parallel lines, diamond-shaped quadrilaterals, E. Memory: words instantly recall, sentence delay memories, meaningless patterns, instant memories, etc., 37 questions, total score 144 Minute.

The advantages of DRS include: the amount of questions is large, but each group of questions is difficult to arrange. If it is difficult to complete, it will not be easier to do in the project, which can save time, so normal old people can complete in 15 minutes. The dementia elderly with poor comprehension usually takes 30 to 45 minutes; the easier topic is very simple, and there is little floor effect, which is often used to judge the severity of cognitive impairment in patients with dementia; it is the earlier frontal lobe And the assessment tool for frontal-subcortical dysfunction, foreign norm data, domestic Hong Kong, Shanghai and other local norms, it is worth noting that the comprehensive cognitive examination scale is not aimed at preclinical dementia or mild Cognitive function (MCI) was developed and tested according to Stuss (1996). Short scales (such as MMSE) and long scales (such as DRS) did not improve sensitivity and specificity in assisting diagnosis of dementia.

In 1979, Hersch added Lenovo learning, building blocks and other projects based on the Mattis Dementia Rating Scale, and expanded to a total of 250 points of the "Decomposition Dementia Scale" (ESD). ESD has learning, attention, memory, orientation, calculation, Eight factors including abstract thinking, language understanding and expression, and spatial structure all took about 1 hour. In 1990, China introduced and developed local norms such as Beijing.

4ADAS: Founded in 1984 by Rosen et al., including cognitive behavioral test (ADAS) and non-cognitive behavioral tests, cognitive behavioral tests including orientation, language (spoken understanding and expression, recall of test guidance, and word finding from speech) Difficulty, instruction understanding, naming 12 real objects with 5 fingers), structure (imitation circle, two interlaced quadrilaterals, diamonds, cubes), the use of ideas, the average number of 3 recalls immediately after reading 10 figurative words Recognition with 12 figurative words, a total of 11 questions, taking 15 to 20 minutes, out of 70 points, non-cognitive test fear, depression, distraction, non-cooperation, delusion, hallucination, gait, increased exercise, tremor, appetite Change 10 items, each item 5 points, a total of 50 points, is currently a rare test for mental symptoms. For the AD group, the reliability between the testers is 0.99, and the correlation is 0.92 after 1 month interval. Normal elderly The group was 0.92 and 0.65, respectively. The AD patient group was significantly worse than the normal matching group in each of the ADAS-cog programs. The untreated AD patients had an annual ADAS-cog total score of 7 to 10 points, usually Will improve by 4 points (equivalent to 6 months) The natural decline score) as a criterion for the clinical efficacy of anti-dementia drugs, compared with the placebo control group of 2.5 points or more to prove that the treatment group is effective, due to the ceiling effect, ADAS-cog on very mild or mild cognitive impairment (MCI Not sensitive enough, ADAS-cog is not suitable for very severe patients. The scale is often used as an acetylcholinesterase inhibitor tacrine, velnacrine, physostigmine, donepezil (Arian) and esin One of the evaluation criteria for the treatment of light, moderate AD large-scale, multicenter, randomized, double-blind, placebo-controlled clinical trials is also commonly used in clinical trials of anti-dementia drugs in China.

Since ADAS-cog does not have a detailed examination of the planned executive function, the revised VDAS-cog increases speech fluency, digital-symbol conversion, maze, reciprocal of digital breadth, etc. in the evaluation of the efficacy of vascular dementia (VD). test.

5CERAD Complete Set of Diagnostic Neuropsychological Tests: In the late 1980s, the United States Alzheimer's Disease Joint Registration Collaboration (CERAD) developed a standardized neuropsychological test for AD diagnosis with normological data. The tests included: A. Speech fluency test; B. Boston naming test; C. vocabulary memory and recognition (10 words repeated reading, recalling 3 times, recalling and recognizing after 10 minutes); D. Structural test; E. Shipley-Hartford Word list; F. word pairing association learning test; G. Nelson adult reading test (used to assess pre-disease intelligence); H. connection test A and B; J. finger tap test; K. clock test, non English-speaking countries such as Germany and South Korea have also established norm data for normal elderly people. Most of the subtests have been used by researchers in China.

A set of neuropsychological tests for the evaluation of cognitive function in the elderly by the World Health Organization, from: auditory words learning test; connection test A and B; speech fluency test; attention test; language test; exercise test; visual matching and reasoning; The composition of the test, etc., is mainly similar to the neuropsychological test for the diagnosis of complete sets of AD in CERAD. This set of tests has a normal model of normal elderly in China.

6 Activity of Daily Living Scale (ADL): Developed by Lawton and Brody in 1969, it is mainly used to assess the daily living ability of the subjects. The ADL is divided into 14 items and the score is 4: A. You can completely Do, B. Some difficulties, C. Need help, D. Can't do it at all, 64 is full score, total score 16 is completely normal, >16 has different degrees of functional decline, single score is divided into normal, 2~4 Sub-function decline, there are 2 or more than 3 or total score 22 is the critical value, suggesting that the function has significantly reduced, China's conventional total score of 18.5 ± 5.5.

Diagnosis and diagnosis of Alzheimer's disease dementia

Diagnostic criteria

The diagnostic criteria include WHO's ICD, APA's DSM and China's CMA's CCMD diagnostic criteria. National standards are basically similar, and the National Institute of Neurology and Language Disorders and Stroke (NINCDS) and AD and related disease associations (ADRDA) are jointly developed. The AD diagnostic criteria are unique, divided into "probable", "susceptible" and "definite" three-level diagnosis, although more detailed, but less practical, in addition to the US application In addition, it is usually only used as a diagnostic standard for scientific research. Readers can refer to the diagnostic points of AD of ICD-10.

Attached: CCMD-2-R diagnostic criteria.

1. Alzheimer's disease (Alzheimer's disease) (290; F00)

(1) Meet the criteria for brain organic disorders.

(2) The onset is slow, and the progressively worsened dementia is the main clinical symptom. Although the disease development can be temporarily paused, it is irreversible.

(3) The following diseases should be excluded:

1 Dementia caused by other brain diseases such as cerebrovascular disease.

2 pseudo-dementia caused by mental disorders such as depression.

2. Alzheimer's disease (Alzheimer's disease), pre-senile type (290.1; F00.0) 1 meets the diagnostic criteria for Alzheimer's disease, 2 the age of onset is under 65 years old, 3 the disease deteriorates faster, can appear earlier Aphasia, loss of writing, loss of reading and misuse.

Alzheimer's disease (Alzheimer's disease), senile type (290.0.290.2; F00.1): 1 meets the diagnostic criteria for Alzheimer's disease, 2 the age of onset is over or over 65 years old, 3 the condition is slowly aggravated, early memory Obstacles are the main performance.

3. Alzheimer's disease (Alzheimer's disease), atypical or mixed type (290.8; F00.2) meets the diagnostic criteria for Alzheimer's disease, but the clinical symptoms are not typical, or combined with cerebrovascular disease.

4. Alzheimer's disease (Alzheimer's disease), other types (290.8; F00.9) meet the diagnostic criteria for Alzheimer's disease, but do not fully meet the diagnostic criteria of the above type 3.

Differential diagnosis

It is estimated that more than 60 diseases can develop clinical symptoms similar to dementia, some of which are treatable or reversible, so differential diagnosis is of great significance.

1. Normal aging and AD: There is a dispute between the two; most scholars believe that the two are different. AD is an independent disease unit with its pathophysiological basis, not normal aging.

2. Benign Senescent Forgetfulness (BSF): the current age-associated memory impairment (AAMI); refers to the elderly with amnesia symptoms and lack of clinical evidence of dementia, is a normal or physiological The performance of non-progressive brain aging, AD memory impairment mainly involves bearing in mind the difficulty of learning new knowledge and the inability to preserve memory, while AAMI's memory loss is mainly due to memory reproduction process obstacles, unable to freely extract saved information from the memory. If you can't remember the name, location, telephone number, and postal code, but after reminding you to remember, the patient often feels a burden, or take the initiative to seek medical treatment or try to make up and take notes, please remind people, etc., AAMI and early Dementia identification may be difficult, because there is some overlap in memory loss between the two, long-term follow-up is required to make a correct judgment.

AAMI diagnostic criteria:

(1) At least 50 years of age.

(2) The main complaint is the gradual loss of memory in daily life (such as the difficulty of remembering the name, misplace things, forget the phone number).

(3) Psychological test evidence of memory loss, such as the recognized standardized test operation is at least one standard deviation lower than the average of young people.

(4) The total intellectual function is not degraded.

(5) No evidence of dementia.

(6) There are no medical problems, neurological or psychiatric diseases, including psychotropic drugs or other drugs, or alcohol abuse, and no history of brain trauma with loss of consciousness for more than 1 hour (indicated from Crook T, Bartus) RT, Ferris SH et al., 1986).

3. Vascular dementia (VD): China's vascular dementia is more common in Western countries and should be differentiated from AD.

4. Pick up disease.

5. Creutzfelt-Jacob disease.

6. Parkinson's disease (PD): is a common neurological disease. Detention is caused in about 1/3 of patients with long-term follow-up. The Mynert basal ganglia in PD patients also has lesions. Therefore, cholinergic function is also low, so PD can have both subcortical And the characteristics of cortical dementia, whether PD-induced dementia is an independent disease or a combination of AD is still controversial.

7.Lewy body dementia: It is reported that the disease is not uncommon, because the pathology may have age spots, but there is no NFTs, it is easy to mistakenly believe that only the age spots of AD, the disease is a progressive dementia, the course of disease fluctuations and early hallucinations, etc. Psychiatric symptoms, which can be distinguished from AD, are often accompanied by obvious extrapyramidal symptoms, so it is clinically difficult to distinguish from PD dementia. The characteristic histopathological changes of the disease are Lewy bodies in the cerebral cortex and substantia nigra. The side effects are very sensitive and may reflect the defect of the nigrostriatal dopaminergic neurons.

Like AD patients, the neocortical ChAT also has extensive loss, dopamine reduction in the caudate nucleus, similar changes in PD, PD without dementia, Lewy body mainly in the subcutaneous region, moderately reduced ChAT in the cortex, PD patients with dementia Lewy bodies are in the cortex and cortical ChAT is significantly reduced.

8. Normal pressure hydrocephalus (NPH): also known as recessive hydrocephalus, hypobaric hydrocephalus, most of the etiology is unknown, some cases have cerebral hemorrhage, brain trauma or meningitis and cerebrovascular disease history, pathological changes The brain basal cistern and the subarachnoid arachnoid thickening adhesion, hindering the flow of cerebrospinal fluid from the ventricle to the sagittal sinus, causing various symptoms, mostly in the age of 60 years old, both men and women can suffer, clinical manifestations of dementia, gait is not Stable, urinary incontinence triad, subacute onset, the course of the disease is fluctuating, often peaks within a few months, check the symmetry of the ventricle, especially the anterior horn of the lateral ventricle, ventricular shunt can relieve neuropsychiatric symptoms.

9. Paralytic dementia: a chronic meningoencephalitis caused by Treponema pallidum, showing a progressive and progressive course of disease, the main clinical phase is progressive dementia and personality changes, often with neurological symptoms, such as Arroyo, blood Kang The watt reaction and the cerebrospinal fluid colloidal gold test are often positive. This disease is rare in China after the founding of New China.

10. Depressive Dementia Syndrome: Depressive symptoms can occur in patients with cognitive impairment. Reding et al (1985) reported that patients who were transferred to the dementia clinic, 27% met the criteria for depression, and he believed that there was a link between depression and dementia: Patients with cognitive impairment may experience depression; 2 depression and dementia may be caused by stroke or PD; 3 symptoms of dementia may resemble depressive symptoms and misdiagnosed as affective disorder; 4 depression may be accompanied by "dementia" syndrome, early depression It is not uncommon to develop in old age. The patient's thinking is slow, the answer is slow, the tone is low, and the movement is reduced. It can give people the illusion of "dementia" (also known as "depressive pseudo-dementia"). The so-called pseudo-dementia refers to Depressive dementia, that is, cognitive impairment is reversible, although depression is more acute and has obvious onset boundaries, pre-information intelligence and personality are good, clinical symptoms are mainly emotional depression, but careful examination reveals that although they are slow to respond, However, there is still a response to the content, and the antidepressant is effective, and there is no residual personality or intelligent defect.

Unlike organic dementia, in fact, the cognitive impairment of depressed patients is not true or false. This patient seems to use the name dementia syndrome of depression (DSD).

The identification of DSD and AD is as follows:

(1) In contrast to primary dementia, the onset of DSD and the interval between treatments are shorter.

(2) DSD has a history of affective disorders in the past.

(3) DSD patients have more depression and delusions than AD.

(4) The behavioral decline of AD patients is consistent with the degree of cognitive impairment.

(5) DSD sleep disorders are more serious, often wake up early.

(6) DSD self-knowledge is saved, and the memory test scores are often improved under encouragement or prompting.

(7) Patients with AD have characteristic speech deficits, which may be associated with dyslexic disease, and DSD.

(8) Structural imaging studies have shown that patients with DSD may also have decreased brain density and a similar ventricle/brain ratio to patients with dementia, but the prognostic significance of this finding is unclear.

(9) DSD functional imaging studies, such as PET showed asymmetrical low frontal lobe metabolism, the left side is more obvious, can be restored to normal after treatment with antidepressants, this low frontal metabolism is different from AD double hazelnut metabolism. .

The outcome of DSD has not been determined. It has been reported that 44 patients with DSD recovered their pre-cognitive levels after treatment. After 8 years of follow-up, 89% had AD.

11. AD and cerebrovascular disease can exist at the same time, but generally the disease does not start with stroke, early can be without hemiplegia, visual field damage and ataxia and other signs; but late may also appear, if there is evidence that the disease and If cerebrovascular disease is present at the same time, a diagnosis of 00.02 Alzheimer's disease mixed type should be determined.

12. Functional psychosis: Fang Yusheng et al (1990) reported 160 patients with early symptoms of AD in accordance with DSM-III-R diagnostic criteria, 56% (90/160) patients with functional mental disorders, lack of clear dementia symptoms, often Misdiagnosed as functional psychosis, including 38 cases (24%) in manic state, manifested as high emotions, increased irritability, exaggerated delusions, overeating, sexual intentions, nosy, illusion delusion in 35 cases (22%), Among them, 19 were imaginary delusions, 10 were auditory hallucinations, 9 were stolen, 3 were exaggerated, 2 were delusional, 17 were depressed (11%), 8 were suspected, 7 were anxious, and 5 were delayed. 4 cases of depression, 3 cases of self-blame.

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