帕金森病认知功能障碍的神经心理学研究
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摘要
目的
1.研究帕金森病(Parinson’s disease,PD)患者认知功能改变的特点,为临床应用神经心理学测验诊断PD患者的认知功能障碍提供有价值的依据。
2.研究伴发抑郁症的PD患者执行功能的特点,进一步探讨抑郁对PD执行功能障碍的影响。
3.研究伴发抑郁症的PD患者记忆功能障碍的特点,进一步探讨抑郁对PD记忆的影响。
对象与方法
对象
1.对象:选取于2004年9月至2006年9月第三军医大学大坪医院就诊的原发性PD患者作为实验组,以年龄、性别及受教育程度相匹配的社区健康老年人和同期就诊的非神经系统器质性疾病的患者为对照组。
2.排除标准:所有患者均进行头部CT或MRI检查及相关的辅助检查排除脑部相关疾病;排除严重的系统性疾病;按照1984年全国锥体外系疾病讨论会制定的帕金森综合症诊断标准除外继发性PD和特发性震颤。
3.诊断标准:
PD诊断标准:按照1984年10月全国锥体外系讨论会规定的PD诊断标准。抑郁诊断标准:美国《精神病诊断和统计手册》修订第4版抑郁症诊断标准。抑郁的严重程度:根据抑郁自评量表(Self-rating depressive scale ,SDS)和汉密尔顿抑郁量表(Hamilton rating scale for depression ,HAMD)的标准评定。痴呆的诊断标准:美国《精神疾病诊断与统计手册》修订第4版诊断标准。痴呆的严重程度:采用临床痴呆量表CDR评定。
4. PD实验分组:按照修订的Hoehn-Yahr分期:早期PD组(修订的Hoehn-Yahr分期≤2)(n=30);晚期PD组(修订的Hoehn-Yahr分期>2)(n=16)。按照是否伴发抑郁: PD抑郁组(Parkinson’s disease patients with depression ,PDD)(n=36); PD非抑郁组(Nondepressed Parkinson’s disease patients ,PDND)(n=44)。5. PD患者的临床评定指标:修订的Hoehn-Yahr分期;Webster评分量表;统一PD评分量表(UPDRS);帕金森病运动功能评分(MDRSPD)。
方法:
1.所有研究对象均进行详细的病史询问、体格检查。
2.全面认知功能初步评定:简易精神状况检查量表(Mini-mental state examination,MMSE)和临床痴呆评定量表(Clinical dementia rating,CDR)进行全面认知功能状态的初步评定。
3.单项认知功能评定:
3.1智商测验:龚氏修订的韦氏成人智力量表(Wechsler adult intelligence scale- revised in China ,WAIS-RC)测验。
3.2记忆:采用龚氏修订韦氏记忆量表(Wechsler memory scale-revised in China ,WMS-RC)(甲式)检测。
3.3注意测验:符号-数字模式测验(Symbol-digital mode test ,SDMT)和连线测验A(Trail making test A ,TMA)。
3.4执行功能:
(1) Stroop字色干扰测验(Stroop color-word test ,SCWT)。
(2)画钟测验(Clox drawing test,CDT)。
(3)床边测查额叶功能评定量表(Frontal assessment battery at bedside ,FAB)。
3.5知觉测验:WAIS-RC中木块图测验(Block design test ,BDT)和图形拼凑测验(Picture arrangement test ,PAT)。
3.6普通心理学评定:对所有研究对象均进行抑郁自评量表(Self-rating depressive scale,SDS)和汉密尔顿抑郁量表(Hamilton rating scale for depression ,HAMD)评定。
3.7非认知功能评定:采用日常生活能力量表(Barthel指数计分法)(Activity of daily living-Barthel index number scoring method,ADL-BI)。
结果
1.早期PD组与晚期PD组相比在发病年龄(61.13±7.17,70.57±4.82)、病程(2.60±1.18,)、UPDRS评分(24.93±5.36,69.00±12.13)、Webster评分(7.13±2.21,19.79±4.21)、ADL评分(76.83±8.04,31.43±13.36)方面差异有显著性意义(P<0.01)。
2.整体认知功能的初步评定结果:早期PD组、晚期PD组与健康对照组MMSE总分(24.83±2.02,19.79±3.56,27.60±1.59)均有差异,差异有显著性意义(P<0.01)。早期PD组与晚期PD组的痴呆发生率分别为(6.25%,64.29%),差异有显著性意义(P<0.05)。
3.早期PD组与晚期PD组和健康对照组相比较:在智商(Intelligence quotient,IQ)(90.87±9.00,72.43±17.58,99.83±6.96)、记忆商(Memory quotient,MQ)(76.23±9.54,62.43±8.70,99.57±8.21)、注意(25.53±8.74,10.00±11.14,35.60±6.03)、知觉(12.80±2.95,5.07±6.71,20.13±5.20)、执行(6.03±1.35,3.57±1.83,9.57±2.10)方面的测验差异具有显著性意义(P<0.01)。早期PD患者的瞬时记忆测试(9.60±1.75)与健康对照组(9.97±1.59)差异无显著性意义(P>0.05),早期PD的言语智商与健康对照组相比较差异无显著性意义(P>0.05),早期PD的言语智商与晚期PD组及晚期PD组与健康对照组相比较差异具有显著性意义(P<0.01)。
4.在单项认知功能测验中,DST结果显示早期PD组(9.60±1.75)与正常对照组(9.97±1.59)差异无显著性意义(P>0.05),与晚期PD组(4.43±3.44)差异具有显著性意义(P<0.01),提示早期PD患者的瞬时记忆无明显受损。而对于SDMT、TMA、SCWT、FAB、CDT、BDT、PAT、VFT测验,早期PD组与晚期PD组以及早期PD组与健康对照组差异均具有显著性意义(P<0.01)。在早期PD组,MMSE未到达痴呆诊断标准时,已经出现了多项单项认知功能的改变。PD认知功能改变与年龄、发病年龄、病程、UPDRS评分、Webster评分、Hoehn-Yahr分期、ADL呈正相关,与受教育水平呈负相关。
5. PD伴发抑郁记忆功能的评定:MQ(PDD组40.28±8.91,PDND组76.55±7.04),短时记忆(Short-term memory,STM)(PDD组20.39±7.02,PDND组34.25±6.69),长时记忆(Long-term memory,LTM)(PDD组15.28±3.56,PDND组34.25±6.69), PDD组MQ、STM和LTM明显下降,差异具有显著性意义(P<0.01)。瞬时记忆(Immediate memory,IM) (PDD组4.61±2.38,PDND组5.11±2.20)差异无显著性意义(P>0.05)。Fuld物体记忆测验(Fuld Object-Memory Evaluation,FOM)(PDD组9.89±2.23,PDND组12.73±1.66) PDD组与PDND组差异有显著性意义(P<0.01)。
按照抑郁严重程度进行组间比较:轻中度抑郁组与重度抑郁症组在LTM(16.68±3.0,12.09±2.59)、STM(23.28±5.8,13.82±4.79)MQ(61.40±5.75,50.73±1.27)、FOM(10.40±2.18,8.73±1.95)差异均有显著性意义(P<0.01)。IM(4.40±2.63,5.09±1.70)差异无显著性意义(P>0.05)。
PDD组记忆障碍的发生率为28/36(77.78%),PDND组记忆障碍发生率为25/44 (56.82%),差异具有显著性意义(P<0.01)。进行相关分析结果显示SDS和HAMD评分结果具有显著正相关。SDS/HAMD与记忆功能和ADL呈负相关,与年龄、MDRSPD评分、Hoehn-Yahr分期均无明显相关(P>0.05)。
6. PD伴发抑郁执行功能评定:PDD组与PDND组在SCWT:Stroop1(14.14±5.09,8.66±4.73)、Stroop2(212.33±59.50,125.32±55.51);CDT(5.42±2.05,6.59±2.50)和RVR:AR (6.97±1.46,8.84±2.93),FR(6.69±1.67,11.30±2.79)VR(7.47±2.38,9.45±2.89)的检测结果差异均有显著性意义(P<0.01)。
按照抑郁严重程度进行组间比较:轻中度抑郁组与重度抑郁症组的执行功能差异无显著性意义(P>0.05)。
7. PDD组痴呆发生率为23/36(63.89%),PDND组痴呆发生率为15/44(34.09%),差异有显著性意义(P<0.01)。
结论
1.早期PD患者在全面认知功能经MMSE检测尚未达到痴呆水平时,已经出现了多个单项认知功能改变,尤其是以额叶认知功能改变明显,MMSE对于PD的认知功能评定不是一个敏感的工具,需要对PD患者进行单项及全面的认知功能评定,以便对PD患者的认知功能障碍早期诊断和治疗。
2.抑郁症对PD记忆功能有显著的影响,伴发抑郁的PD患者记忆功能下降显著。伴发抑郁的PD患者短时记忆和长时记忆功能明显减退,抑郁临床症状严重程度影响记忆功能的改变。
3.抑郁症对PD执行功能有显著的影响,伴发抑郁的PD患者执行功能下降显著,抑郁临床症状严重程度对执行功能的改变无明显影响。
Objective:
1. To study the characteristic of cognitive impairment accomplished with patients of Parkinson’s disease (PD) in order to show the value of neuropsychological testing as tool used in early detection of cognitive impairment of PD.
2. To study the characteristic of memory of Parkinson’s disease accompanied with depression and the influence of memory of depression with of PD patients.
3. To study the characteristic of executive function of Parkinson disease accompanied with depression and the influence of executive function of depression with cognition of PD patients.
Subjects and Methods:
Subjects
1. Subjects:The idiopathic Parkinson’s disease patients which visited Daping Hospital of Third Military Medical University of Chinese PLA from September 2004 to September 2006 were adopted as experimental group,and the healthy community old people were subjected as control group which were matched with age,gender and educational level.
2. Exclusive criteria:All subjects were examined by CT or MRI and other relative auxiliary examination in order to exclude the serious systematic disorders. At the same time they should match with the diagnostic criteria of parkinsonism which was made by the nationwide extracorticospinal tract disease conference’s diagnostic criteria in October 1984.
3. Diagnostic criteria: Diagnostic criteria of PD: According to the nationwide extracorticospinal tract disease conference’s diagnostic criteria of October 1984. Diagnostic criteria of depression: according to the DSM-IV criteria. The severity of depression: according to the SDS and HAMD criteria. Diagnostic criteria of dementia: according to the DSM- IV criteria. The severity of dementia: according to the CDR.
4. Experiment subgroup:
According to the revised Hoehn-Yahr staging there are two groups: early PD group (modified Hoehn-Yahr grade≤2)(n=30) , later PD group(modified Hoehn-Yahr grade>2)(n=16);
According to whether accompanied with depression there are two groups:Parkinson disease with depression group(PDD)(n=36), nondepressed Parkinson’s disease patients group (PDND)group(n=44).
5. Clinical evaluation criteria of parkinsionian:modified Hoehn-Yahr staging;Webster rating scale;Unified Parkinson disease rating scale(UPDRS);Motor dysfunction rating scale for Parkinson’s disease (MDRSPD).
Methods:
1. All subjects need to accept the professional physical examination and record the case history.
2. Global cognition assessment: Mini-mental state examination (MMSE) and Clinical dementia rating (CDR).
3. Single cognition assessment:
3.1 Intelligence quotient test:Wechsler adult intelligence scale revised in China (WAIS-RC);
3.2 Memory:Wechsler memory scale revised in China (WMS)
3.3 Attention test:Symbol digital model test (SDMT)and trail making test A(TMA);
3.4 Execution Function:
(1) Stroop color-word test (SCWT).
(2) Clock drawing test (CDT).
(3) Frontal assessment battery at bedside (FAB).
(4) Rapid Verbal Retrieve (RVR).
3.5 Perception test:Block design test of WAIS-RC(BDT), Picture arrangement test(PAT).
3.6 General psychology assessment:Self-rating depressive scale (SDS) and Hamilton's rating scale for depression (HAMD) .
3.7 Non-cognition assessment: Activity of daily living by Barthel index (ADL-BI).
Results
1. There were significant differences between early PD group and later PD group in age of onset(61.13±7.17, 70.57±4.82)、course of disease(2.60±1.18)、UPDRS score (24.93±5.36, 69.00±12.13)、Webster score(7.13±2.21,19.79±4.21)、ADL score(76.83±8.04,31.43±13.36).
2.The result of initial assessment of the whole cognition: There were significant differences in the early PD group ,later PD group and the healthy control group in the whole scores of MMSE(24.83±2.02,19.79±3.56,27.60±1.59) (P<0.01).The dementia incidence is (6.25%,64.29%,respectively),which is significantly different(P<0.01).
3. There were significant differences in intelligence quotient(90.87±9.00,72.43±17.58,99.83±6.96), (90.87±9.00, 72.43±17.58,99.83±6.96)、memory quotient(76.23±9.54, 62.43±8.70, 99.57±8.21)、attention(25.53±8.74, 10.00±11.14, 35.60±6.03)、perception (12.80±2.95, 5.07±6.71, 20.13±5.20)、executive function(6.03±1.35, 3.57±1.83, 9.57±2.10) between early PD group and later PD group, so as to the healthy control group (P<0.01).There were no significant differences in immediate memory between the earlier PD group(9.60±1.75)and healthy control group(P>0.05),as well as the verbal intelligence quotient.
4. In single cognition testing, the result of DST that there are no significant differences between the early PD group and later PD group by(9.60±1.75, 9.97±1.59,respectively) indicate that the there are no dysfunction in immediate memory.There are great significant differences in the three groups in other tests such as SDMT、TMA、SCWT、FAB、CDT、BDT、PAT、VFT except the area: the verbal intelligence quotient between the early PD group and healthy control group (P<0.05). The cognitive impairment of PD is positive relative with the age, the age onset, the course of disease ,the UPDRS score, Webster score , the modified Hoehn-Yahr staging and the ADL score,but is negative correlated with the education level.
The result of Pearson correlation analysis is that SDS and HAMD scores is positive with executive function scores,excluding age,MDRSPD,Webster,the modified Hoehn-Yahr stage,ADL scores(P>0.05).
5. The memory quotient (MQ)(PDD group 40.28±8.91,PDND group76.55±7.04),short-term memory(PDD group 20.39±7.02 , PDND group 34.25±6.69) , long-term memory(PDD group 15.28±3.56 , PDND group 34.25±6.69) , Fuld Object-Memory Evaluation(PDD group 9.89±2.23,PDND group 12.73±1.66),PDD group were changed significantly than PDND group. Immediate memory( PDD group 4.61±2.38,PDND group
5.11±2.20)is not influenced. The severe depression patients are declined more significantly in LTM(16.68±3.0,12.09±2.59), STM(23.28±5.8,13.82±4.79), MQ(61.40±5.75,50.73±1.27) than the light and moderate depression group by one-factor analysis of variance, There is no significantly difference in IM(4.40±2.63,5.09±1.70) (P>0.05).
The dysmnesia incidence rate in PDD group is 28/36(77.78%) is significantly different to the PDND group’s 25/44 (56.82%) through chi square test(P<0.01).The result of Pearson correlation analysis is that SDS and HAMD scores is positive with memory scores and ADL scores ,excluding age,MDRSPD,Webster,the modified Hoehn-Yahr stage scores(P>0.05).
6. Execution Function evaluation: The PDD group scores are shorter the PDND group in (PDD group and PDND group, respectively) SCWT:Stroop1(14.14±5.09,8.66±4.73)、Stroop2(212.33±59.501,125.32±55.51);CDT(5.42±2.05,6.59±2.50), RVR:AR(6.97±1.46,8.84±2.93),FR(6.69±1.67,11.30±2.79), VR(7.47±2.38,9.45±2.89), there were significant differences between PDD group and PDND group(P<0.01).The result of Pearson correlation analysis is that SDS and HAMD scores is positive with the executive functional scores and is negative with the age,MDRSPD,Webster,the modified Hoehn-Yahr stage and ADL scores(P>0.05).
7. The dementia incidence rate in PDD group is 23/36(63.89%) is significantly difference to the PDND group’s dementia incidence rate 15/44(34.09%) through chi square test(P<0.01).
Conclusions:
1. Early PD patients already changed in single cognition item evaluating even the MMSE and CDR did not achieve the dementia level which sometimes was similar to the dementia of PD, especially in frontal lobe cognition assessment. MMSE is not sensitive to detect the cognitive impairment of PD.We should use multiple single neuropsychological tests to assessment the cognitive disturbances in Parkinson's disease. By neuropsychological testing we can get data on PD cognitive impairment that can be used for diagnostic, therapeutic.
2. Depression and its severity degree can influence the cognition of PD. PD patients accompanied with depression have short term memory and long term memery impairment .
3. Depression can significant influence the executive function. The executive function of Parkinson’s disease patients with depression changed significant.
1.研究帕金森病(Parinson’s disease,PD)患者认知功能改变的特点,为临床应用神经心理学测验诊断PD患者的认知功能障碍提供有价值的依据。
2.研究伴发抑郁症的PD患者执行功能的特点,进一步探讨抑郁对PD执行功能障碍的影响。
3.研究伴发抑郁症的PD患者记忆功能障碍的特点,进一步探讨抑郁对PD记忆的影响。
对象与方法
对象
1.对象:选取于2004年9月至2006年9月第三军医大学大坪医院就诊的原发性PD患者作为实验组,以年龄、性别及受教育程度相匹配的社区健康老年人和同期就诊的非神经系统器质性疾病的患者为对照组。
2.排除标准:所有患者均进行头部CT或MRI检查及相关的辅助检查排除脑部相关疾病;排除严重的系统性疾病;按照1984年全国锥体外系疾病讨论会制定的帕金森综合症诊断标准除外继发性PD和特发性震颤。
3.诊断标准:
PD诊断标准:按照1984年10月全国锥体外系讨论会规定的PD诊断标准。抑郁诊断标准:美国《精神病诊断和统计手册》修订第4版抑郁症诊断标准。抑郁的严重程度:根据抑郁自评量表(Self-rating depressive scale ,SDS)和汉密尔顿抑郁量表(Hamilton rating scale for depression ,HAMD)的标准评定。痴呆的诊断标准:美国《精神疾病诊断与统计手册》修订第4版诊断标准。痴呆的严重程度:采用临床痴呆量表CDR评定。
4. PD实验分组:按照修订的Hoehn-Yahr分期:早期PD组(修订的Hoehn-Yahr分期≤2)(n=30);晚期PD组(修订的Hoehn-Yahr分期>2)(n=16)。按照是否伴发抑郁: PD抑郁组(Parkinson’s disease patients with depression ,PDD)(n=36); PD非抑郁组(Nondepressed Parkinson’s disease patients ,PDND)(n=44)。5. PD患者的临床评定指标:修订的Hoehn-Yahr分期;Webster评分量表;统一PD评分量表(UPDRS);帕金森病运动功能评分(MDRSPD)。
方法:
1.所有研究对象均进行详细的病史询问、体格检查。
2.全面认知功能初步评定:简易精神状况检查量表(Mini-mental state examination,MMSE)和临床痴呆评定量表(Clinical dementia rating,CDR)进行全面认知功能状态的初步评定。
3.单项认知功能评定:
3.1智商测验:龚氏修订的韦氏成人智力量表(Wechsler adult intelligence scale- revised in China ,WAIS-RC)测验。
3.2记忆:采用龚氏修订韦氏记忆量表(Wechsler memory scale-revised in China ,WMS-RC)(甲式)检测。
3.3注意测验:符号-数字模式测验(Symbol-digital mode test ,SDMT)和连线测验A(Trail making test A ,TMA)。
3.4执行功能:
(1) Stroop字色干扰测验(Stroop color-word test ,SCWT)。
(2)画钟测验(Clox drawing test,CDT)。
(3)床边测查额叶功能评定量表(Frontal assessment battery at bedside ,FAB)。
3.5知觉测验:WAIS-RC中木块图测验(Block design test ,BDT)和图形拼凑测验(Picture arrangement test ,PAT)。
3.6普通心理学评定:对所有研究对象均进行抑郁自评量表(Self-rating depressive scale,SDS)和汉密尔顿抑郁量表(Hamilton rating scale for depression ,HAMD)评定。
3.7非认知功能评定:采用日常生活能力量表(Barthel指数计分法)(Activity of daily living-Barthel index number scoring method,ADL-BI)。
结果
1.早期PD组与晚期PD组相比在发病年龄(61.13±7.17,70.57±4.82)、病程(2.60±1.18,)、UPDRS评分(24.93±5.36,69.00±12.13)、Webster评分(7.13±2.21,19.79±4.21)、ADL评分(76.83±8.04,31.43±13.36)方面差异有显著性意义(P<0.01)。
2.整体认知功能的初步评定结果:早期PD组、晚期PD组与健康对照组MMSE总分(24.83±2.02,19.79±3.56,27.60±1.59)均有差异,差异有显著性意义(P<0.01)。早期PD组与晚期PD组的痴呆发生率分别为(6.25%,64.29%),差异有显著性意义(P<0.05)。
3.早期PD组与晚期PD组和健康对照组相比较:在智商(Intelligence quotient,IQ)(90.87±9.00,72.43±17.58,99.83±6.96)、记忆商(Memory quotient,MQ)(76.23±9.54,62.43±8.70,99.57±8.21)、注意(25.53±8.74,10.00±11.14,35.60±6.03)、知觉(12.80±2.95,5.07±6.71,20.13±5.20)、执行(6.03±1.35,3.57±1.83,9.57±2.10)方面的测验差异具有显著性意义(P<0.01)。早期PD患者的瞬时记忆测试(9.60±1.75)与健康对照组(9.97±1.59)差异无显著性意义(P>0.05),早期PD的言语智商与健康对照组相比较差异无显著性意义(P>0.05),早期PD的言语智商与晚期PD组及晚期PD组与健康对照组相比较差异具有显著性意义(P<0.01)。
4.在单项认知功能测验中,DST结果显示早期PD组(9.60±1.75)与正常对照组(9.97±1.59)差异无显著性意义(P>0.05),与晚期PD组(4.43±3.44)差异具有显著性意义(P<0.01),提示早期PD患者的瞬时记忆无明显受损。而对于SDMT、TMA、SCWT、FAB、CDT、BDT、PAT、VFT测验,早期PD组与晚期PD组以及早期PD组与健康对照组差异均具有显著性意义(P<0.01)。在早期PD组,MMSE未到达痴呆诊断标准时,已经出现了多项单项认知功能的改变。PD认知功能改变与年龄、发病年龄、病程、UPDRS评分、Webster评分、Hoehn-Yahr分期、ADL呈正相关,与受教育水平呈负相关。
5. PD伴发抑郁记忆功能的评定:MQ(PDD组40.28±8.91,PDND组76.55±7.04),短时记忆(Short-term memory,STM)(PDD组20.39±7.02,PDND组34.25±6.69),长时记忆(Long-term memory,LTM)(PDD组15.28±3.56,PDND组34.25±6.69), PDD组MQ、STM和LTM明显下降,差异具有显著性意义(P<0.01)。瞬时记忆(Immediate memory,IM) (PDD组4.61±2.38,PDND组5.11±2.20)差异无显著性意义(P>0.05)。Fuld物体记忆测验(Fuld Object-Memory Evaluation,FOM)(PDD组9.89±2.23,PDND组12.73±1.66) PDD组与PDND组差异有显著性意义(P<0.01)。
按照抑郁严重程度进行组间比较:轻中度抑郁组与重度抑郁症组在LTM(16.68±3.0,12.09±2.59)、STM(23.28±5.8,13.82±4.79)MQ(61.40±5.75,50.73±1.27)、FOM(10.40±2.18,8.73±1.95)差异均有显著性意义(P<0.01)。IM(4.40±2.63,5.09±1.70)差异无显著性意义(P>0.05)。
PDD组记忆障碍的发生率为28/36(77.78%),PDND组记忆障碍发生率为25/44 (56.82%),差异具有显著性意义(P<0.01)。进行相关分析结果显示SDS和HAMD评分结果具有显著正相关。SDS/HAMD与记忆功能和ADL呈负相关,与年龄、MDRSPD评分、Hoehn-Yahr分期均无明显相关(P>0.05)。
6. PD伴发抑郁执行功能评定:PDD组与PDND组在SCWT:Stroop1(14.14±5.09,8.66±4.73)、Stroop2(212.33±59.50,125.32±55.51);CDT(5.42±2.05,6.59±2.50)和RVR:AR (6.97±1.46,8.84±2.93),FR(6.69±1.67,11.30±2.79)VR(7.47±2.38,9.45±2.89)的检测结果差异均有显著性意义(P<0.01)。
按照抑郁严重程度进行组间比较:轻中度抑郁组与重度抑郁症组的执行功能差异无显著性意义(P>0.05)。
7. PDD组痴呆发生率为23/36(63.89%),PDND组痴呆发生率为15/44(34.09%),差异有显著性意义(P<0.01)。
结论
1.早期PD患者在全面认知功能经MMSE检测尚未达到痴呆水平时,已经出现了多个单项认知功能改变,尤其是以额叶认知功能改变明显,MMSE对于PD的认知功能评定不是一个敏感的工具,需要对PD患者进行单项及全面的认知功能评定,以便对PD患者的认知功能障碍早期诊断和治疗。
2.抑郁症对PD记忆功能有显著的影响,伴发抑郁的PD患者记忆功能下降显著。伴发抑郁的PD患者短时记忆和长时记忆功能明显减退,抑郁临床症状严重程度影响记忆功能的改变。
3.抑郁症对PD执行功能有显著的影响,伴发抑郁的PD患者执行功能下降显著,抑郁临床症状严重程度对执行功能的改变无明显影响。
Objective:
1. To study the characteristic of cognitive impairment accomplished with patients of Parkinson’s disease (PD) in order to show the value of neuropsychological testing as tool used in early detection of cognitive impairment of PD.
2. To study the characteristic of memory of Parkinson’s disease accompanied with depression and the influence of memory of depression with of PD patients.
3. To study the characteristic of executive function of Parkinson disease accompanied with depression and the influence of executive function of depression with cognition of PD patients.
Subjects and Methods:
Subjects
1. Subjects:The idiopathic Parkinson’s disease patients which visited Daping Hospital of Third Military Medical University of Chinese PLA from September 2004 to September 2006 were adopted as experimental group,and the healthy community old people were subjected as control group which were matched with age,gender and educational level.
2. Exclusive criteria:All subjects were examined by CT or MRI and other relative auxiliary examination in order to exclude the serious systematic disorders. At the same time they should match with the diagnostic criteria of parkinsonism which was made by the nationwide extracorticospinal tract disease conference’s diagnostic criteria in October 1984.
3. Diagnostic criteria: Diagnostic criteria of PD: According to the nationwide extracorticospinal tract disease conference’s diagnostic criteria of October 1984. Diagnostic criteria of depression: according to the DSM-IV criteria. The severity of depression: according to the SDS and HAMD criteria. Diagnostic criteria of dementia: according to the DSM- IV criteria. The severity of dementia: according to the CDR.
4. Experiment subgroup:
According to the revised Hoehn-Yahr staging there are two groups: early PD group (modified Hoehn-Yahr grade≤2)(n=30) , later PD group(modified Hoehn-Yahr grade>2)(n=16);
According to whether accompanied with depression there are two groups:Parkinson disease with depression group(PDD)(n=36), nondepressed Parkinson’s disease patients group (PDND)group(n=44).
5. Clinical evaluation criteria of parkinsionian:modified Hoehn-Yahr staging;Webster rating scale;Unified Parkinson disease rating scale(UPDRS);Motor dysfunction rating scale for Parkinson’s disease (MDRSPD).
Methods:
1. All subjects need to accept the professional physical examination and record the case history.
2. Global cognition assessment: Mini-mental state examination (MMSE) and Clinical dementia rating (CDR).
3. Single cognition assessment:
3.1 Intelligence quotient test:Wechsler adult intelligence scale revised in China (WAIS-RC);
3.2 Memory:Wechsler memory scale revised in China (WMS)
3.3 Attention test:Symbol digital model test (SDMT)and trail making test A(TMA);
3.4 Execution Function:
(1) Stroop color-word test (SCWT).
(2) Clock drawing test (CDT).
(3) Frontal assessment battery at bedside (FAB).
(4) Rapid Verbal Retrieve (RVR).
3.5 Perception test:Block design test of WAIS-RC(BDT), Picture arrangement test(PAT).
3.6 General psychology assessment:Self-rating depressive scale (SDS) and Hamilton's rating scale for depression (HAMD) .
3.7 Non-cognition assessment: Activity of daily living by Barthel index (ADL-BI).
Results
1. There were significant differences between early PD group and later PD group in age of onset(61.13±7.17, 70.57±4.82)、course of disease(2.60±1.18)、UPDRS score (24.93±5.36, 69.00±12.13)、Webster score(7.13±2.21,19.79±4.21)、ADL score(76.83±8.04,31.43±13.36).
2.The result of initial assessment of the whole cognition: There were significant differences in the early PD group ,later PD group and the healthy control group in the whole scores of MMSE(24.83±2.02,19.79±3.56,27.60±1.59) (P<0.01).The dementia incidence is (6.25%,64.29%,respectively),which is significantly different(P<0.01).
3. There were significant differences in intelligence quotient(90.87±9.00,72.43±17.58,99.83±6.96), (90.87±9.00, 72.43±17.58,99.83±6.96)、memory quotient(76.23±9.54, 62.43±8.70, 99.57±8.21)、attention(25.53±8.74, 10.00±11.14, 35.60±6.03)、perception (12.80±2.95, 5.07±6.71, 20.13±5.20)、executive function(6.03±1.35, 3.57±1.83, 9.57±2.10) between early PD group and later PD group, so as to the healthy control group (P<0.01).There were no significant differences in immediate memory between the earlier PD group(9.60±1.75)and healthy control group(P>0.05),as well as the verbal intelligence quotient.
4. In single cognition testing, the result of DST that there are no significant differences between the early PD group and later PD group by(9.60±1.75, 9.97±1.59,respectively) indicate that the there are no dysfunction in immediate memory.There are great significant differences in the three groups in other tests such as SDMT、TMA、SCWT、FAB、CDT、BDT、PAT、VFT except the area: the verbal intelligence quotient between the early PD group and healthy control group (P<0.05). The cognitive impairment of PD is positive relative with the age, the age onset, the course of disease ,the UPDRS score, Webster score , the modified Hoehn-Yahr staging and the ADL score,but is negative correlated with the education level.
The result of Pearson correlation analysis is that SDS and HAMD scores is positive with executive function scores,excluding age,MDRSPD,Webster,the modified Hoehn-Yahr stage,ADL scores(P>0.05).
5. The memory quotient (MQ)(PDD group 40.28±8.91,PDND group76.55±7.04),short-term memory(PDD group 20.39±7.02 , PDND group 34.25±6.69) , long-term memory(PDD group 15.28±3.56 , PDND group 34.25±6.69) , Fuld Object-Memory Evaluation(PDD group 9.89±2.23,PDND group 12.73±1.66),PDD group were changed significantly than PDND group. Immediate memory( PDD group 4.61±2.38,PDND group
5.11±2.20)is not influenced. The severe depression patients are declined more significantly in LTM(16.68±3.0,12.09±2.59), STM(23.28±5.8,13.82±4.79), MQ(61.40±5.75,50.73±1.27) than the light and moderate depression group by one-factor analysis of variance, There is no significantly difference in IM(4.40±2.63,5.09±1.70) (P>0.05).
The dysmnesia incidence rate in PDD group is 28/36(77.78%) is significantly different to the PDND group’s 25/44 (56.82%) through chi square test(P<0.01).The result of Pearson correlation analysis is that SDS and HAMD scores is positive with memory scores and ADL scores ,excluding age,MDRSPD,Webster,the modified Hoehn-Yahr stage scores(P>0.05).
6. Execution Function evaluation: The PDD group scores are shorter the PDND group in (PDD group and PDND group, respectively) SCWT:Stroop1(14.14±5.09,8.66±4.73)、Stroop2(212.33±59.501,125.32±55.51);CDT(5.42±2.05,6.59±2.50), RVR:AR(6.97±1.46,8.84±2.93),FR(6.69±1.67,11.30±2.79), VR(7.47±2.38,9.45±2.89), there were significant differences between PDD group and PDND group(P<0.01).The result of Pearson correlation analysis is that SDS and HAMD scores is positive with the executive functional scores and is negative with the age,MDRSPD,Webster,the modified Hoehn-Yahr stage and ADL scores(P>0.05).
7. The dementia incidence rate in PDD group is 23/36(63.89%) is significantly difference to the PDND group’s dementia incidence rate 15/44(34.09%) through chi square test(P<0.01).
Conclusions:
1. Early PD patients already changed in single cognition item evaluating even the MMSE and CDR did not achieve the dementia level which sometimes was similar to the dementia of PD, especially in frontal lobe cognition assessment. MMSE is not sensitive to detect the cognitive impairment of PD.We should use multiple single neuropsychological tests to assessment the cognitive disturbances in Parkinson's disease. By neuropsychological testing we can get data on PD cognitive impairment that can be used for diagnostic, therapeutic.
2. Depression and its severity degree can influence the cognition of PD. PD patients accompanied with depression have short term memory and long term memery impairment .
3. Depression can significant influence the executive function. The executive function of Parkinson’s disease patients with depression changed significant.
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