Danh gia churc nang nhan thirc a ngudi dai thao duong Ion tudi
PGS.TS. Vu Anh Nhi*. BS. Tong Mai Trang"
"86 mon Thdn Kinh ~ Khoa YBaihoc YDuac TP. Ho ChiMinh
*^Benh viin Bai hocY Duac
T6M TAT
Muc tiiu nghidn cuu: flanh gid loai nlian thCrc nao c6 the bi Anh hudng do ddi thdo dirang. Xdc djnh nhung yiu to nguy co cua dai thao dudng Icim nllng thdm suy gi^m chtrc ndng nhln thCre.
Phuong phap: 129 bdnh nhan dcii thao duong nhap Khoa Ndi Tidt Bdnh vidn Cho Ray dugc dua vao nghidn cuu. Bdnh nhan thda tidu chuSn chpn mau se duoc hdi benh si>, thdm khcim tdng quat vi than kinh sau dd thuc hien cdc test danh gia chCrc ning nhcin thuc: MMSE, VF, CDT, GDS, lADL.
Kdt qui: Khd ndng dinh hudng, trf nhd gcin, chd i^ tap trung, ngon ngir, trf nhd ngu nghia, ki ndng diing tu, chuc nang dieu hanh, thi giac khdng gian tren bdnh nhan dai thao dudng deu gidm hon so vdi ngudi binh thudng chi cd tri nhd tdc tht la khdng hi anh hudng.
Ket luan: oai thao dudng gdp phan gay suy giam nh$n thuc, va cac yeu tS: Phuong phap didu tri, t r i m cam, kiem soat dudng huyet, hoc van, gidi, tudi cd anh hudng den chdc nang nhan thuc.
I. MO DAU ngoai bien da duac chiuYig minh thi nhufng hieu biet ve dai thao dudng trong churc nang nhan thiJc Ngay nay, dai th^o dudng la benh pho bien 6 van con rat han che do chua co nhieu nghien cijfu ngudildn tuoi, no CO the gay tCr vong vS tan phe. ve van de nay. Mpt songhienculichothaydai thao Ben canh nhi^g bien chufng cua dai thao dudng dudng la yeu to nguy co cua sa sut tn tu^ va suy tren than, vong mac, tim mach, benh ly than kinh giam nhan thUc'"''^''".Cac nghien cUu gan day ghi
-,. hoithankinhhocvietnamcom.vn 56 14-QUVIV/2015 ITHANKINHHOCKltlNAM 117
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nhan dai thao dircfng lam tang t>j Ie suy giam nhan thufc mOfc dp nhe, va nhCfng benh nhan nay co ty' le phat trien thanh sa sut trf tue cao hpn. Theo Bruce va cong su**', co den 16% ngudi dai thao dudng Idn tuoi bi suy giam nhan thu'c.
Co nhieu cd che gay suy giam nhan thufc tren benh nhan dai thao dddng, nhPng sinh ly benh chfnh xae thi ehifa dupe xac djnh. Oai thao du'dng la yeu to nguy cP cua benh ly mach mau nao von la nguyen nhan gay suy gicim nhan thifc thong qua benh ly maeh mau, thue day true tiep hay gian tiep benh Alzheimer.
NhiJng yeu to nguy cP suy gicim nhan thufc va sa sut tri tue tren benh nhan tieu dudng can dupe xac dinh la gia tri dudng huyet, che do suf dung thuoc dai thao dudng, thdi gian mac dai thao dudng, benh dpng mach ngoai bien, microalbumin nieu,...
Tai Viet Nam ITnh viic nay ddac quan tam muon hon v^ co rat it nghien cufu ve sa sut tri tue noi ehung hay cac bao cao lien quan den sa sut trf tu$ va suy giam nhan thUc tren benh nhan dai thao dUdng noi rieng eua ngUdi Viet Nam. TCr nhOng ly do neu tren, chung toi tien hanh danh gia chu'c nang nhan thUc tren ngUdi dai thao dudng Idn tuoi tai Khoa Npi tiet Benh vien Chp Ray de tim moi lien quan giUa dai thao dudng va chu'c nang nhan thu'c.
II. DOI TimNG VA PHUDNG PHAP NGHIEN Cl)U
Day la mot nghien eUu mo ta hang loat trudng hpp tren cac benh nhan nhap vien Khoa Npi Tiet xd ngay 01/02/2010 - 31/07/2010. Benh nhan (BN) dupe dua vao nghien eUu theo cac tieu ehuan sau:
1. Tieu chuan dua vao
Oudng huyet bat ky a 126 mg% (> 7.0 mmol/L) hoac dudng huyet 2 gid sau an > 200mg% {s 11.1 118 TH/iN KINH HOC VICT NAM I S6 14 - QUV IV/2015
mmol/L) hoae dupe chan doan benh dai thao dudng trudc do va tuoi > 60 (2010 - nam sinh).
2. Tieu chuan loai triT
BN cd tien can tdn thUPng nao: Opt quy nao, u nao, viem nao, chan thUPng dau gay mau tu,....
Tinh trang noi khoa kem theo nang nhU: Nhiem triJng, nhiem doc, roi loan dien giai, thieu mau nang, suy than phai ehay than djnh ki, xP gan,...
BN da dupc chan doan sa sut tri tu& trUde do.
BN thoa tieu ehi chon mlu va loai trU se dUPe danh gia chu'c nang nhan thUe bSng cac test IVIMSE: Thang diem danh gia chUc nang nhan thUc ehung. IVlfVlSE<24 diem dupe xem la bat thudng'^'^'.
VF: Oanh gia tri nhd ngOf nghla, ky nang diing tCr, VF<12 diem la batthudng.'^'
CDT: Oanh gia thj giac khong gian, chUe nang dieu hanh, CDT< 6 diem la bat thudng"".
GDS: Bang diem danh gia tram c5m 6 ngudi gia, GDS > 5 diem dupc xem la cd bieu hien tram cam'''.
lADL: Bang diem danh gia siJdyng, danh gia khS nang dpe lap trong cupc song hSng ngay lADL > 1 diem dUpc xem la song phu thuoe"".
So lieu thu thap dupe se dupc xCf ly bang phan memStada phien bein lO.O.Cac bien dinh lupng se ddcic diJng phep kiem T-test, IVIann Whitney, bien djnh tfnh ddng phep kiem x^, so sanh trung binh giCfa cac nhom dung phep kiem Anova de tim moi lien quan giiJfa ehUc nang nhan thUe vdi cac yeu to: Tuoi, gidi, hoc van, kiem soat dudng huyet, tram c3m, phUPng phap dieu trj. Gia tri p < 0.05 dupc xem la ed y nghia thong ke.
III. KET QUA
Trong mau nghien edu ciia ehung toi ed 129 benh nhan, t^ le nU 66,67% cao hon nam, do tudi
Website hoitl^ankmlihocvietnam com vn
trung binh: 71,15 ± 7,22, da so song d nong thdn 62,02%; trinh d6 hoc van cap 1 - cap 2: 63,57%;
thdi gian m i c dai thao dUdng trung binh la 7,16
± 6,4 (nam), ph^n idn ki^m soat dudng huyet khong t o t khi HbAlc trung binh 10,65 ± 2,8 (%) va ed 28,91% benh nhSn phai dung den insulin de kiem soat dudng huyet, khong co benh nhan nao dieu ehinh dudng huyet bang loi song va che d o a n .
Ty le benh nhan cd suy giam nhan thde (MMSE < 24diem) trong nghien eUu eua chung toi la 85 benh nhan (65,89%).
T9 le benh nhan thUe hien test VF va CDT kem l l n lupt la 30,23% va 32,56%.
Ty le benh nhan song phu thuoc vao ngudi khac la 38,76%.
Ve yeu to djeh te t r o n g nghien cufu cua chung toi ghi nhan t u o i t^c, gidi, trinh do hoc van ed anh hudng den tat ci cic ehUe nang nhein thUc, cu the t u o i eang eao, gidi nOf, trinh dp hoc van thap se gay suy gicim cac linh vUc nhan t h Uc.
Cac benh di kem nhU: Tang huyet ap, beo phi, tang LDL khdng i n h hudng chifc nang nhan thde vi gia trj eac kiem dinh djnh cd p > 0,05. Rieng tram cSm thi c6 gay suy giam tri nhd ngCf nghia cijng nhuSnh hudng d^n kha nang song dpe lap cCia b$nh nhan p < 0,05.
Khi dung chi so HbAI c de danh gia tinh trang kiem soat dUdng huyet eua benh nhan HbAlc
< 7%: Kiem soat dUdng huyet tdt. HbAlc > 7%:
Kiem soat dUdng huy^t khong tot, chung toi khdng ghi nhan moi lien quan gida kiem soat dudng huy^t va chdc nang nhan thUe. Cu the HbAI c a 7% khdng g i y suy g i i m nhan thdc. Tuy nhien khi ehung tdi chia 2 nhdm: O i l thao dudng kiem soat khong tdt kem bieu hien benh than kinh ngoai bien vdi nhdm dai thao dudng khdng kem bieu hien benh than kinh ngoai bien thi ghi V\'i'^site fioithanl<inhhocvietnamcom.vn
nhan chUc nang nhan thde co bj suy giam khi dai thao dudng co kem bieu hi^n benh than kinh ngoai bien.
Trong nghien cdu eda ehung toi, benh nhan dai thao dudng dieu trj bang insulin thi g i i m trf nhd n g d nghla, cac linh vdc nhan thUe khac nhu dinh hudng, chu y tap trung tfnh toan, trf nhd gan, ngon ngO, ehde nang dieu hanh thi khdng bj anh hudng.
Ket qua cae test danh gia chUe nang nhan thUe d nhdm mdi mac dai thao dudng va nhom cd thdi gian mac lau hPn la nhu nhau.
IV.BANLUAN
Nhdm dan so trong nghien cUu cUa ehung tdi ed moi lien quan giifa tuoi va eac ehde nang nhan thdc vdi xu hUdng nhan thUe g i i m d i n khi so tuoi tang. Oieu nay cung tuang t u nghidn cdu Rotterdam cua Ott""', Le Nguyen Nhut Tin"', Nguyen Kinh Quod", trong do k h i nang ehu y, tap trung, tfnh toan la cd lien quan manh nhat vdi tuoi tae.
Theo nghien cUu cua chung toi gidi n d cd nhieu nguy co giam eae ehde nang n h i n thdc hPn gidi nam. Ket q u i n i y tucrng t u tae g i i Le Nguyen Nhut Tin'^'. Tuy nhien, khdng phii hpp vdi nghien eUu Rotterdam cCia Ott'"', Nguyen Kinh Qude'^' khi eho r i n g khong cd su khac biet cd y nghla thong ke eCia gidi nam va nCf. Do do chua ed su thong nhat anh hudng eua gidi tfnh vdi eae ehde nang nhan thUc, chung toi can mpt nghien eUu khac vdi ed mau Idn hdn de kiem chUng ket q u i nay.
Cd mdi lien quan giCfa trinh dp hpe van va chdc nang nhan thdc trong nghidn edu cua chung toi. Oieu nay cung phu hpp vdi y van va cae nghien cUu sau: Le Nguyen Nhut Tfn'^', Nguyen Kinh Quoe"', Christopher**'...
S6 14 - QUV IV/2015 I THAN KINH HOC VIET NAM 119
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NPi song khdng ed moi tuong quan vdi cac chdc nang nhan thUe: Omh hUdng, chu y, t i p trung, tfnh toan, ngdn ngd, chdc nang dieu hanh, tri nhd ngdn tU. Tat ea eae kiem dinh thong ke deu cho p > 0,05. NPi cU tru it dupe ehu y d eae nghien edu cda nude ngoai va trong y van yeu to npi song cung it dupe nhie den. Do do, theo ket qua eua nghien cdu nay nPi cUtru khong lien quan vdi ehde nang nhan thUe.
Nhieu y van da xae djnh tang huyet ap la yeu to nguy cP cua benh ly mach mau, do dd khi cd tinh trang tang huyet ap khong dupe kiem soat tot thi cd kha nang se gay suy giim nhan thdc thong qua eo ehe maeh miu.
Theo nghien cdu cua chung toi, tang huyet ap khong cd mdi tUPng quan vdi da so cae ehde nang nhan thdc: Omh hUdng, chu y, tap trung, tinh toan, ngon ngCf, trf nhd ngon td, ky nang dung tU. Ket qui nay phu hPp tie gii Le Nguyen NhutTfn'^', va nghien edu doan he ti^n edu Rancho Bernardo cCia Kanaya'"".
Tuy nhien, nghien edu cua Framingham thi ghi nhan tang huyet ap la yeu td nguy cP gay suy giam nhan thde.
Beo phi khong anh hudng chdc nang nhan thdc trong nghien cUu eua chung tdi c6 the do Viet Nam la nUdc dang phat trien, ddi song vat chat khdng cao nhu cac nude phUPng Tay nen ty le beo phi ft han do do khi khao sit vai trd eCia yeu to nay vdi ehde nang nhan thdc thi khong ehi'nh xae.
Munshi va epng su ghi nhan benh nhan dai thao dudng can sU ung hp tir ngUdi than ve ei mat tinh than lan the chat do su suy giam nhan thdc, ket qua nay cung tUPng tU nghien cUu cda chung toi.
Cae tae gia Arvanitakis, Gregg, Munshi, Wastson: Ghi nhin kiem soat dUdng huy^t kem gay suy giim nhan thde. Trong nghien cdu cCia 120 THAN KINH HOC VIET NAM I s6 14- QUf IV/2015
minh chung tot cung ghi nhan kiem soat dUdng huyet khong tdt cd kem bieu hien benh viem than kinh ngoai bien thi chdc nang nhan thdc cua hp kem di.
Yaffe"*' ghi nhan ty le suy giim nhan thde tang theo thdi gian mac dai thao dUdng, edn nghien edu ehung tdi khong ghi nhan moi lien quan nay dieu nay ed the do cae benh nhan dai thao dudng tai Viet Nam mac du la mdi phat hien benh nhung thUc sU da mac benh xd lau nhung khong cd dieu kien phat hien.
V. KET LUAN
Qua nghien cdu cua 129 benh nhan dai thao dudng tai Khoa Npi tiet Benh vien Chp Ray td thing 01/02/2010 - 31/07/2010. Chung tdi nit ra mpt so ket luan sau:
Cac loai chdc nang nhan thdc benh nhin dai thao dudng trong nghien cUu eCia ehdng tdi bi suy giim la: Bjnh hudng, ehu y, tip trung, tinh toan, tri nhd gan, ngdn ngd, tri nhd ngO nghia, ky nang diing td, chdc nang dieu hanh. Trong do, khi nang chu y, tap trung va tri nhd ngd nghla la bj giim nhieu nhat Chi cd tri nhd tdc thdi la khong bj anh hudng.
Cie yeu to anh hudng den ehde nang nhin thdc trong mau nghien cdu cua chung tdi la:
Tuoi, gidi, hpe van, tram cam, dieu tri dii thao dudng vdi insulin, kiem soit dUdng huyet khong tot kem bieu hien benh da day than kinh ngoai bien.
Website: lioitiiankinhhocvietnam.com.vn
TAI LIEU T H A M KHAO
1 - Nguyen Kinh Quoc (2006). Khdo sdt thang diem MMSE trin ngddi Viit Nam binh thddng. Luan van thae sy y hoc. Oai hpe Y DUpc Thanh phd Hd Chi Minh.
2. Le Nguyen Nhut Tin (2006). Tan suafvd cdcyeu fdnguycacuo so siifm'fue sau (?dt quy. Lu|n van np^
Oai hpe Y Dupc Thanh phd Hd Chf Minh.
3. American Psychiatric Association (1994). Diagnostic and Statical Manual of Mental Disorders, fourth edition. Washington.
4. Bruce G. D., Davis A. W., Casey P. G. (2008). Prediaors of Cognitive Decline in Older Individuals With Diabetes. Diabetes Care 31: pp2103 - 2107.
5. Canadian Study of Health and Aging (1994). Study methods and prevalence of dementia. CMAJ;150, pp.899-913.
6. Christopher T. KodI and Elizabeth R( 2008). Cognitive Dysfunction and Diabetes Mellitus. Endocrine Reviews.29: pp.494 -511.
7. D'Ath P, Katona P, Mullan E,...(1994). Screening, detection and management of depression in elderly primary care attenders. I: The acceptability and performance of the 15 item Geriatric Depression Scale (GDS15) and the development of short versions. Fam Pract 11: pp.260 - 266.
8. Grodstein F, Chen J, Wilson RS, et al (2001). Type 2 diabetes and cognitive function in community- dwelling elderly women. Diabetes Care 24:1060 -1065.
9. Haan MN, Mungas DM, Gonzalez HM, et al (2003). Prevalence of dementia in older Latinos: the influence of type 2 diabetes mellitus, stroke and genetic faaors. J Am Geriatr Soc 51: pp.169 -177.
10. Kanaya A M , Barrett - Connor E, Gildengorin G, et al (2004). Change in cognitive function by glucose tolerance status in older adults: a 4 - year prospective study of the Rancho Bernardo study cohort. Arch intern Med 164: pp1327 -1333.
11. Munshi M, Grande L, Hayes M, et al (2006). Cognitive dysfunction is associated with poor diabetes control in older adults. Diabetes Care 29: pp.1794 -1799.
12. Ott A, Stolk RP, Hofman A, et al (1996). Association of diabetes mellitus and dementia: the Rotterdam Study. Diabetologia 39: pp.1392 -1397.
13. Ott A, Stolk RP, Van Harskamp F (1999). Diabetes mellitus and the risk of dementia: The Rotterdam Study. Neurology; 53: pp.1937 - 42.
14. Sinclair AJ, Girling AJ, Bayer AJ (2000). Cognitive dysfunction in older subjects with diabetes mellitus:
impact on diabetes self- management and use of care sen/ices: All Wales Research into Elderly (AWARE) Study. Diabetes Res Clin Pract 50: pp203 - 212.
15. Shulman I.K. (2000). Clock - Drawing: Is It The Ideal Cognitive Screening Test?. IntJ. Geriat. Psychiatry 15, pp.548-561.
16. Yaffe K, Blackwelt T, Kanaya A M , et al (2004). Diabetes, impaired fasting glucose, and development of cognitive impairment in older women. Neurology 63: pp.658 - 663
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