摘要：

目的 总结阿尔茨海默病伴脑白质病变（WML）患者的认知功能和精神行为特点。方法 纳入2010年1月至2020年12月天津市环湖医院收治的共58例阿尔茨海默病患者，采用简易智能状态检查量表（MMSE）和蒙特利尔认知评价量表（MoCA）评价认知功能、日常生活活动能力量表（ADL）评价日常生活活动能力、神经精神科问卷（NPI）评价神经精神行为、汉密尔顿抑郁量表21项（HAMD-21）评价抑郁症状、临床痴呆评价量表（CDR）评价痴呆程度，行头部MRI检查，通过脑白质高信号[WMH，包括脑室旁白质高信号（PWMH）和脑深部白质高信号（DWMH）]对脑白质病变进行半定量视觉评分。结果 （1）WML组患者高血压比例（χ²=4.665，P=0.031）、NPI评分（Z=1.987，P=0.047）和CDR评分（Z=2.069，P=0.039）高于，MMSE评分（t=2.927，P=0.005）和MoCA评分（t=3.394，P=0.001）低于无WML组，其中，WML组MMSE量表中注意力和计算力（Z=2.234，P=0.025）、回忆能力（Z=2.792，P=0.005）、命名（Z=2.382，P=0.017）、复述（Z=2.685，P=0.007）等认知域评分较低，NPI量表中妄想（Fisher确切概率法：P=0.046）、抑郁/心境恶劣（χ²=4.376，P=0.036）、情感淡漠/漠不关心（χ²=4.063，P=0.044）发生率较高。（2）中至重度WML组高血压比例（χ²=11.195，P=0.001）和低密度脂蛋白胆固醇（t=2.573，P=0.013）以及ADL评分（Z=3.269，P=0.001）、NPI评分（Z=3.439，P=0.001）和CDR评分（t=2.740，P=0.006）高于，MMSE评分（t=3.686，P=0.001）和MoCA评分（t=5.225，P=0.000）低于无或轻度WML组。（3）轻度、中度与重度痴呆组同型半胱氨酸（Hcy；F=6.291，P=0.003）、高血压比例（χ²=10.716，P=0.005）、伴脑白质病变比例（χ²=8.100，P=0.017）、Fazekas总评分（H=13.658，P=0.001）、脑室旁白质高信号Fazekas评分（H=6.540，P=0.038）、脑深部白质高信号Fazekas评分（H=21.550，P=0.000）差异均有统计学意义，其中重度痴呆组高血压比例（χ²=6.702，P=0.010；Fisher确切概率法：P=0.006）、Hcy（P=0.039，0.001）、Fazekas总评分（Z=2.898，P=0.004；Z=3.223，P=0.001）、脑深部白质高信号Fazekas评分（Z=2.807，P=0.005；Z=4.144，P=0.000）均高于中度痴呆组和轻度痴呆组，仅伴脑白质病变比例高于轻度痴呆组（Fisher确切概率法：P=0.008），脑室旁白质高信号Fazekas评分高于中度痴呆组（Z=2.567，P=0.010），中度痴呆组脑深部白质高信号Fazekas评分亦高于轻度痴呆组（Z=2.950，P=0.003）。（4）合并高血压组Fazekas总评分（Z=3.284，P=0.001）和脑深部白质高信号Fazekas评分（Z=4.083，P=0.000）高于不合并高血压组。结论 脑白质病变程度与阿尔茨海默病患者认知功能和神经精神行为密切相关，可以作为阿尔茨海默病进展的观察指标，应重视早期脑白质病变危险因素的筛查和预防。

关键词: 阿尔茨海默病, 大脑小血管疾病, 认知障碍, 神经心理学测验

Abstract:

Objective To study the characteristics of cognitive and neuropsychiatric behavioral features of Alzheimer's disease (AD) with white matter lesion (WML). Methods A total of 58 cases of AD patients were reruited from January 2010 to December 2020. The Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) were used to evaluate the degree of cognitive impairments. Activities of Daily Living Scale (ADL) was used to evaluate the abilities of daily living. Neuropsychiatric Inventory (NPI) was used to evaluate behavioral and psychological symptoms. The Hamilton Depression Rating Scale 21 -Items (HAMD -21) was used to evaluate the mental or emotional state. Clinical Dementia Rating Scale (CDR) was used to evaluate the dementia severity. The Fazekas scale was utilized to assess the severity of periventricular white matter hyperintensities (PWMH) and deep white matter hyperintensities (DWMH). Results 1) The distribution frequency of hypertension (χ²=4.665, P=0.031), NPI score (Z=1.987, P=0.047), CDR score (Z=2.069, P=0.039), MMSE score (t=2.927, P=0.005) and MoCA score (t=3.394, P=0.001) in WML group were significantly different than those in non-WML group. Among which, attention and calculation ability (Z=2.234, P=0.025), recall ability (Z=2.792, P=0.005), naming ability (Z=2.382, P=0.017), retelling ability (Z=2.685, P=0.007) were lower than those in non-WML group. The incidence of delusion (Fisher's exact probability:P=0.046), depression/dysthymia (χ²=4.376, P=0.036), apathy/indifference (χ²=4.063, P=0.044) in WML group were significantly higher than those in non-WML group. 2) The distribution frequency of hypertension (χ²=11.195, P=0.001), low-density lipoprotein cholesterol (LDL-C; t=2.573, P=0.013), ADL score (Z=3.269, P=0.001), NPI score (Z=3.439, P=0.001) and CDR score (t=2.740, P=0.006) in moderate to severe WML group were higher than those in mild WML group. MMSE score (t=3.686, P=0.001) and MoCA score (t=5.225, P=0.000) were lower than those in without or mild WML group. 3) Homocysteine (Hcy; F=6.291, P=0.003), distribution frequency of hypertension (χ²=10.716, P=0.005), distribution frequency of WML (χ²=8.100, P=0.017), total Fazekas scores (H=13.658, P=0.001), Fazekas score of PWMH (H=6.540, P=0.038) and Fazekas score of DWMH (H=21.550, P=0.000) were statistically significant. While distribution frequency of hypertension (χ²=6.702, P=0.010; Fisher's exact probability:P=0.006), Hcy (P=0.039, 0.001), Fazekas total scores (Z=2.898, P=0.004; Z=3.223, P=0.001) and Fazekas score of DWMH (Z=2.807, P=0.005; Z=4.144, P=0.000) in severe dementia group were higher than those in moderate and mild dementia group, and only the distribution frequency of WML was higher than that in mild dementia group (Fisher's exact probability:P=0.008), Fazekas score of PWMH was higher than that in moderate dementia group (Z=2.567, P=0.010), and Fazekas score of DWMH in moderate dementia group was higher than that in mild dementia group (Z=2.950, P=0.003). 4) The total Fazekas scores (Z=3.284, P=0.001) and DWMH scores (Z=4.083, P=0.000) in AD patients with hypertension were significantly higher than those in AD patients without hypertension. Conclusions The degree of WML was closely related to cognitive function and neuropsychiatric behavioral symptoms of AD patients, which can be used as an observation index for the development of AD. Therefore, we should pay attention to early screening and prevention of WML related risk factors.

Key words: Alzheimer disease, Cerebral small vessel diseases, Cognition disorders, Neuropsychological tests