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阿尔茨海默病源性轻度认知障碍诊疗中国专家共识2024
中华医学会神经病学分会痴呆与认知障碍学组
作者及单位信息
·
DOI： 10.3760/cma.j.cn113694-20240320-00172
Chinese expert consensus on the diagnosis and treatment of mild cognitive impairment due to Alzheimer′s disease 2024
Chinese Society of Dementia and Cognitive Impairment
Chen Xiaochun
Authors Info & Affiliations
Chinese Society of Dementia and Cognitive Impairment
Chen Xiaochun
Department of Neurology, Fujian Medical University Union Hospital, Fuzhou 350001, China
·
DOI： 10.3760/cma.j.cn113694-20240320-00172
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摘要

随着社会人口老龄化的到来，阿尔茨海默病（AD）给全球公共卫生系统带来了沉重的社会和经济负担。AD源性轻度认知障碍（MCI）是AD最早有临床症状的阶段，该阶段是AD早期诊断和防治最为重要的窗口期。基于近年全球在AD发病机制和诊治研究方面取得的重大进展，中华医学会神经病学分会痴呆与认知障碍学组在《阿尔茨海默病源性轻度认知障碍中国专家共识2021》的基础上进行更新和修订。通过深度查找AD源性MCI的相关文献，包括荟萃分析、系统评价、随机对照试验、队列研究等，采用改编版的证据质量和推荐分级的评估、制订与评价系统方法对证据级别及推荐等级进行分级，从流行病学、发病机制、临床表现、诊断与鉴别诊断、治疗、给医护人员的建议以及风险因素与预防7个方面对AD源性MCI的诊治提出了工作框架和专家推荐，以期为AD的规范诊断、有效干预和精准治疗提供专家共识和指导方案。

认知障碍;阿尔茨海默病;诊断;治疗;早期预防;专家共识
ABSTRACT

As the global population ages, Alzheimer′s disease (AD) emerges as a substantial challenge, imposing significant mental, psychological, and socioeconomic burdens on public health worldwide. Mild cognitive impairment (MCI) represents the initial clinical manifestation, eventually evolving into the distinctive features of AD (MCI due to AD). Consequently, MCI due to AD presents a pivotal opportunity for early detection, diagnosis, and prevention of AD. Building upon the advancements in AD′s pathogenesis, diagnosis, and treatment in recent years, the Chinese Society of Dementia and Cognitive Impairment updated and revised the Chinese expert consensus on the diagnosis and treatment of MCI due to AD 2021. This revision involved a comprehensive review of pertinent literature on MCI due to AD, encompassing meta-analyses, systematic reviews, randomized controlled trials, and cohort studies. The expert panel established evidence and recommendation level standards for evidence-based medicine, employing adapted recommendation rating evaluation criteria. The resulting framework and expert recommendations for the diagnosis and treatment of MCI due to AD encompass 7 key aspects: epidemiology, pathogenesis, clinical manifestations, diagnosis and differential diagnosis, treatment strategies, guidance for medical professionals, risk factors and preventive measures. This initiative aims to furnish the expert consensus and guidance, facilitating early diagnosis, timely intervention, and precise treatment of AD, thereby addressing the escalating challenges posed by the aging population and the associated rise in AD prevalence.

Cognition disorders;Alzheimer disease;Diagnosis;Treatment;Prevention;Consensus
Chen Xiaochun, Department of Neurology, Fujian Medical University Union Hospital, Fuzhou 350001, China, Email: nc.defudabe.umjf899cxnehc
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引用本文

中华医学会神经病学分会痴呆与认知障碍学组. 阿尔茨海默病源性轻度认知障碍诊疗中国专家共识2024[J]. 中华神经科杂志,2024,57(07)：715-737.

DOI:10.3760/cma.j.cn113694-20240320-00172

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阿尔茨海默病（Alzheimer′s disease，AD）是最常见的认知障碍疾病类型，起病隐匿，早期诊断困难。该病以认知障碍、精神行为异常和社会活动及生活能力下降为主要临床表现，给患者家庭及社会带来沉重的负担。AD源性轻度认知障碍（mild cognitive impairment due to Alzheimer′s disease）简称AD源性MCI，是AD连续疾病谱的早期阶段。2020年流行病学调查指出，中国60岁以上人群MCI约3 877万人，痴呆患者约1 507万，其中AD患者约983万人 ［ 1 ］ 。
按照是否存在记忆受损，MCI通常分为两大亚型：遗忘型MCI（amnestic MCI，aMCI）和非遗忘型MCI（non-amnestic MCI，naMCI）。aMCI主要表现为明显的记忆功能损害，而naMCI主要表现为其他认知域的功能损害，如注意力、语言、视觉空间功能和执行功能损害。按照累及的认知域，MCI可分为单认知域MCI和多认知域MCI。MCI的分型可能对疾病转归具有提示意义，aMCI很可能会进展为典型的AD，naMCI可能会进展为血管性痴呆、额颞叶痴呆等其他类型痴呆 ［ 2 , 3 ］ 。
为满足临床实践需求，提高广大医疗工作者对AD源性MCI的认知，中华医学会神经病学分会痴呆与认知障碍学组发布了《阿尔茨海默病源性轻度认知障碍诊疗中国专家共识2021》（简称《2021年专家共识》） ［ 4 ］ 。该共识的发布为AD源性MCI的早期诊断、早期干预和精准治疗提供了专家共识和指导方案。《2021年专家共识》认为，对于不能通过病理和生物标志物确认的MCI患者，如符合AD神经心理认知损害临床特征（海马型遗忘障碍综合征）和头颅磁共振成像（magnetic resonance imaging，MRI）结构影像损害特征，并排除其他类型的MCI（如帕金森病、脑血管病、路易体病、自身免疫性脑炎等所致的MCI），可以临床诊断为“很可能的AD源性MCI”，以此满足更广大的临床工作者在筛查诊断AD源性MCI中的临床实践需求。
随着AD发病机制研究的不断深入和最新进展，美国阿尔茨海默病学会（Alzheimer′s Association，AA）于2023年提供了新的AD临床诊断标准建议草案［简称2023 AA临床诊断标准（草案）］，强调通过生物学概念定义AD，通过特异性生物标志物确诊疾病。该草案指出AD的定义应基于生物学与临床症状的结合；AD是一个连续疾病谱系（Alzheimer′s continuum），从出现脑内病理改变的无症状节点开始，经过病理负担持续增加的阶段，最终出现临床症状并不断进展；AD应通过体内核心生物标志物的异常来诊断 ［ 5 ］ 。对于符合AD核心病理并处于MCI阶段的患者，可诊断为“AD源性MCI” ［ 2 ］ 。
近年来AD的疾病修饰疗法（disease-modifying therapy，DMT）相关研发工作取得了重大进展。DMT是指对导致疾病的潜在病理生理过程进行干预，以期达到改善疾病临床进展轨迹的治疗方法 ［ 6 ］ 。靶向β-淀粉样蛋白（amyloid β-protein，Aβ）的DMT药物，如仑卡奈单抗（lecanemab）和donanemab相继在国内外获批上市或已经公布Ⅲ期临床试验结果，标志着AD治疗药物的开发进入了新阶段。
基于近年AD诊治方面的重大进展，中华医学会神经病学分会痴呆与认知障碍学组在《2021年专家共识》的基础上进行更新和修订，形成《阿尔茨海默病源性轻度认知障碍诊疗中国专家共识2024》，以指导AD源性MCI的早期识别、精准诊断及规范治疗，也指导临床研究的科学开展。本共识分为流行病学、发病机制、临床表现、诊断与鉴别诊断、非药物和药物治疗、给医护人员的建议、风险因素与预防7个部分。本共识根据现有国内外证据作出工作框架和推荐，旨在为AD的规范诊断、有效干预和精准治疗提供指导方案。本共识仅代表中华医学会神经病学分会痴呆与认知障碍学组的专业意见，不代表任何官方立场。临床在使用本共识时，请根据患者的具体情况和需求进行适当的选择和调整。
本共识采用改编版的证据质量和推荐分级的评估、制订与评价（the grading of recommendations assessment，development and evaluation，GRADE）系统方法 ［ 7 , 8 ］ 对证据级别及推荐等级进行分级。
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备注信息
A
陈晓春，福建医科大学附属协和医院神经内科，福州350001，Email： nc.defudabe.umjf899cxnehc
B
在本共识组织专家研讨的过程中，得到科技创新2030-“脑科学与类脑研究”计划重大项目（2022ZD0211603）和上海医学创新发展基金会的支持（负责支付参加讨论的专家的交通、住宿以及研讨会的场地等费用）
C
中华医学会神经病学分会痴呆与认知障碍学组. 阿尔茨海默病源性轻度认知障碍诊疗中国专家共识2024[J]. 中华神经科杂志, 2024, 57(7): 715-737. DOI: 10.3760/cma.j.cn113694-20240320-00172.
D
所有作者声明无利益冲突
E
None declared
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