失智症吞嚥照顧評估及治療

Dysphagia Evaluation and Management in Dementia

隨著臺灣高齡人口逐年增加，失智症人口也逐漸增加，失智症患者的吞嚥照護問題愈受重視。失智症患者的吞嚥困難可以發生在口咽期的任何階段，但一般而言，口腔期異常的比率比咽部期多。同時若有知覺缺失、認知障礙、精神因素等問題，也會加重進食困難。嚴重的吞嚥困難則會發生食物攝取不足、體重減輕、營養不良、誤吸及肺部併發症等。在吞嚥功能的評估包括臨床評估與儀器評估，臨床評估包含病史、認知與溝通、患者因素、環境因素、吞嚥因素等，並配合選擇合適的吞嚥評估量表。儀器評估，則以影像透視吞嚥檢查(videofluoroscopic swallowing studies, VFSS)及吞嚥內視鏡檢查(fiberoptic endoscopic evaluation of swallowing, FEES)為主。吞嚥照顧則應以跨團隊多面向的介入照顧，以直接訓練法為主，而且以訓練及教育照顧者為優先。管灌飲食可作為暫時性的處置，並不建議長期使用。嚴重失智症患者的吞嚥照顧應以安寧照護為主要的考量。本文提供在失智症吞嚥照顧上之參考與應用。

The greater elderly population in Taiwan is, the more the number of people with dementia become. Dysphagia management in dementia patients thus has gained attention. Dysphagia in dementia patients can occur in any stage of oropharyngeal phase, while abnormality in oral phase was more common than that in pharyngeal phase. If concurrent with perceptual deficits, cognitive impairment and psychological factor, dysphagia may aggravate. Severe dysphagia leads to poor oral intake, body weight loss, malnutrition, aspiration and pulmonary complications. Complete evaluation of swallowing includes clinical swallowing evaluation and instrumental evaluation. Clinical swallowing evaluation comprises of medical history, cognitive and communication, client factor, environment factor, swallowing factors as well as several assessment tools and scales. Instrumental evaluation comprises mainly of videofluoroscopic swallowing studies (VFSS) and fiberoptic endoscopic evaluation of swallowing (FEES). Multidisciplinary care approaches for dysphagia management, which uses direct therapy and the main emphasis should be caregiver training. Tube feeding works as temporary management but cannot be used permanently. Dysphagia management in patients with severe dementia should stress more on hospice care. The article provides detailed dysphagia evaluation and management in dementia patients.