{"id":423,"date":"2022-05-14T13:02:26","date_gmt":"2022-05-14T10:02:26","guid":{"rendered":"https:\/\/tatd.org.tr\/geriatri\/?p=423"},"modified":"2022-05-14T17:42:21","modified_gmt":"2022-05-14T14:42:21","slug":"yasli-hastada-3d-deliryum-demans-depresyon-tanisi-koymak-kolay-mi","status":"publish","type":"post","link":"https:\/\/tatd.org.tr\/geriatri\/genel\/yasli-hastada-3d-deliryum-demans-depresyon-tanisi-koymak-kolay-mi\/","title":{"rendered":"Ya\u015fl\u0131 hastada 3D (Deliryum \u2013 Demans \u2013 Depresyon) Tan\u0131s\u0131 Koymak Kolay M\u0131?"},"content":{"rendered":"

Herkese merhaba,<\/p>\n

Bu ay sizlere acil servislerimizde s\u0131k kar\u015f\u0131la\u015ft\u0131\u011f\u0131m\u0131z, geriatri sorunlar\u0131n\u0131n ba\u015f\u0131nda gelen, genellikle benzer semptomlarla ba\u015fvuran ve bu nedenle \u00e7o\u011fu zaman klinisyenleri tan\u0131 koyma konusunda zorlayan Demans, Deliryum ve Depresyon \u00fc\u00e7l\u00fcs\u00fcnden bahsedece\u011fim. Birbirinden farkl\u0131 gibi g\u00f6r\u00fcnmesine ra\u011fmen temelinde birbiri ile ba\u011flant\u0131l\u0131 \u00fc\u00e7 tabloyu konu\u015faca\u011f\u0131z.<\/p>\n

 <\/p>\n

Geriatrik Psikiyatri\u2019nin 3D\u2019si \u2013 Deliryum, Demans ve Depresyon \u2013 ya\u015fl\u0131lardaki en s\u0131k ve zorlay\u0131c\u0131 tan\u0131lar\u0131n ba\u015f\u0131nda gelir. \u00d6zellikle birinci basamak sa\u011fl\u0131k sisteminin yayg\u0131n \u015fekilde kullan\u0131ld\u0131\u011f\u0131 ve n\u00f6roloji, psikiyatri, geriatri gibi \u00f6zellikli b\u00f6l\u00fcmlere ula\u015fman\u0131n zor oldu\u011fu \u00fclkelerde hem hastalar\u0131 hem de sa\u011fl\u0131k \u00e7al\u0131\u015fanlar\u0131n\u0131 (doktor, hem\u015fire, hasta bak\u0131c\u0131 gibi) tedirgin edebilen, ki\u015filerin ya\u015fam kalitesini etkileyen zorlay\u0131c\u0131 bir tan\u0131 s\u00fcrecine sahiptir.<\/p>\n

Peki nedir bizi bu kadar zorlayan 3D?<\/strong><\/p>\n

\u00a0<\/strong><\/p>\n

\u201cSa\u011fl\u0131k \u00e7al\u0131\u015fanlar\u0131ndaki bu durumlar\u0131n ya\u015fl\u0131l\u0131\u011f\u0131n bir sonucu oldu\u011fu d\u00fc\u015f\u00fcncesi en s\u0131k yap\u0131lan hata olup, semptomlar\u0131n g\u00f6zden ka\u00e7mas\u0131na neden olmaktad\u0131r.\u201d<\/em><\/p>\n

Farkl\u0131 tan\u0131sal stratejiler kullan\u0131lsa da, en \u00f6nemli nokta ki\u015filerdeki atipik semptomlar\u0131 fark edebilmek ve \u015f\u00fcphelenmektir. Birbiriyle \u00f6rt\u00fc\u015fen semptomlar\u0131 nedeniyle bu \u00fc\u00e7 durumu birbirinden ba\u011f\u0131ms\u0131z ele almak yerine birbiriyle olan ili\u015fkisinin fark\u0131nda olmak esast\u0131r (1).<\/p>\n

Baz\u0131 hastalarda klinik olarak bu sendromlar aras\u0131nda \u00fcst \u00fcste binme g\u00f6zlenebilirken; baz\u0131 hastalarda \u00fc\u00e7 durum ayn\u0131 anda g\u00f6zlenebilir (Tablo-1) (2).<\/p>\n

Tablo-1<\/strong>: Deliryum, Demans ve Depresyon Ay\u0131r\u0131c\u0131 tan\u0131s\u0131.<\/p>\n

\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n
\u00d6ne \u00e7\u0131kan \u00f6zellik<\/strong><\/td>\nDeliryum<\/strong><\/td>\nDemans<\/strong><\/td>\nDepresyon<\/strong><\/td>\n<\/tr>\n
Haf\u0131za problemleri<\/td>\n+++<\/td>\n+++<\/td>\n+<\/td>\n<\/tr>\n
Uyku bozukluklar\u0131<\/td>\n+++<\/td>\n+\/-<\/td>\n+<\/td>\n<\/tr>\n
Dikkat eksikli\u011fi<\/td>\n+++<\/td>\n+\/-<\/td>\n+\/-<\/td>\n<\/tr>\n
Ruh hali bozukluklar\u0131<\/td>\n+\/-<\/td>\n+\/-<\/td>\n+++<\/td>\n<\/tr>\n
Duygu veya alg\u0131 bozukluklar\u0131<\/td>\n+++<\/td>\n+\/-<\/td>\n+\/-<\/td>\n<\/tr>\n
Dezoryantasyon<\/td>\n+++<\/td>\n++<\/td>\n–<\/td>\n<\/tr>\n
Ani ba\u015flang\u0131\u00e7<\/td>\n++<\/td>\n–<\/td>\n–<\/td>\n<\/tr>\n
Yava\u015f progresyon<\/td>\n–<\/td>\n+<\/td>\n+\/-<\/td>\n<\/tr>\n
Somatik \u015fikayetler<\/td>\n–<\/td>\n+\/-<\/td>\n+<\/td>\n<\/tr>\n
Zevk almama veya apati<\/td>\n+\/-<\/td>\n++<\/td>\n++<\/td>\n<\/tr>\n
Semptomlarda dalgalanma<\/td>\n++<\/td>\n–<\/td>\n–<\/td>\n<\/tr>\n
K\u00f6t\u00fc sa\u011fl\u0131k sonlan\u0131m riski<\/td>\n++<\/td>\n+++<\/td>\n+\/-<\/td>\n<\/tr>\n<\/tbody>\n<\/table><\/div>\n

Deliryum<\/em><\/strong><\/p>\n

\u00a0<\/strong><\/p>\n

Akut ba\u015flang\u0131\u00e7l\u0131 bili\u015fsel fonksiyonlar\u0131 etkileyen, da\u011f\u0131n\u0131k d\u00fc\u015f\u00fcnce yap\u0131s\u0131, haf\u0131zada bozulma, oryantasyon kayb\u0131, dikkat eksikli\u011fi ve alg\u0131 bozuklu\u011fu ile karakterize bir durumdur. Genellikle semptomlarda ini\u015f \u00e7\u0131k\u0131\u015flar mevcuttur. S\u0131kl\u0131kla multi-fakt\u00f6ryel bir yap\u0131ya sahiptir, santral sinir sistemi hastal\u0131klar\u0131, sistemik veya farmakolojik nedenler deliryum geli\u015fimine zemin haz\u0131rlayabilir (Tablo-2). Hastaneye yatan ileri ya\u015f hastalar\u0131n %40\u2019\u0131nda g\u00f6zlenebilen bu durum, asla ya\u015flanman\u0131n normal s\u00fcrecinin bir par\u00e7as\u0131 olarak d\u00fc\u015f\u00fcn\u00fclmemelidir (3). Deliryum ayr\u0131ca uzun s\u00fcreli bak\u0131m merkezleri ve huzurevlerinde ikamet eden ya\u015fl\u0131larda da s\u0131kl\u0131kla g\u00f6zlenirken, bu ki\u015filerde tan\u0131 s\u00fcreci daha \u00e7ok atlanmaktad\u0131r (4). Uzam\u0131\u015f fizyolojik stres\u00f6rler ve i\u015flevsellikteki bozulmalar deliryum geli\u015fim riskini artt\u0131rmaktad\u0131r.<\/p>\n

\u00dc\u00e7 tip deliryum formu tan\u0131mlanm\u0131\u015ft\u0131r. Hiperaktif deliryum<\/em> formunu tan\u0131mak genellikle kolayd\u0131r. Ki\u015finin semptomlar\u0131 \u00e7ok barizdir; ajitasyon, huzursuzluk, yerinde duramama, hal\u00fcsinasyonlar ve sald\u0131rgan hareketler ile karakterizedir. Hasta yak\u0131nlar\u0131 taraf\u0131ndan rahats\u0131z edici davran\u0131\u015flar olarak alg\u0131lan\u0131r.\u00a0 Hipoaktif deliryum<\/em> formunda ise, semptomlar daha silik oldu\u011fundan genellikle klinik olarak atlanabilir. Hastan\u0131n somnolans, konu\u015fma ve motor aktivitede azalma, bili\u015fsel ayr\u0131lma gibi davran\u0131\u015flar\u0131 olup; di\u011fer sistemik durumlardan ay\u0131rt etmek zordur. Hipoaktif formda ki\u015finin semptomlar\u0131 yak\u0131nlar\u0131n\u0131 ve sa\u011fl\u0131k \u00e7al\u0131\u015fanlar\u0131n\u0131 hiperaktif s\u00fcrece g\u00f6re daha az rahats\u0131z etti\u011finden tan\u0131da gecikmeye neden olabilir. Son olarak en s\u0131k kar\u015f\u0131la\u015f\u0131lan Miks tip deliryum<\/em> formunda iki subgrubun semptomlar\u0131 g\u00f6zlenir.<\/p>\n

Deliryumdaki en tipik \u00f6zellik, bili\u015fsel fonksiyonlardaki bozulmad\u0131r. Di\u011fer mental de\u011fi\u015fiklikler farkl\u0131 derecelerde e\u015flik edebilir. Bili\u015fsel harici semptomlar\u0131n \u00f6n planda oldu\u011fu durumlar tan\u0131da kar\u0131\u015f\u0131kl\u0131klara neden olabilir (5). Mortalite ve morbiditesi y\u00fcksek oldu\u011fundan deliryumun tan\u0131nmas\u0131 hayati \u00f6nem ta\u015f\u0131maktad\u0131r.<\/p>\n

Hasta y\u00f6netiminde \u00f6nceli\u011fimiz bilin\u00e7 durumunun de\u011ferlendirilmesidir. AVPU ve Glaskow Koma Skalas\u0131 (GKS) yatak ba\u015f\u0131 de\u011ferlendirme \u00f6l\u00e7ekleri aras\u0131ndad\u0131r. AVPU ile uyaran yan\u0131t\u0131n\u0131n de\u011ferlendirme seviyesi yetersiz olup, GKS\u2019nin non-travmatik ya\u015fl\u0131 hastalardaki etkinli\u011fi ile ilgili yeterli \u00e7al\u0131\u015fma yoktur. Acil servislerde kullan\u0131labilecek basit ve h\u0131zl\u0131 bir di\u011fer \u00f6l\u00e7ek Richmond Ajitasyon ve Sedasyon Skalas\u0131 (RASS) veya modifiye RASS\u2019d\u0131r. Hastan\u0131n uyar\u0131lmaya yan\u0131t\u0131n\u0131 -5 (yan\u0131ts\u0131z) veya +4 (sald\u0131rgan) aras\u0131nda de\u011ferlendirir. Acil serviste -1\u2019den k\u00fc\u00e7\u00fck veya e\u015fit ya da +1\u2019den b\u00fcy\u00fck veya e\u015fit de\u011ferlerde deliryum i\u00e7in duyarl\u0131l\u0131k %84 ve \u00f6zg\u00fcll\u00fck %88 iken; \u2264 -2 yada \u2265 +2 durumunda \u00f6zg\u00fcll\u00fck %99\u2019a \u00e7\u0131kmaktad\u0131r. Demans hastan\u0131n bili\u015fsel durumunu de\u011ferlendirmede kullan\u0131lan Mini-Mental Durum Test <\/em>(MMSE) \u2019inin etkinli\u011fi kan\u0131tlanm\u0131\u015f olmas\u0131na ra\u011fmen, acil servis gibi yo\u011fun ve kaotik ortamlarda kullan\u0131m\u0131 uygun de\u011fildir.<\/p>\n

Deliryumun tan\u0131 ve takibinde en s\u0131k tercih edilen, basit ve k\u0131sa de\u011ferlendirme y\u00f6ntemi Konf\u00fczyon De\u011ferlendirme \u00d6l\u00e7e\u011fidir (CAM) (\u015eekil-1)(6).<\/p>\n

Konf\u00fczyon De\u011ferlendirme \u00d6l\u00e7e\u011fi (The Confusion Assessment Method – CAM)<\/strong><\/p>\n

Uygulay\u0131c\u0131 4 \u00f6l\u00e7\u00fct\u00fc de\u011ferlendirir.<\/p>\n

    \n
  1. Akut ba\u015flang\u0131\u00e7 ve dalgal\u0131 seyir<\/li>\n
  2. Dikkat eksikli\u011fi<\/li>\n
  3. Da\u011f\u0131n\u0131k d\u00fc\u015f\u00fcnce formu<\/li>\n
  4. Bilin\u00e7 durumda de\u011fi\u015fiklik<\/li>\n<\/ol>\n

    (Deliryum tan\u0131s\u0131 i\u00e7in 1 ve 2 olacak, yan\u0131nda 3 veya 4 ile birlikte)<\/strong><\/p>\n

    \"\"<\/p>\n

    \n

    \u015eekil-1:<\/b> <\/b>Konf\u00fczyon De\u011ferlendirme \u00d6l\u00e7e\u011fi (The Confusion Assessment Method – CAM) ak\u0131\u015f \u015femas\u0131.<\/p>\n<\/div>\n

    \n

    Deliryum, altta yatan nedenlerin iyile\u015fmesi sonucunda zaman i\u00e7erisinde kendili\u011finden veya tedavilerin yard\u0131m\u0131yla d\u00fczelir. Saatler ile g\u00fcnler i\u00e7erisinde ba\u015flayan deliryum s\u00fcrecinin tam olarak d\u00fczelmesi haftalar hatta aylar s\u00fcrebilir. Tipik olarak deliryuma neden olan durumlar\u0131n iyile\u015fmesine g\u00f6re daha yava\u015ft\u0131r. Hastan\u0131n kendine veya \u00e7evresine zarar verme riski olmad\u0131k\u00e7a, fiziksel veya kimyasal k\u0131s\u0131tlamalar artm\u0131\u015f yaralanmalar ile ili\u015fkilidir (7).<\/p>\n

    \n

    Tablo-2: <\/b>Deliryumu tetikleyen nedenler.<\/b><\/p>\n

    \n\n\n\n
    Sistemik hastal\u0131klar<\/strong><\/td>\nPrimer SSS hastal\u0131klar\u0131<\/strong><\/td>\n\u0130la\u00e7lar<\/strong><\/td>\n\u00c7evresel ve iyatrojenik nedenler<\/strong><\/td>\n<\/tr>\n
    \u00b7Enfeksiyon\/Sepsis<\/p>\n

    \u00b7Dehidratasyon<\/p>\n

    \u00b7 Hipoksi<\/p>\n

    \u00b7 Hiperkarbi<\/p>\n

    \u00b7\u015eok<\/p>\n

    \u00b7Elektrolit bozukluklar\u0131<\/p>\n

    \u00b7Hipo-hiperglisemi<\/p>\n

    \u00b7Hipo-hipertermi<\/p>\n

    \u00b7Travma<\/p>\n

    \u00b7Akut miyokard infarkt\u00fcs\u00fc<\/td>\n

    		\u00b7 \u0130nme<\/p>\n

    \u00b7 \u0130ntrakranyal kanama<\/p>\n

    \u00b7 Menenjit<\/p>\n

    \u00b7 \u00a0Ensefalit<\/p>\n

    \u00b7 N\u00f6bet ya da postiktal s\u00fcre\u00e7<\/p>\n

    \u00b7 Subdural hemoraji<\/p>\n

    \u00b7 Epidural hemoraji<\/td>\n

    		\u00b7 \u00c7oklu ila\u00e7<\/p>\n

    \u00b7 Alkol ve sedatif \u00e7ekilme<\/p>\n

    \u00b7 Keyif ama\u00e7l\u0131 madde al\u0131m\u0131<\/p>\n

    \u00b7 Antikolinerjik<\/p>\n

    \u00b7 Sedatif hipnotikler<\/p>\n

    \u00b7 Opiyatlar<\/td>\n

    		\u00b7 Uzun acil servis al\u0131\u015f s\u00fcresi<\/p>\n

    \u00b7 Uykusuzluk<\/p>\n

    \u00b7 Fiziksel sabitleme<\/p>\n

    \u00b7 Kal\u0131c\u0131 \u00fcriner kateterler<\/p>\n

    \u00b7 A\u011fr\u0131<\/p>\n

    \u00b7 \u00a0Cerrahi veya giri\u015fimler<\/td>\n<\/tr>\n<\/tbody>\n<\/table><\/div>\n

    Hastalar\u0131 k\u0131s\u0131tlayan foley sonda kateter, intraven\u00f6z damar yolu gibi uygulamalar\u0131n m\u00fcmk\u00fcn oldu\u011funca kullan\u0131lmamas\u0131; ki\u015filerin varsa i\u015fitme cihaz\u0131 ve g\u00f6zl\u00fck gibi rutin kulland\u0131\u011f\u0131 aparatlar\u0131n tak\u0131l\u0131 olmas\u0131 destekleyici bak\u0131m k\u0131sm\u0131n\u0131n \u00f6nemli bir par\u00e7as\u0131d\u0131r. Antipsikotik ajanlar\u0131n kullan\u0131m\u0131 halen tart\u0131\u015fmal\u0131 olup, faydas\u0131 kan\u0131tlanm\u0131\u015f klinik uygulama k\u0131lavuzlar\u0131 hen\u00fcz mevcut de\u011fildir (8).<\/p>\n

    NICE k\u0131lavuzlar\u0131na g\u00f6re di\u011fer tedavilerle sald\u0131rgan, agresif tav\u0131rlar\u0131 kontrol alt\u0131na al\u0131namayan hastalarda k\u0131sa s\u00fcreli d\u00fc\u015f\u00fck doz antipsikotik kullan\u0131m\u0131 \u00f6nerilmektedir (9). Deliryum geli\u015fimine katk\u0131s\u0131 olan nedenler d\u00fczeldikten sonra hastalar\u0131n ev ortam\u0131nda yeterli bak\u0131m\u0131 sa\u011flanabilecek ise hastanede kal\u0131\u015flar\u0131 uzat\u0131lmamal\u0131d\u0131r.<\/p>\n

    Peki kimler deliryum geli\u015fimi i\u00e7in y\u00fcksek risk s\u0131n\u0131f\u0131nda?<\/strong><\/p>\n

    65 ya\u015f ve \u00fczeri ki\u015filer, erkek cinsiyet, Demans veya bili\u015fsel fonksiyonlar\u0131nda bozulma ya\u015fayanlar, Ciddi ve \u00e7oklu kronik hastal\u0131k, \u00e7oklu ila\u00e7 kullan\u0131m\u0131, maln\u00fctrisyon, alkol\/madde kullan\u0131m\u0131 ve kal\u00e7a frakt\u00fcr\u00fc olan hastalar (10).<\/p>\n

    Hastane veya bak\u0131mevine yat\u0131r\u0131lan demans hastalar\u0131nda deliryum geli\u015fme riski toplumda ya\u015fayan demans hastalar\u0131na g\u00f6re daha y\u00fcksektir.<\/p>\n

    Demans tan\u0131s\u0131 olan hastalarda deliryumun tan\u0131 ve tedavisi daha zor olup, akut hastal\u0131k durumunda deliryum geli\u015fme riskinde art\u0131\u015f ile ili\u015fkilidir. Deliryum, demans geli\u015fiminde ba\u011f\u0131ms\u0131z risk fakt\u00f6rleri aras\u0131ndad\u0131r (11).<\/p>\n

    Demans<\/strong><\/p>\n

    \u00c7o\u011fu demans tipinde deliryumun aksine uzun bir ba\u015flang\u0131\u00e7 s\u00fcresi ve aylar ile y\u0131llar boyunca s\u00fcren bir progresyon mevcuttur.\u00a0 Hastal\u0131\u011f\u0131n ileri evresine kadar ki\u015finin bilinci, dikkat ve oryantasyonu korunmu\u015ftur. Demansiyal semptomlarda da zaman zaman dalgalanmalar g\u00f6zlenebilir. Demans hastalar\u0131n\u0131n %60\u2019\u0131n\u0131 olu\u015fturan Alzheimer tipi demans en s\u0131k rastlanan demans nedenidir (12). Daha az s\u0131kl\u0131klar kar\u015f\u0131la\u015f\u0131lan vask\u00fcler demans, Levy cisimcikli demans ve miks tip demans di\u011fer demans tipleridir.<\/p>\n

    Demans\u2019\u0131n ana komponenti bili\u015fsel fonksiyonlardaki bozukluktur. Bili\u015fsel d\u0131\u015f\u0131 semptomlar daha s\u0131k g\u00f6zlenirken, ki\u015filerde fonksiyonel yetersizlik ve s\u0131k\u0131nt\u0131, ruh halinde, afektinde ve psikolojik durumunda de\u011fi\u015fikliklere neden olabilir (13). Erken d\u00f6nemde bak\u0131m evine yat\u0131r\u0131lmas\u0131na ve bak\u0131m\u0131ndan sorumlu ki\u015filerde a\u015f\u0131r\u0131 y\u00fck ile sonu\u00e7lanmaktad\u0131r. Demans\u2019\u0131n \u00f6zellikle aile hekimi veya birinci basamak sa\u011fl\u0131k kurulu\u015funda tan\u0131 almas\u0131 zordur. Hastalar ba\u011f\u0131ms\u0131zl\u0131klar\u0131n\u0131 kaybetme korkusu ile endi\u015fe verici semptomlar\u0131n\u0131 dile getirmeye isteksizdir. Aile \u00fcyeleri durumu fark edip, endi\u015felerini dile getirdi\u011finde ise hastalar\u0131n \u00e7o\u011fu belirli bir bili\u015fsel d\u00fc\u015f\u00fc\u015f ya\u015fam\u0131\u015f olabilir (14).<\/p>\n

    Bununla birlikte haf\u0131za kayb\u0131, davran\u0131\u015f de\u011fi\u015fikli\u011fi veya i\u015flevsellikte azalma semptomu ile ba\u015fvuran t\u00fcm hastalar demans tan\u0131s\u0131 a\u00e7\u0131s\u0131ndan incelenmelidir. <\/em><\/strong><\/p>\n

    Ya\u015fl\u0131larda demans geli\u015fimini ara\u015ft\u0131rmak i\u00e7in kullan\u0131lan pek \u00e7ok tan\u0131 \u00f6l\u00e7e\u011fi mevcuttur. Folstein\u2019\u0131n Mini Mental Durum Testi (MMSE) ve Montreal Bili\u015fsel De\u011ferlendirme (MoCA) \u00f6l\u00e7ekleri klinisyenler taraf\u0131ndan tercih edilmektedir. \u00c7o\u011fu klinisyen %89 sensitivite ve %90 spesifisiteye sahip MMSE kullanmas\u0131na ra\u011fmen, 40 farkl\u0131 dilde geli\u015ftirilmi\u015f ve \u00fccretsiz online olarak ula\u015f\u0131labilen MoCA \u00f6l\u00e7e\u011finin erken d\u00f6nemde bili\u015fsel fonksiyonlardaki bozulmay\u0131 ve demans geli\u015fme riski y\u00fcksek hastalar\u0131 tan\u0131mada daha duyarl\u0131 oldu\u011funu savunan \u00e7al\u0131\u015fmalar da vard\u0131r (15). Test se\u00e7iminden ba\u011f\u0131ms\u0131z olarak, d\u00fc\u015f\u00fck puan alan t\u00fcm hastalar ileri tetkik i\u00e7in y\u00f6nlendirilmelidir. Bu testlerin uzun de\u011ferlendirme s\u00fcresi (5-15 dk), hastan\u0131n g\u00f6rme, duyma, yazma yetilerinin olmas\u0131 ve sakin bir ortamda uygulanmas\u0131 gereklili\u011fi acil servisler i\u00e7in uygunlu\u011funu m\u00fcmk\u00fcn k\u0131lmamaktad\u0131r.<\/p>\n

    Mini Mental Durum Testi en s\u0131k kullan\u0131lan bili\u015fsel de\u011ferlendirme \u00f6l\u00e7e\u011fi olmas\u0131na ra\u011fmen \u00f6zellikle hafif bili\u015fsel bozukluklar\u0131 saptamada yetersiz kalm\u0131\u015ft\u0131r. Bu nedenle daha kapsaml\u0131 bir \u00f6l\u00e7ek olan Montreal Bili\u015fsel De\u011ferlendirme (MoCA) geli\u015ftirilmi\u015ftir. Yap\u0131lan \u00e7al\u0131\u015fmalarda (<\/em>Nasreddine et al., 2005; Smith et al., 2007; Lee et al., 2008; Fujiwara et al., 2010; Larner, 2011) MoCa \u00f6l\u00e7e\u011finin MMSE \u00f6l\u00e7e\u011fine g\u00f6re daha duyarl\u0131 oldu\u011funu g\u00f6stermi\u015ftir. Yine Dong ve ark.\u2019lar\u0131\u00e7al\u0131\u015fmas\u0131ndabili\u015fsel bozukluk nedeniyle takip edilen hastalarda demans geli\u015fme riski y\u00fcksek olanlar\u0131 di\u011ferlerinden ay\u0131rmada MoCa \u00f6l\u00e7e\u011fi duyarl\u0131k ve \u00f6zg\u00fcll\u00fck a\u00e7\u0131s\u0131ndan daha iyi saptanm\u0131\u015ft\u0131r (16).<\/em><\/p>\n

    Demansiyel semptomlar ile ba\u015fvuran t\u00fcm hastalar tan\u0131sal kar\u0131\u015f\u0131kl\u0131\u011fa neden olabilecek durumlar \u2013 anemi, elektrolit bozukluklar\u0131, b\u00f6brek fonksiyon testleri, karaci\u011fer fonksiyon testleri, tiroid fonksiyon testleri (TSH), B vitamini d\u00fczeyi gibi metabolik bozukluklar a\u00e7\u0131s\u0131ndan ara\u015ft\u0131r\u0131lmal\u0131d\u0131r. \u0130\u015fitme ve g\u00f6rme muayenesi uygulanmal\u0131, ki\u015finin kulland\u0131\u011f\u0131 ila\u00e7lar ve alkol kullan\u0131m\u0131, yak\u0131n zamanda yap\u0131lm\u0131\u015f ila\u00e7 de\u011fi\u015fiklikleri mutlaka sorgulanmal\u0131d\u0131r (17). Bili\u015fsel durumda bozulmaya neden olabilecek kanama, kitle, iskemik inme gibi intrakranyal nedenleri d\u0131\u015flamak i\u00e7in Beyin Bilgisayarl\u0131 Tomografisi (BT) ve\/veya Beyin Manyetik Rezonansl\u0131 G\u00f6r\u00fcnt\u00fcleme (MRG) gibi g\u00f6r\u00fcnt\u00fcleme y\u00f6ntemleri kullan\u0131lmal\u0131 ve santral sistemi enfeksiyonu ay\u0131r\u0131c\u0131 tan\u0131s\u0131n\u0131 d\u0131\u015flamak i\u00e7in Lomber ponksiyon uygulanmas\u0131 gerekli olabilir.<\/p>\n

    Hastalar\u0131n davran\u0131\u015flar\u0131 dikkatlice de\u011ferlendirilmeli ve ajitasyonun s\u0131k nedenlerinden olan a\u011fr\u0131, a\u00e7l\u0131k, can s\u0131k\u0131nt\u0131s\u0131, izolasyon, tuvalet ihtiya\u00e7lar\u0131, subklinik enfeksiyon, kan \u015fekeri veya kan bas\u0131nc\u0131ndaki dalgalanmalar gibi durumlar d\u0131\u015flanmal\u0131d\u0131r.<\/em><\/strong><\/p>\n

    Demans hastalar\u0131nda tedavinin \u00f6ncelikli amac\u0131 hastan\u0131n g\u00fcvenli\u011fini, i\u015flevselli\u011fini ve ya\u015fam kalitesini artt\u0131rmaya ve bak\u0131mdan sorumlu ki\u015finin stresini azaltmaya y\u00f6neliktir. Hastal\u0131\u011f\u0131n\u0131n tam olarak iyile\u015fmesini sa\u011flayacak bir tedavi olmamakla beraber, baz\u0131 tedavilerin hastal\u0131\u011f\u0131n seyrini yava\u015flatt\u0131\u011f\u0131 g\u00f6sterilmi\u015ftir. \u0130lk ad\u0131m hasta ve yak\u0131nlar\u0131n\u0131n e\u011fitimi olmal\u0131d\u0131r <\/em><\/strong>(18).<\/p>\n

    G\u00fcn\u00fcm\u00fczde demans hastalar\u0131nda FDA onayl\u0131 d\u00f6rt ila\u00e7 kullan\u0131lmaktad\u0131r. Bunlar\u0131n \u00fc\u00e7 tanesi kolinestaraz inhibit\u00f6rleridir; donepezil, rivastigmin ve galantamin<\/em>. D\u00f6rd\u00fcnc\u00fc ila\u00e7 ise, bir N-metil-D-aspartat resept\u00f6r yar\u0131\u015fmas\u0131z antagonisti olan memantin<\/em>\u2019dir (19). Bu ila\u00e7lar\u0131n ileri d\u00f6nem demans hastalar\u0131nda etkinli\u011fini g\u00f6steren \u00e7al\u0131\u015fmalar olmad\u0131\u011f\u0131 gibi, hastalardaki ilerleyici demansa ba\u011fl\u0131 davran\u0131\u015flar \u00fczerine de etkileri yoktur. \u00d6zellikle selektif-serotonin-reuptake-inhibit\u00f6rleri (SSRI) kullan\u0131m\u0131 tercih edilmektedir. Demans hastalar\u0131nda anti-psikotik ajanlar\u0131n kullan\u0131m\u0131 da tart\u0131\u015fmal\u0131d\u0131r.<\/p>\n

    Demans hastalar\u0131ndailk ba\u015flarda g\u00f6zlenen tatl\u0131 yeme iste\u011fi zamanla kaybolur, hastalar\u0131n b\u00fcy\u00fck k\u0131sm\u0131nda i\u015ftahs\u0131zl\u0131k ve kilo kayb\u0131 g\u00f6zlenir. Azalm\u0131\u015f oral al\u0131m, kilo ve kas kayb\u0131 ve maln\u00fctrisyon ile karakterize Eri\u015fkin Geli\u015fme Yetersizli\u011fi (AFTT \u2013 Adult Failure to Thrive) sendromu ile sonu\u00e7lan\u0131r (20).<\/p>\n

    Bu hastalarda bizi s\u0131k\u0131nt\u0131ya sokan bir di\u011fer sorun ba\u015fvuru \u015fikayetleri neticesinde m\u00fcdahale gerektirecek bir durum saptand\u0131\u011f\u0131nda kim karar verecek?<\/strong><\/p>\n

    Demans hastalar\u0131n\u0131n karar verme kapasitesi ile cezai ehliyeti farkl\u0131 kavramlard\u0131r. Karar verme kapasitesinin de\u011ferlendirilmesi hastan\u0131n primer bak\u0131m\u0131n\u0131 \u00fcstlenen doktoru taraf\u0131ndan yap\u0131labilen dinamik bir s\u00fcre\u00e7tir. Kapasite de\u011ferlendirmesinin esas amac\u0131 ki\u015finin \u00f6zellikle sa\u011fl\u0131k hizmeti ile ili\u015fkili durumlarda karar verebilme yetene\u011fini sorgulamakt\u0131r. Hastan\u0131n karar verme kapasitesinin \u00f6l\u00e7menin en iyi yolu hasta ile diyalog kurmakt\u0131r. \u00d6ncelikle hastan\u0131n ileti\u015fim kurma yetene\u011fini de\u011ferlendirmelisiniz. \u0130leti\u015fim kurabildi\u011finden emin olduktan sonra, hastan\u0131n \u00f6nerilen sa\u011fl\u0131k bak\u0131m\u0131 (\u00f6rne\u011fin bir cerrahi prosed\u00fcr) konusundaki alg\u0131s\u0131n\u0131 belirlemektir. Sonraki ad\u0131mda hastan\u0131n olu\u015fabilecek yarar ve zararlar\u0131 anlad\u0131\u011f\u0131n\u0131, kendi bak\u0131m\u0131 konusunda karar veya se\u00e7enek belirtebilme yetisinin olup olmad\u0131\u011f\u0131n\u0131 sorgulamakt\u0131r. Son olarak, hastadan karar\u0131n\u0131 rasyonalize etmesini isteyin (21).<\/em><\/p>\n

    Depresyon<\/strong><\/p>\n

    G\u00fcnl\u00fck ya\u015famda \u00f6nemli i\u015flevsel bozukluklar ile birlikte ki\u015finin keyif kapasitesini kaybetmesi neticesinde duygusal, bili\u015fsel, davran\u0131\u015fsal dengede bozulmalar\u0131n g\u00f6zlendi\u011fi bir duygu durum bozuklu\u011fudur.<\/p>\n

    Deliryum ve demans y\u00fcksek oranda depresyon ile ili\u015fkilidir. Aile sa\u011fl\u0131\u011f\u0131merkezine ba\u015fvuran ya\u015fl\u0131lar\u0131n %10\u2019unda depresif bozukluklar g\u00f6zlenir. Depresyon nedenli sa\u011fl\u0131k kurumu ba\u015fvurular\u0131n\u0131n %64\u2019\u00fc aile sa\u011fl\u0131\u011f\u0131 merkezlerine olmaktad\u0131r (22). Depresyon ya\u015fl\u0131 bak\u0131m evindeki bireylerin %35\u2019ini ve toplumda ya\u015fayan ya\u015fl\u0131 bireylerin %15\u2019ini etkilemektedir.<\/p>\n

    Ya\u015fl\u0131 hastalarda depresyonun tan\u0131nmas\u0131 ba\u015fvuru semptomlar\u0131n\u0131n daha hafif seyirli, silik ve atipik olmas\u0131ndan dolay\u0131 daha zorlay\u0131c\u0131d\u0131r. Erken tan\u0131 ve tedavi ya\u015fam kalitesinde iyile\u015fmeye ve artm\u0131\u015f intihar riskinde azalmaya yard\u0131mc\u0131 olur. \u00d6zellikle birinci basamak ve aile hekimli\u011fi takiplerinde ki\u015finin depresif semptomlar\u0131n\u0131n ya\u015flanma ile ili\u015fkili oldu\u011fu varsaymak yap\u0131lan en b\u00fcy\u00fck hatad\u0131r <\/em><\/strong>(23).<\/p>\n

    Somatik a\u011fr\u0131lar, kilo ve i\u015ftahtaki de\u011fi\u015fiklikler, kronik kab\u0131zl\u0131k, huzursuzluk, ajitasyon, yorgunluk, ba\u015f a\u011fr\u0131s\u0131, uykusuzluk, a\u015f\u0131r\u0131 uyku ve g\u00fc\u00e7s\u00fczl\u00fck ya\u015fl\u0131 hastalarda depresyonun tipik ba\u015fvuru \u015fikayetleridir (24). Tiroid fonksiyonlar\u0131ndaki bozukluklara ba\u011fl\u0131 geli\u015fen i\u015ftahs\u0131zl\u0131k, isteksizlik ve duygu durumundaki bozukluklar depresyon ile benzerdir. Ay\u0131r\u0131c\u0131 semptomlar alt gruplar\u0131na g\u00f6re de\u011fi\u015febilir.<\/p>\n

     <\/p>\n

    Geriatrik Depresyon \u00d6l\u00e7e\u011fi <\/em><\/strong>ve Cornell\u2019in Demansl\u0131 hastalarda Depresyon Skalas\u0131<\/em><\/strong> ya\u015fl\u0131 hastalarda s\u0131k kullan\u0131lan \u00f6l\u00e7\u00fcm y\u00f6ntemleridir.\u00a0 Test sonucu pozitif gelen t\u00fcm hastalar\u0131n maj\u00f6r depresyon olarak de\u011ferlendirilmesi ve tedaviye ba\u015flanmas\u0131 gereklidir.<\/p>\n

     <\/p>\n

    De\u011ferlendirme s\u0131ras\u0131nda hastan\u0131n uyku d\u00fczeni mutlaka sorgulanmal\u0131d\u0131r. Ya\u015fl\u0131 hastalarda en s\u0131k rastlanan ba\u011f\u0131ms\u0131z depresyon belirtisidir. Ya\u015flanma ile birlikte g\u00f6zlenen toplam uyku s\u00fcresinde azalma, uyku veriminde azalma, REM uykusunda azalma, g\u00fcn i\u00e7erisinde uyuyakalma\/kestirme ve uyku uyan\u0131kl\u0131k siklusundaki b\u00f6l\u00fcnmelere daha az toleransl\u0131 olmak gibi baz\u0131 uyku d\u00fczeni de\u011fi\u015fiklikleri normaldir. Bu de\u011fi\u015fiklikler 60 ya\u015f\u0131ndan itibaren geli\u015fmeye ba\u015flar, 65 ya\u015f \u00fcst\u00fc hastalarda yeni geli\u015fen uyku d\u00fczeni de\u011fi\u015fiklikleri ileri inceleme gerektirir (25).<\/p>\n

    ABD verilerine g\u00f6re, ya\u015fl\u0131 eri\u015fkinler t\u00fcm ya\u015f gruplar\u0131 aras\u0131nda en y\u00fcksek intihar oranlar\u0131na sahiptir. D\u00fc\u015f\u00fck sosyo-ekonomik durumu olanlarda intihar d\u00fc\u015f\u00fcncesinin daha s\u0131k olu\u015ftu\u011fu g\u00f6sterilmi\u015ftir (26). Kendine zarar verme, hayattan zevk almama gibi d\u00fc\u015f\u00fcncelerin fark edilmesi, intihar e\u011filimini g\u00f6stermesi a\u00e7\u0131s\u0131ndan \u00e7ok \u00f6nemlidir. Ya\u015fl\u0131larda madde kullan\u0131m\u0131na gen\u00e7 eri\u015fkinlere g\u00f6re \u00e7ok daha nadir rastlan\u0131r. Bu nedenle depresyon ve intihar giri\u015fimi ile ba\u015fvuran t\u00fcm ya\u015fl\u0131 hastalarda alkol, madde ve re\u00e7eteli ila\u00e7 kullan\u0131m\u0131 sorgulanmal\u0131d\u0131r.<\/em><\/strong> Depresyon semptomlar\u0131 ve intihar d\u00fc\u015f\u00fcncesi en s\u0131k aile hekimli\u011fi veya birinci basamak sa\u011fl\u0131k kurumlar\u0131ndaki pratisyen hekimlere (\u00fclkemiz sa\u011fl\u0131k sistemi ko\u015fullar\u0131 g\u00f6z \u00f6n\u00fcne al\u0131nd\u0131\u011f\u0131nda buraya acil servis ye\u015fil alan hekimlerinin de eklenmesi yerinde olacakt\u0131r) bildirilmektedir (27). Bu nedenle \u00f6zellikle birinci basamak sa\u011fl\u0131k kurulu\u015flar\u0131, aile sa\u011fl\u0131\u011f\u0131 merkezlerinde ki\u015filerin depresyon ve intihar d\u00fc\u015f\u00fcncesi a\u00e7\u0131s\u0131ndan de\u011ferlendirilmesi ve gerekli hallerde tedavi ba\u015flanmas\u0131 elzemdir.<\/p>\n

    Sonu\u00e7 olarak;<\/strong><\/p>\n

    Birbiri ile yak\u0131ndan ili\u015fkili olan bu \u00fc\u00e7 sendromun ayr\u0131m\u0131 \u00f6zellikle ya\u015fl\u0131l\u0131ktan kaynakl\u0131 fonksiyonel ve bili\u015fsel problemlerin de eklenmesi ile klinisyenler i\u00e7in daha da zorlay\u0131c\u0131 bir hal almaktad\u0131r. T\u00fcm D\u00fcnya\u2019da deliryum, demans ve depresyon \u00fczerine kan\u0131ta dayal\u0131 tan\u0131 ve tedavi k\u0131lavuzlar\u0131 mevcuttur.Geriatrik Ara\u015ft\u0131rma, E\u011fitim ve Klinik bak\u0131m Merkezi\u2019nin (GRECC) 2011 y\u0131l\u0131nda geli\u015ftirdi\u011fi \u201c5D – Differential Diagnosis of Delirium, Dementia and Depression\u201d <\/em><\/strong>(https:\/\/www.va.gov\/HOMELESS\/nchav\/resources\/docs\/veteran-populations\/aging\/5D-Guide-for-Reading-2014-FINAL-8-28-14-508.pdf<\/a>) tan\u0131 kart\u0131 ile anla\u015f\u0131l\u0131r, kolay ve h\u0131zl\u0131 bir \u015fekilde Deliryum, Demans ve Depresyon tan\u0131s\u0131n\u0131n ve ayr\u0131m\u0131n\u0131n sa\u011flanmas\u0131 ama\u00e7lanm\u0131\u015ft\u0131r. Demans \u00e7al\u0131\u015fma grubu 2012 y\u0131l\u0131nda bu tan\u0131 kart\u0131n\u0131n daha \u00e7ok kullan\u0131m\u0131 i\u00e7in bir \u00e7al\u0131\u015fma ba\u015flatm\u0131\u015ft\u0131r. \u00c7al\u0131\u015fmaya kat\u0131lan sa\u011fl\u0131k \u00e7al\u0131\u015fanlar\u0131n\u0131n %97\u2019si tan\u0131 kart\u0131n\u0131n ay\u0131r\u0131c\u0131 tan\u0131da faydal\u0131 oldu\u011funu veklinik yakla\u015f\u0131mlar\u0131nda kullanmaya devam edeceklerini ifade etmi\u015ftir. Geriatrik E\u011fitim Program\u0131\u2019n\u0131n \u00e7al\u0131\u015fmas\u0131na kat\u0131lan sa\u011fl\u0131k \u00e7al\u0131\u015fanlar\u0131n\u0131n hastalar\u0131n davran\u0131\u015flar\u0131ndaki de\u011fi\u015fiklikleri daha h\u0131zl\u0131 bir \u015fekilde fark etti\u011fi, bunun bili\u015fsel i\u015flevlerdeki bozulmadan kaynakl\u0131 olabilece\u011fi ve ileri de\u011ferlendirme ihtiyac\u0131na daha h\u0131zl\u0131 kararverebildikleri g\u00f6sterilmi\u015ftir.<\/p>\n

    \u00a0<\/strong><\/p>\n

    \u00d6zetlersek \u2026<\/strong><\/p>\n

     <\/p>\n

    Deliryum \u00f6zellikle ya\u015fl\u0131larda s\u0131k g\u00f6zlenen ciddi bir medikal acildir. Bu \u00fc\u00e7 klinik durum aras\u0131ndaki en \u00f6nemli fark AKUT ba\u015flang\u0131\u00e7t\u0131r. Demans tan\u0131s\u0131 olan ki\u015filerde deliryum geli\u015fme riski genel topluma g\u00f6re daha y\u00fcksektir. Demans ile deliryum ayr\u0131m\u0131n\u0131n do\u011fru \u015fekilde yap\u0131lmas\u0131, gereksiz antipsikotik kullan\u0131m\u0131 gibi hastaya zarar verebilecek m\u00fcdahaleleri engeller.<\/p>\n

    Hastan\u0131n sadece kendisinden ve onu getiren ki\u015fiden de\u011fil, PR\u0130MER BAKIM VEREN<\/u> yak\u0131nlar\u0131 veya bak\u0131c\u0131s\u0131ndan ayr\u0131nt\u0131l\u0131 anamnez almak gereklidir. Ay\u0131r\u0131c\u0131 tan\u0131da d\u00fc\u015f\u00fcn\u00fclmesi gerekli pek \u00e7ok durum vard\u0131r. Tedavide, altta yatan organik neden ara\u015ft\u0131r\u0131lmas\u0131 ve bili\u015fsel bozuklu\u011fa neden olabilecek tedavi edilebilen di\u011fer durumlar\u0131n d\u0131\u015flanmas\u0131 esast\u0131r.<\/p>\n

    Her ne kadar \u00f6zellikle deliryum ay\u0131r\u0131c\u0131 tan\u0131s\u0131nda kullan\u0131labilen algoritmalar olsada, bu hastalar\u0131n ayr\u0131m\u0131n\u0131 yapmak konusunda, birinci basamak, aile hekimli\u011fi ve acil servislerde kullan\u0131labilecek, pratik, anla\u015f\u0131l\u0131r h\u0131zl\u0131 tan\u0131 algoritmalar\u0131n\u0131n geli\u015ftirilmesine ihtiya\u00e7 vard\u0131r.<\/p>\n

    Kaynaklar<\/strong><\/p>\n

      \n
    1. Sar\u0131, N. & Yavuz Van G\u0131ersbergen, M. (2017). YA\u015eLILARDA DEL\u0130RYUM, DEMANS VE DEPRESYON; DE\u011eERLEND\u0130RME VE BAKIM. Ege \u00dcniversitesi Hem\u015firelik Fak\u00fcltesi Dergisi, 33 (3), 153-164. Retrieved from https:\/\/dergipark.org.tr\/tr\/pub\/egehemsire\/issue\/33737\/328361<\/a>.<\/li>\n
    2. Downing L, Caprio T. (2013). Geriatric psychiatric: Differential Diagnosis And Treatment of 3 D\u2019s \u2013 delirium, dementia and depression. Current psychiatry report. 15: 365.<\/li>\n
    3. Cole MG, McCusker J, Voyer P, et al. Subsyndromal delirium in older long-term care residents. Incidence, risk factors, and outcomes. J Am Geriatr Soc. 2011;59:1829\u201336.<\/li>\n
    4. Geriatric Psychiatry Review- Differential Diagnosis and Treatment of the 3 D\u2019s – Delirium, Dementia, and Depression_2013.pdf.<\/li>\n
    5. Lyness JM. Delirium: masquerades and misdiagnosis in elderly inpatients. J Am Geriatr Soc. 1990;38(11):1235\u20138.<\/li>\n
    6. Inouye SK, Van Dyck CH, Alessi CA, et al. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med. 1990;113(12):941\u20138.<\/li>\n
    7. Kopke S, Muhlhauser, Gerlach A, et al. Effect of a guideline-based multicomponent intervention on use of physical restraints in nursing homes. JAMA. 2012;307(20):2177\u201384.<\/li>\n
    8. Flaherty JH, Gonzales JP, Dong B. Antipsychotics in the treatment of delirium in older hospitalized adults: a systematic review. J Am Geriatr Soc. 2011;59:S269\u2013276. This systematic literature review did not support the use of antipsychotics in the treatment of delirium in older hospitalized patients.<\/li>\n
    9. National Institute for Health and Clinical Excellence. NICE clinical guideline 103: Delirium: diagnosis, prevention and management. July 2010. http:\/\/www.nice.org.uk\/nicemedia\/live\/13060\/ 49909\/49909.pdf.<\/li>\n
    10. Holt R, Young J, Heseltine D. Effectiveness of a multi-component intervention to reduce delirium incidence in elderly care wards. Age Ageing. 2013 Nov;42(6):721-7. doi: 10.1093\/ageing\/aft120. Epub 2013 Aug 26. PMID: 23978407.<\/li>\n
    11. Saczynski JS, Marcantonio ER, Quach L, et al. Cognitive trajectories after postoperative delirium. NEJM. 2012;367(1):30\u2013 9. This observational study found significant delirium risk with prolonged impact on cognitive functioning in older post-operative patients who underwent cardiac surgery.<\/li>\n
    12. Yiannopoulou KG, Papageorgiou SG. Current and future treatments for Alzheimer\u2019s disease. Ther Adv Neurol Disord. 2012;6(1):19\u201333.<\/li>\n
    13. Kalapatapu RK, Neugroschl JA. Update on neuropsychiatric symptoms of dementia: evaluation and management. Geriatrics. 2009;64(4):20\u20136.<\/li>\n
    14. US Preventative Task Force: Screening for Dementia. Release Date: June 2003. Available at: http:\/\/www.uspreventiveservicestaskforce. org\/uspstf\/uspsdeme.htm. Accessed March 2013.<\/li>\n
    15. Dong Y, Lee WY, Basri NA, et al. The Montreal cognitive assessment is superior to the mini-mental state examination in detecting patients at higher risk of dementia. Int Psychogeriatr. 2012;24(11):1749\u201355.<\/li>\n
    16. Dong Y, Lee WY, Basri NA, Collinson SL, Merchant RA, Venketasubramanian N, Chen CL. The Montreal Cognitive Assessment is superior to the Mini-Mental State Examination in detecting patients at higher risk of dementia. Int Psychogeriatr. 2012 Nov;24(11):1749-55. doi: 10.1017\/S1041610212001068. Epub 2012 Jun 12. PMID: 22687278.<\/li>\n
    17. Geriatric Psychiatry Review- Differential Diagnosis and Treatment of the 3 D\u2019s – Delirium, Dementia, and Depression_2013.<\/li>\n
    18. Morley JE. Behavioral management in the person with dementia. J Nutr Health Aging. 2013;17(1):35\u20138.<\/li>\n
    19. Yiannopoulou KG, Papageorgiou SG. Current and future treatments for Alzheimer\u2019s disease. Ther Adv Neurol Disord. 2012;6(1):19\u201333.<\/li>\n<\/ol>\n<\/div>\n<\/div>\n","protected":false},"excerpt":{"rendered":"

      Herkese merhaba, Bu ay sizlere acil servislerimizde s\u0131k kar\u015f\u0131la\u015ft\u0131\u011f\u0131m\u0131z, geriatri sorunlar\u0131n\u0131n ba\u015f\u0131nda gelen, genellikle benzer semptomlarla ba\u015fvuran ve bu nedenle \u00e7o\u011fu zaman…<\/p>\n","protected":false},"author":1185,"featured_media":425,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"inline_featured_image":false,"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[1,10014],"tags":[],"class_list":["post-423","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-genel","category-akademik-blog-yazisi"],"acf":[],"_links":{"self":[{"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/posts\/423","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/users\/1185"}],"replies":[{"embeddable":true,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/comments?post=423"}],"version-history":[{"count":0,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/posts\/423\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/media\/425"}],"wp:attachment":[{"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/media?parent=423"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/categories?post=423"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/tags?post=423"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}