Dementia and Neurocognitive Disorders 2004; 3: 24-8 치매의행동신경심리증상에대한비약물학적접근 고려대학교의과대학신경과학교실 Non-pharmacological Approach to BPSD Kun-Woo Park, M.D. Department of Neurology, College of Medicine, Korea University, Seoul, Korea Address for correspondence Kun-Woo Park, M.D. Department of Neurology, College of Medicine, Korea University, 126 Anam-dong 5 ga, Seungbuk-gu, Seoul 136-705, Korea Tel: +82-2-920-5347 Fax: +82-2-929-9435 E-mail : kunu@korea.ac.kr Treatment of BPSD is a crucial problem in the care of patient of AD. Psychotrophic medications are used very commonly to reduce the frequency and severity of these behaviors. However, the evidence in support of their usefulness is limited, and side effects are frequent and often hazardous. Non-pharmacological strategies such as behavioral modification, activity program, carer education and music therapy are promoted as safe, humane and at least as effective as medications, but the evidence for this view is lacking. The purpose of this paper is to provide a review of relevant research findings concerning non-pharmacological approaches to behavioral disturbances in people with dementia. Key Words: BPSD, Treatment, Non-pharmacological approach 서론치매의치료에있어정신병적행동, 우울증, 초조증 (agitation), 공격성및탈억제증상 (disinhibition) 등의행동신경심리증상들 (BPSD) 은매우복잡한문제를야기하게된다. BPSD는개인뿐만아니라그지역사회의건강관리체계에도심각한부담을주며, 이증상들은발생빈도가많고적고를떠나, 치매치료및관리자체를치료자나보호자로하여금포기하게만든다는점에서그문제의심각성이있다 [1, 2]. 이증상의치료에있어의사들이가지고있는치료기법은주로약물치료이다. 특히항정신병약제들의기술적인사용이강조되어왔고, 기타증상의양상에따라항우울제, 항불안제, 항경련제그리고 AChEIs의복합처방이제안되고있다. 그러나임상실제에서느끼는안타까움은 BPSD를치료시약제에의한부작용의문제로약제를투약할수없는상황의발생과약물에잘반응하지않는 BPSD가존재한다는것이다 (Table 1)[3]. 이러한이유로약물학적치료연구논문의마지막부분에보면약물학적치료의한계를인정하면서, 비약물학적접근즉신경심리학적접근법을권장하고있다 [4, 5]. 임상에서환자를대하는의사의입장에서도약물이외에 BPSD 의조절에좋은차선책의필요가절실하게느껴질때가많다. 그러나안타깝게도비약물학적인치료접근은의사들에게는생소한분야로받아들여지고있다. 그이유로는체계적인치료효과분석이매우어렵고, 의학관련자료에서접근이용이하지않으 며, 실제임상에서는간호사나심리치료사혹은사회복지사를중심으로많이시행되고있어, 마치의사들이관여할분야가아닌것으로생각하는경향등을들수있다. 그러나의사는치매라는질환을치료하는팀리더로써역할을수행하는데있어, 어떤치료접근법도무시하여서는안되며, 이에대한올바른이해가환자의치료질을높이고, 환자-가족 -진료팀의만족도를높일수있다는점에서비약물학적치료접근의중요성이있다고하겠다. 이에본종설에서는비약물학적접근즉심리사회적 (psychosocial) 접근법의개념적문제, 대상의문제, 방법선택의문제, 단계적치료전략과개별화된치료전략에대해이야기하고자한다. 1. 개념적문제의사들의입장에서비약물학적치료법이라고할때, 습관적으로일반적인약물학적치료접근과비슷한것으로생각하는경우가종종있다. 무슨무슨증상에할로페리돌이효과적이지않으면비약물학적인치료법인회상기법 (reminiscence therapy) 을사용한다.' 라고어떤논문에써있다면, 우리들중몇몇은 회상기법하루 3번 ' 이라고처방을내는사람이있을것이다. 그러나이러한처방은비약물학적치료즉심리 -사회적접근방식에대한오해에서비롯된것이다 [6]. 의사들은증상자체를정의하고증상군으로분류하고, 이에대한적절한약을주려고노력하는경향이있다. 그래서어떤증상에는어떤약를쓴다는대응관계로환자를치료한다. 그런데치 24
치매의행동신경심리증상에대한비약물학적접근 25 Table 1. BPSD definition according to drug responsiveness Drug responsive symptoms Drug non-responsive symptoms Anxiety, agitation Wandering/pacing Depressed mood Interfering behavior Apathy, negativism Repetitive questioning Regressive behavior Mannerism Insomnia, hyperactivism Intrusiveness Verbal aggressiveness Dressing/Undressing Delusions, paranoid idea Poliphasia Hallucination Autolesionism 매환자의 BPSD는그차체가치료대상이아니라그심리행동증상이주는영향이치료대상이된다. 다시말해불안, 우울, 초조증그자체가치료목표가아니라, 그증상이문제를일으켰을때치료의대상이된다. 즉왜불안한지를모르면서큰문제를일으키지도않는불안에대해, 불안을줄이는약을줄필요는없는것이다. 도리어이러한과정으로인해숨겨진환자의괴로움이덮여짐으로써, 또는약물의부작용에의해, 자기표현을못하는치매환자가더많은괴로움을겪게되는경우가있다. 또한서로다른치매환자가같은증상을보인다고할때그증상을유발시키는요소는서로다를것이다. 즉어떤증상에어떤약을쓴다는대응방식은심리-사회적접근방식에서는적용이되지않는다. 다시말해서심리-사회적치료접근법에서는어떤치료도요리책의조리법처럼적용되어서는안된다. 철저한개별화된가설- 검증적접근방식이필요하다. 2. 대상선택의문제개별화된심리사회적치료접근방식은누구를대상으로시행할것인가? 환자를대상으로할것인가아니면보살피는사람을대상으로할것인가? 치매환자는그어떤환자보다보호자에의존하게되며, 그과정은매우상호작용이강하고역동적인면을지니고있다. 보호자의태도는그대로환자에게반영되며, 다시환자의반응은보호자에게나타난다 [7]. 또한환자의이상행동이심하다고보호자의부담이커지는것은아니며, 그상호작용사이에는많은변수가개입한다 [8]. 즉환자자체의변수가아닌, 보호자가환자의행동을어떻게평가하느냐 [9] 혹은보호자의우울정도가변수로작용을한다 [10]. 따라서환자만을대상으로하는치료는많은제한점을가질수밖에없다. BPSD의치료목표는보호자의부담을덜어주고, 환자의행동을제어하는 2가지로맞추어져야한다. 보호자를위한지역사회프로그램의개발 [11], 도우미들이나친구들의전화격려 [12], 보호자에대한우울증치료 [13], 간호사나간병인들을대상으로한교육등이고려되어야한다 [14]. 임상실제에서문제행동을보인다는치매환자를치료하는데있어우선적으로보호자나간병인니그행동에대해어떤생각을가지고있는지, 보호자의걱정거리는무엇인지, 격려를줄수 Table 2. Summary of review data including author, number of subjects, intervention, and statistical test results on activity program and music therapy First author 있는도우미들이있는지를알아보아야한다는강력한근거중심문헌들이발표되고있다. 보호자의부담을인식하지못하는것은의사가매우제한된레파토리의치료기법을가지고있다는것을반증한다 [15-17]. 3. 방법선정의문제 N Behaviour Intervention Effect Results Cohen-Mansfield [22] 32 Multiple SIG Holmberg [23] 11 Walking SIG Lantz [24] 14 Relaxation SIG Namazi [25] 20 Exercise SIG Clark [26] 18 Individual music SIG Woods [27] 27 Family tapes SIG 비약물적치료요법들이환자혹은보호자에게어떻게적용되었는지에대한체계적분석은아직미미하다. 그러나시행되고있는여러방법에대하여문헌중심으로요약하면다음과같다. 1) 주변환경의정비변화된물리적환경이환자의증상을악화시키는요소라고판단이된다면, 치매환자로하여금그환경에적응케하거나, 환경을단순화하거나, 혹은환경의질을높이는방법들이강구될수있다. 자꾸밖으로나가려고하는환자들의경우나가는문의손잡이를적절한방법으로가리거나, 문을벽과잘구분못하도록위장을하는방법들이있다 [18]. 환경을단순화하는것이도움이되는예를들어본다면, 집단배식으로인해식당으로이동하는도중에공격성이나타나는노인요양시설의경우에, 식사를평소환자들의행동공간에서제공하는것으로바꿈으로써, 환자들의공격성이줄었다는보고가있다 [19]. 환경의질을풍요하게하는방법들의예를본다면, 수용된환자들이가장헤매는공간인복도의벽을여러사진, 포스터, 그림으로장식하고, 화초도꾸며놓고, 조용한음악을들려주어, 다른방에쓸데없이들어가는빈도를줄이고, 운동초조증을감소시키며, 치료관계자들의만족도가높아졌다는보고가있다. 또한목욕시킬때공격성을나타내는환자들에게물흐르는소리, 새소리, 벌레소리들이녹음된테이프를틀어주면서, 간단한음료를제공하여공격성을줄였다는보고도있다 [20, 21]. 2) 활동프로그램과음악기분을전환시키는유희, 신체자극및운동이불안과초조를
26 시로일깨워주는현실지남력치료는비록치료접근이강압적일수있다는비판에도불구하고환자의인지기능과행동에도움이된다고한다 [32]. Fig. 1. Seven-tiered model of management of behavioural and psychological symptoms of dementia (adopted from Brodaty et al. 2003, MJA[38]). 감소시키기위해시도되어비교적좋은성적을보여주었다 [22-27](Table 2). 음악또한스트레스를받거나초조해하는환자의치료에유용하게이용되어왔다 [28]. 표에소개된프로그램을열거해보면, 환자가좋아하는음악이나가족들에의해만들어진비디오테이프를틀어주고, 대화를하면서같이간단한운동을함으로써소리지르는행동을감소시키고, 목욕중에나타나는공격성을감소시켰으며, 반복적인관심요구의빈도를감소시켰다고한다. 배회하는증상은손을잡고산책을함으로써줄일수있었고, 공격성을보이는환자를긁어주고운동시켜줌으로써공격성을줄였다는보고도있다. 3) 행동치료행동요법은치매환자들에게잘시도되지않았었다. 그이유는새로운학습이과연치매환자에게일어날것인가에대한의심이있었기때문이다. 그러나이분야의문헌에따르면상당한혼돈을보이는환자에서도학습이일어날수있다는것을보여주었다. 조용히하면좋아하는음식을주고, 떠들면관심을안주고, 적절히음악, 대화, 접촉을유지하여치매환자의소리지르는것을줄였다는보고가있으며 [29], 다른환자들의방에들어가훔치는행동을하는환자에게커다란멈춤사인이있으면그자리에서서다른곳으로가라는학습을시킨후, 각방에멈춤사인을걸어두었더니환자의다른방에들어가는행동이줄었다는보고도있다 [30]. 4) 회상 (reminiscene) 치료및현실지남력 (reality orientation) 치료회상치료란혼자혹은집단으로자신의과거회상을사진이나비디오등을이용하여조용히혹은다른사람들앞에서발표하게하는치료접근이다. 연구자들은상당히긍정적평가를내리고있지만, 통계적으로유의한결과는아직없다 [31]. 이에반해현실의세계를시간장소사람에대해지남력을수 5) 광치료 (light therapy), 아로마요법및마사지해가지면초조해지는증상이나저녁때지남력이감소하는현상을감소시키기위해낮동안강한빛을비추는광치료의효과에대한여러연구가있었다. 하루편안한시간에 2시간씩 2,500룩스의빛을쪼임으로써운동초조증이감소하였고, 저녁 7시에서 9시까지 1,500-2,000룩스의빛을쪼여저녁때나타나는안절부절한증상을줄였다는보고도있다 [33, 34]. 좋은향기와신체를부드럽게만져주는것이스트레스를받고, 초조증상을보이는환자에게효과가있다는보고가있으며, 특히여성에서운동초조증을감소시켰다고한다 [35]. 6) 보호자교육치료의대상이환자에국한되는것이아님은전술한바있다. 보호자를대상으로한 BPSD에대한교육과대처방안에대한비디오테이프나역할모델이제시되어환자의문제행동을줄일수있었고, 전문적간병및치료진에대한훈련을통해환자의공격성을줄일수있었다고한다 [36, 37]. 4. 단계적치료전략 전술한여러기법이나방법은모든환자들에게모두시행될수있는것은아니며, 개별화되어야한다는것은이미강조한사항이다. 그러나개별화이전에개념적으로단계별치료전략이선행되어야한다. 즉치료대상군의적절한선택과각대상을적절히단계를나누어치료방식의변화를추구해야한다. 이러한의미에서 Henry 등이제안한 7단계의단계적치료전략이좋은모델이될것이다 (Fig. 1). 이모델에서비약물학적치료는 3단계및 4단계, 즉경도및중등도의 BPSD 환자군에주로적용할수있다고할수있으며, 대상인원은전체치매환자의약 50% 에해당한다 [38]. 5. 개별화된치료전략 BPSD의치료에있어개별화된치료전략을가져야된다는것은많은임상의사들에의해주장되어왔다. 이러한접근의시발점은다음과같은전반적 (holistic) 평가에있다 [6]. 1) 정말로괴로운것인가? 치매환자의치료결정에있어그행동이단순히기괴하다는이유로치료를결정하지않아야한다. 환자나가족이실질적으로스트레스를받고있는지, 가족에게주의깊게보아달라고만해도되는것인지를잘살펴야한다.
치매의행동신경심리증상에대한비약물학적접근 27 2) 환자가보여주는것의의미는? 저환자의증상이초조증이다, 혹은공격성을나타내는것이다 ' 등의증상군을구별하는것이큰도움이안될경우가많다. 더중요한것은어떤상황에서그러한증상이나타났으며, 그의미는무엇인가를파악해야한다. 가까운사람에대한공격성과자신의갈길을막는낯선사람에대한공격성은그의미가다르며, 치료도달라져야한다. 3) 무엇이문제를일으킨것인가? 두가지변수를생각한다. 환자자신의문제인가 (within patient variables) 혹은주변환경의문제인가 (environment variables). 환자자신의과거경험이나병적문제로인해발생하는오해가있는지, 아니면인지기능장애에의한증상을망상으로오해하는것은아닌지살펴보아야한다. 또한우울증이나기타정신과적문제적문제의유무, 신체적질환의악화, 표현되지못한통증등을살펴보고이에대한적절한조치를취하여야한다. 병실이나보살피는곳의환경변화또한잘알려진 BPSD의악화요인이다. 그밖에중요한주변환경인자는치료자나보호자의태도이다. 4) 치료접근의선택첫째, 환자의남아있는역량과성격을파악한다. 읽지도못하는환자에게주의문구는소용이없다. 둘째로주어진환경에서적용가능한것인가를판단해야한다. 좋다는프로그램을모자이크처럼장식한다면, 스테프들은쉽게지치고말것이다. 즉주어진환경에맞는치료환경을하나씩만드는것이중요하다. 작은변화가좋은결과를가져오는경우가많다. 결 지금까지 BPSD에대한비약물학적접근을요약해보았다. 그러나이러한접근은약물학적치료와상반된관계에있는것이아니라상호협조적관계에있다. 단약물학적접근법에대한이러한차선책에관심이없어약물학적치료의문제가발생시해결방법을찾기어려운경우를종종겪게되는것이다. 비약물학적접근법이약물학적접근법과효능면에서비슷하다는보고에의사들은귀를기울여야할때가되었다 [5, 39]. 그리고이상행동에대한단순한증상학적인접근에서벗어나그행동의뒤에숨어있는환자의갈등을헤아리는지혜가필요하다. 론 참고문헌 1. Herrmann N, Black SE. Behavioral disturbances in dementia. Will the real treatment please stand up? Neurology 2000; 55: 1247-8. 2. Sourai R, McCusker J, Cole M, Abrahamowicz M. Agitation in demented patients in an acute care hospital: prevalence, disruptiveness and staff burden. Int Psychogeriatr 2001; 13: 183-97. 3. Parnetti L, Amici S, Lanari A, Gallai V. Pharmacological treatment of non-cognitive disturbances in dementia disorders. Mech Ageing Dev 2001; 122: 2063-9. 4. American Psychiatric Association. Practice guideline for the treatment of patients with Alzheimer s disease and other dementias of late life. Am J Psychiatry 1997; 154: 139. 5. Teri L, Logsdon RG, Peskind E, Reaskind M, Weiner MF, Tractenberg RE, et al. Treatment of agitation in AD: a randomized, placebo-controlled clinical trial. Neurology 2000; 55: 1271-8. 6. Bird M. Psychosocial management of behavioral problems in dementia, In: O Brien J, Ames D & Burns A. Dementia 2nd eds. NY: Oxford University Press 2000; 603-15. 7. Jenkins H, Allen C. The relationship between staff burnout/distress and interactions with residents in two residential homes for older people. Int J Genriatr Psychiatry 1997; 13: 466-72. 8. Bourgeois MS, Beach S, Schulz R, Burgio LD. When primary and secondary caregivers disagree: predictors and psychological consequences. Psychol Aging 1996; 11: 527-37. 9. Gitlin LN, Winter L, Corcoran M, Dennis MP, Schinfeld S, Hauck WW. Effects of the home environmental skill-building program on the caregiver- care recipient dyad: 6-month outcomes from the Philadelphia REACH Initiative. Gerontologist 2003; 43: 532-46. 10. Teri L. Behavior and caregiver burden: behavioral problems in patients with Alzheimer s diseaseand its association with caregiver distress. Alzheimer Dis Associ Disord 1997; 11(Suppl 4): S35-8. 11. Haupt M, Karger A, Janner M. Improvement of agitation and anxiety in demented patients after psychoeducative group intervention with their caregivers. Int J Geriatr Psychiatry 2000; 15: 1125-9. 12. Hinchliffe AC, Hyman IL, Blizard B, Livingston G. Behavioral complications of dementia-can they be treated? In J Geriatr Psychiatry 1995; 10: 839-47. 13. Mizuno E, Hosak T, Ogihara R, Higano H, Mano Y. Effectiveness of a stress management program for family caregivers of the elderly at home. J Med Dent Sci 1999; 46: 145-53. 14. Gerdner LA, Buckwalter KC, Reed D. Impact of a psychoeducational intervention on caregiver response to behavioral problems. Nurs Res 2002; 51: 363-74. 15. Brodaty H. Caregivers and behavioural disturbances: effects and interventions. Int Psychogeriatr 1996; 8: 455-8. 16. Opie J, Rosewarne R, O Connor DW. The efficacy of psychosocial approaches to behaviour disorders in dementia: a systematic literature review. Aust N Z J Psychiatry 1999; 33: 789-99. 17. Haupt M, Karger A, Janner M. Improvement of agitation and anxiety
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