2011 년대한임상건강증진학회추계통합학술대회 치매검진 이상현국민건강보험일산병원가정의학과 2-10 치매조기검진사업 1. 목적 치매의위험이높은 60 세이상노인을대상으로치매조기검진을실시하고치매환자를조기에발견 관리함으로써치매노인및그가족들의삶의질제고 치매환자의등록 관리를통해효과적으로치매를치료 관리 국가치매검진사업은? 2. 근거법령 노인복지법제 29 조제 1 항, 시행규칙제 11 조 ~ 제 12 조 3. 사업개요 가. 배경및필요성 치매는다양한원인에의해발생되면조기에발견하여적절히치료할경우완치또는중증상태로의진행을억제시키거나증상을개선하는것이가능함 치매를적절히치료관리하고치매에동반된문제증상들을개선시킬경우환자와그가족의고통과부담을크게경감시킬뿐만아니라치매로인한사회적비용도절감할수있음 나. 기본방향 치매조기검진대상자의확대를통해효과적으로치매를예방하고치료 관리 치매조기검진을통해발전된치매노인에대해서는관련기관간의협력을통해적절한치료 관리서비스를연계하여지원 다. 사업의연혁 2006년치매조기검진사업 ( 민간단체보조사업으로실시 : 한국치매협회 ) - 국민건강증진기금 (200백만원), 사업목표량 ( 선별검사 : 20,000명, 정밀검진 : 3,000명 ) - 실적 23,840명 ( 선별검사 :20,544명, 정밀검진 : 3,296명 ) 2007년지방자체단체보조사업으로전환 : 87개보건소, 60개병원참여 - 국민건강증진기금 : 400백만원, 지방비 : 400백만원 - 실적 99,638건 ( 선별검사 87,912, 진단검사 9,431. 감별검사 2,295건 ) 2008 년치매조기검진사업 : 118 개보건소, 88 개병원참여 - 국민건강증진기금 : 400 백만원, 지방비 : 400 백만원 - 실적 144,125 건 ( 선별검사 128,373 건, 진단검사및감별검사 15,752 건 ) 2009 년치매조기검진사업 : 191 개보건소, 151 개병원참여 - 치매진단검사비용인상 : 55,000 원 80,000 원 - 국민건강증진기금 : 800 백만원, 지방비 :800 백만원 2010 년치매조기검진사업 : 전국모든보건소로확대실시 - 정밀및감별진단 : 32 천명 - 국민건강증진기금 : 1,280 백만원, 지방비 : 1,280 백만원 2011 년치매조기검진사업 - 정밀및감별진단 : 40 천명 - 국민건강증진기금 : 1,600 백만원, 지방비 : 1,600 백만원 라. 사업주체 : 시 군 구 ( 보건소 ) 마. 검진대상인원 구분 시 군 구 ( 보건소 ) 거점병원 검진비부담 -치매선별검사 748천명 지자체부담 ( 치매상담센터운영비등 ) -치매진단검사 32천명 국고 50%, 지방비 50% -치매감별검사 8천명 국고 50%, 지방비 50% 4. 세부사업내용 가. 검진대상자선정기준 60 세이상모든노인을대상으로하되저소득층에우선권부여 보건소장이치매예방및관리를위하여치매조기검진이필요하다고인정하는자는시 군 구 ( 보건소 ) 별로자체기준을정하여시행 22
검진분야의최근변화동향 검진결과에따른조치 -치매군: 치매환자등록관리 ( 장기요양보험서비스, 치매치료관리비지원, 인지재활프로그램, 조호물품제공, 치매인식표보급등연계, 기타치매관련정보제공 ) -정상군 치매고위험군 : 치매예방프로그램과연계 특히치매고위험군은고혈압, 당뇨병, 비만, 고지혈증, 우울증등치료관리프로그램, 운동프로그램등에참여할수있도록적극적으로지원 마. 검진비용지원범위 1인당지원액 : 치매진단검사, 감별검사비용 - 진단검사 : 진찰료, 치매척도검사비, 일상생활수행척도검사, 치매신경인지검사비등정액지원 ( 상한 8만원 ) - 감별검사 : 치매의원인규명을위하여감별검사 ( 혈액검사, 뇌영상촬영등 ) 를실시하는경우건강보험 ( 또는의료급여 ) 체계에따라이용자의본인부담금지원 ( 의원 병원 종합병원급상한 8만원, 종합전문요양기관의경우상한 11만원 ) 기존의치매선별검사지침 Q1: Does screening for dementia in primary care settings affect any of the selected outcomes? We were unable to locate any RCTs or systematic reviews addressing the use of screening tools for dementia and the effects of screening on the outcomes of interest. Clinical Considerations Although current evidence does not support routine screening of patients in whom cognitive impairment is not otherwise suspected, clinicians should assess cognitive function whenever cognitive impairment or deterioration is suspected, based on direct observation, patient report, or concerns raised by family members, friends, or caretakers. 23
2011 년대한임상건강증진학회추계통합학술대회 Q2: What is the prevalence of undiagnosed dementia in primary care patients? How Common Is Undiagnosed Dementia? Two studies in North American populations showed that 1.8% and 5.7% of persons older than age 65 have undiagnosed dementia; 2 studies in non-us populations reported prevalence rates of undiagnosed dementia of 3.2% and 12%. Epidemiology and Clinical Consequences Age is the strongest risk factor for dementia: 3 to 11 percent of people older than 65, 25 to 47 percent of those older than 85 have dementia. First degree relatives of patients with Alzheimer's disease have a cumulative lifetime risk of 39 percent, approximately twice the risk of Alzheimer's disease in the general population. Some genetic mutations have been associated with Alzheimer's disease: about 20 to 30 percent of the general population and 45 to 60 percent of people with late-onset Alzheimer's disease have the apolipoprotein E-epsilon4 genotype. Cardiovascular risk factors such as hypertension are associated with an increased risk of both Alzheimer's disease and vascular dementia. The percentage of primary care patients over age 65 who have unrecognized dementia is between 2% and 12%. We estimate that one-half to two-thirds of cases of early dementia are not diagnosed by a routine history and physical examination. Considerable evidence shows that the prevalence of dementia increases with age; thus, the prevalence of missed dementia cases likely increases among older individuals. Q3: Does a reliable and valid screening test exist to detect dementia in primary care patients? How Accurate Are the Screening Tests? MMSE has a sensitivity of 71% to 92% and specificity of 56% to 96%. The predictive value of a positive test may range from 15 to 72 %. A drawback of MMSE is that its accuracy depends upon age, education, and ethnicity of the individual; 24
검진분야의최근변화동향 Effectiveness of Early Detection Q4: Do pharmacological interventions improve any of the selected outcomes? 1.5% of all cases of mild to moderate dementia are fully reversible. ChEI : improve cognitive and global function & delay functional decline by 3 to 5 months. Neuroleptics reduce agitated behaviors The natural history of Alzheimer's disease is of progressive decline in cognitive function, thus an "improvement" from an intervention means a slowing of the rate of decline. Only 1.5 percent of cases could be classified as fully reversible dementia. Q7: What are the adverse effects of dementia screening? Q8: What are the costs and costeffectiveness of dementia screening? No study meeting our inclusion criteria addressed this question. Potential Adverse Effects of Screening A diagnosis of dementia could have effects on a patient's autonomy, but the USPSTF found no evidence supporting this concern. More established risks of receiving the diagnosis of dementia are difficulty obtaining medical or life insurance, or acceptance into assisted-living communities. The most commonly reported adverse effects in patients taking cholinesterase inhibitors are nausea, vomiting, weight loss, and diarrhea Screening Age? Potential benefits would accrue to the 3% to 12% of primary care patients age 65 and older who have undiagnosed dementia. Based on the strong association between advancing age and the risk of dementia, a proposed screening strategy will have increased yield if it is begun at more advanced ages such as 75 years Reversible? Treatment of potentially reversible dementia is often proposed as a justification for screening, but we found few of these patients whose dementia was actually reversible with therapy. Thus, screening must benefit the large majority of patients with irreversible causes to demonstrate public health benefit. 25
2011 년대한임상건강증진학회추계통합학술대회 Summary of Recommendation The U.S. Preventive Services Task Force (USPSTF) concludes that the evidence is insufficient to recommend for or against routine screening for dementia in older adults. Rating: I Recommendation Insufficient Evidence to Make a Recommendation. Recommendations of Others There are no formal recommendations for routine screening for dementia. The American Academy of Neurology and the Canadian Task Force on Preventive Health Care concluded that there is insufficient evidence to recommend cognitive screening of asymptomatic individuals. The American Medical Association and the American Academy of Family Physicians recommend that physicians be alert for cognitive and functional decline in elderly patients for recognition of dementia in its early stages 최근의논의들 -I View of Subspecialists Brain Image two purposes: exclude other, potentially surgically treatable diseases include specific findings for AD. imaging procedure should be carried out once in every patient. MRI coronal T1 and axial T2 or fluidattenuated inversion recovery sequences without contrast Primary prevention of AD in cognitively normal subjects Not modifiable RF age, sex and genotype Potentially modifiable RF vascular risk factors hypertension, smoking, diabetes, atrial fibrillation and obesity head injury However, whether modifying these factors will reduce risk of dementia is not yet known. 26
검진분야의최근변화동향 Secondary prevention of AD A&D Consensus Group in non-demented subjects with some evidence of cognitive impairment. MCI progress to Dementia No differences in rate of conversion to AD between active and placebo groups No treatments have demonstrated efficacy for preventing or delaying development of AD in MCI subjects until now Patient Problems unable to perceive the extent or significance of their own memory impairment Family may avoid addressing the presence of cognitive impairments Clinician rarely take the necessary time to investigate subtle cognitive difficulties in elderly individuals France In 2003, the ANAES provided no recommendation for general screening at the population level. However, between 2003 and 2005, the French Ministry of Health developed the Alzheimer s Disease Initiative (2003, 2005, and 2007 Action Plans) promoting the development of Memory Consultation and Research Memory Centers with the aims to improve the early diagnosis of AD and related disorders and to organize a network with general practitioners and other professionals involved in the field. The North of England Evidence Based Dementia Guideline Development Group population screening for dementia in the over 65s is not recommended; a case finding approach is recommended. complaints of memory impairment are not a good indicator of dementia, a history of loss of function is more indicative, the general practitioner s judgment alone compares unfavorably with the use of formal cognitive testing in the diagnosis of dementia. general practitioners should consider using formal cognitive testing to enhance their clinical judgment. Case finding secondary prevention through early detection of cases among persons using health services for other reasons, eg, checking blood pressures of all patients who attend a physician s office The Dictionary of Epidemiology 27
2011 년대한임상건강증진학회추계통합학술대회 The Canadian Consensus Conference on Dementia there is insufficient evidence to recommend for or against screening for cognitive impairment in the absence of symptoms of dementia. memory complaints should be evaluated and the patient followed up to assess What type of screening should be used? Mass/Community/formal screening to a population Prescriptive screening to a specific risk group Opportunistic screening to individuals who for other reasons come progression, What level of screening test should be chosen? A controversy has arisen in the field regarding the construct of MCI. A recent definition of MCI is memory impairment without impairment of social function. However, this definition lacks clinical precision, particularly with regard to the extent of cognitive impairment that distinguishes the MCI construct from normal aging and dementia. Instead, these earliest, preclinical or prodromal stages of dementia (including MCI) and particularly AD would be better viewed AD Dementia & Predementia phases Prodromal AD ( predementia stage of AD ) This term refers to the early symptomatic, predementia phase of AD in which (1) clinical symptoms including episodic memory loss of the hippocampal type (characterised by a free recall deficit on testing not normalised with cueing) are present, but not sufficiently severe to affect instrumental activities of daily living and do not warrant a diagnosis of dementia; and in which (2) biomarker evidence from CSF or imaging is supportive of the presence of AD pathological changes. This phase is now included in the new definition of AD. The term of prodromal AD might disappear in the future if AD is considered to encompass both the predementia and dementia stages. 28
검진분야의최근변화동향 Conclusions Dementia screening in clinical settings is clearly appropriate for those whose risk is above a certain threshold, for example, persons older than the age of 75 years. Widespread screening of the whole elderly population also has merit, although systematic recommendations need to be developed. Full public health screening will become justifiable when more substantive therapeutic and/or preventive interventions are developed, Annual dementia screening beginning at 75 years of age As early as 60 years of age depending on risk factors and other considerations Cf; APOE E4/4 genotype 2% of the US population 20% of the AD population 최근의논의들 -II View of Primary Care & Public Health 29
2011 년대한임상건강증진학회추계통합학술대회 The Rule of Two Age 2% Dementia at 65 years The risk doubling every five years Each first-degree relative with a Hx of dementia Doubles the risk Each vascular RF Doubles the risk 30
검진분야의최근변화동향 Conclusions Consistent with current evidence, neither the USPSTF nor the UK National Institute for Health and Clinical and Health Excellence (NICHE) recommend population screening for dementia. In usual practice, good case finding on the basis of clinical suspicion remains the appropriate course of action. Pressures to institute screening of unproven benefit could divert much-needed resources from the health and social care systems and have overall negative consequences for care of patients with dementia and other illnesses, ultimately delaying the point when dementia screening becomes a useful intervention. 향후방향은? 치매검진사업 전노인대상 치매감별검사지원 신경인지검사, CT 등고가치매검사비용지원 치매관리사업 고연령 / 고위험군대상 치매선별검사지원 일차의료치매진료및교육지원 31