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1 Original Article J Korean Geriatr Soc 2009;13(2):69-78 노인에서인지능평가를위한전산화캠브리지신경인지검사법의유용성 : 예비연구 1 한패밀리병원신경과, 2 경북대학교의과대학신경과학교실, 3 영남대학교의과대학신경과학교실 김찬석 1 이진영 1 하태현 1 최재혁 1 유은미 1 이선주 1 이호원 2 박미영 3 The Usefulness of The Cambridge Neuropsychological Test Automated Battery (CANTAB) for Assessing Cognitive Functions in the Elderly: a Pilot Study Chansok Kim, MD 1, Jin Young Lee, MD 1, Tae Hyun Ha, MD 1, Jae Hyuk Choi, MD 1, Eun-Mi Yu, MS 1, Sun Ju Lee, BA 1, Ho Won Lee, MD 2, Mee Young Park, MD 3 1 Department of Neurology, Han Family Hospital, Daegu, Korea 2 Department of Neurology, College of Medicine, Kyungpook National University, Daegu, Korea 3 Department of Neurology, College of Medicine, Yeungnam University, Daegu, Korea Background: We selected a computerized neuropsychological test, the Cambridge Neuropsychological Test Automated Battery (CANTAB), along with other conventional neuropsychological tests. The aim of this study was to assess CANTAB's usefulness in diagnosing dementia in the elderly and to compare it with conventional neuropsychological assessment kits. Methods: We recruited 17 dementia patients diagnosed with Alzheimer's disease or vascular dementia for the dementia group and 52 healthy persons who met our criteria for the control group. We administered four CANTAB subtests to assess their cognitive functions along with the conventional Seoul Neuropsychological Screening Battery, which includes the Rey-Osterreith Complex Figure Test (RCFT) to assess visual memory. The four CANTAB subtests chosen were big/little circle (BLC), paired associates learning (PAL), spatial recognition memory (SRM), and spatial span (SSP). Results: The dementia group showed impairment on the PAL and SRM tasks. The results of the other two subtests were not different between the two groups. The mean adjusted total errors on the PAL task was higher in the dementia group (130.88) than in the control group (51.38), which was statistically significant (p). The percentage of correct response on the SRM task was lower in the dementia group (58.75%) than in the control group (67.25%), also statistically significant (p=0.03). We also compared the correlations of the CANTAB subtests with the RCFT parameters (immediate recall, delayed recall, and recognition). Again, the results showed that the PAL task correlated well with these three parameters (r=-0.59, -0.60, and -0.56, respectively). Conclusion: The CANTAB was useful for assessing cognition in the elderly. In particular, the PAL task, which correlated well with the RCFT parameters, can be used to assess visual memory. It showed to be a valuable tool in diagnosing dementia. Key Words: Computer-assisted instruction, Neuropsychological tests, Dementia Received: Dec 15, 2008 Revised: Jun 15, 2009 Accepted: June 18, 2009 Address for correspondence: Mee Young Park, MD, PhD Department of Neurology, College of Medicine, Yeungnam University, 317-1, Daemyeong-dong, Nam-gu, Daegu , Korea Tel: , Fax: , mypark@med.yu.ac.kr * 이연구는 2007 년도대한노인병학회연구비지원에의해수행되었음. J Korean Geriatr Soc 13(2) June

2 김찬석외 : 노인에서인지능평가를위한전산화캠브리지신경인지검사법의유용성 : 예비연구 서 론 대상및방법 Cambridge Neuropsychological Test Automated Battery (CANTAB) 는전산화된신경심리검사집으로노인인구에서치매를진단하기위해개발되었다 1). 가장최근의검사집은 22개의세부검사로구성되며, 컴퓨터와연결된부속기기와터치스크린을이용하여검사를수행한다. 각세부검사는 1) 선별검사 (screening tests), 2) 시각적기억력검사 (visual memory tests), 3) 수행기능, 작업기억및계획력검사 (executive function, working memory and planning tests), 4) 주의집중력검사 (attention tests), 5) 의미 / 언어적기억력검사 (semantic/verbal memory tests), 6) 의지결정및반응제어력검사 (decision-making and response control tests) 로구성되어있다 2). 이중의미 / 언어적기억력검사를제외한대부분의세부검사에사용되는자극은비언어적이며, 화면에나타나는사물의모양과위치에대한판단에근거하여검사자의세부인지능력을평가하는검사이다. 외국의여러연구에서 CANTAB의신경퇴행성질환에서의유용성을보여주는연구 3-8) 가이루어져있으며, 내재된데이터가문화및언어의차이에서수행의차이가없음 9) 이알려져있고, 소아에서도유용함을보여주는연구 10) 가있다. 치매는나이가많아짐에따라발병률이높아지는질환으로 65세이상의노인에서연령이 5세증가할때마다치매의유병률은 2배씩증가한다 11) 고알려져있다. 우리나라에서는아직정부의료기관의검증을거친정확한치매의유병률이제시되지않고있어정확한치매노인의숫자는파악할수없으나, 65세이상노인 1백명중 8.3명정도가치매노인으로추정 12) 되고있으며, 2000년에는 27만 7천여명, 2005년 36만 7천여명, 2020년에는 70만 3천여명으로증가할것으로예상되고있다 13). 이와같이노인인구는지속적으로증가할것이며, 치매등노인성질환자수또한기하급수적으로증가할것으로예상되어이로인한노인의료비의증가는사회에큰부담을주게될것이다. 본연구에서는한국인에서치매를진단함에있어 CANTAB 을통한전산화인지기능검사의유용성을알아보고자하며, 기존의신경심리검사와 CANTAB 세부검사간의상관관계를알아보고자한다. 1. 대상 2007년 5월부터 2008년 8월까지대구수성구지역 65세이상주민을대상으로한치매조기검진사업을통해모집된사람중자발적으로대구에위치한 1개병원에서시행된연구에협조적으로참여한피검자를연구의대상으로하였다. 선별검진에는 Korean version of Mini-Mental State Examination (K-MMSE) 과 Korean Dementia Screening Questionnaire (KDSQ) 가이용되었으며, K-MMSE의점수가교육과연령을보정한정상치에서 -1 표준편차보다낮거나 K-DSQ의점수가 5점을초과하는피검자는신경심리검사를위해병원으로의뢰되었다. 병원으로의뢰된피검자는총 130명이었으며, 신경심리검사를완벽히수행하지못하거나, 거부한피검자는 10명이었고, CANTAB을거부한피검자는 10명, CANTAB을수행하였더라도완료하지못한피검자가 20명이었다. 이와같이신경과에내원한후병력청취, 신경학적검사및신경심리검사와 CANTAB을모두수행한 90명중아래의기준에부합하는 17명의치매군과 52명의정상군을선별하여총 69명 ( 남자 23명, 여자 46명 ) 을연구의대상으로하였다. Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-Ⅳ) 진단기준 14) 을사용하여치매의여부를판단하였고, 알츠하이머병은 National Institute of Neurologic, Communicative Disorders and Stroke- Alzheimer's Disease and Related Disorders Association (NINCDS- ADRDA) 의진단기준 15) 을사용하였으며, 혈관성치매는 National Institute of Neurological Disorders and Stroke- Association Internationale pour la Recherche et al. Enseignement en Neurosciences (NINDS-AIREN) 의진단기준 16) 을사용하였다. 검진을통해총 19예의치매가발견되었으나, 1예의파킨슨병치매와 1예의전두측두엽치매는치매환자군의분류에서제외하였으며, 따라서, 전체치매군은 17명이었다. 치매가없는것으로나타난검사자 71명중에서 52명의정상군을추출하였으며, 이들의선정기준은신경학적검사에서특이소견이없고, 과거의뇌졸중및두부외상의병력이없으며, 정신병력이없고, 인지기능의감퇴와연관 70 J Korean Geriatr Soc 13(2) June 2009

3 Chansok Kim, et al: Computer-assisted Instruction, Neuropsychological Tests, Dementia 될수있는약물복용력이없으며, 인지기능에영향을미칠수있는질환이없는사람들중 K-MMSE 검사에서평균에서표준편차를뺀값을기준으로점수가그이상인사람들을대상으로하였다. 2. 인지기능검사의뢰된모든피검자들은한명의임상심리사가 K-MMSE, digit span, Korean version of Boston Naming Test (K-BNT), Seoul Verbal Learning Test (SVLT; 즉각회상, 지연회상, 재인검사 ), Rey Osterreith Complex Figure Test (RCFT; 즉각회상, 지연회상, 재인검사 ), word fluency, Controlled Oral Word Association Test (COWAT), calculation, Stroop test, apraxia test 등으로구성된 Seoul Neuropsychological Screening Battery (SNSB) 17) 를시행하였고, 추가적으로, Clock Drawing Test, Geriatric Depression Scale, Bathel index와 Clinical Dementia Rating scale (CDR) 을시행하였다. 같은날잠깐의휴식시간을가진후다른검사자가 CANTAB 중 Big/Little Circle (BLC), Intra/Extradimensional Set Shift (IED), Stocking of Cambridge (SOC), Paired Associates Learning (PAL), Spatial Recognition Memory (SRM), Spatial Span (SSP) 을검사하였다. 하루에두가지인지기능검사를모두시행하였으며, 모든피검자가먼저 SNSB를시행한후최대 30분의휴식시간을가진다음에 CANTAB을시행하였다. 본연구에서는이중 BLC, PAL, SRM과 SSP를분석에이용하였다. 1) BLC IED 검사를위한일차적인선별및훈련검사이며, 검사의규칙을충분히이해하여학습하고또변환할수있는지를평가할수있다. 화면중앙의두곳에색깔이있는원이나타나면피검자는첫 20회동안은그중작은것을, 다음 20회동안은그중큰것을지적하는검사이다. 정반응의잠시 (correct latency) 를기록하여피검자가화면에나타나는자극에대해반응을보이는속도를측정하였고, 정반응의백분율 (percent correct) 을통해전체반응중정반응의백분율을측정하였다. 정반응의백분율이 BLC 검사의전반적인수행능력을평가하는지표로이용되며, 본연구에 서도이를변수로사용하였다. 2) PAL 화면에원형으로배열된 6개또는 8개의흰색사각형이배열되어있는상태에서무작위로하나씩사각형이열리며, 그중한가지이상의사각형내부에는추상적인무늬가나타난다. 이후화면의중앙에이전에나타났던무늬가나타나면피검자는그무늬가있었던흰색사각형의위치를짚어내는검사이다. 난이도별로여덟단계로구성되어있으며, 이는두번의한무늬단계, 두번의두무늬단계, 또두번의세무늬단계와, 각한번의여섯무늬단계와여덟무늬단계로이루어진다. 기억에실패한경우에는다시화면을반복하고, 각단계에서최대 10회의기회가주어진다. 열번의반복에도피검자가모두실패한경우는다음단계로진행되지않고검사가종료된다. 결과는다양하게나타날수있는데, 먼저전체오류횟수 (total errors) 는검사도중나타난오류의합을의미하며, 만약검사도중어느단계에서건검사가중단되면검사를완료한사람보다오류를측정할수있는기회자체가더적어질수있다. 이를보정하기위해, 즉검사가중단된경우와제 8단계까지종료된후의오류횟수간의오차를수정하기위해조정된전체오류횟수 (total errors, adjusted) 를계산하여이용할수있으며, 통상적으로전체오류횟수보다는조정된전체오류횟수를분석에이용하며, 본연구에서도이를사용하였다. 조정된전체오류횟수를계산하는방법은, 실패로인해수행하지못한단계의무늬의수에서이수를이단계에서제시되는사각형의수로나눈값을뺀수를구한다. 이수에각단계에서허용되는시도의수 (10회) 를곱한값이조정된전체오류횟수가된다. 전체시도횟수 (total trials) 는각단계를통과하는데걸린전체시도의횟수의합을의미하며, 이또한검사도중어느단계에서검사가중단되면검사를완료한사람보다시도할수있는기회자체가더적어질수있다. 이를보정하기위해조정된전체시도횟수 (total trials, adjusted) 를이용할수있는데, 이는실패로인해수행하지못한단계의시도횟수를 10씩더해주는방법으로구해진다. 완료한단계 (stages completed) 란몇번째단계까지성공하였는지를나타내는지표이다. 검사 J Korean Geriatr Soc 13(2) June

4 김찬석외 : 노인에서인지능평가를위한전산화캠브리지신경인지검사법의유용성 : 예비연구 가중단된경우여러지표들이완료된경우와직접비교할수없는값을제시하는경우가많아이를분석할때완료한단계를고려하여평가하는것이중요하다. 첫시도에완료한단계수 (stages completed on first trial) 는전체여덟단계중한번의시도로성공한단계의수를의미한다. 첫시도중기억횟수 (first trial memory score) 란각단계에서첫시도중에정확히기억한무늬의수의합을나타낸다. 최대치는 26이며, 이는각각의단계를단한번씩의시도로성공하여여덟단계를모두통과하였을때얻을수있다. 3) SRM 검은색화면에흰색의테두리가쳐진정사각형이다섯군데에위치에차례로나타난후이를재인하여피검자의인식여부를알아보는검사이다. 재인시에는자극순서와역순으로정사각형이나타나는데혼란을주기위해자극위치와다른한곳에서또하나의정사각형이나타나며, 나타난두개의정사각형중앞서보았던위치에있는것을고르는검사이다. 결과는정반응의잠시 (correct latency) 를통해피검자가화면에나타나는자극에대해반응을보이는속도를측정할수있고, 정반응의백분율을통해전체반응중정반응의백분율을나타낼수있다. 4) SSP 흰색의사각형이화면에여러개표시된상태에서하나씩색이바뀌면피검자는색이바뀌는사각형의순서를기억하여그위치를순서대로화면에짚어가는검사이다. 자극은 2개에서 9개까지진행되며, 각단계별로세번의기회를가질수있다. 피검자가최대로기억한공간적주의폭 (span length) 을변수로이용하였고, 최대치는 9이다. 3. 통계분석통계처리는 SPSS 13.0 for Windows (SPSS Inc., Chicago, IL, USA) 를이용하여연구대상군의인구학적분석에독립표본 T검정을시행하였고, 치매군과정상군간신경심리검사결과의분석에독립표본 T검정을시행하였다. CANTAB 세부검사와 RCFT 간의상관관계분석을시행하였다. 결 과 1. 조사대상의인구학적특성 전체검사자는 69명이며, 치매군은 17명, 정상군은 52명이었다. 평균연령은치매군 72세, 정상군 71.6세로차이가없었으며, 성별및교육수준도통계학적으로유의한차이는없었다. K-MMSE 를통한인지기능의비교에서치매군이 21.4점으로정상군의 27.2점에비해유의하게낮았다 (Table 1). 2. SNSB Digit span은 forward/backward 모두에서치매군 (4.06/2.82) 이정상군 (5.17/3.44) 보다유의하게낮았다 (p과 p<0.05). K-BNT는축약형검사를시행한경우 60문항의전체검사결과로변환하여분석하였으며, 치매군 (32.47) 이정상군 (43.13) 보다유의미하게낮았다 (p). 시각적기억력을보기위한 RCFT의지연회상에서치매군 (5.13) 은정상군 (11.41) 에비해유의하게낮은점수 (p) 를보였으며, 언어적기억력을보기위한 SVLT의지연회상에서도치매군 (1.65) 은정상군 (5.38) 에비해낮은점수 (p) 를기록하였다. 구성능력을보기위한 RCFT의모방검사에서치매군 (19.22) 이정상군 (26.98) 보다낮은점수를나타내었다 (p< 0.01). COWAT 에서는동물이름, 물건이름, 음소로시작하기모두에서치매군 (9.06, 10.71, 10.79) 에서정상군 (12.12, 14.84, 20.92) 보다낮은점수를보였다 ( 모두 p). Contrasting Table 1. Demographic data of the subjects Demented (n=17) Control (n=52) p-value Age (years) 71.59± ±5.43 NS Sex (M:F) 1:1.65 1:1.67 NS Education (years) 6.38± ±4.81 NS K-MMSE 21.41± ±1.96 Data presented as mean±sd. Statistical significance tested by Student's t-test. K-MMSE, Korean version of Mini-Mental State Examination; NS, not significant; M:F, male:female. 72 J Korean Geriatr Soc 13(2) June 2009

5 Chansok Kim, et al: Computer-assisted Instruction, Neuropsychological Tests, Dementia program에서는양군간에차이가없었으나 (p=0.054), Go- No-Go에서는치매군 (12.24) 에서정상군 (18.27) 보다유의한수행저하를보였다 (p). Stroop test의글자읽기에서는치매군과정상군간의유의한차이는나타나지않았으나 (p=0.109), 색깔읽기에서치매군에서 42.71, 정상군에서는 65.06으로유의한차이가있었고 (p), 간섭지수에서도치매군 (1.80) 과정상군 (0.75) 간에유의한차이가있었다 (p <0.05). 다른검사및자료의결과는 Table 2에표시하였다. 3. CANTAB 1) BLC 정반응의잠시 (correct latency) 는치매군 (n=16) 이 ± ms, 정상군 (n=51) 이 ± ms로차이가있었으나유의하지는않았다 (p=0.17). 정반응의백분율도치매군이 98.59±3.16%, 정상군이 99.71±0.81% 로나타나유의한차이는없었다 (p=0.18). Fig. 1. Comparisons of errors in PAL subset of CANTAB between the demented and the control group. Data are presented as mean±standard deviation. PAL, Paired Associates Learning; CANTAB, Cambridge Neuropsychological Test Automated Battery. 2) PAL 전체오류횟수 (total errors) 는치매군 (n=17) 41.59±25.81 회, 정상군 (n=52) 38.77±21.30회로유의한차이가없게나타났으나 (p=0.66), 전체오류횟수는검사가중단된경우이후의오류에대한정보가기록되지않아단순히비교할수없으므로 CANTAB에서는조정된전체오류횟수 (total errors, adjusted) 를나타내고있다. 조정된전체오류횟수에서치매군은평균 회의오류를범하였으며, 정상군은평균 51.38회의오류를범하였다. 이는통계학적으로유의하여 (p) PAL 검사에서치매군은정상군보다오류를더많이보였다 (Fig. 1). 전체시도횟수 (total trials) 도치매군 20.00±7.95회, 정상군 18.98±4.59회로유의한차이가없게나타났으나 (p=0.52), 이또한검사가중단된경우이후의시도에대한정보가기록되지않아단순히비교할수없으므로 CANTAB에서는조정된전체시도횟수 (total trials, adjusted) 를출력하고있다. 조정된전체시도횟수는치매군이평균 39.41±17.88회시도하였고, 정상군은평균 20.83± 6.12회시도하여치매군의시도횟수가정상군보다유의하게더많았다 (p). 전체여덟단계중완료한단계의수 Fig. 2. The receiver operating characteristic curve of the Paired Associates Learning (PAL), adjusted total errors. (stages completed) 는치매군이 5.29±2.23단계로정상군의 7.52±0.78단계보다유의하게낮았다 (p). 각단계를첫시도만에완료한횟수와첫시도중기억횟수를분석하였다. 첫시도에완료한단계수 (stages completed on first trial) 는치매군 2.59±1.28, 정상군은 4.69±1.02로치매군이낮게나타났으며 (p), 첫시도중기억횟수 (first trial memory score) 또한치매군이 7.59±4.46개로정상군의 13.46±4.12개보다낮게나타났다 (p). PAL의민감도와특이도를구하기위하여 receiver operating character (ROC) 곡선을구하였다 (Fig. 2). 곡선아래의 J Korean Geriatr Soc 13(2) June

6 김찬석외 : 노인에서인지능평가를위한전산화캠브리지신경인지검사법의유용성 : 예비연구 면적은 89.8% (standard error 0.049) 이었다. 대각선에서가장먼 ROC 곡선위의점인 98.5점을기준으로하여그이상을치매로진단했을때민감도는 88%, 특이도는 87% 였다. 3) SRM 정반응의백분율을분석하였으며, 치매군 (n=16) 은 58.75± 12.58%, 정상군 (n=51) 은 67.25±13.83% 로치매군에서유의하게오반응이더많았다 (p=0.03). 하지만, 정반응의잠시 (correct latency) 를분석하였을때치매군은 ± ms, 정상군은 ± ms로나타나두군간유의한차이는없었다 (p=0.11). 4) SSP 공간적주의폭 (span length) 을분석하였고, 치매군 (n=11) 의평균폭은 4.45±1.04, 정상군 (n=51) 의평균폭은 5.04± 0.92로치매군의폭이더낮았으나, 통계적으로유의하지는않았다 (p=0.07). Table 2. Results of the Seoul Neuropsychological Screening Battery and other tests. Digit Span, forward Digit Span, backward K-BNT, adjusted Calculation RCFT, immediate recall RCFT, delayed recall RCFT, recognition score SVLT, immediate recall SVLT, delayed recall SVLT, recognition score RCFT, copy score RCFT, copy time (sec) COWAT, animal COWAT, supermarket COWAT, phonemic Contrasting program Go-No-Go Stroop, word reading Stroop, color reading Stroop, interference score CDR CDR, sum of boxes Demented (n) Control (n) p-values 4.06±1.52 (17) 2.82±1.13 (17) 32.47±11.04 (17) 9.00±2.89 (17) 5.60±3.64 (15) 5.13±3.81 (15) 17.13±2.47 (16) 12.29±3.92 (17) 1.65±1.37 (17) 16.94±2.01 (17) 19.22±10.16 (16) ±79.56 (16) 9.06±2.95 (17) 10.71±5.13 (17) 10.79±7.89 (14) 15.06±6.54 (17) 12.24±5.56 (17) 88.80±24.57 (15) 42.71±26.72 (14) 1.80±1.45 (14) 0.82±0.39 (17) 4.35±2.14 (17) 5.17±1.23 (52) 3.44±1.00 (52) 43.13±9.67 (52) 10.29±1.97 (52) 11.33±6.25 (51) 11.41±6.15 (51) 19.69±1.89 (51) 17.92±5.25 (52) 5.38±2.44 (52) 20.23±1.89 (52) 26.98±7.04 (52) ±83.14 (52) 12.12±4.04 (52) 14.84±5.37 (51) 20.92±8.25 (50) 18.47±3.65 (51) 18.27±3.67 (51) ±19.88 (52) 65.06±22.24 (52) 0.75±0.42 (52) 0.34±0.24 (52) 0.84±0.94 (52) <0.05 NS NS NS NS <0.05 B-ADL 19.00±3.62 (17) 19.98±0.14 (52) NS KDSQ 7.41±5.87 (17) 5.63±3.57 (52) NS Data are presented as mean±sd. Statistical significance was tested by Student's t-test. K-BNT, Korean version of Boston Naming Test; RCFT, Rey-Osterreith Complex Figure Test; SVLT, Seoul Verbal Learning Test; COWAT, Controlled Oral Word Association Test; CDR, Clinical Dementia Rating scale; B-ADL, Bathel Activities of Daily Living index; KDSQ, Korean Dementia Screening Questionnaire; NS, not significant. 74 J Korean Geriatr Soc 13(2) June 2009

7 Chansok Kim, et al: Computer-assisted Instruction, Neuropsychological Tests, Dementia Table 3. Results of the CANTAB subtests Demented (n) Control (n) p-value BLC, percent correct 98.59±3.16 (16) 99.71±0.81 (51) NS PAL, total errors, adjusted ±48.81 (17) 51.38±36.14 (52) SRM, percent correct 58.75±12.58 (16) 67.25±13.83 (51) 0.03 SSP, span length 4.45±1.04 (11) 5.04±0.92 (51) NS Data presented as mean±sd. Statistical significance tested by Student's t-test. CANTAB, Cambridge Neuropsychological Test Automated Battery; BLC, Big/Little Circle; PAL, Paired Associates Learning; SRM, Spatial Recognition Memory; SSP, Spatial Span; NS, not significant. Table 4. Correlations between subtests of the CANTAB and the RCFT PAL, total errors, adjusted SRM, percent correct SSP, span length BLC, percent correct RCFT, immediate recall * * * RCFT, delayed recall * * * RCFT, recognition score * * * CANTAB, Cambridge Neuropsychological Test Automated Battery; RCFT, Rey Osterreith Complex Figure Test; PAL, Paired Associates Learning; SRM, Spatial Recognition Memory; SSP, Spatial Span; BLC, Big/Little Circle. * p. 4. CANTAB 세부검사와 RCFT 의상관관계분석다음으로, 시각적기억력검사간의상관관계를분석하여 Table 4에요약하였다. PAL은 RCFT의즉각회상, 지연회상, 재인점수모두에서각각 r=-0.591, r=-0.597, r= 의상관관계를보였다 ( 모두 p). 또, SSP에도각각의 RCFT 세부항목과 r=0.461, r=0.489, r=0.331의상관관계가나타났고 ( 모두 p), SRM에서도 RCFT의즉각및지연회상점수와각각 r=0.349, r=0.384의상관관계가나타났으나 ( 모두 p) PAL보다는약하였다. BLC는 RCFT의세부항목과상관관계가나타나지않았다. 고찰 신경심리검사가치매의진단, 치매의정도에대한평가, 추적관찰에는매우유용한도구이지만, 검사자에의해실시하고채점하는것은많은시간이소요되는반복된절차이다. Allard 등 18) 은구조화된설문지점수를수기채점 (hand scoring) 하는과정에서발생하는오류에대해연구하 여대상자의 59% 가한가지이상의채점오류를범하며, 19 % 는임상진단을바꿀수있는정도의오류를범할수있다고하였다. Moon 등 19) 은미국심리학회수련과정을이수한대학원생에서도웩슬러성인용지능검사개정판 (Wechsler adult intelligence scale-revised) 의실시와채점과정에서 67% 의정확도만을유지한다고하였다. 이러한신경심리검사의실시와채점에서보일수있는문제점으로인해검사반응의점수화과정에서의채점프로그램을이용하거나, 그결과를분석하여해석하는데컴퓨터를활용하는 컴퓨터보조검사 (computer-assisted testing) 에서부터컴퓨터에의해실시되고채점되는검사도구를사용하는 전산화된검사 (computerized testing)' 가생겨났다. 이로인해엄격하게표준화된검사를통해검사과정혹은검사자간의차이로발생할수있는오차를최소화할수있었으며 20), 소요되는검사시간을단축할수있었고 21), 정확한반응시간을수량화할수있게되었다 20). 또한신체장애로인해검사에필요한운동수행이제한된사람에게도반응을기록하여평가에이용할수있게되었다 22). 이러한심리검사의전산화는검사자의편이성뿐아니라, 피검자의평가에도유용한 J Korean Geriatr Soc 13(2) June

8 김찬석외 : 노인에서인지능평가를위한전산화캠브리지신경인지검사법의유용성 : 예비연구 도구가될것으로생각된다. 본연구에서는 CANTAB을사용하였는데, 신경퇴행성질환의연구에많은연구 3-8) 가있을뿐아니라, 문화와언어에구애되지않아다국가간연구가가능하고언어적지침이없이도적용될수있으며 1), 오스트레일리아원주민을대상으로한기존의연구 9) 에서도이들의수행이기존의표준자료 23) 와상이하지않아문화적차이에따른변화가없음이알려진바있어국내에서의치매환자의진단에유용한지를확인하고자했다. Mishkin 24) 은원숭이를이용하여시각적기억력을처리하는과정에서의내측측두엽의중요성을연구한바있다. 연구를위해 delayed non-matching-to-sample task가시행되었으며, 원숭이는한가지사물을먼저본후얼마의시간이경과된뒤에다시제시된두가지사물중에새로운것을지적하는방법이었다. 중요한점은매시도마다제시된사물이바뀌어원숭이는이를단한번만보고기억하여야하는것이었다. 이용된사물은실생활에흔한작은인형이나볼펜뚜껑과같은것들이었는데이것들은원숭이에게는처음접해보는사물로인식되므로, 사람에적용하기위해서는독창적이며, 쉽게인식되어지지않는새로운사물이필요하기에 CANTAB에서는다양한추상적인무늬를적용하였다. 이러한과제는정상노인인구에적용하여표준화가된 CANTAB의일부이며, 이자료에의하면 delayed matching-to-sample task에서는나이에따른수행저하가나타나며, 지연경과시간의증가에따른수행의정확성이떨어지고반응의잠재기가증가함이알려져있다 23). Shagal 등 5) 은 PAL 과제를이용한연구에서알츠하이머병환자군이정상군의수행완료단계에도달하지못함을보이며, 각단계별수행완료를위한시도횟수또한월등히많아알츠하이머병환자들이정상군에비해많은오류를보임을밝혔다. Fowler 등 25) 은 PAL 과제가초기의알츠하이머형치매환자의평가에예민함을보고하였으며, 경도의인지저하만을보이는경우에도추적관찰하였을때 PAL 과제가알츠하이머형치매로의전환을예측하는데유용한검사임을보고하였다 26,27). 본연구에서도 PAL 과제에서치매군의조정오류횟수가 130.9회, 정상군의조정오류횟수가 51.4회로치매의진단에있어 PAL 과제가유용하게이용될수있음 (Fig. 1) 을보 여주는결과가나타났으며, SRM 과제에서도정반응의백분율이치매군에서 58.8%, 정상군에서 67.3% 로차이가있었으나, BLC와 SSP 과제들은두군간차이가나지않았다 (Table 3). BLC 과제는단순한훈련및선별과정이어서치매군과정상군 `간의차이를유발할정도의과제가아니기때문이라생각되며, SSP 과제는 PAL 과제와달리지연경과시간이거의존재하지않아기억력을필요로하는과제이기는하나, 보다짧은시간동안기억을유지하는작업기억력을더요구하는과제이기때문이리라여겨진다. 즉, 이들과제들은주어진자극의위치를잠시기억에유지하고있는작업기억력을필요로하는과제이며, 이때는전전두엽의기능을더요구한다고하겠다. 이와는달리 SRM 과제와 PAL 과제는자극의종류와그자극이있었던위치를함께연상하여야할뿐더러, 길게는 12초가량의지연시간이주어지므로시각적자극의정보가기억으로처리되는내측측두엽의기능을더요구하는과제이기때문이리라생각된다. 이를확인하기위해 SNSB 내에서시각적기억력을검사하기위해존재하는 RCFT와 CANTAB 세부과제들간의상관관계를분석하였으며, 이를통해 PAL 과제는 RCFT의즉각회상, 지연회상, 재인점수등모든변수들과각각유의한상관관계를가지고있으며, SRM 과제또한 RCFT의즉각회상과지연회상점수와상관관계를보였다. 반면, BLC 과제는 RCFT 세부변수들과의상관관계가나타나지않았다 (Table 4). 저자들은알츠하이머병과혈관성치매가합해진치매군의균질성을확인하기위해연구와는별도로알츠하이머병으로진단된 13명을다시분석하여결과를제시하고자한다. PAL 과제의경우알츠하이머병군의조정오류횟수는 122.8회로나타나두군간차이는여전히유의미하였다. 그러나알츠하이머병군의 SRM 과제에서의정반응의백분율은 60.8% 로나타나정상군과차이는있으나유의미하지는않았으며, BLC와 SSP 과제들은여전히두군간차이가나타나지않았다. 본연구는지역에서의치매검진사업의일환으로계획되었으며, 지역사회에서생활하는노인을대상으로하여진행되었으므로치매군이라하더라도보호자등에의해이상증상또는이상행동이관찰되어병원으로내원하는환 76 J Korean Geriatr Soc 13(2) June 2009

9 Chansok Kim, et al: Computer-assisted Instruction, Neuropsychological Tests, Dementia 자들보다초기의치매에해당하리라생각한다. 이는 KDSQ 를통한평가를확인하였을때치매군에서도 7.4점으로나타나정상군과유의한차이가없을뿐아니라, 기존의연구 28) 와비교하여도경도의치매환자들과유사한점수라할것이다. CDR을통한평가에서도치매군의평균 CDR 점수는 0.82로낮게나타났으며, 치매군에포함된 CDR 2 이상의피검자는단 1명임을밝힌다. 여기에서한명의 CDR 2 피검자가결과에미치는영향을배제하기위해이한명을제외한분석을시행하였다. PAL 과제의경우조정오류횟수는 127.8회로여전히유의미하였고, SRM 과제의정반응의백분율은 60.3% 로나타나유의미한차이가없었으며, BLC와 SSP 과제들도유의미하지않았다. 결론적으로 CANTAB은국내에서치매의진단을위한신경심리검사로이용될수있으리라판단되며, 특히 PAL 과제는 RCFT와유사하게시각적기억력을평가할수있을것이며, 초기의치매환자들에서유용한평가도구가될것으로생각한다. 요약 연구배경 : 본연구의목적은국내에서치매의진단에있어 Cambridge Neuropsychological Test Automated Battery (CANTAB) 를이용한전산화신경심리검사의유용성을알아보고, 기존의신경심리검사와의상관관계를알아보고자하였다. 방법 : 2007년 5월부터 2008년 8월까지대구수성구에거주하는 65세이상노인중검사를위해병원에내원한사람들을대상으로하였다. 알츠하이머병과혈관성치매로진단된 17명을치매군으로구성하였고, 정상인지기능을보이는 52명을본연구의선별기준에의거하여정상군으로구성하였다. 모든피검자에게시각적기억력을평가하는 Rey Osterreith Complex Figure Test (RCFT) 가포함된 Seoul Neuropsychological Screening Battery (SNSB) 등의신경심리검사를시행하였으며, 이어서 CANTAB을시행하였다. 연구에이용된 CANTAB 과제는 Big/Little Circle (BLC), Paired Associates Learning (PAL), Spatial Recognition Memory (SRM), Spatial Span (SSP) 이다. 결과 : PAL 과제에서조정오류횟수는치매군에서 회, 정상군에서 51.38회로통계학적으로유의미한차이가있었고, SRM 과제의정반응의백분율또한치매군에서 58.75% 로, 정상군의 67.25% 보다의미있게낮았다. BLC, SSP 과제들은두군간의미있는차이가나지않았다. 또, 시각적기억력을검사하는기존의신경심리검사법인 RCFT 와비교하였을때 PAL 과제는 RCFT의세부변수 ( 즉각회상, 지연회상, 재인점수 ) 와각각의미있는상관관계를보였다. 결론 : CANTAB은국내에서치매의진단을위한신경심리검사로이용될수있으리라판단되며, 특히 PAL 과제는 RCFT와유사하게시각적기억력을평가할수있을것이며, 초기의치매환자들에서유용한평가도구가될것으로생각된다. 참고문헌 1. Fray PJ, Robbins TW, Sahakian BJ. Neuropsychiatric applications of CANTAB. Int J Geriatr Psychiatry 1996;11: CANTAB Test descriptions by function [Internet]. Cambridge: Cambridge Cognition Limited; c2009. Available from: Sahakian BJ, Morris RG, Evenden JL, Heald A, Levy R, Philpot M, et al. A comparative study of visuospatial memory and learning in Alzheimer-type dementia and Parkinson's disease. Brain 1988;111: Sahakian BJ, Downes JJ, Eagger S, Evenden JL, Levy R, Philpot MP, et al. Sparing of attentional relative to mnemotic function in a subgroup of patients with dementia of the Alzheimer type. Neuropsychologia 1990;28: Sahgal A, Sahakian BJ, Robbins TW, Wray CJ, Lloyd S, Cook JH, et al. Detection of visual memory and learning deficits in Alzheimer's disease using the Cambridge Neuropsychological Test Automated Battery. Dementia 1991;2: Sahakian BJ, Owen AM. Computerized assessment in neuropsychiatry using CANTAB: discussion paper. J R Soc Med 1992;85: Lange KW, Sahakian BJ, Quinn NP, Marsden CD, Robbins TW. Comparison of executive and visuospatial memory function in Huntington's disease and dementia of Alzheimer J Korean Geriatr Soc 13(2) June

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