A BAO CAO TONG QUAN
Tiep can chan doan va xutri sam sa sut tri tue
GS.TS. LeDufcHlnh HOI Than kinh hoc Viet Nam
TbMTAT
Sa Slit tri tu^ la m$t hdi chdng co th^ do nhieu benh ly kh^c nhau gSy ra va c6 the hdi phuc ho^c khdng hoi phuc dddc. Hpi chdng lam sang nay co dac trung la mpt tinh tr^ng suy thoai mac phai dai dang ft nhait trong ba Irnh virc chdc nang: ngon ngur, tri nhd, ky nang thi giac - khong gian, khh ndng dl^u hanh va cam xuc. Sa sut tri tu^ thudng noi ti^p sau suy gidm nh$n thdc nhe co the phat hi^n dU0c theo tieu thddng tien trien chuan ci]a Petersen. Phan ldn cdc trudng h^p sa siit tri tue (vi dy benh Alzheimer) nhung cac benh nhan bj chan thuong so nao, sau nhigm khu^n ho^c mpt so hOi chdng dot quy nao cd the thay thoai gi^m phan nao cac roi lo^n nhan thdc.
B^i vi^t ndy mang den mot so'thong tin trong thuc hdnh cho cac d6ng nghidp cong tdc tgi nhieu CO sd dieu tri, nhan manh tdi vi^c thdm kham lam sang de phat hi^n sdm va xur trf sa sut tri tue mdt each phu hpp.
I. DAT VAN DE
Hoat dong tam tri cua con ngudl la mflt chdc nang rat phUc tap vdi nhieu hdp phan nhd c^m giac, tri giac, chu y, trf nhd, tri nang, tu duy... Co sd vat chat cUa hoat dpng tam tri la nao bo vdi moi lien quan hdu cd den cac chat dan truyen than kinh thong qua su cung Ung mau cua tuan hoan nao.
Hoat dpng tam trf tuan theo quy luat tien hda va thoai hda cua cdthe. Sdtien hda lien quan den qua trinh phat trien va trudng thanh cdn sdthoai hda lien quan den qua trinh lao hda. Lao hfla ^nh hudng den toan bp co the bao gom c^ he than kinh, tao dieu kien cho benh tat phat sinh va phat trien. Tuy nhien lao hda dien ra "khong dong toe, khong dong bp, khong dong thi"
10 THANKINHHOCVIETNAMI so 10/2014
Theo nguyen ly, su lao hda cua he than kinh se dan den nhdng bien doi cac chdc nang than kinh va tam tri: Pham vi bao cao nay de cap den mpt van de cd tinh thdi sd hien nay la sa siit trf tue d ngudi cao tuoi vdi trpng tam la benh Alzheimer va cac benh lien ket.
II. TiNH HINH SA SUT TRI TUE: HIEN TAI VA TUUNGUI
Nam 1997,PrinceMJdUtfnh the gidi cd tdi 18 trieu ngudi mac sa sut tri tue, phan Idn tap trung d khu vdc cac nudc dang phat trien.
Nam 2009, Dartigues JF ddc tfnh cd 850.000 benh nhan sa sut tri tue va hang nam cd 220.000 trudng hdp mdi phat hien tai Phap.
d Viet Nam, nam 2001 Vien Sdc khde Tam
Website: hoithankinhhocvietnam.com.vn
BAO CAO T O N G Q U A N k
than Quoc gia nghien cdu d Thai Nguyen cho biet ty le hien mac sa sut trf t u e la 7,9%. Ty le do tang theo t u o i : n h d m t u o i 60 - 69 la 4,2%; nhom tuoi 70 - 79 la 10,6%; tren 80 tudi la 16,6%.
Nam 2005 - 2006, PhamThang va cpng sUthay d Ba Vl thupc Ha Tay (cu), t y le hien mac suy giam nhan thdc nhe la 1,4% va sa sut trf tue la 4,63%.
Theo nghien cdu d o n g thuan DELPHI cua To chUc Quoc te ve benh Alzheimer, nam 2001, bay nUdc cd nhieu benh nhan sa sut t r i t u e nhat la Trung Quoc (5,0 trieu), Cong dong Chau Au (5,0 trieu), Hoa Ky (2,9 trieu). An D p (1,5 trieu); Nhat Ban (1,1 trieu), Nga (1,1 trieu), Indonexia (1,1 trieu). Cac benh nhan sa sut t r i tue sinh song phan Idn tai cac nddc dang phat trien va se tang t U 6 0 , 1 % nam 2001 len 71,2% vao nam 2040. Ty suat gia t a n g nay khong d o n g nhat: 6 cac nudc phat trien se tang 100% t d 2001 den 2040; cdn d An Dp, Trung Quoc, Nam A va Tay Thai Binh Duong se t a n g tren 300%.
Cung t h e o nghien cdu DELPHI, nam 2005 cd tdi 24,3 trieu ngUdi mac sa sut tri tue va moi nam lai cd t h e m 4,6 trieu trdOng hpp mdi. N h u vay cii hai m d d i nam so benh nhan lai tang gap doi va tdi nam 2040 se cd the la 81,1 trieu.
III. NHAC U I SINH LY BENH
1 . Bi4n doi he than kinh do lao hoa Td 20 den 30 t u o i , t r p n g Idpng nao g i ^ m 10- 20%. Te bao t h a n kinh teo, sd Idpng te bao than kinh giam; cd t h e t d i 50% d vo nao. Tuoi tang cao lam cho nao teo dan ro ret nhat tai tran, dinh, thai d u o n g ; con cac vCing phia sau teo nhe hon. Than nao va tieu nao teo mdc d p vda; t h e chai cd t h e m d n g di 1/3 d p day; cac hach day nao cung teo.
Khoi Idong nao bj giam, te bao than kinh ngay cang ft di c u n g nhU mot te bao than kinh cung cd t h i bj teo d i . Gidm so lUpng te bao than kinh
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va bien doi cau true d nao cung anh hudng tdi chuyen hda nang Idpng. Nao cd trpng Idpng bang 2% trpng Idpng co the nhiflig tieu thu tdi 20% glucose va oxy do mau cung dng.
Cung vdi giam sd Idpng te bao than kinh la hien t u o n g thoai bien cac khdp than kinh, gay anh hudng quan trpng tdi cac chat dan truyen than kinh, dac biet la he dopamin. Cd ba dudng dan truyen dopamin tac d p n g chu yeu tdi hoat d p n g t r i tue:
- DUdng liem den - the van dieu hda cac hoat dpng van d p n g ;
- D d d n g nao gida - the van cd vai trd trong qua trinh cd ban cua hanh vi lien quan den cam xuc, khf sac va d p n g co;
- D u d n g nao gida - vd nao chi phoi chu y, canh gidi, trf nhd, dp tap trung.
6 ngudi cao tuoi cd the cd su suy giam cac chat dan truyen than kinh tren ba dudng ndi tren va n h u v a y s e a n h hudng tdi chUc nang than kinh ndi chung, chdc nang nhan thdc ndi rieng.
2. Suy giam giac quan tuoi gia Ngudi ta nhan thay 75% ngddi tren 80 tuoi bi gicim khiid giac sinh ty. Giam thj lUc cd the gap d 10-20% ngudi cao tuoi. Cac benh ly n h u due the t h u y tinh, thoai hda diem vang, benh glocom kha p h o bien. Cac dpng tac liec mat cung bj ban che.
Vj giac ndi chung va kha nang phan biet cac vj bj giam.
Ngoai ra ve thinh lUc, sau 65 tuoi, c U 4 ngUdi cd 1 ngudi nghe kem.
3. Roi loan he thdc vat
Y van cho biet d ngudi cao tuoi, roi loan tieu tien cd t h e gap vdi t y le tU 5 den 34% cac trudng hpp. Roi loan dai tien xay ra that t h u d n g cdn roi loan ket hpp dai tieu tien vao khoang 25%.
4 . Chu trinh thufc - ngu
NOi chung, nhieu ngddi cao tuoi it ngu. Giac ngu ban dem hay bj gian doan vdi nhieu lan tinh
S 6 10/2014 I THAN KINH HOC VIET NAM I 11
A BAO CAP TONG QUAN
giac ngan. Do do khi thdc day thddng cam thay met mdi, kem thoai mai. Mot so ngUdi cfl the ngu bu vao ban ngay hoac buoi trUa.
IV. CHUK; NANG NHAN THUfC
ChUc nang nhan thdc la cac kha nang cua tam tri con ngudi bao gom: tri giac, nhan biet, tU duy, tri nhd, phan doan, danh gia, tudng tdpng, lap ke hoach v.v...
6 ngUdi cao tuoi, chdc nang nhan thdc cd the bj nhieu loan, nhat la trf nhd; tuy nhien roi loan tri nhd CO the chda dddc chu y tdi dung mdc va cd the bi bd qua ve phia ban than ngudi cao tuoi cung nhu td ngUdi than can. Tri nhd lien quan mat thiet den trinh dp hpc van, dieu kien hoat dpng tu duy, tinh trang sdc khde ciia tdng ca nhan. Mot dieu dang chii y la 5% ngUdi cao tuoi cd tri nhd dac biet.
Thdc te cho thay ngddi cao tuoi cd the giam chii y, kem tap trung, thieu nhanh nhen, kho ghi nhd, hay quen, giam kha nang va hieu suat lao dpng v.v... Dd la hau qua cua qua trinh lao hda nao, giam hoat tfnh ciia cac chat dan truyen than kinh. Ngddi ta nhan thay suy giam tri nhd cd xu hudng tang theo tuoi: vf du d tuoi 50-59, ty le khoang 39%, d tuoi 60-69 la 50%, dtuoi 70-79 la 63% va d tuoi tren 80 la 82%.
Nhu tren da neu, hoat dpng nhan thdc binh thudng ciia con ngddi lien quan den cam giac, tri giac va trf nhd. Co sd giai phau cua tri nhd chu yeu la hoi hai ma va vd nao. Qua trinh tri nhd bao gom:
-Thu nhan thflng tin: ghi nhd.
Day la qua trinh vac ma vdi vai trd cda vd nao lien hpp {chu yeu d thuy tran) vdi sU phan tich va cau true hoa cac thong tin td cac tin hieu giac quan.
- Cung CO thong tin: nhac nhd.
12 THAN KINH HOC VIET NAM I 50 10/2014
Day la qua trinh trinh cung co thong tin tai cac cau true hai ma va ddpc Idu trd tai vd nao.
- Nhac nhd thong tin: phuc hien.
Day la qua trinh phuc hoi lai cac thdng tin vdi vai trd cua vo nao trddc tran.
Cac nghien cdu cho biet cac qua trinh tri nhd cd the chju tac dpng cua nhieu benh ly khac nhau. Vi du rdi loan ghi nhd cd the bj roi nhieu do gidm chii y, trang thai tram cam, lo au, lu ldn, roi loan giac ngii, thudc an than...; roi loan cimg CO thong tin cd the do ton thUdng hai ma trong viem nao vung vien, viem nao do herpes, benh Alzheimer...; roi loan phuc hien khi bj roi loan chdc nang thdc hien trong benh canh sa sut tran - thai dddng, sa sut dddi vd vimg tran, tram cdm va cd trong lao hda nao binh thdOng.
V. Tir LAO HOA BINH T H U O N G DEN SA SUT
TRI TUE
Ai cung biet d ngudi cao tuoi cd the cd mdt sd bieu hien nhu giam chu y, kem tap trung, kho ghi nhd, hay quen v.v;.. Dd la nhdng hau qud ciia qua trinh lao hda nao va cd the do suy giam hoat tinh cua cac chat dan truyen than kinh, nhat la ciia he dopamin nhu da trinh bay tren day. Cac bien doi do khong nhat thiet lien quan den mpt benh than kinh va thudng ddpc coi la do sinh ly cua lao hda cCjng vdi giam mat do xUdng, gidm kha nang dung nap glucose, giam ty l§ Ipc cau than, v.v... Van de dupe quan tam la phai phan djnh cac bien doi sinh ly vdi cac bien hien benh ly trudc cdc trudng hdp kha nghi cd roi loan chdc nang nhan thUc d ngddi cao tuoi trong qua trinh phat hien sdm sa sut tri tue de cd hudng xd tri phu hpp kjp thdi.
Cac nghien cdu ve benh ly sinh hpc va than kinh - tam ly cho biet sd chuyen bien td hoat dpng nhan thUc binh thudng sang roi loan nhan Website: hoithankinhhocvietnam.com.vn
BAO CAP TONG QUAN ^
Nhan thiic binh thuong
Tien trieu sa Slit tri tue
IkO HOA NAO
SUYGIA]rtNH.4NTmrCNHE--' ^ ^ - - ^ ^ ^ ^ ^ ^ i phuc duoc
thdc thddng dien ra vdi tfnh chat noi tiep. Mat khac qua trinh chuyen bien td chdc nang nhan thdc binh thudng sang boat dpng nhan thdc benh ly (sa siit tri tue, benh cdnh Alzheimer) bao gid cung qua mpt giai doan trung gian vdi dac diem la "suy gidm nhan thdc nhe" (Mild Cognitive Impairment/MCI).
ChuTig "suy gidm nhan thdc nhe" gom nhieu thuc the lam sang khde nhau vf du nhd cac rdi loan cd bdn chat ehUe nang (lien quan den mpt nguyen nhan ehuyen hda) hoac suy giam tri nhd do tdn thUdng ede eau true hai ma (nhU trong trudng hdp benh Alzheimer va cac benh lien ket).
Vi vay can eanh giac doi vdi suy giam nhan thdc nhe la thdi ky trudc sa sut tri tue.
Sd do dudi ddy minh hoa sU tien trien tU lao hda binh thddng den sa sut tri tue (Golomb J,Kluger A, Ferris SH, 2000):
1. Suy gidm nhdn thuTc nhe
Petersen va epng sU da de ra tieu chua'n xac djnh suy giam nhan thde nhe nhd sau (2001):
- Benh nhan phan nan ve roi loan tri nhd cua ban thdn va dUpc ngudi than thda nhan.
- Cd suy giam nhan thde (thudng Id tri nhd) so vdi Ida tuoi va trinh dp hpe van.
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- ChUc nang nhan thdc chung co ban binh thddng.
- Hoat dpng trong ddi song hang ngay ddpc bao ton binh thddng.
- Khdng bj sa siit tri tue.
So do dddi day minh hpa cac bude chan doan suy gidm nhan thdc nhe theo Petersen (2006).
2. Sa sut tri tue
Theo Sach Chan doan va Thong ke benh Tam than, "sa sut trf tue la sd suy gidm tri nhd d mot doi tdpng vdpt mdc du kien so vdi Ida tuoi ciia doi tupng do va ft nhat ed them roi loan mot ITnh vUc nhan thdc khde nhu chu y, ngdn ngU, ky nang thj giac - khong gian hoac gidi quyet van de.
Ngoai ra khong kem theo roi loan y thUc nhU me sdng hoac lu lan".
Nhu vay, ddc diem ciia sa sut tri tue d mpt benh nhdn 6iigc the hien la:
- Su suy giam nhieu chUc nang eao cap ciia vd nao nhU: tri nhd, djnh hudng, tu duy hieu biet, tinh toan, khd nang ren tap, ngon ngd, phdn doan, chdc nang thdc hien, thj gidc - khong gian.
- Thddng ed kem theo hoac trddc do co suy giam kiem soat cam xuc, dng xd xa hpi, dpng cd hanh dpng.
S6 10/2014 I THAN KINH HOC VIET NAM 13
A BAP CAP TPNG QUAN
Benh nhan phan nan ve tri nha i
MMSE / (Fobteln) T "
SUY GIAM T R i N H d
SGNTN c6 qugn
Chi suy giam Irinhdr
SGNTN qu6n m^t ITnh vuc
SGNTN qu6n nhieu Hnh -njc
SGNTN khfing qu£n
1
Kh6ng MStllnh vucnhSn
thiic Wiftng phSi tri nh6 b) suy giim
SGNTN (khong qu5n) mot linh w c
SGNTN (khong quen) n h i ^ Ilnh vuc
- Khong bj roi loan y thde.
- Cd the xay ra trong benh Alzheimer, tai bien mach nao va cae benh khac anh hddng tdi nao.
VI. NGUYEN NHAN VA MdT SO BENH CANH SASUTTRiTUE
Sa silt t r i tue la tinh trang benh ly pho bien vdi ty le khodng 10% d ngUdi tren 65 tuoi va cd the tdi 50% d ngUdi tren 85 tuoi. Trong cac benh canh lam sang khde nhau, ngddi ta t h u d n g dac biet chii trpng tdi benh Alzheimer. Hien nay benh Alzheimer ddpc col la mpt benh sa sut quen tien trien vdi hai giai doan tiep noi nhau, giai doan dau trUde sa sut ed dac diem la quen kieu hai ma tien trien, doi khi ket hpp vdi cac dau hieu roi loan ehde nang thuc hien; va giai doan sa sut tien trien t u o n g Ung vdi cdc tdn t h d d n g lan toa tai cac dien lien hdp cua vo nao mdi xam pham vao cac linh vdc nhan thUc khac (ngon ngd, s d d u n g thuc hdnh d p n g tae, nhan biet) cung sUxuat hien ede roi loan tdc phong tam ly lam eho benh nhan mat dan kha nang t u chii.
14 THAN KINH HOC VIET NAM I 5 0 10/2014
1 . M o t so nguyen nhan chu yeu - (Svo ndo: Can ehu y tdi benh Alzheimer va thoai hda tran - thai dUdng.
Nhdm t o n t h d d n g tran - thai dddng gflm:
benh Pick, sa sut tran - thai d d d n g , that ngon tien trien, sa sut tri tue n g d nghTa, do rUdu.
- CfdUcfi vo nao: Bao g o m sa sut tri tue do nhoi mau nao nhieu 6, benh Parkinson, liet tren nhan tien trien, benh Huntington, tran djch nao dp Idc binh t h u d n g , sa siit t r i tue lien quan AIDS.
- d vo nao va dU&i vo ndo: Co the ke ra sa sut trf tue do mach mau, sa sut tri tue the Lewy, thoai hda v d - n h a n day.
- loan the: Oac biet la benh d o prion bao gom ca benh Creutzfeldt- Jakob.
- Cdc nguyen nhan khac: Hal nhdm Idn la roi loan chuyen hoa-nhiem doe (bao g o m thieu nang giap, thieu hut vitamin B,^, d o thuoc hoac kim loai) va nhiem khuan (bao g o m giang mai than kinh).
Trong cac nguyen nhan neu tren, m o t so t r u d n g hdp ed the dieu trj duoc nhd: thieu hut
Website- hoithanl<inhhocvietnam.com.vn
B A P C A P T P N G Q U A N k
vitamin B,^, acid folic; cddng giap, suy giap, cddng can giap, suy can gidp, hpi ehdng Cushing, benh Addison; phde h o p sa sut t r i tue-AIDS, giang mai;
do thuoc hoac kim loai nang; mau t u dddi mang CiJng, tran djch ndo dp luc binh t h d d n g ; tram cdm (sa sut gid dang).
Theo Cummlngs JL va Trimble MR (2002), d Chdu Au tan suat sa sut t r i t u e da dupe xdc djnh d benh nhan ngoai tru nhusau:
- Benh Alzheimer chiem 60-70%; sa sut tri tue do mach mau la 10-30%, sa sut t r i tue t h e Lewy Id 10-25%, tram cam chiem 5-15%, sa sut t r i tue tran - thai d d d n g la 5-10%.
- Sa sut t r i tue lien quan rUflu, rdi loan chuyen hda, rdi loan do ngp dpeed ty le 1 -10% moi nhdm.
-Tran djch nao, chiem t y le 1-5%.
-Ton t h u o n g nao thieu oxy, nhiem khuan he than kinh t r u n g Udng, u nao, chan thUdng nao, mau t u dddi mang edng, moi n h d m ehiem 1 -2%.
- Cdc nguyen nhan khac cd ty le 10-20%.
2 . Phan b i e t sa sut t r f t u e v 6 n a o v d i dUdi v d Can xem xet toe dp tam ly - van dpng, ngdn ngd, t r i nhd, chdc nang thdc hien, he van d p n g va bieu hien tram cam trong khi kiem tra tham kham benh nhan. Oien hmh eua sa siit t r i tue vd nao la benh Alzheimer, con benh canh sa sut t r i tu§ dudi v d co t h e gap trong benh Huntington, benh nao d o HIV, trang thai 6 khuyet nao, v.v...
Trong thdc hanh, can dac biet quan tam tdi benh Alzheimer, sa siit t r i t u e do mach mau va sa siit t r i t u e t h e Lewy.
3. B d n h A l z h e i m e r
Oay la nguyen nhdn p h o bien nhat cua sa sut trf tue. Benh t h u d n g gap d ngddi tren 60 tuoi, xuat hien tan phat d ngddi dudi 50 t u o i va trong gia d i n h d ngddi d d d i 60 tuoi. Oac ^ e m Id bao gid benh nhan cung bj mat t r i n h d tien trien cham cdn cac ITnh vdc nhdn thUc khac cung bj suy giam sau nhieu nam. Sau khi bi mat t r i nhd, benh nhan
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cung cd the bj roi loan ngfln ngd, thj giac - khflng gian va chdc nang thdc hien.
Cac tieu chuan chan doan benh Alzheimer bao g o m (DSM-IV, 1994);
- Khiem khuyet tri n h d (tiep thu hoac nhac nhd).
Cd mpt hoac nhieu hdn: Mat ngon n g d (aphasia) / mat sd dung (dpng tac thUc te) (apraxia)/ mat nhan biet (agnosia)/ roi loan chdc nang thdc hien (lap ke hoach, to ehde, lap trinh, trdu t d p n g hda).
- Suy giam nhan thUc d mUc dii nang anh hudng tdi hoat d p n g xa hpi hoac nghiep vu va the hien co bien doi so vdi trude.
- Dien bien lam sang co khdi phat t d n g bddc vd suy thoai tien trien.
- Khflng do me sdng.
- Khong giai thich ddpc do he than kinh trung uong, vi d u tai bien mach ndo, benh Parkinson.
4 . Sa sut t r i t u e d o m a c h m a u
Sa silt trf tue d day la hau qua ciia benh mach mau nao doi vdi hoat dpng nhan thde. Benh t h d d n g khdi phat dot ngpt va tien trien t d n g bddc. MUc dp khiem khuyet nhan thdc phu thuflc vao vj t r i nao bj t o n t h d d n g .
5. Sa sut t r i t u e t h e Lewy
Benh canh lam sang giong benh Alzheimer nhung t h u d n g cd dac diem la trieu ehdng Parkinson xuat hien sdm va noi bat hon; chdc nang nhan thdc dao dpng, cd do thi va cd xu hddng tien trien nhanh hon.
Cae trieu chdng nhan thde khdi phat lien quan vdi van d p n g cham chap dudi m p t nam. Oac biet benh nhan t h u d n g nhay cam vdi tae dpng ngoai thap cua cac thuoc dieu trj loan than.
6. Sa Slit t r i t u e t r a n - t h a i diTdng Benh nay t h u d n g xdy ra d dp tuoi 50-60. CJ giai doan sdm, benh nhdn co bien doi nhan edeh, suy thoai ky nang xa hdi, cam xuc kem nhay va cd
5 6 10/2014 I THAN KINH HOC VIET NAM 15
A BAP CAP TPNG QUAN
K I E M T R - \ N G A N T R . \ N G T H A I T A M T R I ( T i i c n g h i e m F O L S T E L V )
( M i n i - M e n t a l Stare E x a m i n a r i o n / M M S E ) Not d u n g (cau hoi / v e u c a u )
- N a m nay la nam nao'' - Miia nay la miia nao?
- Hdm nay la ngay bao nhicu?
- Hdm oay la ngay thur m a y trong tuan ? - Thang nay la thang m a y ?
- Day la noi nao "^
- Ta dang cr nirdc nao ? - Ta dang d tinh' thanh p h o nao '^
• Ten ciia dia diem n a y ' '
- Day la t ^ g nha thur may ? - X m nhac lai U n lucrt ten 3 \.'at sau
6 td o i a hoa hong
- 100 - 7 va trir 7 t i ^ tuc (93 - 86 - 79 -72 - 65 ) - X m nhac lai ten 3 vat liic tnrdc
6 to ciia hoa hong
- Chi vao ddng ho ^-a boi: Cai nay la cai gi ? - Chi vao biit chi va boi Cai nay la cai gi "^
- Xin nhic lai cau "khong N £ U . V A h o i c ^fHU^IG gi ca"
- Dpc cau ghi tren giay nay "HAY N H A M M A T L A I " va lam theo n h u vay
- L a m theo y lenh sau. X m cam lay m a n h giay nay bang b a n tay phai. gap inatih giay bang hai tay roi dat manh giay xuong dat t m d c m^t"
- Xin v i ^ mpt cau cd du y n g h ^
- Ve hai hmh n a m canh cat len nhau. Qo
B a n b gia kgt q u a : (Moi cau tra left dimg cho 1 diem)
{ Mu chu-: d u d i 17 d i ^ Tieu hoc dirdi 20 d i e m Trung hoc dirdfi 24 d i e m
{ tren 23 diem binh thdcmg 13 - 23 : sa Slit tri tue nhe
5 - 1 2 : sa siit tri tue \'\ra d u d i 5 sa siit tri tue nang
16 THAN KINH HOC VIET NAM I SO 10/2014 Website: hoithankinhhocvietnam.com.vn
BAP CAP TPNG QUAN k.
rdi loan ngon ngd. Khi benh tien trien, ede trieu ehdng khac cua sa sut xuat hien tiep theo roi loan tri nhd. Can chu y la benh thddng tien trien nang va ed xu hddng nhanh hon benh Alzheimer.
7. Sa sut trf tu^ vdi benh Parkinson Y van eho biet khoang 3/4 benh nhan cao tuoi mac benh Parkinson se bj sa sut tri tue sau mddi nam. Oac diem gom nhdn thde vd van dpng cham chap, suy giam tri nhd va ehUc nang thUc hien.
Thdi gian khdi dau cua ede trieu chdng nhdn thdc lien quan den trieu chdng van dpng vao khoang tren mpt nam.
VII.TIEP CAN BENH NHAN
1. Tham kham lam sang
- Hdi benh: Can ket hpp hdi va nghe benh nhan trd Idi, hdi benh nhan va ca ngudi nhd benh nhan. Can chu y cdc dau hieu bao dpng va cac yeu to nguy ed.
- Kham than kinh: Bao gid eung phai kham mpt each he thong. Can chu y trddng lUc cO, ede dpng tac, su dieu phoi, cdc phan xa, van dpng nhan cau va thj trudng, thinh lue.Trong danh gia ehde nang tdm tri eo bdn phai xem tri giae, chu y, tri nhd, cdm xuc, tU duy, ngdn ngd, hdnh vi, phan dodn cua benh nhan.
- Kham toan the: Chu y tdi cae cd quan, he thong.
- Kiem tra ng6n trgng thdi tam tri: (Mini- Mental State Examination/ MMSE). Oay la trac nghiem da dddc Folstein va epng sd de xUdng vd hien rat thong dung trong Idm sang, dac biet de phat hien sdm cae trang thai suy gidm nhan thde nhe va cdc trang thai sa siit tri tue.
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Trac nghiem gom 20 cau hdi va moi cau trd Idi dung dddc cho 1 diem. Neu dat tren 24 diem la binh thddng; dddi 17 diem cd the bi suy gidm nhan thdc nhe va dudi 13 diem cd the la sa sut tri tue.
2. Thang diem danh gia thieu mau nao Hachinski
Tinh trang benh nhan ddpc danh gia qua 13 dac diem lam sang. Neu tong diem dddi 7 thudng la sa sut tri tue do mach mdu; neu dat tU 0 den 4 diem cd khd nang la benh Alzheimer.
Oac diem " ^ y "
Khdi phat dot ngot Trang thai nhan tiiijTc suy giSm tutig bLfdc
Dien bien dao dong Ld lan ban d^m
Nhan each con duoc biio ton taong doi
Tram cam
Hay phan nan ve mat co the Khong kiem che di/oc c3m xiic Ti^n sCftang huyet ap Tien sijrtai bi^n mach nao C6 bSng chiiTig bj vCra xO mach ket hop
C6 cac trieu chuTig than kmh cue bfl Cd cac dlu hieu than kmh cue bo
Co 2 1
2
2 1
2 2
Khdng 0 0
0 0 0
0 0 0 0 0 0
0 0 Ket qui: t6ng diem dirdi 7: sa siit tri tue do mach mau
5 va 6 : cd khS nang the ket hop 0 -4 : benh Alzheimer
3. Can lam sang
- Can lam ede xet nghiem ed ban thddng quy ve huyet hpc (cdng thUc mau; toe dp mdu lang...),
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A B A P C A P T P N G Q U A N
sinh hda (mdu, nude tieu), vi sinh y hpc (ehu y phan dng viem gan, giang mai, HIV...). Can chu y tdi nong dp vitamin B,;, chdc nang tuyen giap, nong dp mdt sd thuoc trong cd the.
-Tham dd chdc nang: ghi dien tim, ghi dien nao...
- Hinh anh h p c Sieu am Doppler, sieu am xuyen so, chup X quang quy Udc ngUc, chup cat ldp vi tinh, chup cpng hddng tU, chup mach mau nao (CLVT, CHT, so hda xda nen), chup CLVT phat dien t d d u a n g (PET), chyp CLVT phat photon don (SPECT).
- Xet nghiem djch nao-tuy.
4. Xet nghiem dau an sinh hpc
Xet nghiem dich nao-tuy va huyet thanh, do nong dp beta-amyloid 1-40 va beta-amyloid 1 -42, Lejia K va cs (2010) thay:
Nong dp beta-amyloid 1-42 giam thap ngay t d giai doan tien lam sang khong phu thupc tuoi, gidi, thdi gian mac benh.
Ty le beta-amyloid 1-42/beta-amyloid 1-40 giam khdng phu thupc vao tuoi va gidi.
Tran Viet Lde (2011), nghien eUu 81 benh nhan Alzheimer va 81 benh nhan chdng nhan thay ndng dp beta-amyloid gidm dan theo sU tien tnen cua benh; beta-amyloid 1-42 gidm rd va nhanh hdn; chi so beta-amyloid 1-42/ beta- amyloid 1 -40 giam dan khi benh nang.
VIII. xur TRi SOM SUY GIAM TRI NHd / SA SUTTRiTUE
Hien nay van chda cd khuyen cao hoac dong thuan nao ve xd tri sdm sa suttritue-Tuy nhien qua theo ddi lam sang, can cii vao cac nghien cUu sinh hpc ve ehde nang nhan thUe va qud trinh lao hda d nguc^ cao tuoi, cd the dexuat mpt sd van de dUdi day.
1 . Xur trf cac yeu to nguy ccr
Ngudi ta nhan thay ba phan t d so ngUdi 80 tuoi cd It nhat mpt benh man t i n h . Nhdng trddng hpp t d vong d tuoi nay trung binh thay mcie khoang sau benh d o n g dien (Serdaru M, 1992).
N h u vay, ngoai cac bien doi cua he than kinh, ve mat npi khoa can quan tam giai quyet cac chdng benh n h u tang huyet dp, dai thdo dudng, roi loan lipid mdu, thoai hda xddng khdp, viem phe qudn man tinh, giam tddi mau nao man tfnh, v.v... Cdn dae biet ehu y tdi suy gidm nhan thdc do mach mau. (vascular cognitive impairment).
2. Lieu phap dinh dirdng va noi tiet Trong cdc gid thuyet sinh ly benh ve dinh d u d n g lien quan den sa sut tri tue, ngudi ta chu y den tac d u n g eua cdc acid beo va kieh Ide oxy- hda trong qua trinh lao hda nao. Nao cd nhay cam dae biet doi vdi kieh lue oxy-hda vl trong thanh phan cau tao cua nao cd cac acid beo da phan khong bao hoa ehudi dai rat nhay cam vdi peroxy- hda nhat la DHA, omega-3. Trong benh Alzheimer, protein dang bpt ed the true tiep dan tdi su gia tang san sinh cae goc t u do va gia tang peroxy-hda lipid. Cae acid beo da phan khong bao hoa omega-3 va cac chat chdng oxy-hda se cd tde dpng hiep dong. Cac chat acid beo da phan khdng bdo hda, ngoai vai t r d la thanh phan trong edu tao va dp long eua mdng cdc te bao than kinh va cac dac tinh cua mach mdu edn tac dpng vao dien bien cua qua trinh viem d nao va cdc gien lien quan den dp deo hoat (plasticity) cua ndo.
Cac t h d nghiem bo sung vitamin E eho thay c6 hieu qua thuan lpi doi vdi benh nhan Alzheimer.
Cdc nghien cdu dich te hpc cung da chdng minh vai trd bao ve chong nguy eo sa sut t r i tue hoac
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B A P C A P T P N G Q U A N k.
suy gidm nhan thdc khi eho benh nhan sd d u n g loai ca beo (cd nhieu DHA) hoac cac acid beo da phan khong bao hoa omega-3 (Barberger- GateauP,2005).
Trong d u p h d n g tien phat hoac t h d phdt, y van cdn de cap tdi lieu phdp npi tiet vdi tac d u n g dudng than kinh cua cac estrogen, lam giam sU tich t u eua eac peptid beta dang bpt, tac d p n g tren dan truyen than kinh, bdo ve chong kich lUc oxy-hda. Tuy nhien ehua ed su nhat t r i ve ch! dinh doi vdi lieu phap nay (Berr C, 2005).
S . L i e u p h a p d U t f c l y
Nhieu loai thuoc cd kha nang tac d p n g den cdc trieu chUng khde nhau trong giai doan dau cCia suy gidm nhan thUc nhe.
- The he thit nhdt: Cdc chat ed dnh hddng toan the bao g o m :
Thuoc dieu hda tuan hoan nao.
Thuoc kieh thich tam tri.
Thudc htmg khi, kfeh thi'ch nhan thdc.
Thuoc chong oxy hda.
- Thehe thuthai: Cac chat dae hieu doi vdi dan truyen than kinh nhd:
Thuoc de ehe men cholinesterase.
Thuoc chu van nicotin.
Thuoc chi!i van d o p a m i n . Thuoc chu van kenh Natri.
Thuoc dieu bien cae t h u t h e AMPA.
- The he th&ba: Cac chat nham vao sinh ly benh n h d :
Cae yeu t o d u d n g than kinh.
Cac ehat Ue che ublqultin-hda.
Cdc chat Ue che men secretase.
Gay mien djch khdng A-beta.
Dddi day se nhan manh tdi vai t r d ci!ia cac
thudc dieu hda tuan hoan nao. Od la nhdng chat cd the tac d p n g tdi cae mach mau, tang kha'u kinh cua cac dpng mach nhd, d i n tdi tang cudng cung lupng tuan hoan, g d p phan edi thien qua trinh oxy-hda d eac m d Oac tinh cua cac thuoc chong co mach la cd kha nang lam giam dp nhdt cua mau, cd the tang kha nang bien dang eua hong cau, kieh thich khd nang tieu sdi huyet npi sinh cua huyet t d o n g , lam giam dp ket dinh va ngdng tap tieu cau.
Mdt so thuoc tde ddng thu the d dpng mach nao nhU boat hda thu t h e adrenalin beta (Isoxsuprin, Bemethan, Nyltdrin) hoac chen thu the alpha (Hydergin, Dihydroergotamin, Raubasin, Tolazoline, Mexisylite, Ifenprodil). Mpt so khae ed tae d p n g hddng co n h d Papaverin, Khelline (tac ddng khdng dac hieu, dnh hddng tdi tat cd he cd tron) hoac cdc dan xuat nicotinic, Naftidrofuryl, Piribedil, Vincamin, Pentoxiphyllin (tac d p n g chCi yeu tdi thanh d p n g mach).
Trong thdc hanh lam sang, co the can nhac sd d u n g eac thudc nhU; Clnnarizin, Vincamin, Ginkgo biloba, Piracetam, Naftidrofuryl, Pentoxiphylline, Hydergine, Nicergolin, Buflomedil, Flunarizin, Citicholin, Raubasin, Nimodipin, Cerebrolysin, v.v...
4.f>ieu c h i n h p h o n g each sinh hoat Can chu y tdi cac yeu to nhd:
- Hpe van: Cd sd khac biet dang ke gida chUe nang nao eua ngudi trudng thanh ed boat d p n g tri de va it hoat d d n g tri dc.
- T a p luyen: Nen duy tri dl bp (nhanh) 30-45 phut it nhat ba lan moi tuan.
- Nghi n g o i : M d i d e m ngu deu dan khodng 8 g i d .
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A BAP C A P T P N G Q U A N
- Tam ly: Khi ed kich Idc (stress), cd the con ngddi tiet ra cortizon; Iddng nhd cortizon cai thien t r i nhd cdn Iddng ldn se xdi m d n hoat d p n g cua te bao than kinh d hai ma.
Ngoai ra can quan tam tdi 10 dau hieu cdnh bao benh Alzheimer (theo Hiep hdi benh Alzheimer Hoa Ky).
- Mat t r i nhd anh hddng tdi ky nang nghiep vu.
- Khd thuc hien cdng viee trong gia dinh.
- Kho khan trong giao tiep ngdn ngd.
- Sai lac dinh hudng thdi gian va vj tri.
- Suy giam phdn doan.
- Khd khan trong suy nghi trdu tddng.
- Oe do vat khong dung cho.
- Cd bien doi khi sdc hodc dng xd.
- Nhan each bien doi.
- Mat nang Idc chCi dpng.
IX. KET LUAN
Theo dieu tra dan sd nam 2009, nddc ta da CO 85.789.573 ngddi, d d n g hang t h d 13 dan so tren the gidi. Hi^n nay t y le ngddi tren 60 tuoi da ehiem xap xi 10% dan so.
Ode diem da benh ty t h d d n g gap d ngudi eao tudi. N h u vdy eung vdi cac benh t h u d n g gap n h d tang huyet ap, tai bien mach ndo, dai thao dddng, v.v... van de roi loan nhan thdc can dddc chu t r p n g trddc mat va lau ddi, dac biet la sa sut t r i tue vdi benh cdnh Alzheimer.
Trong d u p h d n g , ngUdi thuoc men can quan tam tdi nhieu bien phap dieu chinh phong each sinh hoat va cdc bien phap tam ly - xa hpi de bdo ve sdc khoe eua eon ngddi va nang cao chat lupng cupe song cua m p i benh nhan.
SUMMARY
APPROACH TO EARLY DIAGNOSIS AND MANAGEMENT OF DEMENTIA
LE DUC HINH Vietnamese Association of NeurologyA/NA Dementia is a syndrome that can be produced by a wide variety of disorders and it may be reversible or irrreversible.This clinical syndrome is characterized by an acquired persistent impairment in at least three of the following domains of function: language, memory, visuospatial skills executive abilities and emotion. Dementia is usually preceded by mild cognitive impairment that could be detected according to Petersen's criteria. In most cases, dementia is progressive (e.g. Alzheimer's disease) but patients with head trauma, postinfectious states or some stroke syndromes may exhibit partial remission of cognitive deficits.
This article provides information in medical practice for our colleagues working in a variety of treatment settings, emphasizing on clinical examination for early detection and adequate management of dementia.
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BAP CAP TPNG QUAN W
TAILieUTHAMKHAO
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