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转引文献综述: 痴呆患者的行为障碍--非药物干与和精神药物的应用, 美国家庭医生杂志, American Family Physician, 2016年8月15日。 这里摘录用药的部分。尽管 FDA警告精神药物增加痴呆病人的死亡危险, 14%的老人院痴呆病人还是用了这类药物。 约15%一75%的痴呆病人有妄想, 妄想性的自我定向障碍 (误判自己的身份), 幻觉(常是幻视), 乱走, 激越, 攻击性, 和其它精神行为异常。 FDA 不批准抗精神药物的使用是因为说明有效的证据很差而对病人造成伤害的证据却是高质量的。所以, 医生在开始这项未得到批准的治疗时, 要在病人承受的风险和得到好处间作出权衡。开始用尽可能低的剂量, 再慢慢调节。晚间睡前服用。 有效性: 三个综述关于非典型抗精神病药物的报导一致地显示了aripiprazole (Abilify) 有减轻痴呆病人行为和精神症状, 虽然这种减轻的程度是有限的, Abilify 的用量是2-10mg 每日, 是低量。 对olanzapine (Zyprexa) 5 mg/day, quetiapine (Seroquel) 50 mg/day, risperidone (Risperdal) 0.25--1.5 mg/day 的效果却没有得出一致的结论, 用量化方法(用数字给分) 去测定症状轻重的结果, Olanzapine 和quetiapine 效果最差。 没有效的抗精神病学物有: ziprasidone (Geodon), paliperidone (Invega), clozapine (Clozaril), a senapine (Saphris), 还有iloperidone (Fanapt)。不过这些一般是精神科医生才开的药, 用于治疗精神分裂症。 付作用: 抗多巴胺作用 antidopaminergic effects, 例如运动性障碍, 也可以出现在非典型抗精神病物治疗中, 其它的付作用有抗胆碱作用, 锥体外系症状, 神经恶性症状, 体位性低血压, 过度镇静, 中风, 长期应用会增加发生下列情况的危险性: 肥胖症, 糖尿病, 高血压, 血脂相异常。 令人关注更多的是有证据说明这类药物增加死亡率。在2015年, 一项回顾性的研究搜集了90000名患痴呆症的复员军人的病历, 发现得到抗精神病药物, 典型的药物抑或不典型的, 比没有得到这类药物的有较高的死亡的危险。这里引用了一个概念, 叫 NNH, a number needed to treat to harm, 治多少个病人会伤害病人? 具体数字如下: 对第一代抗精神病药物, haloperidol 26, 第二代的, 死亡率增加最少的是 quetiapine NNH 50, 其次是olanzapine 40, riperidone 27。作为一个组, 用高剂量和低剂量相比, 用Olanzapine, quetiapine, risperidone 的病例死亡率有3.5%的增高。Aripiprazole 增大心血管的风险, NNH 58, 但对死亡率的影响不明。
Lei Ding：This is complicated. Very
D2 antagonist is still the best.
Leaving sundowning alone without intervention is far worse than the risks they had claimed.
Lei Ding：Once you prescribe such a medication for a demented patient, sooner or later, a warning from the insurance company would come to you. In this dillema, we may not be sure how we are supposed to respond to them. Now, with this article, we at least have better idea to position ourselves.
Lei Ding：EMR gives you an option and you choose 'you are aware of the side effect' Then you will be ok. We treat the patient not insurance companies.
Lei Ding：大部分痴呆病人开始被使用精神药物源于护理人员的要求，病人不睡觉，试图走动，看到鬼怪等等；然后幻觉的诊断就来了。我个人觉得应该像对待2，3岁的孩子那样对待晚期痴呆的病人，照着教科书上做，护理人员应该首先看病人是不是饿了，或是想大便，或是想小便，或者裤子湿了，或者白天被别护理指挥睡多了，或者只是想找个人说说话，记住他们只有几岁的智力了。如果都不是，可以到下一步，是不是尿道感染，肺炎........ 精神药物的作用应该是临时的，不应该超过几天
Lei Ding：说的太好了。我觉得这是精神药物滥用的重要因素之一。on the other hand, our doctors are at same positions. We don't want to spend too much time to explain the real situation or take responsibility if anything happens. JUST GIVE A PILL.
Lei Ding：I agree。Medications can make matters worse. However, doctors often prescribed medication to justify patient visit.
Lei Ding：是啊,人文关怀胜过药物。病人也不想吃精神药物。
Lei Ding：those patients may not be able to 'think '.
Lei Ding：这些病人在有语言表达错乱,行为异常的时候,不能立刻以为其语言理解能力也同等程度下降了。因为他们可以知道哪种药是精神药物,并且拒绝吃。
Lei Ding：另外这类药太贵，药厂起了不好的作用
Lei Ding：There should be a dementia specialist and insomnia specialist. It is hard to take care of these patients when patients don't want to see a psychiatrist and all these meds need to be metered. Home aids and family members usually have no skill to take care these patients. Every one around it is suffering, and we don't have much to offer.
Lei Ding：yes. It is complicated and time consuming issues. So far we don't have specialist on this field except psychiatrists.
Lei Ding：Neuropsychiatrist is a subspecialty is psychiatrist for dementia
Lei Ding：how can we find them? There are very few around with difficulty to make appointment and not accept most insurance.
Lei Ding：Geriatric psychiatrist Dr. Austria.
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