31.3 🩺 內科專科考前版

31.3.0.1 📌 䞀頁重點

  • 22E 革呜anti-amyloid mAblecanemab, donanemab改寫 AD 治療
  • Blood-based biomarkers emergingplasma Aβ42/40, p-tau
  • Lewy body / FTD 認可床䞊升
  • Taiwan 倱智症照護政策

31.3.0.2 🧠 進階機蜉

31.3.0.2.1 AD Pathophysiology
  • Amyloid hypothesis: Aβ accumulation → tau phosphorylation → 神經元死
  • Tau hypothesis: tauopathy 范與 cognitive decline 盾關
  • Inflammation, vascular, mitochondrial 共同
  • APOE4 是 strong genetic risk
  • Familial AD: APP, PSEN1, PSEN2 mutations
31.3.0.2.2 DLB Pathology
  • α-synuclein aggregation
  • 與 PD dementia 同䞀 spectrum
31.3.0.2.3 FTD Pathology
  • TDP-43 (50%), tau (40%), FUS (5-10%)
  • Genetic: C9orf72, MAPT, GRN
  • bvFTD vs PPA variants
31.3.0.2.4 Vascular Dementia
  • Multi-infarct
  • Strategic single infarct
  • Subcortical (Binswanger)
  • Mixed AD + VaD

31.3.0.3 💊 進階治療

31.3.0.3.1 Anti-Amyloid mAb22E 焊點

Lecanemab (Leqembi): - IV 10 mg/kg q2w - CLARITY-AD trial: 27% slowing in CDR-SB at 18 mo - Approved early AD (mild dementia or MCI) with amyloid + - ARIA-E (edema) ~13%, ARIA-H ~17% - APOE4 homozygote: ARIA risk × 3 - MRI monitoring 5×

Donanemab (Kisunla): - IV q4w - TRAILBLAZER-ALZ 2: similar efficacy - ARIA risk similar - 可圚 amyloid clearance 埌停藥

31.3.0.3.2 Behavioral Symptoms (BPSD)
  • Non-pharm first
  • Antipsychotic caution:
    • Black box warning: ↑ mortality in dementia
    • DLB: avoid typical (haloperidol); use quetiapine/clozapine
  • SSRI for depression / agitation
  • Cholinesterase inhibitor 郚分緩解
31.3.0.3.3 Sleep + REM Behavior
  • Melatonin 3-15 mg HS
  • Clonazepam (caution falls)
31.3.0.3.4 Family / Caregiver Support
  • 倱智家屬照顧 burden 極倧
  • 喘息服務
  • Adult day care
  • Long-term care

31.3.0.4 🌟 Pearls (10)

  1. Anti-amyloid mAb 是 disease-modifying — 䜆 modest 效果 + 高副䜜甚
  2. APOE4 testing before initiation 22E 暙配
  3. DLB diagnosis 最容易被當成 AD
  4. FTD 早期 倚被當 psychiatric
  5. Pseudodementia 䞍胜挏depression-related
  6. NPH triad = wet/wacky/wobbly + tap test
  7. Cognitive reserve (education, social engagement) ç·© onset
  8. Modifiable risk: HTN, DM, smoking, hearing loss, social isolation, depression
  9. Lancet Commission 202414 modifiable risk factors prevent 45% dementia
  10. Hearing aid use prevent 8% dementia (largest single)

31.3.0.5 🔍 特殊情境

  • Young-onset dementia< 65FTD, AD genetic, prion, autoimmune
  • Rapidly progressive dementia: CJD, autoimmune encephalitis (NMDA), HIV
  • Post-stroke cognitive decline
  • HIV-associated neurocognitive disorder

31.3.0.6 📍 台灣 Context

  • 65+ 倱智盛行率 8%、80+ 25%
  • TADA台灣倱智症協會
  • 健保倱智症共照
  • 衛犏郚倱智症蚈畫
  • 長照 2.0
  • Lecanemab 2024 通過䜆自費高昂
  • 友善瀟區、瑞智孞堂

31.3.0.7 ⚠ 老闆地雷

  1. 倱智當老化
  2. DLB 絊 haloperidol
  3. Anti-amyloid mAb 䞍查 APOE4 / amyloid status
  4. 䞍評䌰 caregiver burden
  5. Reversible 䞍查
  6. Antipsychotic 長期甚無 monitor

31.3.0.8 🎓 內專重點

  1. 5 倧類型
  2. DLB criteria
  3. FTD variants
  4. Reversible workup
  5. Anti-amyloid mAb (22E)
  6. BPSD management
31.3.0.8.1 跚章節
  • Ch 29 Delirium
  • Ch 32 Aphasia
  • Ch 442 AD
  • Ch 31 specifically PDCh 442

31.3.0.9 📖 延䌞閱讀

  • AAN AD Practice Guideline
  • Lancet Commission 2024 (modifiable risk factors)
  • CLARITY-AD, TRAILBLAZER-ALZ 2 trials
  • McKeith DLB Consensus Criteria
  • TADA 台灣指匕

31.3.0.10 📚 玢匕

⚠ AI 草皿。