剛診斷有失智的病患容易自殺


  【24drs.com】January 21, 2010 — 研究者報告指出,有失智診斷的病患有自殺的風險,需訂定規範來加以監督和處置,研究者警告,診斷後3個月的風險最大。
  
  第一作者、澳洲雪梨新南威爾斯大學的Brian Draper醫師向Medscape Neurology表示,關鍵是醫師必須警覺到,阿茲海默氏症診斷會激起憂鬱和自殺行為,特別是剛診斷後的幾個月。
  
  他指出,雖然及早診斷有許多助益,但也有挑戰,他在發表於1月Alzheimer's and Dementia期刊的文獻中強調這些議題。
  
  研究作者解釋,失智專家一直認為告知病患和家屬這個壞消息的方法很重要,他們可能會有憂鬱反應,但是未曾認為與自殺行為有關,這種偏見現在必須改變。
  
  【自殺風險】
  研究作者強調,醫師應聚焦在病患診斷宣告後的情緒需求,他們指出,宣告的內容很重要,應該是以簡單明瞭的訊息告知,且強調病程是緩慢的,可以維持生活品質,也可以進行症狀治療。
  
  研究作者們指出,後續應提供全球有許多研究中之治療方式的實際希望,他們也提議定期追蹤回診和諮商。
  
  他們指出,也可以透過阿茲海默氏症組織以及「與失智症共處」等其他資源提供諮商給家屬,此類計畫目標在降低壓力和改善因應技巧。
  
  Draper醫師表示,他預期這些問題在未來幾年會增加,因為嬰兒潮世代有更多人年老,且阿茲海默氏症的生物標記也更廣為使用。
  
  有憂鬱病史或自殺行為史的失智患者特別有風險。
  
  【需要基因檢測指引】
  Draper醫師的團隊建議,專家們應考慮重提用於亨丁頓舞蹈症(Huntington's disease)基因檢測的指引,該指引強調面對面溝通,鼓勵病患花時間重新思考自己的定位,建議在病程中有充分的諮商。
  
  研究者指出,建議病患同意家人參與,以幫助計劃和改善情緒支持。
  
  病患在發生顯著惡化之前也會考慮自殺、研究輔助自殺、準備以安樂死作為臨終照護。
  
  Draper醫師表示,我們看了目前有關合法安樂死之前提的詮釋,阿茲海默氏症患者並不符合規定,我們也強調,在這類情況下,依賴代理人做決定的困難點。
  
  之前在「Risk Evaluation and Education for Alzheimer's Disease (REVEAL)」研究的報告中,研究者探討雙親之一有阿茲海默氏症的162名無症狀成年人,這些研究對象被隨機分派接受或不接受基因組結果,研究者接著在6週、6個月與1年時測量焦慮、憂鬱症狀、相關壓力。
  
  相對於目前的回顧所提出的顧慮,該研究發現,各組的這些測量在短期之間並無顯著差異,結果發表於7月的新英格蘭醫學期刊(New England Journal of Medicine) (2009;361:245-254)。
  
  該研究首次發表時,第一作者、波士頓大學醫學院的Robert Green醫師向Medscape Neurology表示,本研究的重點不是「開門見山」,認為對每個人宣告脂蛋白E的情況是安全的,重點在略為改變對話技巧。
  
  Green醫師表示,脂蛋白 ε4對偶基因是比較明顯的感受性基因組。
  
  【REVEAL研究】
  明尼蘇達大學公共衛生學院、老化中心、生物醫學倫理中心、Rosalie Kane博士與Robert Kane醫師在編輯評論中,形容Green醫師等人的研究「在告知的倫理指引中是罕見而令人欣然接受的試驗」。
  
  不過,他們提出了如何確保提供檢測結果和宣告時不造成傷害問題。舉例來說,納入的研究對象在開始時沒有明顯焦慮或憂鬱,且追蹤只有1年,他們推測,檢測陽性者「可能在1年後、或許是在他們第一次忘記姓名或發現有關失智的壓力時才做出回應」。
  
  阿茲海默氏症協會、醫學與科學諮詢委員會主席、梅約診所的Ron Petersen醫師向Medscape Neurology指出, REVEAL研究結果讓大家有共識不對健康人公佈脂蛋白E基因組結果,因為缺乏介入機會、可能會有心理上的傷害、對於獲得長期照護保險的能力也可能有風險。
  
  Draper 醫師指出,由一些專業機構以及意見和實務回顧,修改失智症診斷宣告的處置指引與最佳實務模式,強調追蹤以符合病患需求的重要性,採用逐步的方式來查明一個人的希望和探索他對診斷的反應。
  
  作者們皆宣告沒有相關財務關係。

Patients With Newly Diagnosed Dementia May Become Suicidal

By Allison Gandey
Medscape Medical News

January 21, 2010 — Patients diagnosed as having dementia are at risk for suicide, and protocols need to be developed to monitor and manage this, report researchers. Investigators caution that the 3-month period after diagnosis is when people are most at risk.

"The key message is that clinicians need to be aware that the diagnosis of Alzheimer's disease can provoke depression and suicidal behavior — especially in the early months after diagnosis," lead author Brian Draper, MD, from the University of New South Wales in Sydney, Australia, told Medscape Neurology.

Although early diagnosis has many benefits, he noted, it also presents challenges. These issues are highlighted in a literature review published in the January issue of Alzheimer's and Dementia.

"Dementia specialists have long recognized the importance of a sensitive approach to conveying bad news to patients and families and the possibility of depressive reactions," the study authors explain, noting that suicidal behavior has not been regarded as a likely outcome. "Such preconceptions will need to change."

Suicide Risk

Clinicians should focus on the emotional needs of the patient after the diagnosis has been disclosed, the study authors emphasize. "The content of the disclosure is important," they add. "The message should be given in a simple, easily understood manner, with an emphasis that progression is slow, quality of life can be maintained, and symptomatic treatments are available."

Realistic hope about the future should be provided about the many new potentially effective treatments being researched worldwide, the study authors note. They also advocate for regular follow-up appointments and counseling.

Counseling may also be provided for families through Alzheimer's organizations or other courses, such as the Living with Memory Loss Program, they point out. Such programs are designed to reduce stress and improve coping skills.

Dr. Draper says he anticipates these problems will increase in the coming years as a better informed baby boomer generation ages and biomarkers for Alzheimer's disease become widely available.

People with dementia who have a history of depression or suicidal behavior may be at particular risk.

Guidelines Needed for Genetic Testing

Dr. Draper's team suggests that specialists consider repurposing the guidelines used in genetic testing for Huntington's disease. The guidelines emphasize face-to-face communications, encourage time for patients to reconsider their position, and recommend plenty of counseling throughout the process.

Family involvement with the consent of the patient is desirable, the study authors add, to assist in planning and to provide emotional support.

Patients may also consider suicide before significant deterioration occurs, investigate assisted suicide, and prepare instructions about euthanasia for end-of-life care.

"We take the view that under current interpretations of prerequisites for euthanasia — in jurisdictions where it is legal — persons with Alzheimer's disease would not be competent to give instruction," Dr. Draper said. "We also highlight the difficulties of relying on proxy decision makers in such circumstances."

In the previously reported Risk Evaluation and Education for Alzheimer's Disease (REVEAL) study, investigators looked at 162 asymptomatic adults who had a parent with Alzheimer's disease. Participants were randomized to receive genotyping results or not. Investigators then measured symptoms of anxiety, depression, and test-related distress at 6 weeks, 6 months, and 1 year.

In contrast to the concerns raised in the present review, this study found no significant differences between the groups on any of these measures in the short term. Results were published in July in the New England Journal of Medicine (2009;361:245-254).

The importance of this study is not to "open the floodgate," suggesting it is safe to disclose apolipoprotein E status to everybody, lead investigator Robert Green, MD, from Boston University School of Medicine in Massachusetts, told Medscape Neurology when the study was first published. "The importance of this paper is maybe it will change the dialogue a little bit."

The apolipoprotein ε4 allele is one of the more robust susceptibility genotypes, Dr. Green said.

REVEAL Study

In an editorial accompanying the article, Rosalie Kane, PhD, and Robert Kane, MD, from the University of Minnesota's School of Public Health and Center on Aging and the Center for Biomedical Ethics, Minneapolis, called the work by Green and colleagues "a rare and welcome trial of a process that might inform ethics guidelines."

They raised the question, however, of how much reassurance it provides that testing and disclosure will not be harmful. Subjects who were included did not have high anxiety or depression at baseline, for example, and were followed up for only 1 year. Those who tested positive "might react years later, perhaps when they first forget a name or observe distress in a relative with dementia," they speculate.

Ron Petersen, MD, from the Mayo Clinic in Rochester, Minnesota, and chair of the Alzheimer's Association Medical and Scientific Advisory Council, pointed out to Medscape Neurology that when the REVEAL results were made public most consensus panels recommended against apolipoprotein E genotyping in healthy people because of the lack of opportunity for intervention, the possibility of psychological harm, and the potential risk to the ability to obtain long-term care insurance.

"A number of professional organizations, as well as reviews of opinion and practice, have constructed guidelines or best-practice models for handling diagnostic disclosures in dementia," Dr. Draper added. "These emphasize the importance of tailoring the process to suit the needs of the patient, using a stepped procedure to ascertain a person's desire to know, and exploring patient reactions to diagnosis."

The authors have disclosed no relevant financial relationships.

Alzheimers Dement. 2010;6:75-82.

    
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