Introduction
< span>After 14 years, the “Guidelines for the Prevention and Treatment of Senile Dementia in China” (2021) carries the tradition of the 2007 edition, adding new research results and clinical practice methods and experiences, and finally published in the Geriatric Psychiatry Group of the Chinese Medical Association Psychiatry Branch Under the leadership of the team leader, Professor Yu Enyan, it lasted for two years and was launched in 2021, which gathered the efforts and expectations of experts.
On the basis of emphasizing scientificity, advancement, applicability, operability, and emphasis on diagnosis and treatment, this guide emphasizes “prevention”. The three major features of early intervention” and “home management and rehabilitation” emphasize the concept of whole-course management. Let’s follow Professor Yu into the guide and taste its originality!
01
cognitive The concept of disorder continuum guides early intervention, and the whole management concept is in line with the current status of dementia prevention and treatment in China
The concept of the cognitive impairment continuum guides early intervention. Alzheimer’s dementia refers to dementia that occurs in old age (over 65 years old) due to various reasons. Dementia from pre-senile onset to old age is sometimes referred to as senile dementia. . Cognitive impairment in dementia patients is mostly a slowly progressive process, especially in degenerative brain dementia. Pathological changes may occur before significant clinical symptoms appear. Based on this, the disease is divided from three different grades of mild, moderate and severe, to the classification that tends to the continuum of cognitive impairment: subjective cognitive decline (SCD), mild behavioral impairment (MBI) and/or mild cognitive impairment. cognitive impairment (MCI), moderate and severe neurocognitive impairment. From mild impairment of cognitive function to dementia is a continuous spectrum, and it is also a slow and gradual irreversible process. The best time for early intervention is when the SCD and MCI stages have not yet reached the level of dementia.
The whole-course management of dementia is feasible and realistic. At present, the number of dementia patients in my country has accounted for more than 20% of the total number of patients in the world. Alzheimer’s disease (AD) is the most common type of dementia, accounting for about 60% to 70% of dementias. The prevalence of AD in people aged 65 and over in my country was 3.21%-6.9%, with an annual incidence rate of 0.82%, and the prevalence increased with age. Senile dementia has become a major challenge that my country needs to address in order to achieve healthy aging. Preventing and reducing the incidence of senile dementia and improving the quality of life of senile dementia patients and their caregivers have become major livelihood and social problems in my country. . The management of dementia patients has expanded from clinical diagnosis and treatment to risk management, clinical diagnosis and treatment, community rehabilitation, life care, and caregiver support, covering almost the entire course of the disease, providing early identification, early diagnosis, early treatment, and early prevention of the disease. Work creates conditions. Referring to my country’s hierarchical diagnosis and treatment system and the national basic public health service system, it is feasible and realistic to actively promote the whole-process management of dementia patients based on the community.
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Focus on the management of controllable risk factors for dementia, and actively carry out primary, secondary and tertiary Prevention
Management of manageable risk factors is preventive for dementia Focus. More than half of the global dementia burden is due to underlying, modifiable risk factors, including diabetes, midlife hypertension, midlife obesity, low physical activity, depression Various risk factors are not independent, such as smoking and low education level. Strengthening education and improving lifestyle can greatly reduce the above risk factors or reduce the incidence of dementia.
Primary and secondary prevention is the key to dementia prevention. Primary prevention is etiological prevention, which aims to eliminate various pathogenic factors, avoid or reduce the influence of pathogenic factors, and prevent the occurrence of dementia. It is the top priority of prevention work and the most active and proactive preventive measure, but it is also the weak link of current prevention work. Including the management of physical exercise, smoking cessation, dietary intervention, alcohol consumption, cognitive training, social activities, weight, hypertension, diabetes, dyslipidemia, depressive disorders, special sensory (audio-visual) disorders, etc. Secondary prevention is the measures taken to prevent or slow down the development of dementia, including early detection, early diagnosis and early treatment, hence the nameFor the “three early” prevention, it is the best window period for the treatment of dementia. Early screening should be carried out for high-risk groups for early diagnosis and early treatment. Early intervention is better for MCI and dementia patients. Tertiary prevention is the clinical management and life care of dementia, with the purpose of enabling patients to receive systematic treatment and care guidance to improve their quality of life. Including standardizing clinical management, strengthening patient care, improving the quality of life of patients, and assisting caregivers.
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Comprehensive assessment of ABC symptoms is the basis of dementia treatment, and biomarkers help in the diagnosis of dementia< /span>
Learn more about“ABC” symptoms< /strong> (decreased activities of daily living, psycho-behavioral symptoms, cognitive impairment) specific manifestations and their severity, which are useful for judging the presence or absence of dementia, the severity of dementia (MCI or dementia), the cause of dementia, etc. It is also the basis for rational treatment of dementia.
Table 1Summary of commonly used tools for ABC symptom assessment of dementia
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Note: MMSE: Mini-Mental State Exam; MoCA: Montreal Cognitive Assessment Scale; CDT: Clock Drawing Test; ACE: Andenbrooke Cognitive Test; AVLT: Listening to Visual Word Learning Test; CVLT: California Vocabulary Learning Test; DSR: Story Delayed Recall; BNT: Boston Naming Test; VFT: Verbal Fluency Test; ABC: Chinese Aphasia Test; DST: Numerical Span Test; CFT: Complex Figure Test; JLO: Line Orientation Test ; VOSP: Visual Object and Spatial Perception Test; ADAS-cog: Alzheimer’s Disease Rating Scale Cognitive Subscale; SIB: Severe Impairment Rating Scale; CDR: Clinical Dementia Scale; GDS: Global Decline Scale; DRS : Mattis Dementia Assessment Scale; CANS-TAB: Cambridge Neuropsychological Examination Automated Edition; BEHAVE-AD: Behavioral Pathology Rating Scale for Alzheimer’s Disease; NPI: Neuropsychiatric Symptom Questionnaire; CMAI: Cohen-Mansfield Agitation Questionnaire; GDS: Emotion Rating Scale; FBI: Frontal Lobe Behavior Questionnaire; ADL: Activities of Daily Living Scale; FAQ: Social Activity Scale; FAST: AD Functional Assessment Scale;
With the development of science and technology, imaging, genetic testing and some promising biomarkers have gradually attracted attention.
imagingdiagnosis of dementia must be Essential and sometimes important for diagnosis and differential diagnosis. Structural imaging (such as CT, MRI) is a commonly used method, and all patients with cognitive impairment should undergo routine brain structural imaging; functional imaging is currently mainly used in clinical research, and there are difficulties in routine clinical use. Conditional units should actively carry out molecular imaging examinations (such as 18F-FDG, PET, DAT) to improve the accuracy of the diagnosis of neurodegenerative diseases.
biomarkersare a Objectively detected and evaluated indicators can reflect the biological process or biological response of an individual under normal or pathological conditions, and have a specific role in diagnosing AD. Biomarkers of β-amyloid (Aβ) and tau protein can significantly improve the accuracy of AD diagnosis and effectively predict the transformation of SCD or MCI to dementia, but considering the invasiveness of cerebrospinal fluid (CSF) detection and the invasiveness of PET examination. Factors such as low penetration, standardization of detection and analysis processes, and economic cost have not yet been fully implemented. Therefore, for patients with difficulties in early diagnosis or differential diagnosis, and in the case of considering the application of disease-modifying drugs in the future, it is recommended to detect biomarkers of Aβ and tau by CSF or PET; MRI brain atrophy biomarkers are used for the diagnosis of AD. , Differential diagnosis and assessment of disease progression can all provide help, and it is recommended to perform routine testing in qualified units; FDG PET has the significance of early identification and differential diagnosis of dementia caused by neurodegenerative diseases or inflammatory diseases, and is recommended in qualified units. The unit of 10000000000000001 detects patients with difficult early or differential diagnosis; the detection of peripheral blood biomarkers is promising for the clinical diagnosis of AD in the future, but it is still in the exploratory stage and is not a routine examination for the clinical diagnosis of dementia.
Patients with dementia who have a family history of dementia should undergo genetic testing to confirm the diagnosis.
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The treatment of dementia is based on classic drugs, emphasizing multidisciplinary collaboration, and rehabilitation treatment throughout
Classical drug therapy for dementia< /strong>Mainly based on reducing abnormal glutamatergic neurotransmission or improving the function and level of acetylcholine in the brain, mainly including NMDA receptor antagonists and AChEIs. For moderate to severe AD, memantine can be used, and the combination of memantine and AChEIs can also be used. For patients with BPSD, the principle of individualized treatment is followed, and non-drug therapy and cognitive-promoting drugs (such as memantine) are the first choice.
Actively carry out multidisciplinary consultation and collaboration,Elderly patients often suffer from multiple diseases Therefore, risk assessment of comorbidities, optimization of treatment plans, and active prevention and treatment of complications are beneficial to improve the cognitive function and quality of life of patients. Subject therapy to reduce cognitive impairment.
dementia rehabilitationneeds a comprehensive approach , the process is long until the end of life, so it must be carried out under the guidance of occupational rehabilitation therapists on the basis of comprehensive and comprehensive evaluation. Rehabilitation of dementia mainly includes the core symptoms of dementia, such as cognitive, behavioral and social functional status.A series of comprehensive rehabilitation methods and interventions, follow the principle of “tailor-made”, try to improve the patient’s cognition and living ability as much as possible, improve the quality of life and self-efficacy, and maintain their independence in life. Guideline recommendations: Cognitive training and rehabilitation can improve partial or overall cognitive function in patients with dementia; non-specific occupational therapy, multidisciplinary therapy, cognitive stimulation such as music or art therapy, and exercise can help maintain social participation in dementia patients sex and improve caregiver satisfaction.
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Insist on individualized home care and pay attention to palliative care in the terminal stage of senile dementia
Care is the foundation of treatment and recovery, especially for patients with BPSD Therefore, the impact of patient-centered scientific care on the quality of life of dementia patients is crucial, and palliative care is particularly important for patients in the terminal stage of dementia.
Home Care:Recommended for severe BPSD problems, take countermeasures according to the community environment and BPSD risk assessment to prevent harm to patients themselves, caregivers and society; it is recommended to take relevant measures for medical-related home care, and to deal with medication adherence problems according to specific scenarios; it is recommended to regularly measure patients Weight, according to the assessment of the patient’s dietary nutritional status, and take relevant measures to reduce the occurrence of malnutrition and diet-related adverse events. At the same time, pay attention to the safety issues in the eating process; it is recommended to make appropriate modifications according to the patient’s condition and the home safety environment to improve the safety and convenience of the living environment and prevent accidents; it is recommended to take measures such as wearing a sign card with you to prevent you from being lost and unable to find it. .
Palliative care: in terminal dementia Palliative care is especially important when the patient, ie, dementia, has progressed to the most severe stage, with severe impairment of memory and other cognitive abilities, loss of activities of daily living, and the need for complete care from others. The principle of palliative care is to reduce pain and maintain the dignity of the patient, and to improve the comfort of the patient as the goal, and provide positive physical, psychological, spiritual and other care and humanistic care to the patient. Use antibiotics; continue oral feeding instead of indwelling nasogastric tube or gastrostomy; use drugs for pain relief and symptomatic treatment; stop useless drugs; give music and other methods to soothe the patient, etc.
06
Empowering caregivers and reducing the burden of care< /span>
At present, dementia patients in my country are still mainly cared for at home. Long-term care of dementia patients brings heavy burden to the caregivers. burden, which seriously affects the quality of life of caregivers, and the psychosomatic state of caregivers determines the quality of life of patients, so it is recommended to empower caregivers, including empowerment education and support services; set up a multidisciplinary team, including psychiatrists, psychologists Doctors, community nurses, social workers, senior caregivers, and volunteers provide empowering education and assistance for caregivers. This helps to improve the self-efficacy of caregivers, promote positive psychology, and exert their subjective initiative, thereby improving care outcomes.
Summary
The Chinese Elderly In line with the spirit of inheritance and innovation, the Guidelines for the Prevention and Treatment of Dementia in China (2021) combines the latest research results at home and abroad in recent years with the specific national conditions and practices of my country. While focusing on clinical diagnosis and treatment, it also focuses on prevention The importance, concepts and methods of rehabilitation, home care and whole-course management provide practical guidance and reference for front-line clinical and scientific researchers, benefit more senile dementia patients, and contribute to a healthy China.
Professional Profile
Yu Enyan /span>Professor
Chief Physician, Professor, Doctoral Supervisor span>
Head of the Department of Clinical Psychology, Cancer Hospital, University of Chinese Academy of Sciences, and the Department of Mental Health Science, Zhejiang Provincial People’s Hospital
The leader of key medical disciplines in Zhejiang Province, enjoying the special allowance of the State Council
China’s outstanding psychiatrist, winner of China’s Outstanding Contribution Award for Mental Health Work
Vice-Chairman of the Chinese Alzheimer’s Association (ADC)
Vice-chairman of the Geriatric Cognition and Mental Illness Branch of the China Association for Geriatric Health Care
Vice-chairman of the Anti-aging Research Branch of the China Association of Geriatric Health Care Medicine
Deputy Head of Cancer Psychology Collaborative Group of China Cancer Foundation
Executive Director of Chinese Mental Health Association
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Member of the Standing Committee of the Psychiatry Branch of the Chinese Medical Association
Head of the Geriatric Psychiatry Group of the Psychiatric Branch of the Chinese Medical Association
President of Zhejiang Rehabilitation Medical Association
Chairman of Zhejiang Medical Association Psychiatry Branch
Chairman of the Sleep Disorders Professional Committee of Zhejiang Rehabilitation Medicine Association
Chairman of the Oncology Psychology Professional Committee of Zhejiang Anti-Cancer Association
Chairman-designate of Zhejiang Medical Association Geriatric Mental Disorders Branch
Chinese Journal of Medicine , Chinese Journal of Psychiatry, Chinese Journal of Geriatrics, JNNP Chinese Edition
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Chairman of the Chinese Mental Health Association Geriatric Mental Health Professional Committee
Reference: Yu Enyan. Guidelines for the Prevention and Treatment of Senile Dementia in China [M]. Beijing: People’s Health Publishing House, 2021.11
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