NGHIEN CL/U MOT SO DAC DIEM LAM SANG VA
TRAC NGHIEM THAN KINH TAM LY CUA BENH ALZHEIMER
Pham Thing, Nguyen Thanh Binh / Benh vien Lao khoa Trung dang Muc tieu: nghien cdu vd phdn tich mot sd ddc diem Idm sang vd trac nghiem than kinh tdm 11 cua benh nhdn mdc benh Alzheimer tai Vien Ldo khoa Qudc gia. Dd'i tUgng va phuang phap nghien cdu: nghien 'cdu theo phdang phdp md ta cdt ngang. 81 benh nhan ddac chan doan xac dinh mdc benh Alzheimer theo tieu chuan DSM- IV- TR. Tat ca cdc benh nhdn ddac khdm lam sdng, Idm cdc trdc nghiem than kinh tam ly can thie't. Ke't qua: nhdm tudi thddng gap nhat Id tren 60. Quen Id bieu hien thddng gap nha't khien benh nhdn di khdm (100%), rdi loan tam than vdi bieu hien chinh Id hoang tddng, do gidc chiem tl le cao trong nghien cdu. Sd benh nhan cd ket qua diem khdng binh thddng trong trdc nghiem tn nhd, ve dong ho, hoat dong hang ngdy rat cao. Ke't luan: td't ca cdc benh nhdn Alzheimer deu cd rdi loan td nhd, chu yeu Id rd'i loan td nhd gan va anh hddng den boat ddng hdng ngdy bang dung cu, phdang tien. Rdi loan tam than Id bieu hien thddng gap vdi bieu hien chinh la hoang tddng vd ao gidc.
Tii khoa: Alzheimer, d|c diem lam sang, trie nghiem tam ly
I. DAT VAN DE
Sa sut tri tue (SSTT) la mdt hpi chdng lam sang bieu hien bang sd suy g i i m n h i l u iTnh vdc nhan thdc, gay e i n trd hoat dpng chdc nang hang ngay eua benh nhan. Sa sut tri tue la nguyen nhan chinh gay tan phe, nhap vien va giam tudi thp.
Cd nhieu nguyen nhan gay sa sdt tri tue nhd: benh Alzheimer, sa sdt tri tue do nguyen nhan maeh mdu, sa sut tri tue thdy tran - thai dddng, sa sdt tri tue the Lewy... trong dd Alzheimer la nhdm nguyen nhan thddng gap nha't.
T i n sua't m i e sa sut trf tue tang theo ham sd mu vdi tudi. Do hien tddng gia h d i dan so' tren quy md toan eau, sa sut tri tue da trd thanh mdt trong nhdng thdch thdc Idn ddi vdi sdc khoe cpng ddng va eac he thdng chain sdc ngddi gia.
Trong nhdng nam g i n day, van de benh ly sa sut tri tue va Alzheimer ngay eang ddde quan tam n h i l u hdn. Nhieu edng trinh nghien edu v l ede khia eanh khac nhau eua benh ly nay da va dang ddde thdc hien tren k h i p the gidi. Tai Viet Nam eae d l tdi nghien edu sau ve benh Alzheimer eung ehda n h i l u . Xud't phat td thdc te tren, chdng
tdi da tien hanh de tai: "Nghien edu mpt sd dae diem lam sang va t r i e nghiem than kinh tam li eda benh Alzheimer" vdi muc tieu:
Phan tich cac bieu hien thudng gap nhat ve lam sang cua benh Alzheimer va y ngbla cua trac nghiem than kinh tam ly trong chan doan benh nay.
II. DOI TUONG VA PHUONG
P H A PNGHIEN CUU
1. Doi tupng nghien cu'u
- Nhdm benh: 81 benh nhan ddde ehan dean xae djnh bj benh Alzheimer thee tieu chuan eua DSM-IV-TR.
- NhOng benh nhan bi c l e benh cap tinh lam rdi loan y thdc nhd: tai bie'n maeh mau nao giai doan cap edu, viem nao, ap xe ndd, viem mang nao cap, rd'i loan chuyen hda, cha'n thddng sp nac giai doan ca'p cdu se khdng ddde dda vao nghien edu. Cae benh nhan tham gia nghien edu khdng bj cae tat giac quan va khdng mu chd.
- Ta't e l eae benh nhan hoac ngddi dai dien trong nghien cdu deu td nguyen ky gia'y ddng y tham gia
nghien edu. Quy trinh nghien cud eua de tai da ddpc Hpi ddng Y ddc eua benh vien thong qua.
2. Phuong phap nghien cihi:
- PhUdng phap nghien cdu md ta e l t ngang.
- C l e benh nhan ddde tham kham lam sang va lam t r i e nghiem than kinh tam ly (trie nghiem MMSE, t r i e nghiem dinh danh cai tien eua Boston, Bp t r i e nghiem thuy tran, ADL va lADL) theo m i u
b?nh an ddpc thie't ke rieng eho nghien edu.
3. Xuf ly so l i f u
- Cae sd lieu nghien edu ddpc xd ly tren may vi tinh theo phddng phap thdng ke bang chddng trinh Epi Info phien ban 2008 va SPSS 16.0.
- T i n h phan t r a m , gia tri trung b i n h , dp lech c h u a n .
- Kiem djnh x2 test t - student, tinh gia tri p.
III. KETQUA
Bang 1. Phan loai theo nhdm tudi va gidi
Tuoi
< 6 0 61 - 70 71 - 8 0 81 - 9 0
> 9 0 Tdng
Nam n 2 11 14 3 1 31
(%)
(2,5) (13,6) (17,3) (3,7) . (1,2)
(38,3)
Niif n 6 12 23 9 0 50
(%)
(7,4) (14,8) (28,4) (11,1) (0) (61,7)
,,
Tong 8 23 37 12 1 81
%
9,9 28,4 45,7 14,8 1,2 100 Tuoi trung binh chung 67,26 ± 10,59.
Nhan xet: nhdm tudi chie'm ty le cao nha't trong nghien cdu cua chung tdi la td 6 7 de'n 80, chiem ty le 74,1 %, nd nhieu ban nam, sd khac biet khdng cd y nghia thd'ng ke.
Bang 2. Trieu chdng lam sang Trieu ehufng
That ngdn (aphasia) That dung (apraxia) Mat nhan biet (agndsia) Rdi loan chdc nang thdc hien Rdi loan hanh vi
So b$nh nhan (n 42 46 60 54 46
= 81)
%
52,5 57,5 75 67,5 57,5
Nhan xet bang 2: da phan benh nhan cd mat nhan biet (75%o) mat chdc nang thdc hien (67,5%), that dung (57,5%), rdi loan hanh vi (57,5%).
Nhan xet bang 3: cac trieu chdng tam than ndi bat la hoang tddng, ao giac va rdi loan hanh vl ban dem.
Nhan xet bang 4: phan Idn benh nhan khdng dat diem binh thddng vdi trdc nghiem nhd lai danh sdeh td hay ke lai mau chuyen (100% benh nhan khdng the ke lai mau truyen cd tri hoan). 100% ty le benh nhan khdng dat diem binh thddng trong trdc nghiem hoat dong hang ngdy . ,:t<
Bang 3. Thang diem NPI (Neuropsychiatric Inventory: danh gia trang thai tam than)
Trifu ehu'ng Nam NQ
n (%) n (%)
Hoang tddng Ao giac Kieh dpng T r i m e l m Lo au Hdng pha'n Vd e l m Mat de ehe Cau kinh RL van dpng RL hanh vi ban RL an udng
dem
. '• . .
Ket qua tri nhd tiiT
7 3 6 2 6 4 3 3 8 7 10 4
(10,8) (4,6) (9,2) (3,1) (9,2) (6,2) (4,6) (4,6) (12,3) (10,8) (15,4) (6,2)
Bang 4. Kit qua trac nghiem
So' BN khong dat diem 10 10 4 6 4 1 9 7 12 8 13 6
binh (15,4) (15,4) (6,2) (9,2) (6,2) (1,5) (13,8) (10,8) (18,5) (12,3) (20,0) (9,2)
thudng (n = 81) 0,97 0,13 0,19 0,31 0,19 0,07 0,19 0,42 ,0,87 0,65 0,81 0,92
%
Nhd danh saeh tlf
Nhd lai ngay 70
Nhd lai ed tri hoan 74
Chdc nang boat ddng hang ngay bang
edng eu 81
86,42 91,36 Nhan biet ed tri hoan
Ke lai mau Ke lai ngay chuyen Ke lai ed tri hoan
70 70 81
86,42 86,42 100 Ket qua tri nhd hinh
Nhd lai ngay Nhd lai ed tri hoan Nhan biet ed tri hoan
68 78 81
83,95 96,29 100 Su chii y
Dpc xuci day so Ddc ngdde day sd
28 53
34,57 65, 43 Ngon ngu'
Gpi ten eua Boston Ndi lUu loat td
60 60
74,07 74,07 Danh gia hoat dpng hang ngay
Chdc nang hoat dpng hang ngay 66 81,5
100
IV. BAN LUAN
Sa sut tri tue ndi ehung va sa sut trf tue do Alzheimer ndi rieng tang len theo tudi. Dieu nay da ddde ta't e l eae t i e gia khi nghien edu de cap den. (^ cae nUde edng nghiep phat trien, sa sut tri tue ehiem 8% d ngddi td 60 tudi trd len va 3 5 % ngddi td 85 tudi trd len [4]. N g u y i n Kim Viet trong mdt nghien edu ve benh Alzheimer nhan tha'y nhdm tudi td 65 - 69 ehiem tdi 4 0 % tdng sd benh nhan nghien cdu, tudi td 60 - 64 ehiem 28,6% [2]. Trong nghien edu eua ehung toi tudi trung binh la 67,6. Day la Ida tudi eao vi ta't e l eae benh nhan den vien kham deu la ngddi eao tudi. So vdi cdc tae g i i trong nddc thi cung khong cd sd khac biet ldn chdng td day la benh ly eua ngUdJ eao tudi [2, 6].
Trieu chdng tam t h i n eua eae benh nhan trong nghien edu rat phong phu. Bieu hien hay gap nha't la hoang tddng (17 benh nhan), rdi loan hanh vi ban dem (23 benh nhan), l o giac (13 benh nhan). Theo cae tae gia [2, 4], ty le hoang tddng trong sa sut tri tue thay ddi td 10 - 7 8 % eac benh nhan, edn !•/ le l o giac thi thay ddi td 1 - 49
% eae benh nhan. Sd khac biet nay tuy thupc vao thdi diem nghien edu va se ed ty le rat eao neu chung ta ehi chpn mau la cae benh nhan nam d i l u trj tai vien vdi eac trieu chdng rdi loan tam than dae biet la hoang tddng, ao tddng la ly do chinh khien gia dinh dda benh nhan vao vien.
Trong eae loai hoang tddng ehung tdi gap phd bien nhat la hoang tddng bi hai. Benh nhan eho r i n g minh da bi la'y het dd dae tien eua. Dieu nay phu hpp vdi nghien edu cua nhieu tae gia nhan thay hdang tddng bi trdm cap gap d mpt nda sd benh nhan sa sut tri tue. Benh nhan nghi ngd ngddi than hoac nhdng ngddi chain sdc hp lay c l p dd dae cua hp. Hau het eae benh nhan trong nghien cdu eua ehung tdi deu d giai doan eudi va toan phdt (75%). Sd Iddng benh nhan den khdm d giai doan khdi phdt ehda nhieu, ed le do benh
nhan va gia dinh ehda ed nhan thdc dung d i n ve benh Alzheimer, eho r i n g quen la van de sinh If binh thddng.
Trong nghien cdu eua ehung tdi, ta't ea eae benh nhan deu ed rdi loan tn nhd (100%). Tri nhd g i n va tri nhd vTnh v i l n eung bj suy g i i m nhdng mdc do nhe hdn. Phan tich ky hdn eac rdi Idan tri nhd bao gdm tri nhd hinh, tri nhd td, ke lai mau chuyen da thay ea ba loai nay deu cd rdi loan nang, dae biet la k h i nang nhd lai eae sd vat, hien tddng. Hien tddng quen, lan dd dae, mat kha nang sd dung dgng eu trong sinh hoat hang ngay, hay lam di lam lai mpt viee gi dd eung thddng gap d sd benh nhan nghien edu, vi du benh nhan gpi dien thoai eho mpt ngddi nao dd nhieu lan trong ngay de hoi mpt viee va mpt lue sau lai hdi lai... de ddi phd vdi tinh trang nay, benh nhan thddng dung eae bang Met ke eae eong viee, day la nhufng tin hieu sdm nhat eua Alzheimer
[ 3 , 4 , 5 1 .
Chdc nang thi giac khong gian ddde d i n h gia nhd t r i e nghiem ve ddng hd. Day la t r i e nghiem rat ed gia trj trong viee danh gia ehdc nang nhan thdc vdi dp nhay va dp dae hieu eao. Chdc nang thj giac khong gian eua benh nhan khdng dat diem binh thddng ra't eao 73/81 benh nhan. Chdc nang thi giac khong gian la chdc nang kha phCfc tap, lien quan de'n nhieu he thdng trong nao, dae biet la ban eau dai nao phai. Thi giac la giac quan ddng vai trd ehfnh trong viec thdc thi chu'c nang nay. Trong nghien edu cua ehung toi chiic nang nay bi giam nhieu nha't chie'm ty le rat eao tdi 9 0 % .
Trong sa sut tri tue thddng ed sd ma't can bang gida k h i nang nhan biet nhufng kieh thieh mdi va tap trung vao nhdng kieh thieh ed lien quan. Sif ehu y ed chpn loc bi suy g i i m lam eho benh nhan hdae sao nhang hoac tap trung qua'mde, do vay bd sdt nhcmg tin hieu xung quanh. Ngoai ra benh nhan eung thddng bi g i i m nhdng kha nang duy tri hoac phan ehia sd chd y, cho du sd chu y gian
ddn v l Cd ban vdn td't.
De danh gia sd chd y gian ddn ed the yeu eau ngddi benh dee xudi day sd. Ngoai ra sd chd y gian ddn edn the hien qua each benh nhan tiep thu nhcmg hddng dan hdi thoai va tra ldi cau hdi.
Nhdng ky nang chu y ed ban nhd vay thddng ehda bj I n h hddng trong giai doan d i u cua benh SSTT va khdng it benh nhan m i e benh Alzheimer v i n thdc hien ddde trie nghiem dpc xuoi day sd hoan toan binh thddng mac du ed g i i m tri nhd [3, 4).
De danh gia tri nhd chpn lpc, ed the sd dung phddng phap dpc ngdpc day sd. Trong nghien edu eua chdng tdi ket qua thu ddde eung tddng td nhd mpt sd nghien cClu khac.
Rdi loan tri nhd d ta't ea eac benh nhan trong nghien edu eua ehung tdi ehiem ty le eao lam eho sinh hoat hang ngdy cua benh nhan bj I n h hddng nghiem trpng. Danh gid chdc nang hoat ddng hang ngay ed tdi 66/81 benh nhan khong dat diem binh thddng. Danh gia ehdc nang boat dpng hang ngay b i n g cdng cp ed tdi 100% benh nhan khdng dat diem binh thddng. Nguyen Kim Viet [2]
nhan tha'y ta't e l eac benh nhan nghien edu (100%) deu vao vien d thdi k'/ toan phat va mupn hdn nen deu mat k h i nang lao dpng nghe nghiep, benh nhan khdng lam ddde eae edng viee eu ke e l cdng viee thu edng eua ngddi ndng dan. 82,8%
benh nhan giam va mat kha nang tham gia c l e hoat dpng va quan he xa hdi. Tde gia eho rang day la hau qua trdc tiep eua suy giam tri nhd va thdt ngdn... lam eho benh nhan gap khd khan trong giao tie'p, khdng ddi phd vdi eac ddi hdi eua tinh hudng thdc te, khdng thieh dng ddde vdi nhdng thay ddi va ddi hdi trong eong viee, quan he xd hdi.
V. KET LUAN
Qua nghien edu 81 benh nhan ddde ehan dean sa sut tri tue do benh Alzheimer td thang 11/2008 den thang 10/2009 tai Vien Lao khoa
Qud'c gia theo tieu chua'n cua Saeh Thdng ke Chan doan eae benh Tam t h i n (DSM - IV - TR) chdng tdi nhan tha'y: Nhdm tudi mac nhieu la tren 60 tudi, khdng ed sd khac biet gida nam va nd. 100% benh nhan ed rd'i loan tri nhd, ehu ye'u la rdi loan tri nhd tde thdi, tri nhd g i n , edn tri nhd vinh vien it bj I n h hddng. Rdi loan tain t h i n la bieu hien thddng gap vdi bieu hien chinh la hoang tddng, l o giac. 100% benh nhan ed giam boat dpng hang ngay bang eong cu.
KHUYEN NGH!
C i n ed nhieu nghien ei'ftj sau hdn, vdi ed m i u Idn hdn de tim hieu dae diem lam sang va trie nghiem than kinh tam ly eua benh nhan Alzheimer.
T A I LIEU THAM KHAO
1. Pham Khue (1999), "Nam qudc te ngddi eao tudi va van de eham sdc sdc khoe ngddi eao tudi", Thdng tin y ddde, (1), trang 1 - 3.
2. Nguyen Kim Vi?t, Tran Viet Nghj, Hoang DiJc Ki?t (2001), "Bddc dau danh gia sa sdt tri tue d ngddi gia tai mpt q u i n the dan ed thanh p h d Thai Nguyen", Tuyen tap Cdng trinh nghien edu khca hpe eua nghien edu sinh, trddng Dai hpc Y Ha Npi, trang 1 7 6 - 1 8 1 .
3. American Psychiatric Association (1994), Diagnostic and Statistical Manual cf Mental Disorders. Fdurth Ed. (DSM - IV), Washington DC: American Psychiatric Association.
4. Spreen O, Strauss E (1998), A Compen- dium of Neuropsychological Test, 2nd Edition, New York, Oxford University Press.
5. West R, Beeri MS, Schmeidier J, Hannigan C M , Angelo G, Grossman HT, Rosendorff C, Silverman JM. (2008), "Better memory functioning associated with higher total and low - density lipoprotein cholesterol levels in very elderly subjects without the apoiipdprdtein e4 allele.", Am J Geriatr Psyehiatry.;16 (9): 781 - 5
6. Wimo A, Winblad B, Aguero - Torres H, occurrence in the w o r l d " , Alzheimer Dis Assoc von Strauss E (2003), "The magnitude of dementia Disord, (1 7): 63 - 67.
Summary
STUDY ON CLINICAL AND NEUROPSYCHOLOGICAL TESTS CHARACTERISTICS IN PATIENTS SUFFERING ALZHEIMER DISEASE
Objective: To study and analyze some clinical and neuropsychological tests characteristics of Alz- heimer disease. Method: 81 patients were diagnosed as Alzheimer disease based on the criteria of DSM IV TR, All the subjects in the study were examined thoroughly and carefully. Necessary neuropsychological tests as well as paraelinicai exams have been done. Result: The main group age is dver 60. Memory disorder is common (100%) and is key reason for healtheheek. Psycholdgical disorder such as hallucination and illusion are quite popular in Alzheimer patients. Conclusion: All Alzheimer's patients have memory disorders, mainly near and memory disorders that affect daily activities with tools and means. Psychosis is common feature including delusions and hallucinations of different types.
Keywords: Alzheimer, neuropsychological test
CHAN DOAN VA DIEU TRj
TRAO NGLfOC DA DAY THL/C QUAN (GERD)
Nguyen Duy Thing Benh vien Ndng nghiep Ddnh gid trieu chdng lam sdng vd ndi soi cd do tin cay cao trong chan dodn vd dieu tri CERD. Muc tieu:
nghien cdu cdc tneu chdng lam sang, ndi soi trddc vd sau dieu tri. Dd'i tugng va phuang phap nghien cdu:
58 benh nhdn cd tneu chdng Idm sdng, ddac ndi soi vd dieu tri vdi esomeprazole trong 4 tuan. Ke't qua: cac trieu chdng lam sdng dien hinh trddc va sau dieu tn: ndng rdt (87,9 % va 25,5%), dau ngdc (84,5 % vd 26,5
%), ho (81,0 % va 36,2 %), a chua 72,4 % va 26,2 %). Viem thdc quan trdc'lc vd sau dieu tri: do A (67.4% va 18,9%) do B (28,2% vd 8,6%), do C (4,4% vd 1,7%). Ke't luan: tneu chdng lam sang chu yeu Id ndng rat sau xddng dc, dau ngdc, e3 ndng, cf hai. Viem thdc quan do A chiem da sd. Sau dieu tri trieu chdng Idm sang va viem thdc qudn deu giam .
Jii khoa: trao ngUdc da day thUc quan
