卒中后失语患者认知障碍的康复特点及影响因素研究

发布时间：2018-04-20 15:09

本文选题：卒中 + 失语　；参考：《南方医科大学》2017年硕士论文

【摘要】：研究背景失语症是因大脑病变而导致的语言障碍,包括听、说、读、写等能力受损。急性缺血性脑卒中后约有1/3的患者伴有不同程度的失语。卒中后认知功能障碍(poststroke cognitive impairment,PSCI)现已成为临床医师在卒中康复进程中关注的热点问题,但受限于缺少适用的非语言性认知评估量表、患者配合度不高等原因,卒中后失语(post-strokeaphasia,PSA)患者的非语言性认知障碍却常常被忽视。国内外研究发现在卒中急性期PSA患者非语言性认知障碍的发生率为86%。发病后3个月,有88%的PSA患者出现至少一个非语言认知域的损害。而研究对象为卒中后非失语患者的大样本调查显示卒中发生后3个月PSCI的发生率大约为47.3%-56.6%。表明PSA患者非语言性认知障碍的发生率远高于非失语的脑卒中患者。目前临床常用于评估认知功能的量表主要包括简易精神状态量表(Mini-mental State Examination,MMSE)、蒙特利尔认知评估量表(Montreal Cognitive Assessment,MoCA)等,因其操作具有较强的语言依赖性,故难以应用于PSA患者的认知功能评估。而专用于失语患者的认知功能评估量表,如失语检查量表(Aphasia Check List,ACL),在识别PSA患者认知障碍方面具有良好的敏感性和特异性,然而目前尚未在我国经过汉化修订,更没有在国内经过大样本的信效度检验。为了尽可能客观地评估PSA患者的认知功能,本课题组在前期研究中编制了非语言性认知功能评估量表(Non-language-based Cognitive Assessment,NLCA),用图片示范加演示的方式代替传统指导语,专门用于失语患者的认知功能评估,该量表包括记忆力、视空间、注意力、逻辑推理能力以及执行力五个认知域的检测,经过检验具有良好的信度和效度。本研究现将NLCA量表应用于PSA患者的随访研究,并全面评估语言功能及抑郁情绪、日常生活能力,以了解缺血性脑卒中发生后3个月失语患者语言及其他认知功能的康复情况,探讨卒中后3个月失语患者认知状况的重要影响因素,为PSA患者的整体康复提供新的思路和参考依据并更进一步剖析语言认知的复杂系统。目的1.了解卒中后失语患者语言及其他非语言性认知障碍的康复特点;2.卒中后失语患者认知障碍康复的影响因素分析。方法选取自2015年6月至2016年11月在本院神经内科病房住院的急性缺血性脑卒中后失语患者。纳入标准:(1)符合中华医学会神经病学分会全国第四届脑血管病会议制定的脑卒中诊断标准,并经CT或MRI证实;(2)发病时间大于1周,意识清楚,病情稳定,至少一侧肢体肌力大于3级且愿意配合检查;(3)经汉语失语检查量表(Aphasia Battery of Chinese,ABC)评估确定为失语症患者;(4)患者及家属知情同意并已签署知情同意书。排除标准:(1)意识障碍、严重精神症状或严重听力、视力损害;(2)既往有脑血管病史或本次发病前已有本人或家属可察觉的认知功能下降症状。选择符合纳入标准的首次脑卒中患者,确定为失语症后判断失语类型,并采用波士顿诊断失语检查(Boston Diagnostic Aphasia Examination,BDAE)中的失语严重程度分级评估失语严重程度。然后记录基本资料(年龄、性别、利手、受教育年限、发病时间、电话号码等)、头颅MRI/CT结果(病灶部位,病灶大小按最大直径≤1cm、1-5cm、≥5cm分为小、中、大病灶)、出院时是否使用改善认知药物及抗抑郁药物。所有研究对象均接受美国国立卫生研究院脑卒中量表(NIHSS)、非语言性认知功能评估量表量表以及卒中后失语患者抑郁问卷(医院版)(Stroke Aphasic Depression Questionnaire Hospital Version,SADQ-H)量表、日常生活活动能力量表(activities of daily living scale,ADL)的检查。发病后3个月电话通知患者前来随访,再次使用以上量表对患者进行评估,并记录患者出院后的药物使用情况。所有测验均由经过正规神经心理测验培训的神经内科研究生在安静无干扰的环境下进行。共纳入卒中后1-2周(作为基线)的PSA患者41例,卒中3个月后随访患者共30例(随访率73.17%)。(1)所有患者均为缺血性脑卒中;男24例,女6例;年龄(55.70±15.11)岁;病程(9.40±5.25)天;受教育年限(8.80±4.40)年;均为右利手。(2)失语类型:Broca失语4例(13.33%),Wernicke失语3例(10%),完全性失语5例(16.67%),经皮质混合性失语2例(6.67%),经皮质运动性失语3例(10%),经皮质感觉性失语7例(23.33%),命名性失语1例(3.33%),传导性失语3例(10%),未分类失语2例(6.67%)。(3)入组时情况..NIHSS 评分(5.70±4.53),SADQ-H 评分(17.53±10.48),ADL 评分(45.97±18.39)。所有数据通过SPSS20.0软件进行统计学处理。以P0.05表示差异有统计学意义。结果1.PSA患者卒中后3个月对比基线,流利性[(21.80±6.08)分,(15.83±7.39)分]、听理解[(203.33±35.30)分,(139.70±72.82)分]等语言评估各项分数均明显提升,差异有统计学意义(P0.01);2.卒中后3个月NLCA总分[(65.83±13.02)分,(48.00±25.11)分]及记忆力[(17.23±2.49)分,(13.30±5.42)分]、视空间能力[(10.67±2.43)分,(8.07±3.75)分]、逻辑推理能力[(6.53±1.48)分,(4.97±2.43)分]、注意力[(25.57±5.79)分,(17.43±12.33)分]、执行力[(5.77±3.47)分,(4.20±4.23)分]各项均较基线明显改善,差异有统计学意义(P0.05)。3.卒中后3个月失语未完全康复患者NLCA总分[(62.40±14.23)分]及视空间能力[(9.95±2.67)分]、逻辑推理能力[(6.05±1.54)分]两个亚项评分均显著低于失语完全康复患者[分别为(72.70±6.34)分、(12.10±0.74)分、(7.50±0.71)分],且日常生活能力[(32.55±12.57)分,(23.40±5.82)分]及抑郁评分[(10.35±7.85)分,(2.40±2.37)分]更高,差异具有统计学意义(P0.05)。4.多元回归分析提示与失语患者卒中后3个月内认知功能改善情况显著相关的因素为基线NLCA评分(β=-0.603,P=0.000)。结论1.PSA患者非语言性认知功能的康复特点同语言功能类似,在卒中后3个月内能明显改善。2.卒中后3个月失语未完全康复患者非语言性认知功能及日常生活能力更差,抑郁情绪更严重。3.卒中1-2周的认知功能是PSA患者卒中后3个月认知结局的良好预测因子。
[Abstract]:Background aphasia is a language disorder caused by brain lesions, including impaired listening, speaking, reading, writing, and so on. Patients with 1/3 after acute ischemic stroke are associated with varying degrees of aphasia. Cognitive impairment after stroke (poststroke cognitive impairment, PSCI) has become a fever for clinicians in the process of stroke rehabilitation. The problem is limited, but it is limited to the lack of a nonverbal cognitive assessment scale, and the nonverbal cognitive impairment of patients with post-strokeaphasia (PSA) is often neglected. The incidence of nonverbal cognitive impairment in PSA patients at acute stroke is 3 months after the onset of 86%., 88% of PSA patients had at least one nonverbal cognitive impairment. The study of a large sample of non aphasic patients after apoplexy showed that the incidence of PSCI was about 47.3%-56.6%. after 3 months of stroke, indicating that the incidence of non verbal cognitive impairment in PSA patients was much higher than that of nonverbal apoplexy. The scale of cognitive function assessment mainly includes the Mini-mental State Examination (MMSE), the Montreal cognitive assessment scale (Montreal Cognitive Assessment, MoCA) and so on. Because of its strong language dependence, it is difficult to apply to the cognitive function assessment of the PSA patients. It is used for the cognitive function of the aphasia patients. The assessment scale, such as the Aphasia Check List (ACL), has a good sensitivity and specificity in identifying the cognitive impairment of patients with PSA. However, it has not yet been revised in China by Sinization and has not been tested in large samples in China. In order to evaluate the cognitive function of PSA patients as objectively as possible, this subject is subject to the objective evaluation of the cognitive function of the patients. In the previous study, the Non-language-based Cognitive Assessment (NLCA) was developed to replace the traditional guidance with a picture demonstration and demonstration, which was used to evaluate the cognitive function of the aphasia, including memory, visual space, attention, logical reasoning, and execution. Five The test of cognitive domain has good reliability and validity. The NLCA scale is applied to the follow-up study of PSA patients, and the language function and depression, daily life ability are evaluated in order to understand the rehabilitation of the language and other cognitive functions of aphasia patients after 3 months of ischemic stroke, and to explore the 3 after stroke. The important influencing factors of cognitive status in patients with aphasia for the month of aphasia provide new ideas and references for the overall rehabilitation of PSA patients and further analyze the complex system of language cognition. Objective 1. to understand the rehabilitation characteristics of language and other nonverbal cognitive impairment after apoplexy; 2. the image of cognitive impairment after apoplexy aphasia patients Methods the patients with apoplexy after acute ischemic stroke hospitalized in the neurology ward of our hospital from June 2015 to November 2016 were selected. (1) the standard of stroke diagnosis was established in accordance with the fourth session of the National Conference on cerebrovascular disease of the Chinese Medical Association, which was confirmed by CT or MRI; (2) the onset time was more than 1 weeks. Clear consciousness, stable condition, at least one side of the limb muscle strength greater than 3 and willing to cooperate with the examination; (3) the Chinese aphasia Checklist (Aphasia Battery of Chinese, ABC) was evaluated as aphasia; (4) the patients and their families informed consent and signed informed consent. (1) consciousness disorder, severe mental symptoms or severe hearing, visual Force impairment; (2) the symptoms of cognitive impairment that had already been perceived by the patient or family before the history of cerebrovascular disease or this disease. Select the first stroke patients in accordance with the inclusion criteria, determine the type of aphasia after the aphasia, and use the Boston Diagnostic Aphasia (Boston Diagnostic Aphasia Examination, BDAE) and the aphasia. The severity of aphasia was assessed by the degree of severity. Then the basic data (age, sex, benefit, time of education, time of disease, telephone number, etc.), and the results of the head MRI/CT (the location of the focus, the size of the lesion at the maximum diameter less than 1cm, 1-5cm, > 5cm were divided into small, medium, large), and the use of improved cognitive and antidepressant drugs at discharge. The subjects received the National Institutes of Health Stroke Scale (NIHSS), the nonverbal cognitive function assessment scale and the post apoplexy aphasia depression questionnaire (hospital Edition) (Stroke Aphasic Depression Questionnaire Hospital Version, SADQ-H), the daily living ability scale (activities of daily living), 3 months after the onset of the disease, the patients were followed up 3 months after the onset of the disease, and the above scale was used again to assess the patients and to record the use of the patients after discharge. All the tests were conducted in a quiet, silent environment trained by a regular neuropsychological test for 1-2 weeks after a stroke (as a result of a stroke). A total of 41 patients with PSA and 3 months after stroke were followed up in 30 cases (73.17%). (1) all patients were ischemic stroke, 24 men, 6 women, age (55.70 + 15.11) years, course (9.40 + 5.25) days and years of Education (8.80 + 4.40); all were right hand. (2) aphasia, Wernicke aphasia 5 cases (16.67%) had sexual aphasia, 2 cases (6.67%), 3 cases of motor aphasia (10%), 7 cases of sensory aphasia (23.33%), 1 named aphasia (3.33%), 3 (10%) conduction aphasia (10%), and unclassified aphasia (3.33%), SADQ-H score, ADL score, ADL score. 18.39). All data were statistically treated with SPSS20.0 software. The difference was statistically significant by P0.05. Results the contrast baseline of 1.PSA patients after 3 months of stroke, fluency [(21.80 + 6.08), (15.83 + 7.39)]), listening comprehension [(203.33 + 35.30), (139.70 + 72.82)], and other scores were significantly improved, and the differences were statistically significant 2. ((65.83 + 13.02) points, (48 + 25.11) points) and memory [(17.23 + 2.49) points, (13.30 + 5.42) points], visual space capability [10.67 + 2.43), (10.67 + 2.43) points, logical reasoning ability [(25.11 + 17.23) points], attention [(25.11 + 25.11) points]. The scores, (4.20 + 4.23) points, were obviously improved compared with the baseline, and the difference was statistically significant (P0.05) in the 3 months after.3. apoplexy, the total score of NLCA [(62.40 + 14.23)] and the visual space ability [(9.95 + 2.67)], and the logical reasoning ability [(6.05 + 1.54)] were significantly lower than those of the complete rehabilitation patients [(72] (respectively) .70 + 6.34), (12.10 + 0.74) points, (7.50 + 0.71) points, and the daily living capacity [(32.55 + 12.57), (23.40 + 5.82)] and depression score [(10.35 + 7.85), (2.40 + 2.37)] was higher, and the difference was statistically significant (P0.05).4. multiple regression analysis suggested that the cognitive function improvement of aphasia patients was significantly related to cognitive function within the period of stroke. Conclusion the baseline NLCA score (beta =-0.603, P=0.000). Conclusion the non verbal cognitive function of 1.PSA patients is similar to the language function. In the 3 months after stroke, the patients with.2. stroke can obviously improve the non verbal cognitive function and daily living ability of the patients with the 3 months of apoplexy after.2. stroke, and the depression is more serious for 1-2 weeks of.3. stroke. Knowledge function is a good predictor of cognitive outcomes in PSA patients at 3 months after stroke.

【学位授予单位】：南方医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R743.3

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