Diagnosis and treatment of dementia in primary care 의학강좌 Primary care Primary care Exploring cognitive impairment Screening test (e.g., MMSE) Clinical

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1 Continuing Education Column pissn: eissn: 정현강 1,2 한창수 1,2* 고려대학교 1 의과대학정신건강의학교실, 2 정신건강연구소 Diagnosis and treatment of dementia in primary care Hyun-Ghang Jeong, MD 1,2 Changsu Han, MD 1,2* 1 Department of Psychiatry, Korea University College of Medicine, 2 Korea University Mental Health Institution, Seoul, Korea *Corresponding author: Changsu Han, hancs@korea.ac.kr Received September 29, 2013 Accepted October 13, 2013 Dementia has became a major public health problem as the aged population is rapidly increasing. Dementia is underdiagnosed in primary care and many primary care physicians are hesitate to diagnose dementia. Early detection and starting appropriate treatment has been emphasized in managing dementia patients. The role of primary care physicians in caring for patients with demantia is important to efficiently manage dememtia and related socioeconomic burden since they meet first many patients mostly in initial stage of diseases. Primary care physicians pay attention to early sign and symptoms of dementia and are able to differentiate pathologic condition from normal age related cognitve decline. They should actively performe the screenig test and comprehensive clinical evaluation for suspected dementia patients. After diagnosis of dementia, they have to help thier patients to start and maintain appropriate pharmacological and non-pharmacological treatments and provide supports for dementia patients and their caregivers. To optimal management of dementia, primary care physicians also need to strengthen collaboration with specialists in treatment and lead their patients to utilize social servicies. It is necessary to develop systemized education programs for primary care physicians and standardized giudeline for maniging demenita in parimary care. Primary care physicians need to keep acquring up-to-date knowlege about dementia and to screen and detect dementia in suspected dementia patients. They should provide appropriate treatments for patinets in the collaboration with specialists and infrom their patients available social services. Keywords: Dementia; Memory disorders; Primary health care; Alzheimer disease 서 론 치매는단일질환을일컫는말이아니라일련의질환에의해기억력을비롯한다른인지기능의장애로인해일상생활및사회활동의장애를유발하는증후군을지칭한다. 치매를유발하는가장흔한질환은알츠하이머병이며다음으로뇌혈관질환에의한혈관성치매가많다. 알츠하이머치매외에가장흔한퇴행성뇌질환에의한치매는루이소체 치매와전측두엽치매가있으며, 우리나라에서는지속적인음주에의한알코올성치매도흔하다. 현재치매환자에대한가장효과적인관리는조기에진단을하여이른시기에치료를시작함으로써중증치매단계에이르기까지의기간을최대한지연시킴으로써환자의기능상실을최소화하고치매환자보호자의부담을가능한경감시키는것이다. 향후질병의경과를변화시키는치료기법이나오더라도조기에치매를진단하여이른시기에치료를시작하는것은치매치 c Korean Medical Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 1104

2 Diagnosis and treatment of dementia in primary care 의학강좌 Primary care Primary care Exploring cognitive impairment Screening test (e.g., MMSE) Clinical evaluation - history taking - neurologic examination - physician examination Collaboration with specialists in treatment Neuroimaging evaluation Laboratory examination Neuropsychological test Management for comorbid illness Support for patient and caregiver Pharmacological & non-pharmacological treatment of dementia Figure 1. Schematic overview of the diagnosis and treatment of dementia in primary care. 료에있어서핵심적인부분일것이다. Refer to Specialist for dementia Diagnostic approach Therapeutic approach Facilitating access to social services Center for dementia Long-term care insurance 치매를조기에진단하고치료를빨리시작하기위해서는 의료체계내에서환자를가장먼저만나게되고, 보통질환의초기에접하게되는일차의료인의역할이중요하겠다. 하지만, 일차의료현장에서많은의사가자신이치료하는환자에게치매진단을내리는것에대해불편해하는것으로알려져있다 [1]. 그결과일차의료현장에서치매환자에대한적절한평가가이뤄지지않는경우가많다고한다. 이에본종설을통해일차의료현장에서의치매에대한적절한평가방법및치료적접근에대해서다뤄보고자한다 (Figure 1). 일차의료현장에서치매의진단및평가 치매는한두가지의검사결과에의존하여진단을확정할수있는질환이아니다. 기억력을비롯한인지기능장애가의심되는환자에서증상에대한자세한병력청취및평가를 통해인지기능의장애로인한일상생활및사회활동의장애를확인하고, 이학적검사, 신경학적검사, 표준화된신경심리검사, 뇌영상검사, 검사실검사등종합적인진단적평가를통해원인질환을밝혀치매아형을진단해야한다. 치매를조기에진단하기위해서는환자및보호자에의해서주관적으로인지기능저하에대한증상이보고되기전에일차의료현장에서증상에대한탐색이이뤄지는것이중요하다. 이를위해서진료의사는기억력및인지저하를시사하는다양한단서에대해주의를기울여야한다. 예를들면, 노인환자에서예약된진료일이아닌날에내원을하거나투약순응도가떨어지는것으로확인될때, 이러한문제가기억력저하로나타나는것이아닌지의심하고환자및보호자에게이에대해확인하는것이필요하다 [2]. 치매의가족력이있거나치매발생의위험도를높이는당뇨, 고지혈증, 고혈압과같은공존질환으로치료받는노인환자, 뇌혈관질환이나두부외상기왕력이있는노인환자, 알코올문제를가진환자등에서는기억력저하에대해서진료의사가먼저조사해야한다. 1. 진단기준치매진단기준으로는 Diagnostic and Statistical Manual of Mental Disorder (DSM) 제4판이흔히쓰이고있고 [3], 보험처리, 사인정리등에는 International Statisitical Calssification of Disease and Related Health Problems 제10판 (ICD-10) 에기반을둔한국표준질병분류가이용되고있다 [4]. 치매진단에흔히쓰이는 DSM-IV 진단기준에의하면, 기억력장애와함께실어증, 실행증, 실인증, 집행기능장애중하나이상이인지기능장애가동반되어야하며, 이러한인지기능장애들이과거에비해확실한감퇴를보여야하고, 이로인해현재사회적, 직업적장애를일으키기에충분한경우치매를진단하게된다. 2013년발표된 DSM-5 진단기준에서는치매라는용어대신좀더포괄적으로주요신경인지장애 (major neurocognitive disorder) 와경도신경인지장애 (mild neurocognitive disorder) 로진단기준을개정하였다. 이는기존의치매기준에비해증상이경한환자에서도임상적관심을기울이고진단하는것이필요하다는 대한의사협회지 1105

3 Jeong HG Han C 요구가반영된것으로볼수있다. 알츠하이머치매진단기준에 DSM-IV 진단기준과더불어 National Institute of Neurological and Communicative Diosrders and Stroke and the Alzheimer s Disease and Related Disorders Association (NINCDS-ADRDA) 이흔하게사용되어왔다 [5]. 2010년을전후로이에대한개정의필요성이대두되면서, Dubois 등 [6] 을주축으로전문가들이제시한진단기준과 McKhann 등 [7] 이개정한진단기준이발표되었다. 이들모두알츠하이머치매의초기및잠복기에해당하는환자들까지를진단할수있도록진단적개념을확장하고, 그동안의연구를통해알려진생물학적표지자를진단기준에포함하는방향으로진단기준을개정할것을제안하였다. 혈관성치매에대해서는 National Institute of Neurological Disorders and Stroke-Association Internationale pour la Recherche et l Enseignement en Neurosciences (NINCDS-AIREN) 진단기준이흔히사용되고있다 [8]. 루이소체치매에대해서는루이소체치매컨소시움에서제안한진단기준 [9], 그리고알코올성치매에대해서는 Oslin과 Cary [10] 가제안한기준이흔히쓰이고있다. 2. 선별검사일차의료현장에서인지기능저하가의심되는환자에서일차적인선별목적으로가장널리쓰이는검사는 Mini- Mental State Examination (MMSE) 라고할수있다. 검사시행지침을숙지하기용이하며 5-10분정도의짧은시간에시행할수있는장점이있다. 국내에서는 MMSE-K, K-MMSE, MMSE-KC가표준화되어사용중에있다 [11]. MMSE-K는무학대상자에게가산점을부여하는방식으로점수를보정할수있다. MMSE-KC, K-MMSE는연령, 성별, 교육수준에따라층화된집단의총점평균및표준편차값을선별기준에이용할수있다 [12,13]. 보통선별대상자에서 -1.5 이하의표준편차점수를보이는경우에정밀검사를고려하는데, 표준편차점수는아래와같이산출할수있다. 표준편차점수 =( 대상자의 MMSE 총점-규준집단의 MMSE 총점평균 )/ 규준집단의 MMSE 표준편차 MMSE 검사는선별검사일뿐이지 MMSE를이용하여치 매를진단하는것이아님을유념해야한다. 특히, 무학노인에서는치매가아님에도 MMSE 점수의저하를보이는경우가흔히있을수있다. 고학력자나과거기억력이좋았던대상자들에서도 MMSE 점수를해석함에주의하여야한다. 이러한대상자들에서는 MMSE 점수자체가정상범주에있더라도치매가시작되었을수있으므로, 주관적인지감퇴에대한호소가있거나신뢰할만한보호자에의해인지감퇴가보고된다면유의하여평가하여야한다. 3. 임상적평가환자의증상에대한병력청취는기억력, 언어, 지남력, 판단력, 행동및성격변화, 정서적문제에대해포괄적으로이뤄져야한다. 각각의증상이시작된양상, 진행양상, 증상의양상및시간에따른변화에대해서자세히파악하여야하며, 증상으로인한환자의일상생활및사회활동의장애가초래되었는지여부를판단해야한다. 임상평가를시행할때에는인지기능의저하를유발한원인질환을감별하고치매아형을진단하기위해이학적검사및신경학적검사를반드시함께시행하여야한다. 임상적평가시다음과같은척도및도구들을활용할수있다. 1) 전반적치매평가척도치매의전반적인증상을평가하고증상의심각도를결정하기위해 Clinical Dementia Rating (CDR) [14] 과 Global Deterioration Scale (GDS) [15] 이흔히쓰이고있다. 이는치매약제처방시에국민건강보험관리공단으로부터급여혜택을받기위해서도시행하여야한다. CDR은환자및보호자를대상으로기억력, 지남력, 판단력및문제해결력, 사회활동, 집안생활과취미, 그리고위생및몸치장의여섯가지세부항목에대해 0-5점으로평가하도록되어있다. GDS 는인지기능저하의진행및그에따른기능의퇴화에따라, 전치매단계를포함하여 1-7단계로평가하도록되어있다. 2) 일상생활능력평가척도일상생활능력 (activities of daily living, ADL) 은크게신체적일상생활능력과도구적일상생활능력으로구분한다. 신체적일상생활능력 (physical ADL) 에는개인위생관리, 식사, 착의, 대소변관리, 이동과같은기본적이고육체적인기 1106

4 Diagnosis and treatment of dementia in primary care 의학강좌 능들이포함된다. 도구적일상생활능력 (instrumental ADL, IADL) 은전화사용, 물건사기, 음식장만, 재정관리, 교통수단이용및길찾기, 복약, 세탁등신체적일상생활에비해복잡한기능들을포함하며보통치매초기에서먼저손상을보이는기능이다. 국내에서표준화되어사용중인일상생활능력평가도구에는 K-IADL [16], Bayer ADL [17], Disability Assessment for Dementia Scale (DAD-K) [18], Seoul-ADL [19], Seoul-IADL [20] 이있다. 3) 정신심리행동증상평가척도치매환자들은인지기능저하외에정서, 사고, 성격, 행동상에서임상적으로관심및치료를요하는다양한정신심리행동증상 (behavioral and psychiatric symptoms of dementia, BPSD) 을보인다. 대표적인평가도구로는 Neurospsychiatric Inventory (NPI) 가있으며, 이는망상, 환각, 초조 / 공격성, 우울 / 낙담, 불안, 다행감 / 기분의들뜸, 무감동 / 무관심, 탈억제, 과민 / 불안정, 비정상적인반복행동, 야간의행동, 식욕 / 식습관의변화의 12가지영역에대해평가하도록구성되어있다 [21]. 좀더간단하게사용할수있는 NPI-10, NPI-Q와같은개정판도있다. 이외에도 Behavior Pathology in Alzheimer s Disease Rating Scale (BEHAVE- AD) 가흔히사용된다 [22]. 4) 우울증상평가척도노인우울증환자에서는인지저하증상이흔하게나타나며 [23], 심한우울증에서보일수있는가성치매와같은경우에는치매와구분하는것이어려울수도있다. 따라서, 인지저하및기분증상중선행된증상이어떤것인지, 각증상의진행된경과와증상의양상은어떠한지에대해자세히평가하여감별진단하는것이필요하다. 또, 치매환자에서도정신심리행동증상의하나로써우울증이흔하게동반되며치료를요하는경우가많기때문에적절한평가가필요하다. 평가도구로는 30문항으로구성된노인우울척도 (Geriatric Depression Scale) 나 15문항으로구성된단축형노인우울척도가흔히쓰이며 [24,25], 성인에서자가보고척도로널리쓰이고있는 Beck Depression Inventory (BDI) 역시노인환자들에서도유용하다 [26]. 임상현장에서좀더짧은시간이소요되며국민건강영양조사에포함되어있는 Patient Health Questionnaire for depression (PHQ-9) 도노인의우울증상평가를위해이용될수있다 [27]. 치매환자의우울증상평가를목적으로만들어진 Cornell Scale for Depression in Dementia도있다 [28]. 5) 포괄적치매증상평가척도최근에표준화된치매증상통합척도 (Gottfries-Brane- Steen scale, GBS scale) [29] 는인지기능과일상생활능력뿐만아니라감정표현및정신심리행동증상까지하나의척도를이용하여평가할수있도록구성되어있다. 이도구는보호자나주조호자의보고를바탕으로평가할수있기때문에, 병식이부족하거나신체적이유로내원이힘든치매환자및요양기간입소치매환자의평가에도이용할수있는장점이있다. 4. 신경인지기능검사총집인지기능의심층적인평가를위한포괄적인신경인지기능검사중국내에서치매환자를대상으로흔히쓰이고있는신경심리검사총집에는 Consortium to Estabilish a Registr for Alzheimer s Disease- Neuropsychological Assessment Battery (CERAD-NP) [30] 및 Seoul Neuropsychological Screening Battery (SNSB) [31] 가있다. 이외에도치매환자의인지기능을평가를위해한국판 Dementia Rating Scale (K-DRS) [32], 한국판 Memory Assessment Scales (K-MAS) [33] 등도국내에서사용되고있다. 이러한검사는정신건강의학과전문의와같은전문가의지도감독하에임상심리학자나숙련된검사자가시행하고결과를해석하는것이원칙이다. 일차의료기관의경우와같이검사여건이충분치못한상황에서는전문의료기관으로의뢰하거나각지역치매지원센터나각지역구내에서시행되고있는조기검진사업기관에의뢰하여시행토록할수있다. 5. 검사실검사치매의일차적원인및치매와감별해야하는의학적상태를평가하고, 공존질환이나치매의위험인자를밝히기위해시행된다. 일차의료현장에서도치매에대한초기평가 대한의사협회지 1107

5 Jeong HG Han C 시에혈액침강율, 전혈구수치, 전해질, 칼슘, 당, 신기능, 간기능, 갑상선호르몬검사, 비타민 B12, 엽산수치, 매독, 인간면역결핍바이러스등의검사가흔히권장된다. 6. 뇌영상검사치매환자평가를위해구조적뇌영상검사인뇌전산화단층촬영과뇌자기공명영상과기능적뇌영상검사인일광자방출단층촬영과양전자방출단층촬영을시행할수있다. 뇌영상검사는인지저하를유발할수있는원인질환을감별하고, 치매의아형을진단하는데도움이된다. 특히, 일차의료현장에서가역적인치매를유발할수있는정상압수두증, 종양, 혈종등이의심되는경우에는반드시구조적뇌영상검사의시행을고려하는것이필요하다. 7. 진단에대한설명치매로진단을하는경우에는반드시환자및보호자에게치매진단에대해서설명을하고, 환자및보호자가치매진단에대해어떻게느끼고받아들이는지에대해서도물어봐야한다. 치매에대해올바르게이해할수있도록설명하고, 치료방법및제반사회서비스등에대해서도알려주면서안심시키고지지해주는것이필요하다 [34]. 정확한진단이내려지기이전이나진단에대한확신이부족하여환자및보호자에게자세한설명없이인지기능개선제를먼저투여하며경과관찰을하는것은치료순응도를떨어뜨리고예후에좋지않은영향을미칠수있으므로피하는것이좋다 [35]. 치매는확진하는것이어렵고, 더욱이일차의료현장에서는주로임상양상에의존하여진단적평가를시행하게되는경우가많기때문에진단의어려움이더클수있다. 이경우에는일차진료의가고려하고있는임상적인상과그진단적 가능성 에대해서설명하여주는것이필요하다. 치료자가치매가의심은되나진단적으로확신이없거나비전형적인양상을보여전문치료기관으로의뢰할때에도환자및보호자에게치매진단의 가능성 이어느정도이며다른진단과의감별이필요함에대해서함께설명을해주는것이향후의치료적관계에있어서도중요하다. 일차의료현장에서치매의치료 Iliffe 등 [36] 에의하면일차의료현장에서 치매환자를치료해서뭐하나크게좋아지는것도없을텐데. 와같은치료에대한비관론 (therapeutic nihilism) 이흔하게보여진다고한다. 치료자가병을바라보는태도가환자의치료순응도및환자가질환에대처하는자세에영향을미치기때문에치료자가긍정적인태도로치료에임하는것이중요하다. 현재임상현장에서치매에대해이뤄지고있는치료적접근은, 전체치매의 10-15% 에해당하는일부가역적인치매를제외하고는, 병전기능의회복을치료적목표로하고있지는않다. 즉, 질병의경과를변화시키는약제 (disease modifying drug) 은아직실용화된것이없는실정이다. 하지만, 치매가만성적인경과를밟게되고, 특히중증치매의경우에는경도나중등도의치매에비해서환자의조호를위한물리적, 경제적부담이급격하게증가하기때문에질환의경과를지연시키는것만으로도큰치료적의의를갖고있다. 치매환자의진행경과를최대한늦춰환자의기능을가능한유지시키는것은향후새로운치료약제가나왔을때환자에게좀더많은치료적혜택을줄수있는길이기도하다. 또, 치매환자에서동반되는여러정신심리행동증상의경우는치료적으로조절이가능한경우가많다. 일차의료의는이러한치료적이득에대해서명확하게이해하고환자에게치료의긍정성에대한메시지를전달하고환자와환자보호자를격려하고지지해주는것이필요할것이다. 1. 인지기능개선약제현재국내에서는다음의네가지치매약제가대표적으로사용되고있다. 아세틸콜린분해효소의억제에관여하는것으로알려진도네페질, 리바스티그민, 갈란타민세가지약제와, NMDA 수용체에작용하는것으로알려진메만틴이있다. 체계적문헌고찰결과이들약제는알츠하이머치매환자에서효과가있었으며 [37], 일부혈관성치매환자에서도도움이될것으로생각된다 [38]. 약물투여를하면서정기적으로증상에대한추적평가를하는것이필요한데, 현재국내에서이들치매약제가국민건강보험공단으로부터 1108

6 Diagnosis and treatment of dementia in primary care 의학강좌 Table 1. Anti-dementia drugs: eligibility for National Health Insurance coverage in Korea MMSE CDR GDS Donepezil (5-10 mg) Donepezil (23 mg) Less than Rivastigmine Galantamine Memantine Less than MMSE, Mini-Mental State Examination; CDR, Clinical Dementia Rating; GDS, Global Deterioration Scale. 줘야한다. 또, 알코올의존이나문제음주와, 흡연과같은니코틴중독에대해서도치료적으로접근하는것이필요하다. 알코올의존이나문제음주를보이는치매환자나인지기능장애환자에서는고용량의티아민 ( mg/day) 을장기적 (6개월이상 ) 으로처방하는것이도움이된다. 급여적용을받기위해서는 6개월에서 1년마다정기적으로 MMSE와 CDR 혹은 MMSE와 GDS를시행하여야만한다. Table 1에서각약제에따른보험인정기준을제시하였다. 2. 정신심리행동증상조절치매환자에서는수면문제, 우울증상, 환각, 충동적인행동, 공격성, 배회증상, 상동행동등다양한정신심리행동증상이동반된경우가많다. 도네페질, 리바스티그민, 갈란타민, 메만틴과같은인지기능치료약제가정신심리행동증상의경감에도도움이되는것으로알려져있다. 하지만, 실제임상현장에서는이러한치매약제로충분히정신심리행동증상이조절되지않을경우가많다. 이때에는항우울제, 항전간제, 벤조디아제핀계열의항불안제등이도움이될수있으며, 비약물학적치료를통해증상을개선하는것이필요한경우도많다 [39]. 2012년개정된미국노인병학회 Beers Criteria에서는치매환자를포함한노인에서행동장애나수면장애에대한안정제혹은항정신병약물사용에대해엄격한제한을권장하고있기때문에 [40], 정신건강의학과전문의혹은치매치료전문의와의협진이효과적이다. 3. 공존질환의관리치매를앓고있는많은노인환자들에서당뇨, 고혈압, 고지혈증등과같은공존질환에이환되어있다 [41]. 이러한질환들이잘관리되지않으면, 뇌혈관질환을악화시켜혈관성치매뿐만아니라알츠하이머치매의경과를악화시킬수있다. 따라서, 이러한공존질환의관리가질환자체뿐만아니라치매치료에도도움이됨을설명하고적극적으로관리해 4. 치매조호가족들에대한지지치매는인지기능의손상으로인해독립적인일상생활수행에장애를초래하기때문에가족및보호자의조호가필요하다. 질환의특성상만성적인경과를밟게되고증상이심해지면서가족들의심리적, 물리적, 경제적인부담도함께커지게된다. 주된치매환자의조호를맡고있는가족의경우에는지치게되고우울증을앓게되는경우도많다. 일차의료현장에서이러한치매가족에대한지지가필요하며전문적인치료가요하는경우에는정신건강의학과전문의에게의뢰하는것이좋다 [42]. 일부가족에서는질병에대한이해가부족하여치료를받지않게내버려두거나, 동반된정신심리행동문제에대해서병으로이해하지못하고감정적이고폭력적인방법으로대처하는경우도있다. 치료자는환자보호자가치매증상에대해올바르게이해할수있도록돕고가족치료나가이드북과같은리소스를안내할수있어야한다 [43]. 치매환자에게있을수있는가족들의학대나방임에대해서도유의해야한다. 5. 치매치료전문기관및사회서비스와연계촉진치매환자의치료에있어서다양한비약물학적치료도도움이될수있다. 대표적으로인지재활치료프로그램이치매환자들에게효과가있으며 [44], 음악치료, 미술치료, 인정치료등도치매환자의증상개선에부분적으로도움이되는것으로알려져있다 [45]. 이러한치료에대해서도환자및보호자에게충분히정보를제공하고치료를원할경우치료여건이갖춰진전문병원으로의뢰하여야한다. 각지역사회에서운영되고있는치매지원센터에서도인지재활치료, 음 대한의사협회지 1109

7 Jeong HG Han C 악치료, 미술치료등의비약물학적치료프로그램과가족치료프로그램이운영되고있으므로이를활용할수도있다. 치매환자는국민건강보험공단에의해운영되는장기요양보험을통해시설급여, 재가급여, 방문목욕, 방문간호, 주야간보호등과같은서비스를받을수있다. 이를위해국민건강보험공단측에의사소견서를제출하고장기요양보험을신청하면공단측으로부터등급판정을받은뒤그에따른서비스를제공받게된다. 결 론 치매환자는가능한한치매가시작되는초기에진단하여일찍치료를시작하는것이필요하다. 따라서, 일차의료현장에서기억및인지장애가의심되는환자에서적극적인진단적평가가이뤄져야하며, 치매가진단된환자들이적절한치료를받을수있도록도와야할것이다. 이를위해일차의료인은지속적으로치매에대한최신지견을익히고치매치료전문가와의협진을강화하며치매환자를대상으로하는각지역의사회서비스프로그램에대해서도이해를넓혀실제임상현장에서환자를연계할수있어야한다. 이와함께전문가와국가기관이협력하여국내여건에맞춰일차의료인을대상으로한체계화된치매진료교육프로그램을제공하고일차의료현장에서의치매관리에대한표준화된지침을마련하기위한노력도병행되어야할것이다. Acknowledgement This study was supported by a grant of the Korean Health Technology R&D Project, Ministry of Health & Welfare, Republic of Korea. (A070001) 핵심용어 : 치매 ; 기억장애 ; 일차의료 ; 알츠하이머병 REFERENCES 1. Downs M, Bowers B. Caring for people with dementia. BMJ 2008;336(7638): Bamford C, Eccles M, Steen N, Robinson L. Can primary care record review facilitate earlier diagnosis of dementia? Fam Pract 2007;24: American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-IV. 4th ed. Washington, DC: American Psychiatric Association; World Health Organization. ICD-10: international statistical classification of diseases and related health problems. 10th ed. Geneva: World Health Organization; McKhann G, Drachman D, Folstein M, Katzman R, Price D, Stadlan EM. Clinical diagnosis of Alzheimer s disease: report of the NINCDS-ADRDA Work Group under the auspices of Department of Health and Human Services Task Force on Alzheimer s Disease. Neurology 1984;34: Dubois B, Feldman HH, Jacova C, Dekosky ST, Barberger- Gateau P, Cummings J, Delacourte A, Galasko D, Gauthier S, Jicha G, Meguro K, O brien J, Pasquier F, Robert P, Rossor M, Salloway S, Stern Y, Visser PJ, Scheltens P. Research criteria for the diagnosis of Alzheimer s disease: revising the NINCDS-ADRDA criteria. Lancet Neurol 2007;6: McKhann GM, Knopman DS, Chertkow H, Hyman BT, Jack CR Jr, Kawas CH, Klunk WE, Koroshetz WJ, Manly JJ, Mayeux R, Mohs RC, Morris JC, Rossor MN, Scheltens P, Carrillo MC, Thies B, Weintraub S, Phelps CH. The diagnosis of dementia due to Alzheimer s disease: recommendations from the National Institute on Aging-Alzheimer s Association workgroups on diagnostic guidelines for Alzheimer s disease. Alzheimers Dement 2011;7: Roman GC, Tatemichi TK, Erkinjuntti T, Cummings JL, Masdeu JC, Garcia JH, Amaducci L, Orgogozo JM, Brun A, Hofman A. Vascular dementia: diagnostic criteria for research studies. Report of the NINDS-AIREN International Workshop. Neurology 1993;43: Bonanni L, Thomas A, Onofrj M. Diagnosis and management of dementia with Lewy bodies: third report of the DLB Consortium. Neurology 2006;66: Oslin DW, Cary MS. Alcohol-related dementia: validation of diagnostic criteria. Am J Geriatr Psychiatry 2003;11: Lee KS, Cheong HK, Oh BH, Hong CH. Comparison of the validity of screening tests for dementia and mild cognitive impairment of the elderly in a community: K-MMSE, MMSE-K, MMSE-KC, and K-HDS. J Korean Neuropsychiatr Assoc 2009; 48: Han C, Jo SA, Jo I, Kim E, Park MH, Kang Y. An adaptation of the Korean mini-mental state examination (K-MMSE) in elderly Koreans: demographic influence and population-based norms (the AGE study). Arch Gerontol Geriatr 2008;47: Lee DY, Lee KU, Lee JH, Kim KW, Jhoo JH, Youn JC, Kim SY, Woo SI, Woo JI. A normative study of the mini-mental state examination in the Korean elderly. J Korean Neuropsychiatr Assoc 2002;41:

8 Diagnosis and treatment of dementia in primary care 의학강좌 14. Hughes CP, Berg L, Danziger WL, Coben LA, Martin RL. A new clinical scale for the staging of dementia. Br J Psychiatry 1982;140: Reisberg B, Ferris SH, de Leon MJ, Crook T. The Global Deterioration Scale for assessment of primary degenerative dementia. Am J Psychiatry 1982;139: Kang SJ, Choi SH, Lee BH, Kwon JC, Na DL, Han SH; Korean Dementia Research Group. The reliability and validity of the Korean Instrumental Activities of Daily Living (K-IADL). J Korean Neurol Assoc 2002;20: Choi SH, Na DL, Lee BH, Kang SJ, Ha CK, Han SH, Erzigkeit H. Validation of the Korean version of the Bayer activities of daily living scale. Hum Psychopharmacol 2003;18: Suh GH. Development of the Korean Version of Disability Assessment for Dementia Scale (DAD-K) to assess function in dementia. J Korean Geriatr Soc 2003;7: Ku HM, Kim JH, Lee HS, Ko HJ, Kwon EJ, Jo S, Kim DK. A Study on the Reliability and Validity of Seoul-Activities of Daily Living (S-ADL). J Korean Geriatr Soc 2004;8: Ku HM, Kim JH, Kwon EJ, Kim SH, Lee HS, Ko HJ, Jo S, Kim DK. A Study on the Reliability and Validity of Seoul-Instrumental Activities of Daily Living (S-IADL). J Korean Neuropsychiatr Assoc 2004;43: Cummings JL, Mega M, Gray K, Rosenberg-Thompson S, Carusi DA, Gornbein J. The Neuropsychiatric Inventory: comprehensive assessment of psychopathology in dementia. Neurology 1994;44: Reisberg B, Borenstein J, Salob SP, Ferris SH, Franssen E, Georgotas A. Behavioral symptoms in Alzheimer s disease: phenomenology and treatment. J Clin Psychiatry 1987;48 Suppl: Lim J, Oh IK, Han C, Huh YJ, Jung IK, Patkar AA, Steffens DC, Jang BH. Sensitivity of cognitive tests in four cognitive domains in discriminating MDD patients from healthy controls: a meta-analysis. Int Psychogeriatr 2013;25: Jung IK, Kwak DI, Shin DK, Lee MS, Lee HS, Kim JY. A reliability and validity study of geriatric depression scale. J Korean Neuropsychiatr Assoc 1997;36: Lee SH, Kang MH, Kim CE, Lee JS, Bae JN, Cho MJ. Comparing various short-form geriatric depression scales in elderly psychiatric patients in Korea. J Korean Geriatr Psychiatry 2009;13: Jo SA, Park MH, Jo I, Ryu SH, Han C. Usefulness of Beck Depression Inventory (BDI) in the Korean elderly population. Int J Geriatr Psychiatry 2007;22: Han C, Jo SA, Kwak JH, Pae CU, Steffens D, Jo I, Park MH. Validation of the Patient Health Questionnaire-9 Korean version in the elderly population: the Ansan Geriatric study. Compr Psychiatry 2008;49: Alexopoulos GS, Abrams RC, Young RC, Shamoian CA. Cornell scale for depression in dementia. Biol Psychiatry 1988; 23: Oh I, Huh Y, Lim J, Han C. A Preliminary study for the standardization of the Korean version of the GBS scale. J Korean Geriatr Psychiatry 2012;16: Lee JH, Lee KU, Lee DY, Kim KW, Jhoo JH, Kim JH, Lee KH, Kim SY, Han SH, Woo JI. Development of the Korean version of the Consortium to Establish a Registry for Alzheimer s Disease Assessment Packet (CERAD-K): clinical and neuropsychological assessment batteries. J Gerontol B Psychol Sci Soc Sci 2002;57:P47-P Ahn HJ, Chin J, Park A, Lee BH, Suh MK, Seo SW, Na DL. Seoul Neuropsychological Screening Battery-dementia version (SNSB-D): a useful tool for assessing and monitoring cognitive impairments in dementia patients. J Korean Med Sci 2010;25: Chey JY, Lee SA. Development of the norms for the Korean Dementia Rating Scale. Korean J Clin Psychol 1997;16: Lee HS, An CI, Jeong IK. A preliminary study on standardization of K-MAS (Korean version of Memory Assessment Scales). Korean J Clin Psychol 1999;18: Iliffe S, Robinson L, Brayne C, Goodman C, Rait G, Manthorpe J, Ashley P; DeNDRoN Primary Care Clinical Studies Group. Primary care and dementia: 1. diagnosis, screening and disclosure. Int J Geriatr Psychiatry 2009;24: Clare L. Managing threats to self: awareness in early stage Alzheimerʼs disease. Soc Sci Med 2003;57: Iliffe S, Wilcock J, Haworth D. Obstacles to shared care for patients with dementia: a qualitative study. Fam Pract 2006; 23: Birks J. Cholinesterase inhibitors for Alzheimer s disease. Cochrane Database Syst Rev 2006;(1):CD Kavirajan H, Schneider LS. Efficacy and adverse effects of cholinesterase inhibitors and memantine in vascular dementia: a meta-analysis of randomized controlled trials. Lancet Neurol 2007;6: Overshott R, Byrne J, Burns A. Nonpharmacological and pharmacological interventions for symptoms in Alzheimer s disease. Expert Rev Neurother 2004;4: American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc 2012;60: Woo EK, Han C, Jo SA, Park MK, Kim S, Kim E, Park MH, Lee J, Jo I. Morbidity and related factors among elderly people in South Korea: results from the Ansan Geriatric (AGE) cohort study. BMC Public Health 2007;7:10. 대한의사협회지 1111

9 Jeong HG Han C 42. Robinson L, Iliffe S, Brayne C, Goodman C, Rait G, Manthorpe J, Ashley P, Moniz-Cook E; DeNDRoN Primary Care Clinical Studies Group. Primary care and dementia: 2. Long-term care at home: psychosocial interventions, information provision, carer support and case management. Int J Geriatr Psychiatry 2010;25: Lee DY, Woo JI. Interventions for Alzheimer s disease: a caregiver s complete reference. Seoul: One-Book; Ballard C, Khan Z, Clack H, Corbett A. Nonpharmacological treatment of Alzheimer disease. Can J Psychiatry 2011;56: Grasel E, Wiltfang J, Kornhuber J. Non-drug therapies for dementia: an overview of the current situation with regard to proof of effectiveness. Dement Geriatr Cogn Disord 2003;15: Peer Reviewers Commentary 본논문은일차의료현장에서의료인이알고있어야할치매전반에대한소개와진단및치료에대해알기쉽게기술한논문이다. 고령화로인해알츠하이머병을비롯한치매에대한사회적관심이높아지고있다. 따라서노인연령층이일차의료기관을이용하는빈도는늘어날것이며치매에대한올바른인식은일차의료인에게필수적이다. 이논문은치매의진단및평가에대해간결하면서중요한점을잘기술해놓았으며가족, 사회서비스까지기술한점은실제임상에서유용한자료로인식될것이다. 치매는인지기능의현격한저하, 정신행동장애, 기분장애, 운동장애및일상생활기능의저하등을동반하고결국전반적인기능의황폐화를초래한다. 따라서, 일차의료현장에서기억및인지장애가의심되는경우적극적인평가및치료가이루어질수있도록최선의도움이주어져야한다. 이러한배경으로볼때본종설은일차치료의책임을맡고있는임상의들에게치매의진단에있어서기본적이며실용적이고포괄적인지식을정리하여전달한다고볼수있다. 특히진단부분에서실제임상진료현장에서즉시사용할수있는간단한척도들과보다특성화 / 전문화된기관들과연계하여야할부분을잘정리하였으며현재의최신약물치료경향도잘반영하고있다. [ 정리 : 편집위원회 ] 1112

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노인정신의학회보14-1호 제14권 1호 통권 제23호 www.kagp.or.kr 발행인 : 정인과 / 편집인 : 이동우 / 발행처 : 정인과 (152-703) 서울특별시 구로구 구로동 80번지 고려대학교 구로병원 정신과 / TEL : 02-818-6608 / FAX : 02-852-1937 발행일 : 2008년 4월 30일 / 제 작 : (주)엠엘커뮤니케이션 140-846 서울특별시