E Mintzer J, F Mirski D, S Hoernig K
Medical University of South Carolina, Department of Psychiatry and Behavioral Sciences, Charleston, SC, USA.
Dialogues Clin Neurosci. 2000 Jun;2(2):139-55. doi: 10.31887/DCNS.2000.2.2/jmintzer.
Alzheimer's disease typically presents with two often overlapping syndromes, one cognitive, the other behavioral. The behavioral syndrome is characterized by psychosis, aggression, depression, anxiety, agitation, and other common if less well-defined symptoms subsumed under the umbrella entity "behavioral and psychological symptoms of dementia" (BPSD), itself divided into a number of subsyndromes: psychosis, circadian rhythm (sleepwake) disturbance, depression, anxiety, and agitation, it is BPSD with its impact on care providers that ultimately precipitates the chain of events resulting in long-term institutional care. The treatment challenge involves eliminating unmet medical needs (undiagnosed hip fracture and asymptomatic urinary tract infection or pneumonia). Pharmacologic intervention relies on risperidone and, increasingly cholinesterase inhibitors for the control of psychosis (but with response rates of only 65% at tolerable doses), olanzapine and risperidone for anxiety, and carbamazepine and valproic acid for agitation. However, evidence increasingly favors nonpharmacologic interventions, to the extent that these should now be considered as the foundation of BPSD treatment. Problem behaviors are viewed as meaningful responses to unmet needs in the therapeutic milieu. Because the progression and impact of BPSD varies between patients, interventions must be explored, designed, implemented, and assessed on an individual basis. They include: family support and education, psychotherapy reality orientation, validation therapy, reminiscence and life review, behavioral interventions, therapeutic activities and creative arts therapies, environmental considerations (including restraint-free facilities), behavioral intensive care units, and workplace design and practices that aid the ongoing management of professional caregiver stress.
阿尔茨海默病通常表现为两种常常相互重叠的综合征，一种是认知方面的，另一种是行为方面的。行为综合征的特征包括精神病、攻击行为、抑郁、焦虑、激越以及其他一些常见但定义不太明确的症状，这些症状被归入“痴呆的行为和心理症状”（BPSD）这一总体范畴，BPSD本身又分为若干子综合征：精神病、昼夜节律（睡眠 - 觉醒）紊乱、抑郁、焦虑和激越。正是BPSD及其对护理人员的影响最终引发了一系列事件，导致长期的机构护理。治疗挑战包括消除未满足的医疗需求（未诊断出的髋部骨折以及无症状的尿路感染或肺炎）。药物干预依赖于利培酮，并且越来越多地使用胆碱酯酶抑制剂来控制精神病（但在可耐受剂量下的有效率仅为65%），使用奥氮平和利培酮来治疗焦虑，使用卡马西平和丙戊酸来治疗激越。然而，越来越多的证据支持非药物干预，以至于现在应将其视为BPSD治疗的基础。问题行为被视为对治疗环境中未满足需求的有意义反应。由于BPSD在患者之间的进展和影响各不相同，干预措施必须基于个体情况进行探索、设计、实施和评估。这些干预措施包括：家庭支持与教育、心理治疗、现实定向、验证疗法、回忆与生活回顾、行为干预、治疗性活动和创意艺术疗法、环境考量（包括无约束设施）、行为重症监护病房，以及有助于持续管理专业护理人员压力的工作场所设计与实践。
