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Dementia: Foreword. 痴呆:前言。
Q3 Medicine Pub Date : 2023-11-01
Karl T Rew
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引用次数: 0
Dementia: Helping Caregivers and Family Members Cope. 痴呆症:帮助照顾者和家庭成员应对。
Q3 Medicine Pub Date : 2023-11-01
Scott T Larson

Physicians who care for patients with dementia also must provide support for patient caregivers and family members. Caregiver burden requires attention from the health care team because most caregivers of patients with dementia report high levels of emotional stress. This burden is more severe when patients have comorbid conditions, behavioral and psychological symptoms of dementia, and more severe functional impairments. A functional assessment of activities of daily living can be done using standardized screening tools. Driving is a specific instrumental activity of daily living that can become dangerous in dementia; decisions about stopping driving often are complicated by patient resistance and loss of independence. Clinicians will be faced with questions regarding patient decision-making capacity, which is the ability to comprehend information and use reason to communicate an informed choice. As complex decision-making capacity is likely to diminish with dementia progression, discussing advance directives and designation of a surrogate decision-maker early in the disease course is paramount. Dementia remains an incurable progressive disease; therefore, management often is directed toward maintaining quality of life, managing symptoms, and palliating suffering. Patients with dementia may become eligible for hospice when they lose speech, locomotion, or consciousness.

照顾痴呆症患者的医生也必须为病人的照顾者和家庭成员提供支持。照顾者的负担需要卫生保健团队的关注,因为大多数痴呆症患者的照顾者报告了高水平的情绪压力。当患者有合并症、痴呆的行为和心理症状以及更严重的功能障碍时,这种负担更为严重。日常生活活动的功能评估可以使用标准化的筛查工具来完成。驾驶是一种特定的日常生活工具活动,对痴呆症患者来说可能会变得危险;关于停止驾驶的决定往往会因为病人的抵抗和独立性的丧失而变得复杂。临床医生将面临关于患者决策能力的问题,这是理解信息并使用理性来传达知情选择的能力。由于复杂的决策能力可能会随着痴呆症的进展而减弱,因此在病程早期讨论预先指示和指定替代决策者是至关重要的。痴呆症仍然是一种无法治愈的进行性疾病;因此,治疗通常以维持生活质量、控制症状和减轻痛苦为目标。失智症患者在失去语言、运动或意识时,可能有资格接受安宁疗护。
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引用次数: 0
Dementia: Diagnostic Evaluation. 痴呆:诊断评估。
Q3 Medicine Pub Date : 2023-11-01
Ellie Fishbein

Early and accurate diagnosis are crucial to appropriate care, ensuring timely intervention, and planning for future needs of patients with dementia. Dementia is a clinical diagnosis and should include comprehensive evaluation of patient cognitive and functional abilities, diagnostic laboratory evaluation, and brain imaging. A comprehensive evaluation for dementia includes a thorough medical history and physical examination, which may reveal important clues about the potential underlying causes of cognitive decline. A detailed medical history, physical examination, laboratory tests, and imaging studies can help identify any contributing factors. In addition, validated cognitive assessment tools can help clinicians identify the extent and nature of cognitive deficits, and track disease progression over time. Advances in the field of dementia research, such as serum biomarkers, are showing promise in facilitating an earlier and more accurate diagnosis. With the rise of telemedicine, new opportunities for virtual diagnosis have emerged, which can expand access to care for individuals in remote or underserved areas. The use of telemedicine for dementia diagnosis is still in its infancy, but research suggests that it has the potential to be an effective and convenient tool for evaluating patients with suspected dementia.

早期和准确诊断对于适当护理、确保及时干预和规划痴呆症患者的未来需求至关重要。痴呆是一种临床诊断,应包括患者认知和功能能力的综合评估、诊断实验室评估和脑成像。对痴呆症的全面评估包括全面的病史和体格检查,这可能会揭示认知能力下降潜在潜在原因的重要线索。详细的病史、体格检查、实验室检查和影像学检查可以帮助确定任何致病因素。此外,经过验证的认知评估工具可以帮助临床医生确定认知缺陷的程度和性质,并随时间跟踪疾病进展。痴呆症研究领域的进展,如血清生物标志物,正在显示出促进早期和更准确诊断的希望。随着远程医疗的兴起,虚拟诊断出现了新的机会,这可以扩大偏远或服务不足地区的个人获得护理的机会。远程医疗用于痴呆症诊断仍处于起步阶段,但研究表明,它有可能成为评估疑似痴呆症患者的有效和方便的工具。
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引用次数: 0
Dementia: Dementia Types. 痴呆症:痴呆症的类型。
Q3 Medicine Pub Date : 2023-11-01
Jason Wilbur

Dementia, also called major neurocognitive disorder, is characterized by a chronic progressive loss of cognitive function in the absence of fluctuating consciousness. It represents a primarily geriatric syndrome that may be caused by one of several underlying conditions. There is insufficient evidence to support universal screening for cognitive impairment in older adults; however, clinicians should be alert to patient and caregiver concerns about cognitive changes and investigate such concerns with validated cognitive assessment tools. Alzheimer disease is the leading cause and prototypical form of dementia, presenting insidiously and causing progressive cognitive impairment with increasing severity over a period of years. Vascular dementia is the second most common form of dementia and often co-occurs with other progressive cognitive disorders. Lewy body dementias encompass Parkinson disease dementia and dementia with Lewy bodies, which have similar features and are differentiated primarily by the order of motor and cognitive symptom onset. Frontotemporal dementias occur earlier than other forms of dementia, progress rapidly, and often have a genetic component. An understanding of the conditions that cause dementia will assist clinicians in making an accurate diagnosis and providing appropriate treatment recommendations and counseling regarding the diagnosis and prognosis.

痴呆症,也被称为严重神经认知障碍,其特征是在没有波动意识的情况下,认知功能的慢性进行性丧失。它主要是一种老年综合症,可能由几种潜在条件之一引起。没有足够的证据支持对老年人进行普遍的认知障碍筛查;然而,临床医生应该警惕患者和护理人员对认知变化的担忧,并使用有效的认知评估工具调查这些担忧。阿尔茨海默病是痴呆症的主要原因和典型形式,在一段时间内隐匿地呈现并引起进行性认知障碍,其严重程度随着时间的推移而增加。血管性痴呆是第二常见的痴呆形式,常与其他进行性认知障碍同时发生。路易体痴呆包括帕金森病痴呆和路易体痴呆,它们具有相似的特征,主要通过运动和认知症状的发病顺序来区分。额颞叶痴呆比其他形式的痴呆发生得早,进展迅速,通常有遗传因素。了解痴呆症的病因将有助于临床医生做出准确的诊断,并就诊断和预后提供适当的治疗建议和咨询。
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引用次数: 0
Dementia: Management and Controversies in Management. 痴呆:管理和管理争议。
Q3 Medicine Pub Date : 2023-11-01
John Swegle

Dementia management requires individualized patient encounters that focus on education and realistic expectations. Numerous vitamins and supplements are promoted for memory enhancement, but they lack evidence to support their use. Nonpharmacotherapy should be used through all stages of dementia. Common initial pharmacotherapy includes cholinesterase inhibitors and memantine, with use guided by dementia type, tolerability, patient goals, and disease stage. Assessment of benefit should incorporate caregiver input, functional improvements, behavioral symptoms, and tolerability. Management length is individualized. When a drug is discontinued, physicians should evaluate the patient for early worsening of cognitive or functional symptoms. Newer treatments, such as aducanumab, can reduce beta-amyloid plaques, but evidence for cognitive improvements is lacking; these treatments also are expensive and patient access is limited, resulting in barriers to widespread use. As dementia progresses, patients often develop behavioral and psychological symptoms, which are challenging for patients and caregivers. Nonpharmacotherapy is the first-line treatment for behavioral and psychological symptoms of dementia. Use of antipsychotics and benzodiazepines should be limited unless symptoms are placing the patient or others in imminent danger. Pharmacotherapy for these symptoms should be individualized, often requiring trials of various therapeutic options.

痴呆症管理需要个性化的患者接触,注重教育和现实的期望。许多维生素和补品都被认为可以增强记忆,但它们缺乏证据来支持它们的使用。非药物治疗应该贯穿痴呆的所有阶段。常见的初始药物治疗包括胆碱酯酶抑制剂和美金刚,根据痴呆类型、耐受性、患者目标和疾病分期指导使用。益处评估应包括照顾者的投入、功能改善、行为症状和耐受性。管理长度是个性化的。当停药时,医生应评估患者认知或功能症状的早期恶化。较新的治疗方法,如aducanumab,可以减少β -淀粉样蛋白斑块,但缺乏改善认知的证据;这些治疗也很昂贵,而且患者获得的机会有限,从而阻碍了它们的广泛使用。随着痴呆症的发展,患者往往会出现行为和心理症状,这对患者和护理人员来说都是一个挑战。非药物治疗是痴呆症行为和心理症状的一线治疗方法。应限制使用抗精神病药物和苯二氮卓类药物,除非症状使患者或他人处于迫在眉睫的危险之中。针对这些症状的药物治疗应该个体化,通常需要对各种治疗方案进行试验。
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引用次数: 0
Chronic Pain Syndromes: Foreword. 慢性疼痛综合征:前言。
Q3 Medicine Pub Date : 2023-10-01
Barry D Weiss
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引用次数: 0
Chronic Pain Syndromes: Fibromyalgia. 慢性疼痛综合征:纤维肌痛。
Q3 Medicine Pub Date : 2023-10-01
Diane Flynn

Fibromyalgia is a chronic pain syndrome that is considered a pain processing disorder; its pathophysiology is not completely understood. The estimated prevalence in the general population varies from 0.5% to 12%, depending on the population studied and diagnostic criteria used. It is more common in females than males. There is no diagnostic laboratory test. The two currently used diagnostic methods are scoring criteria from the American College of Rheumatology (ACR) and the Analgesic, Anesthetic, and Addiction Clinical Trial Translations Innovations Opportunities and Networks (ACTTION)-American Pain Society (APS). These diagnostic criteria include chronic widespread pain of at least 3 months' duration plus poor sleep and/or fatigue and other somatic symptoms. Other pain syndromes also should be considered in the differential diagnosis. A multimodal, targeted symptom management approach that emphasizes self-management is recommended. Nonpharmacotherapies include patient education, exercise, and cognitive behavior therapy. Pharmacotherapy should be based on predominant symptoms. Amitriptyline and pregabalin are effective for management of pain, fatigue, and sleep issues. Milnacipran (Savella) is effective for pain and fatigue. Duloxetine is effective for management of pain and depression. There is no evidence of benefit of analgesics. Common comorbidities, such as regional pain conditions and mental disorders, should be addressed.

纤维肌痛是一种慢性疼痛综合征,被认为是一种疼痛处理障碍;其病理生理学尚不完全清楚。根据所研究的人群和使用的诊断标准,普通人群的估计患病率在0.5%至12%之间。它在女性中比男性更常见。没有诊断性实验室测试。目前使用的两种诊断方法是美国风湿病学会(ACR)和镇痛、麻醉和成瘾临床试验转化创新机会和网络(ACTTION)-美国疼痛学会(APS)的评分标准。这些诊断标准包括持续至少3个月的慢性广泛疼痛,加上睡眠不足和/或疲劳和其他身体症状。在鉴别诊断中也应考虑其他疼痛综合征。建议采用多模式、有针对性的症状管理方法,强调自我管理。非药物治疗包括患者教育、锻炼和认知行为治疗。药物治疗应以主要症状为基础。阿米替林和普瑞巴林对治疗疼痛、疲劳和睡眠问题有效。Milnacipran(Savella)对疼痛和疲劳有效。度洛西汀对治疗疼痛和抑郁有效。没有证据表明止痛药有益处。常见的合并症,如局部疼痛和精神障碍,应该加以治疗。
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引用次数: 0
Chronic Pain Syndromes: Myofascial Pain Syndrome. 慢性疼痛综合征:肌筋膜疼痛综合征。
Q3 Medicine Pub Date : 2023-10-01
Julie Henson

Myofascial pain syndrome (MPS) is a regional musculoskeletal pain disorder characterized by trigger points within the muscle or fascia. There are no universally accepted diagnostic criteria. Diagnosis currently is based on a physical examination finding of at least one localized trigger point that, when palpated, recreates the pain at the site or produces pain away from the site in a referral pattern. MPS is thought to be related to sustained muscle contraction from under- or overuse. This syndrome commonly coexists with other chronic pain conditions, including fibromyalgia. The difference between MPS and fibromyalgia is that MPS involves localized pain with discrete areas of tenderness, whereas fibromyalgia symptoms are more diffuse and widespread. Most management recommendations for MPS are based on low-quality clinical trials or expert opinion. A multimodal approach is recommended, involving patient education, exercise, behavior modification, pharmacotherapy, and procedural interventions. Commonly used drugs include topical analgesics, nonsteroidal anti-inflammatory drugs, and muscle relaxants. Procedural interventions include manual therapy (eg, deep tissue massage, spray and stretch technique, myofascial release), dry needling, trigger point injections, onabotulinumtoxinA injections, acupuncture, kinesiology tape, transcutaneous electrical nerve stimulation, extracorporeal shockwave therapy, and low-level laser therapy. Symptoms often resolve with these interventions if they are used early in the course of the condition. As MPS enters the chronic stage, it becomes increasingly refractory to treatment.

肌筋膜疼痛综合征(MPS)是一种以肌肉或筋膜内触发点为特征的区域性肌肉骨骼疼痛障碍。没有公认的诊断标准。目前的诊断是基于至少一个局部触发点的体检结果,当触诊时,该触发点会在该部位重现疼痛或在转诊模式中在远离该部位的地方产生疼痛。MPS被认为与过度使用或不足导致的持续肌肉收缩有关。这种综合征通常与其他慢性疼痛共存,包括纤维肌痛。MPS和纤维肌痛的区别在于,MPS涉及局部疼痛和离散的压痛区域,而纤维肌痛症状更为分散和广泛。大多数MPS的管理建议都是基于低质量的临床试验或专家意见。建议采用多模式方法,包括患者教育、锻炼、行为矫正、药物治疗和程序干预。常用药物包括局部镇痛药、非甾体抗炎药和肌肉松弛剂。手术干预包括手法治疗(如深层组织按摩、喷雾和拉伸技术、肌筋膜松解)、干针、触发点注射、肉毒杆菌毒素A注射、针灸、运动学胶带、经皮神经电刺激、体外冲击波治疗和低水平激光治疗。如果在病情早期使用这些干预措施,症状通常会得到缓解。随着MPS进入慢性期,其治疗变得越来越难。
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引用次数: 0
Chronic Pain Syndromes: Chronic Neuropathic Pain. 慢性疼痛综合征:慢性神经性疼痛。
Q3 Medicine Pub Date : 2023-10-01
Tyler J Raymond

Neuropathic pain affects 7% to 10% of the population and has major effects on quality of life. It is defined as pain caused by a lesion or disease of the somatosensory nervous system and may be central or peripheral. Diagnostic testing may yield inconclusive or inconsistent results, so physicians often rely on clinical judgment based on the history and physical examination findings. Questionnaires and scoring systems can aid in diagnosis. Neuropathic pain is differentiated from other types of chronic pain by abnormal sensory symptoms, such as shooting pain, burning pain, or numbness. It is difficult to manage and can be accompanied by mood and sleep disturbances. Referral for psychotherapy may be useful for these patients. Nonpharmacotherapy options include mindfulness training, transcutaneous electrical nerve stimulation, and massage. Acupuncture also may be effective, but the data are mixed. Topical drugs (eg, lidocaine, capsaicin), gabapentinoids, tricyclic antidepressants, and serotonin-norepinephrine reuptake inhibitors are considered first-line drugs. Tramadol is considered a second-line drug, but may considered first-line for certain patients. For persistent pain, physicians can consider referring patients to a pain specialist for nerve blocks or other procedural interventions. Opioids may be considered for refractory pain, but their additional benefit has been shown to be modest compared with those of other treatments.

神经性疼痛影响7%至10%的人口,对生活质量有重大影响。它被定义为由体感神经系统的损伤或疾病引起的疼痛,可能是中枢或外周疼痛。诊断测试可能会产生不确定或不一致的结果,因此医生通常依赖于基于病史和体检结果的临床判断。调查表和评分系统可以帮助诊断。神经性疼痛与其他类型的慢性疼痛的区别在于异常的感觉症状,如射痛、灼痛或麻木。它很难控制,并且可能伴随着情绪和睡眠障碍。心理治疗的转诊可能对这些患者有用。非药物疗法包括正念训练、经皮神经电刺激和按摩。针灸也可能有效,但数据喜忧参半。局部用药(如利多卡因、辣椒素)、加巴喷丁类药物、三环类抗抑郁药和5-羟色胺去甲肾上腺素再摄取抑制剂被视为一线药物。曲马多被认为是一种二线药物,但对于某些患者可能被认为是一线药物。对于持续疼痛,医生可以考虑将患者转介给疼痛专家进行神经阻滞或其他程序干预。阿片类药物可能被认为是治疗难治性疼痛的药物,但与其他治疗方法相比,它们的额外益处已被证明是适度的。
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引用次数: 0
Chronic Pain Syndromes: Complex Regional Pain Syndrome. 慢性疼痛综合征:复杂区域疼痛综合征。
Q3 Medicine Pub Date : 2023-10-01
Ghena Grinshpun

Complex regional pain syndrome (CRPS) is a chronic pain condition characterized by intense pain, usually in a body region that has experienced trauma, and autonomic and inflammatory features. It most commonly develops after an arm or leg injury. Patients typically present with extreme hyperalgesia and/or allodynia. The Budapest Criteria are used to make this clinical diagnosis. Prompt diagnosis and aggressive management are critical because long-term outcomes are improved when treatment is initiated soon after symptom onset. The primary management options are rehabilitation and physical therapy, including such approaches as progressive tactile stimulation, normalization of movement to prevent limited range of motion, and others. No drugs are approved by the Food and Drug Administration (FDA) for CRPS management, but some evidence supports the use of drugs used to manage other types of neuropathic pain (eg, gabapentin, tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors). Nonsteroidal anti-inflammatory drugs also are used, and corticosteroids, bisphosphonates, ketamine, and other drugs can be helpful, particularly for early-stage CRPS. When pain severity prevents patients from participating in rehabilitation, referral to a pain specialist is warranted for consideration of procedural interventions, including sympathetic nerve blockade and spinal cord stimulation.

复杂区域疼痛综合征(CRPS)是一种以剧烈疼痛为特征的慢性疼痛,通常发生在经历过创伤的身体区域,具有自主神经和炎症特征。它最常见于手臂或腿部受伤后。患者通常表现为极度痛觉过敏和/或异常性疼痛。布达佩斯标准用于进行临床诊断。及时诊断和积极治疗至关重要,因为在症状出现后不久开始治疗,长期结果会得到改善。主要的管理选择是康复和物理治疗,包括渐进触觉刺激、运动正常化以防止有限的运动范围等方法。美国食品药品监督管理局(FDA)没有批准任何药物用于CRPS治疗,但一些证据支持使用用于治疗其他类型神经性疼痛的药物(如加巴喷丁、三环类抗抑郁药、5-羟色胺-去甲肾上腺素再摄取抑制剂)。也使用非甾体抗炎药,皮质类固醇、双磷酸盐、氯胺酮和其他药物可能会有所帮助,尤其是对早期CRPS。当疼痛严重程度使患者无法参与康复时,有必要转诊给疼痛专家,以考虑程序干预措施,包括交感神经阻断和脊髓刺激。
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引用次数: 0
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