indication Target symptoms Initial dose starting dose Target

使用抗精神病藥物 • • 診斷與indication(適應症) —建立治療性關係 Target symptoms(目標症狀) Initial dose (starting dose, 起始劑量) Target dose(預定的有效劑量) Maintenance dose(長期維持劑量) Days to mid-target dose (調藥時間間隔) Days to effect(等待藥效開始的時間) • Days to maintenance dose(減至維持劑量的時間) • Full dose, Full term (考慮有效的最大劑量及時間 4

Inhibition potential of CYP 450 by newer antidepressants + : inhibition potential De Vane et al. , J. Clin. Psych. 1998; 59(suppl 20): 85 -93

老人憂鬱症的治療與副作用 5 HT Norepinephrine Dopamine Anticholinergic BW↑ Arrhythmia Imipramine ++ ++ 0 +++ +++ Fluoxetine +++ 0 +/- 0 0? /+ ½+ Sertraline/cipram +++ 0 +/- 0 0? /+ ½+ Venlfexine +++ ++ + ½+ 0 ½+ Trazodone ++ +/- 0 ½+ ½+ ½+ mirtazapine +? +++ 0 ? 0 ++ ? 0 + + 0 0 ½+ Bupropion 7

老人憂鬱症的治療與副作用 sedation Insomnia Hypo/agitated tension Imipramine +++ GI nausea + ++++ + Fluoxetine ½+ ++ 0 +++ Sertraline + 0 +++ Venlfexine ½+ ++ 0 +++ Trazodone + 0 ++ ++ Mirtazapine 0 ++ ++ + ½+ ++ Bupropion ½+ 8

2 nd generation antipsychotics (Pies 1998. Muller-Spahn F Eur Psychiatry 2002) Prolactin* D 2 5 HT 2 a M 1 H 1 α 1 -adrenergic BW Clozapine 0 ++ ++++ + +++ Quetiapine 0 +/- + + ½+ ½+? Olanzapine ½+ + ++++ ++ ½+ +++ Zotepine +/- + Risperidone** + +++ +/- ½+ ++ + Ziprasidone* + +++ 0 +/- 0 Amisulpride** +/D 3 +/- 0 0 ? + ++ 9

2 nd generation antipsychotics (Pies 1998. Muller-Spahn F Eur Psychiatry 2002) EPS TD seizure Agranulocytosis Drowsy/s edation hypotension Clozapine 0 0 +++ +++ ++ Quetiapine +/- 0 +/- + + Olanzapine ½+ 0 +/- ½+ ++ ½+ Zotepine + ? ++ +/- +++ ++ Risperidone + + +/- 0 + + Ziprasidone + + + 0 + ½+ Amisulpride ½+ +/- 0 ? 0 + 0 10

文獻搜尋策略 • 資料庫 : Pub. Med • 關鍵字：“Alzheimer disease” , “Alzheimer’s disease” or “dementia” and “depression” and “各種抗憂鬱劑“ • 限制進階搜尋條件： w Dates： 1990 -1 -1~2010 -05 -31 w Type of article ：Clinical Trial, Meta-Analysis, Practice Guideline, Randomized Controlled Trial, Review w Humans and English • 若搜尋到的文章篇數少於 3篇時，就取消”Type of article”之限制 再搜尋一次 • 之後以Medline資料庫(1966 -2010)再作比對 林口長庚吳冠毅, 歐陽文貞 9906 14

納入分析之文章 RCT Comparative study Citalopram 1 1 Fluoxetine 1 1 Paroxetine Sertraline Open trial 3 4 1 1 Escitalopram 1 Milnacipran 1 Venlafaxine 1 Moclobemide 1 Clomipramine 1 Imipramine 1 16

Dog-assisted therapy • Perkins J, et al. Australas J Ageing. 2008. No RCT, The most frequently reported findings were an increase in social behaviour and a decrease in agitated behaviour during dog contact. 30

文獻搜尋策略 • 在Pub. Med上以“AD” or “dementia” and “非藥物治療英文”為 關鍵字搜尋, 如 music therapy, reminiscence therapy, aromatherapy。 • 限制進階搜尋條件為 Dates: 1990 -01 -01 to 2009 -12 -31; Type of Article: Clinical Trial, Meta-Analysis, Practice Guideline, Randomized Controlled Trial; Species: Humans; Languages: English。 • 若搜尋到的文章篇數少於 4篇時，就取消Type of Article之 限制再搜尋一次。若有未搜尋到之相關重要文章，也可在 評估過後納入。 31 31

The Evidence Pyramid 32 32

納入之文章種類 Meta-analysis (Cochrane review) Randomizedcontrolled trails Open trials 音樂治療 11(2004) 3(2004年後含non. AD 有8篇 ) -- 懷舊治療 1(2005更新, 舊版2000) 0(1 篇-Va. D after 2005) 0(2005年後 dementia 3) 芳香療法 1(2003), 1(2008 非Cochrane) 0 (after 2003) 3(after 2003) 肢體運動 待確認 待確認 0/0 3/0 家屬認知教育 1(2008) 待確認 家屬情緒支持(團體) 1(2008) 待確認 寵物陪伴/園藝治療 35 以上不含guideline性質的 Livingston G. et al. Am. J Psychiatry 2005; 162: 1996– 2021 Systematic Review of Psychological Approaches to the Management of Neuropsychiatric 35

重點結果摘要_芳香療法 • Nguyen QA, Paton C. Int J Geriatr Psychiatry. 2008. (The use of aromatherapy to treat behavioural problems in dementia. ) 搜尋 Medline, Cochrane and EMBASE的RCT aromatherapy. 結果: 11篇RCT aromatherapy 用在BPSD上. • 香油使用差異大. The aromatherapy oils tested, method of administration and outcome measures used varied widely across the studies. • 大多樣本少 • 研究設計差異大使得無法詮釋其結果. 43

重點結果摘要_芳香療法 • Ward-Smith P, et al. Am J Alzheimers Dis Other Demen 2009. 介入: multisensory stimulation environments (MSSE) 6個月, 量表: Psychotic Behavior Assessment Record (PBAR), 結果: 可 降低行為問題(disruptive behavior). • Fujii M, et al. Geriatr Gerontol Int 2008. Lavender aroma therapy(薰衣草) 有效. 44

重點結果摘要_芳香療法 • Snow LA, et al. J Altern Complement Med. 2004 結果: 無效! Split-middle analyses conducted separately for each patient revealed no treatment effects specific to lavender, no treatment effects nonspecific to pleasant smelling substances, and no treatment effects dependent on order of treatment administration. There were no differences between participants with more and less intact olfactory abilities. • 介入: ABCBA (A = lavender oil, B = thyme oil, C = unscented grape seed oil): 4 weeks of baseline measurement, 2 weeks for each of the five treatment conditions (10 -week total intervention time), and 2 weeks of post intervention measurement. 45