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1 Visiting Dementia Clinic Doh Kwan Kim, M.D., Ph.D. Department of Psychiatry Samsung Medical Center, Sungkyunkwan University School of Medicine

2 특화클리닉의명칭 치매클리닉 기억장애클리닉 노인정신건강클리닉 노인성치매및노인정신건강클리닉 기억장애 ( 치매 ) 클리닉 Neuropsychiatry Clinic Memory Disorder Clinic Dementia Clinic AD Clinic GRECC (Geriatric Research Education & Clinical Center)

3 Dementia Clinic I Integral part of clinical program, which could conduct typical dementia evaluation Patients are referred via hospital consultation, local health care professionals and family members. After the work-up has been completed, a family meeting is held at which time the clinical team reports the results of the workup to the patient and family.

4 치매환자에대한전형적인평가 1. 병력청취 2. 정신의학적검사와신경심리검사 3. 신경학적검사및이학적검사 4. 임상병리검사등 5. 뇌영상의학적검사 (CT, MRI) 6. F/U examination

5 노인환자와의첫면담 1. 환자를먼저단독면담한다. 환자를단독으로면담하는것은환자로하여금가장중요한사람이라는느낌을전달할수있으며, 의사 - 환자관계성립에매우중요하다. 환자스스로자유로운표현을함으로써다른어떤정보원으로부터도획득하기어려운정보를얻는기회가된다. 가족들과같이면담한다면, 하기어려운내용 ( 예 : 가족에대한망상적사고 ) 들을편하게표현하고축소해서표현하기쉬운부끄러운생각이나자살사고, 우울감등을보다솔직하게말할수있다.

6 노인환자와의첫면담 2. 동반자나가족과의면담환자가제공한정보에대한비밀을유지하면서문제가되는증상의발현과경과에대하여검증한다. 항상가족보다는환자의입장에서생각하는것이옳다. 환자가가족의역동에의한희생양은아닌지, 학대여부등에대해서도면밀하게조사해야한다.

7 노인환자와의첫면담 3. 환자와동반가족과의면담 환자와가족의상호작용에대한관찰한다. 때로서로다르게제공한정보에대하여는조심스럽게토의를갖는기회를가진다. 상호간에서얻어진정보에대하여는비밀유지에각별히주의한다.

8 노인환자와의첫면담 4. 환자와의재면담과정신의학검사환자와다시면담을함으로써다시한번환자에게관심이집중되어있음을환기시킨다. 그동안의정보에기초하여주문제가되는 target behavior 를집중적으로평가한다. 경우에따라서다른가족구성원이나친척, 친구들에대한집중적인평가가이루어질수있으나, 이때도역시환자가배제되거나무시되지않도록신경을써야한다.

9 History taking for the elderly patient 1. Focus on the target problem behavior 2. Initial heralded symptom 3. Onset and duration of problem behavior 4. Clinical progress and symptom fluctuation 5. Co-morbid medical problems 6. Drug and alcohol history 7. Family history 8. Personal history

10 Ms. WJ, a 59 year old woman 현병력 (1/2) : 3 년전, 남편에대해서의심하는일이생김. 다니는직장주변의식당여자들과여자동창들과남편의관계를의심하고, 지금누구랑같이살고있지않느냐? 며소리를지르고, 남편의직장에찾아와행패를부리는일이있어서 C 대학병원정신과병동에강제로입원하게됨. 당시 정신분열병 의진단하에 1 개월반정도입원치료를함. 퇴원후에는통원치료를환자가거부하여치료하지않았지만, 큰문제는없었음. 망상증상이그후에전혀없는것은아니었지만, 그때그때마다달래주면전처럼문제를일으킬정도는아니었음.

11 Ms. WJ, a 59 year old woman 현병력 (2/2) : 하지만퇴원직후부터 의치 를목욕탕에두고오는일이반복됨. 의치를두세번은다시찾았지만, 그후에도계속잃어버려서여태까지 5-6 차례의치를다시제작하여야하였음. 6 개월정도전부터는기억력이더욱떨어져서방금들은이야기를다시돌아서서물어보고, 시장에가서는집에가득있는물건을또사오는일이잦아짐. 2 주전, 잘자고일어나서는자기얼굴에난베개자국을보고는 남편이칼로그랬다 고하고, 남편이다른여자와딴살림을차렸다 고다시의심하는증상이나타남. 배우자는환자의의심하는증상과기억력감퇴에대한평가를위하여병원에방문함.

12 Ms. WJ, a 59 year old woman 현병력 : 환자본인의말에따르면, 3 년전병원에입원하기전부터방금들은이야기가가물가물하고말이막히는일이있었던것같다.

13 Ms. WJ, a 59 year old woman 현병력 : 환자배우자의말에따르면, 3 년전, 남편에대해서의심하는일이생김. 다니는직장주변의식당여자들과여자동창들과남편의관계를의심하고, 지금누구랑같이살고있지않느냐? 며소리를지르고, 남편의직장에찾아와행패를부리는일이있어서 C 대학병원정신과병동에강제로입원하게됨. 하지만퇴원직후부터 의치 를목욕탕에두고오는일이반복됨. 의치를두세번은다시찾았지만, 그후에도계속잃어버려서여태까지 5-6 차례의치를다시제작하여야하였음.

14 Ms. WJ, a 59 year old woman 현병력 : 3 년전, 남편에대해서의심하는일이생김. 망상증상이그후에전혀없는것은아니었지만, 그때그때마다달래주면전처럼문제를일으킬정도는아니었음. 2 주전, 잘자고일어나서얼굴에난베개자국을보고는 남편이칼로그랬다 고하고, 남편이다른여자와딴살림을차렸다 고다시의심하는증상이나타남.

15 Ms. WJ, a 59 year old woman 주증상 : 남편이바람을피운다 고한다 기억력이떨어졌다 onset 3 YA

16 Ms. WJ, a 59 year old woman Paranoid symptom 3 년전, 남편에대해서의심하는일이생김. 다니는직장주변의식당여자들과여자동창들과남편의관계를의심하고 퇴원후에는통원치료를환자가거부하여치료하지않았지만, 큰문제는없었음. 망상증상이그후에전혀없는것은아니었지만, 그때그때마다달래주면전처럼문제를일으킬정도는아니었음. 2 주전, 잘자고일어나서는자기얼굴에난베개자국을보고는 남편이칼로그랬다 고하고, 남편이다른여자와딴살림을차렸다 고다시의심하는증상이나타남.

17 Ms. WJ, a 59 year old woman Memory impairment 3 년전병원에입원하기전부터방금들은이야기가가물가물하고말이막히는일이있었음. 3 년전병원에서퇴원한직후부터 의치 를목욕탕에두고오는일이반복됨. 의치를두세번은다시찾았지만, 그후에도계속잃어버려서여태까지 5-6 차례의치를다시제작하여야하였음. 6 개월정도전부터는기억력이더욱떨어져서방금들은이야기를다시돌아서서물어보고, 시장에가서는집에가득있는물건을또사오는일이잦아짐. 잊어버리는정도가점점더심해지는것은분명하다.

18 History taking for the elderly patient 1. Focus on the target problem behavior 2. Initial heralded symptom 3. Onset and duration of problem behavior 4. Clinical progress and symptom fluctuation 5. Co-morbid medical problems 6. Drug and alcohol history 7. Family history 8. Personal history

19 Ms. WJ, a 59 year old woman 과거병력 : 빈혈 (?) 이있다는이야기를동네의원에서들었다고함. 혈압, 심장질환, 당뇨, 관절염, 시각장애, 청각장애, 두부외상력등은없었음.

20 Ms. WJ, a 59 year old woman 복용약물 : 술담배는하지않았고, 현재복용약물없음.

21 Ms. WJ, a 59 year old woman 가족력 : 아버지는 50 대에사고로객사를하셨고, 어머니는현재 83 세로건강하심. 4 촌이내의가족들중치매나노망이증상을나타내는사람은없었음. 남편과슬하에 1 남 (28 세 ) 1 녀 (25 세 ) 가있음. 현재아들딸은모두출가하고남편과함께기거함. 80 대중반의시모는한달에한번정도방문하여일주일정도씩환자부부와같이지냄.

22 노인환자가족구성원들의유형 1. Facilitator 2. Victim 3. Manager 4. Supporter 5. Care-giver 6. Escaper 치료자는노인환자를단기간혹은장기간돌볼가족구성원이누구인지를파악해야한다. 환자에대한교통수단, 투약, 물리치료, 계속적인보호, 식사준비, 법적행정적도움, 경제적보조등이가족중누구에의해서제공될지를아는것도유익하다.

23 Ms. WJ, a 59 year old woman 사회발달력 : 2 년제초급대학교를졸업하였고, 결혼후에는줄곳가정주부로서집안생활을해옴. 매우꼼꼼하게집안일을챙기는주부로서사교적이지는않았음. 젊을때부터배우자를의심하는일은있었지만그정도가전혀달랐다고함. 초경은 16 세에, 폐경은 48 세에있었음.

24 History taking for the elderly patient 1. Focus on the target problem behavior 2. Initial heralded symptom 3. Onset and duration of problem behavior 4. Clinical progress and symptom fluctuation 5. Co-morbid medical problems 6. Drug and alcohol history 7. Family history 8. Personal history

26 치매환자에대한전형적인평가 1. 병력청취 2. 정신의학적검사와신경심리검사 3. 신경학적검사및이학적검사 4. 임상병리검사등 5. 뇌영상의학적검사 (CT, MRI) 6. F/U examination

27 Measurement of Demented Symptoms Cognition (ADAScog) Global (CIBIC-plus) Function (IADL/ADL) Behavior (NPI) Caregiver Burden

28 Ms. WJ, a 59 year old woman Severity/Staging of Demented Symptom K-MMSE : 17/30 CDR : 1/3 GDS : 4/7

29 Neuropsychological assessment of Ms. WJ, a 59 year old woman Gross Cognitive functioning Functional Descriptions of Neuropsychological Status Intact Questiona ble Impaired MMSE = 17 / 30, CDR = 1 Spontaneous speech, Comprehension, Repetition, Place/Person Orientation, Frontal & Executive Functioning / Attention / Naming Ability / Verbal fluency Memory (verbal, visual) / Time Orientation Visuospatial constructional ability, Calculation Activities of Daily Living Diagnostic Impression 일상생활활동기능상기본적인자기관리에별다른도움을필요로하고있지않으나 (ADL=0/24), 복잡한기능을필요로하는도구적일상생활활동에서는약먹기, 소지품관리, 최근일따라가기등에서어려움을보이고있다 (IADL=18/45). 현재 memory 기능에서의저하가두드러지고있으며, 시공간구성능력및일부 frontal lobe functioning 에서의저하도함께나타나고있어 Axis I. Dementia of Alzheimer's Type, Early onset 이시사된다. 또한자신의 memory impairment 및처지에대해 mild 한 inadequacy 를경험하는것으로보이며, 간헐적으로 delusion 이나타나고있다.

30 수록내용 치매선별검사인지기능종합평가일상생활기능평가행동증상평가치매임상단계평가치매환자간병인의부담치매환자삶의질

31 Ms. WJ, a 59 year old woman Neurological Examination Cranial Nerves: intact Motor: intact Reflexes: intact Sensory: Vibration sense of foot (left < right) Gait: mild swaying on eye closure during Romberg test Neck Bruit: no carotid bruit

32 Ms. WJ, a 59 year old woman Routine Laboratory Tests for Dementia Urine toxicology/drug screening: W.N.L. Urinalysis: W.N.L. Blood cell counts, Sedimentation rate: W.N.L. Blood chemistry, Electrolytes: W.N.L. Thyroid function tests: W.N.L. Serum B12 level, Serum Folate level: W.N.L. Serologic test for neurosyphilis: W.N.L. Chest x ray, Electrocardiogram: W.N.L.

33 Ms. WJ, a 59 year old woman

34 Dementia protocol T2 FLAIR T1 GRE obl-coronal T1

36 Diseases causing dementia Psychiatric NPH Toxic_Metab Infectious DLB Pure AD Mov Dis FTLD Pure VaD AD_VD Adopted from Dementia, 3 rd ed., 2003, by Mendez and Cummings

37 Dementia Clinic I Integral part of clinical program, which could conduct typical dementia evaluation Patients are referred via hospital consultation, local health care professionals and family members. After the work-up has been completed, a family meeting is held at which time the clinical team reports the results of the workup to the patient and family.

39 Dementia Clinic II The dementia clinic is reserved for patients who have been diagnosed with dementia and have put on multidisciplinary treatment program including cognitive enhancer. This treatment program may be conducted differently depending on the diagnosis and patient s condition.

40 치매의치료대책 회복이가능한부분을찾아서치료한다 문제가되는행동증상들을해결한다 인지기능저하를막아주는약제를투여하고, 신경심리적재활을도모한다 환자의가족을도와준다

41 Clinical Characteristics of Reversibility Younger age Sudden onset Short duration of illness Step-wise progression of symptoms Less severe cognitive deficits More prescription drugs Co-existing medical or neurological conditions

42 Common Causes of Reversible Dementia Drug effects and Toxins Anticholonergics/ Antihypertensives/ Antidepressants/ Antipsychotics/ Anticonvulsants/ Barbiturates/ Benzodiazepines/ Corticosteroids/ Digitalis/ Ethanol/ Aluminium/ Lead/ Organophosphates/ Organic solvents/ Carbon monoxide Psychiatric conditions Depression/ Anxiety/ Paranoid disorders Metabolic & endocrine disturbances HPA axis disorders/ Thyroid disorders/ Parathyroid disorder/ Hypoglycemia/ Hepatic failure/ Renal failure/ Hypercarbia/ Electrolyte imbalaces/ Volume depletion Nutritional deficiencies Vitamine B 12 / Folate Miscellaneous conditions Sensory deprivation/ Fecal impaction/ Hospitalization

43 치매의치료대책 회복이가능한부분을찾아서치료한다 문제가되는행동증상들을해결한다 인지기능저하를막아주는약제를투여하고, 신경심리적재활을도모한다 환자의가족을도와준다

44 치매의치료대책 회복이가능한부분을찾아서치료한다 문제가되는행동증상들을해결한다 인지기능저하를막아주는약제를투여하고, 신경심리적재활을도모한다 환자의가족을도와준다

45 Mean change from baseline in the total ADAS-cog-K score Mean(SE) change of the ADAS-cog-K score Galantamine-treated Estimation of decline Baseline 4w 13w 26w 39w 52w improvement worsening Time (weeks)

46 Between-group difference in the total ADAS-cog-K scores over 12 months, *p<0.05 Mean(SE) change of the ADAS-cog-K score Responder Non-responder * * Baseline 4w 13w 26w 39w 52w * * * improvement worsening Time (weeks)

47 Fact #1 About 50 to 60% of the patients with AD of mild to moderate severity were responding to initial administration of ChE-I.

48 치매환자에대한전형적인평가 1. 병력청취 2. 정신의학적검사와신경심리검사 3. 신경학적검사및이학적검사 4. 임상병리검사등 5. 뇌영상의학적검사 (CT, MRI) 6. F/U examination

49 Measurement of Demented Symptoms Cognition (ADAScog) Global (CIBIC-plus) Function (IADL/ADL) Behavior (NPI) Caregiver Burden

50 치매의치료대책 회복이가능한부분을찾아서치료한다 문제가되는행동증상들을해결한다 인지기능저하를막아주는약제를투여하고, 신경심리적재활을도모한다 환자의가족을도와준다

51 Shaping Her Daily Schedule

52 Ms. WJ, a 59 year old woman

53 치매환자의일과표작성예

54 치매환자에대한신경심리검사시행의 목적 손상영역과보존영역에대하여질적으로양적으로평가한다. 중추신경계의손상부위를추정한다. 치매의여부와정도를평가한다. 원인질병의진단에응용한다. 인지재활훈련을위한정보를제공한다.

55 Ms. WJ, a 59 year old woman Attention & Intention Memory & Learning Attention Intention Strength Immediate recall Delayed recall Recognition Weakness Language related Spontaneous speech Borderline impaired in Naming Visuospatial related Comprehension Repetition Reading Writing Mild disturbance in Calculation Praxis & Gnosia Praxis Borderline impaired in Gnosia Frontal / Executive Word generation Abstract thinking Set-shifting ADL / IADL ADL total 0 score IADL total 18 score

56 Cognitive Rehabilitation

57 치매의치료대책 회복이가능한부분을찾아서치료한다 문제가되는행동증상들을해결한다 인지기능저하를막아주는약제를투여하고, 신경심리적재활을도모한다 환자의가족을도와준다

58 Care-giver Supporting Program

59 치매환자가족교육프로그램일정 치매에대한의료적인이해 치매환자의문제행동및대처방법 치매환자의일상생활간호 치매환자를위한활동제안 가족의 stress 관리및가족관계 치매환자와가족들에게유용한지역사회서비스및사회자원에대한정보제공

60 치매환자가족교육프로그램의진행 지난주과제 ; 문제제기와그룹토론 교육 다음과제 ( 교육내용과연관하여 ) 부여

61 치매가족과더불어 행복한가족은다들비슷하게닮았지만, 어려움을겪는가족은제각기다른이유가있고겪어나가는방법들이다르다고합니다 내가겪는어려움을남들은어떻게겪어나가는지 더지혜로운방법을찾아나갔으면합니다! 치매환자가겪는어려움들이가족들의불행으로발전되지않는지혜를찾아보고자합니다

62 고령자를위한의료 - 요양체계 치매환자 가족 자치단체의기관장 복지행정기관 정부기관 의료보험 / 보호제도 치매센타 / 만성병원 치매클리닉 너싱홈 / 요양원 복지관 / 낮병원 대학병원입원시설 가족 Samsung Medical Center

63 Day-care service

64 Home care service

65 Dementia Clinic I Integral part of clinical program, which could conduct typical dementia evaluation Patients are referred via hospital consultation, local health care professionals and family members. After the work-up has been completed, a family meeting is held at which time the clinical team reports the results of the workup to the patient and family.

66 Dementia Clinic II The dementia clinic is reserved for patients who have been diagnosed with dementia and have put on multidisciplinary treatment program including cognitive enhancer. This treatment program may be conducted differently depending on the diagnosis and patient s condition.

67 Personnel for Team Approach Doctors Nurses including visiting nurse Neuropsychologist Social worker Occupational therapist

68 Personnel for Team Approach Doctors Nurses including visiting nurse Neuropsychologist Social worker Occupational therapist Physical therapist Pharmacist Nutritionist Care manager Home helpers

69 Dementia Clinic 운영의요령 환자의질병치료과정에보호자가참여할수있도록하여야한다 From Cure Model to Care Model 참여치료진에대한교육과정이필요하다 의료진, 간호사, 사회사업가, 신경심리학자, 피교육자등 일반신체질환에대한주의가요망된다 타진료과 ( 내과, 신경과, 정형외과, 신경외과, 가정의학등 ) 와의상호협력관계와자문 신체기능과처방된약물에대한주기적평가

70 Dementia Clinic 운영에서고려할사항 법적인문제들 자녀들, 보호자들간의환자 care 및재산권갈등 금치산 / 한정치산법정문제 운전가능 / 불가능여부의판정 진단서 / 소견서발급의문제 병원운영의측면 일반적인정신과진료와달리많은인원의진료팀필요 다양한검사, 의학적지식과경험, 해석요구 타의료진과의협조, 경쟁, 갈등의가능성 사회복지, 노인복지, 요양기관과의공생 / 갈등의가능성 정부 / 지방자치단체노인의료복지제도와의연계 환자를중심으로한노인요양보험제도등의활용 정부 / 지방자치단체노인의료복지제도입안과정에자문

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