1 2 3 臨床案例 77 69 1 Madopar(250mg) 1 tab q4h Entacapone 1 tab tid 1 10 9 5 2 1 2 1 1 彰化基督教醫院家庭醫學科住院醫師 2 彰化基督教醫院家庭醫學科主任 3 彰化基督教醫院家庭醫學科主治醫師 Parkinson's disease, psychosis, hallucinations, delusions (CASI) Entacapone Madopar (250mg)1 tab q4h 0.5 tab qid Quetiapine(25mg) 2 tab hs 流行病學 ( c r o s s - sectional study) 6 40%0-22% 17-72%6 33-55% 4 23-56%20 17-74% 50% 臨床表現及診斷 90% 家庭醫學與基層醫療 第六期 261
8% 13% 40% ( P a r k i n s o n s d i s e a s e - a s s o c i a t e d psychosis, PDAP) (NINDS-NIMH criteria ) UK Brain Bank ( ) () 病理生理 (PDAP) A. - (Illusions) - (False sense of presence) - (Hallucinations) - (Delusions) B. UK Brain Bank C. A D. A E. 資料來源 : 參考資料 2 262 家庭醫學與基層醫療 第六期
家庭醫業 Trihexyphenidyl (Artame) Biperiden (Akineton) B (MAO-B inhibitor) N-methyl-D-aspartate glutamate (dopamine agonist) Cathechol-O-methyltransferase (COMT) + (lovodopa + decarboxylase inhibitor) 資料來源 : 參考資料 3 Selegiline Amantadine Pramipexole (Mirapex) Ropinirole (Requip) Entacapone (Comtan) Levodopa 100mg + carbidopa 25mg (Sinemet) Levodopa 100mg + beserazide 25mg (Madopar) 危險因子 1. (Levodopa) ( ) (Stowe RL et al, Baker WL et al) 2. 30%4 6 10 75% ( M i n i - M e n t a l S t a t u s E x a m i n a t i o n ) (Cognitive Abilities Screening Instrument, 家庭醫學與基層醫療 第六期 263
C A S I ) ( C l i n i c a l Dementia Rating, CDR) ( C a m b r i d g e C o g n i t i v e Examination) (95% vs 98%) (94% vs 77%) level B( ) 25.8% (mild cognitive impairment) 3. (0100% 60-80%) 4. UPDRS (Unified Parkinson Disease Rating Scale) The Hoehn and Yahr Stages 5. (vivid dream ) (nightmare) (REM sleep behavior disorder ) 6. 7. 50% (Beck Depression Inventory-I) ( H a m i l t o n D e p r e s s i o n Rating Scale)level B Montgomery Asberg Depression Rating Scale, MADRS)level C( 264 家庭醫學與基層醫療 第六期
) (major d e p r e s s i v e d i s o r d e r w i t h p s y c h o t i c features) 8. 9. (Cholecystokinin ) 治療 () Quetiapine 12.5mg4 712.5mg 2 5-1 5 0 m g Clozapine 6.25mg 4 7 6. 2 5 m g 6.25-50mg (mg/d) Aripiprazole 1-10 Clozapine 6.25-50 Olanzapine 2.5-10 Quetiapine 25-150 Risperidone 0.5-1.5 Ziprasidone 資料來源 : 參考資料 8 家庭醫學與基層醫療 第六期 265
1% 18 D o n e p e z i l Rivastigmine Rivastigmine 預後 新 266 家庭醫學與基層醫療 第六期
結論 50% Aspirin () 參考資料 1. Fénelon G, Alves G: Epidemiology of psychosis in Parkinson's disease. J Neurol Sci 2010; 289:12-7. 2. B e r n a r d R, K a r e n M, H u b e r t H F, e t a l: Diagnostic criteria for psychosis in Parkinson's disease: report of an NINDS, NIMH work group. Mov Disord 2007; 22:1061-8. 3. Schrag A: Psychiatric aspects of Parkinson's disease--an update. J Neurol 2004; 251:795-804. 4. M i y a s a k i J M, S h a n n o n K, Vo o n V, e t a l: Practice parameter: evaluation and treatment of depression, psychosis, and dementia in Parkinson disease (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2006; 66:996-1002. 5. Aarsland D, Kurz MW: The epidemiology of dementia associated with Parkinson disease. J Neurol Sci 2010; 289:18-22. 6. Aarsland D, Bronnick K, Williams-Gray C, et al: Mild cognitive impairment in Parkinson disease: a multicenter pooled analysis. Neurology 2010; 75:1062-9. 7. Josephs KA, Whitwell JL: Parkinson disease and down in the dumps: pumped or stumped? Neurology 2010; 75:846-7. 8. Hasnain M, Vieweg VR, Baron MS, et al: Pharmacological management of psychosis in elderly patients with Parkinsonism. Am J Med 2009; 122:614-22. 9. Friedman JH: Recommendations on the drug treatment of psychosis in Parkinson's disease. Am J Med 2010; 123:19. 10. Forsaa EB, Larsen JP, Wentzel-Larsen T, Alves G: What predicts mortality in Parkinson disease: a prospective population-based longterm study. Neurology 2010; 75:1270-6. 家庭醫學與基層醫療 第六期 267