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혈관성 치매

Vascular Dementia

곽경필|김태우
대한생물정신의학회 (The Korean Society Of Biological Psychiatry)|2016.08|생물정신의학 (Journal of Korean Society of Biological Psychiatry)|제23권 제3호|pp. 80-88

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치매Dementia혈관성 치매Vascular cognitive impairmentVascular dementia뇌혈관질환Treatment치료Cognitive dysfunctionCerebrovascular disease인지손상혈관성인지장애
주제분류정신과학

초록

혈관성 치매는 알츠하이머병 다음으로 가장 흔한 유형의치매이나, 혈관성 치매의 개념, 질병의 분류와 진단 기준, 치료가 정립되어있지 않아 치료에 여러 가지 난항을 겪고 있다. 1960년대 후반만 해도, 노년기 발병의 치매는 대뇌 동맥경화증이 기여를 한다고 여겨졌다. 그러나 후기 연구들을 통해 알츠하이머병에 대해 밝혀졌고, 뇌혈관성 질환은 다발성 뇌경색(multi-infarct dementia)에 의해 치매가 발생한다고 여겨졌다. 이러한 개념은 국제질병분류(International Classification of Diseases, 10th revision, 이하 ICD-10)와 정신질환의 진단 및 통계편람 제4판(Diagnostic and Statistical Manual of Mental Disorders-4th edition, 이하 DSM-IV)을 포함하여혈관성 치매의 분류 체계에 많은 영향을 주었다. 그러나 연이은 연구에서 대부분의 혈관성 치매가 다발성 뇌경색 치매가아닌 피질하 허혈성 혈관성 치매(subcortical ischemic vascular dementia)라는 것이 밝혀졌다.1)2) 미국 국립 신경질환및 뇌졸중 협회와 국제 신경과학 연구 및 교육 협회(National Institute of Neurological Disorders and Stroke-Association Internationale pour la Recherche et l’Enseignement en Neurosciences, 이하 NINDS-AIREN) 진단기준은 가장높은 특이도와 가장 낮은 민감도를 가지고 있었으며, 정신질환의 진단 및 통계편람과 알츠하이머병 진단 및 치료기관 연합회(Alzheimer’s Disease Diagnostic and Treatment Centers, 이하 ADDTC) 진단기준은 전자에 비해 민감도는 더 높고, 특이도는 더 낮았다.3) 기억장애가 알츠하이머병에서는 핵심 증상으로 적절할지모르나, 다양한 범위의 영향을 받는 혈관성 치매에는 적절하지 않다. 이러한 제한점 때문에 뇌혈관질환이 주로 다른 병리적 변화와 더불어 인지기능 장애를 일으킨다는 의견이 지지를 받아왔으며, 보다 넓은 의미를 가지는 혈관성 인지장애라는 용어가 사용되었다.4)5) 혈관성 인지장애에서는 다양한 성질의 혈관성 병리가 치매 발병에 기여를 하며, 다양한 아형이존재한다(Table 1). 정신질환의 진단 및 통계편람 제5판(Diagnostic and Statistical Manual of Mental Disorders-5th edition, 이하 DSM-5) 진단체계에서는 치매 진단기준에서 기억장애를 필수 진단기준에서 삭제하고, 주요신경인지장애라새로이 정의하였다. 또한 혈관성 인지장애의 범주에 혈관성 주요신경인지장애(major vascular neurocognitive disorders) 와 혈관성 경도신경인지장애(mild vascular neurocognitive disorders)를 포함시켰다. 기존에 널리 사용되던 혈관성 치매를 대신해서 혈관성 주요신경인지장애라는 용어로 변경하였다. 혈관성 치매의 진단 및 질병분류학적 부분에 대한 논란은 혈관성 치매에 대한 명확하고 접근하기 용의한 병태생리학적 기전이 밝혀지기 전까지는 지속될 것으로 전망된다.4)6) 이 글에서는 혈관성 치매의 역학, 위험요인, 진단, 그리고 치료에 대해서 다루고자 한다.

Abstract

identifiable treatment targets will continue until distinct pathophysiological mechanism of vascular dementia is found. Clinical diagnostic criteria are sufficiently strong to be useful for clinical trials, but need further refinement. Cognitive changes in vascular dementia are more variable than other disorders, and are dependent on the vascular pathology. Accurate diagnosis of vascular dementia is known to need the presence of reliable cerebrovascular disease on brain imaging. Although it seems obvious that cerebrovascular disease causes pathological damage and impaired cognition, it is very difficult to find the accurate contribution of cerebrovascular pathology to cognitive decline. Most studies have shown a small but significant benefit of cholinesterase inhibitors on cognition, the significance of this effect has been slight and benefits on global functioning, activities of daily living, and behaviour have not been consistently reported. Management of vascular dementia should focus on identifying and managing vascular risk factors.

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