過去文獻對於阿滋海默型失智症患者，在疾病早期是否呈現功能缺損覺知障礙？阿茲海默型失智症患者之功能缺損覺知障礙是侷限於某些特定功能，亦或對整體功能皆有覺知障礙？仍有爭議。許多學者建議，建立一份客觀且量化測量覺知障礙的研究工具是研究功能缺損覺知障礙首要解決的問題。在探討覺知障礙之前，有必要先對處於不同疾病階段之阿滋海默型失智症患者，其實際神經心理功能缺損之性質作一瞭解。本研究目的：(1)驗證高級大腦皮質功能檢查量表是否能反映失智症患者隨病程進展，在神經心理功能改變之範疇與嚴重度；(2)建立較完整涵蓋阿滋海默型失智症患者功能缺損之層面，且具清楚信效度資料之覺知量表；(3)透過覺知量表之建立嘗試探討早期阿滋海默型失智症患者，是否呈現功能缺損覺知障礙？功能缺損覺知障礙的範疇是局部性或整體性？
　　六十一位阿滋海默型失智症患者及其主要照顧者，與三十二位年齡與教育程度與失智組患者配對之正常組受試者參與本研究。每位失智症患者與正常組受試者均接受高級大腦皮質功能檢查量表之施測、神經行為標準晤談量表之晤談，並作答覺知量表。主要照顧者接受神經行為標準晤談量表之晤談，並作答患者之日常活動功能量表、精神症狀量表與覺知量表。另外由臨床心理師評定患者在神經行為量表與臨床失智量表的得分。分別將受試者在覺知功能量表之自評，與受試者之神經心理測驗表現、主要照顧者在覺知量表對受試者之評估、臨床心理師對受試者之評估作比較，探討受試者之功能缺損覺知障礙的表現。
　　依據臨床失智量表結果將受試者分為正常(32人)、輕度失智(30人)與中重度失智組(31人)三組。結果發現：(1)輕度失智組在時間與個人資料定向、遠期與近期記憶、語文與非語文學習、語意聯想、視空間建構、推理與右手手部靈巧測驗的表現比正常組差。中重度失智組在時間與個人資料定向、遠期與近期記憶、語文與非語文學習、數字複誦、聽覺理解、算術、推理、雙手手部靈巧與雙手協調測驗的表現比正常組與輕度失智組差，在地點定向與物體命名測驗表現僅比正常組差。(2)覺知功能量表具有良好之內部一致性、內容效度與效標關聯效度。因素分析結果發現十個因素共可解釋本量表78.91%的變異量。(3)在認知功能部分採用神經心理測驗為基準，顯示輕度失智組患者對認知功能缺損沒有明顯覺知障礙；中重度失智組患者對學習、短期記憶儲存、遠期記憶與空間判斷之功能缺損呈現覺知障礙。在非認知功能部分，合併採用臨床心理師與主要照顧者之評估為基準，顯示輕度失智組對自我照顧功能缺損呈現覺知障礙；中重度失智組對日常生活與自我照顧功能缺損呈現覺知障礙。
　　針對本研究所探討之第一個問題，研究結果顯示，配合臨床失智量表，神經心理檢查比簡短智能評估(Mini-Mental State Examination)，更能清楚反映失智症患者隨疾病進展，在各種認知功能受損層面逐步增加且愈來愈嚴重之趨勢，建議未來研究可採用臨床失智量表配合神經心理檢查了解患者之認知功能，以提供更完整之復健與照顧之訊息。第二，本研究所發展之覺知功能量表，可供未來相關研究之使用，惟量表部分功能層面題數較少，且效標關聯效度偏低，此為未來修訂本量表應補強之處。第三，透過覺知功能量表之發展，本研究結果證實中晚期阿滋海默型失智症患者對其功能缺損之覺知功能已明顯受損，早期患者僅對自我照顧功能缺損呈現覺知障礙，對其他功能缺損保有較好的覺知。此研究結果部分支持過去文獻(Frederiks, 1985; Joynt & Shoulson, 1985)所提，早期阿滋海默型失智症患者之覺知功能已有部分受損。此外，本研究發現在覺知功能量表的使用上，不但病人對於自我功能之評估會有偏誤，單純依賴主要照顧者對於病人之功能評估也會有偏誤。為了避免這些誤差，建議未來在研究功能缺損覺知障礙，認知功能部分可採用神經心理測驗作為比對基準，非認知功能部分可合併採用照顧者與臨床心理師之共同評估作為比對基準，以提高研究結果之正確性。

　　The issues of whether patients in the early stage of dementia of the Alzheimer type (DAT) are unaware of deficits and whether unawareness in all DAT patients is in the general or specific domain have been controversial. Several reports suggested that establishing an objective and quantitative measure of unawareness is the essential step in resolving these issues. Before we explore the issue of unawareness, we need to know the features of DAT patients’ neuropsychological functions in terms of the course of the disease. The aims of this study were as follows: first, to examine whether the higher cortical function examination scale (HCFE) can reflect the deterioration of different neuropsychological functions in patients with DAT; second, to develop an awareness rating scale (ARS), which includes more deficit domains in patients with DAT and which has good reliability and validity; third, to use the ARS data to explore whether patients with mild DAT are unaware of their deficits and whether unawareness in all DAT patients is in the general or specific domain.
　　Sixty-one patients with DAT and 32 healthy controls matched for age and education were included in the study. All subjects received a short-form battery of neuropsychological tests, the HCFE, the neurobehavioral standard interview (NBI), and the ARS. Sixty-one primary caregivers of DAT patients received the NBI, ARS, Instrumental Daily Living Function questionnaire, and the Symptoms Checklist-90-Revised to evaluate patients’ function and neurobehavioral symptoms. A clinical psychologist completed the Neurobehavioral Rating Scale (NRS) and the Clinical Dementia Rating (CDR) to evaluate the patients’ neurobehavioral symptoms and the severity of dementia. In order to explore the DAT patients’ unawareness, we compared each patient’s rating in the ARS with his/her performance in the HCFE, the caregiver’s rating in the ARS, and the psychologist’s rating in the NBR and CDR.
　　Subjects were divided into healthy, mild dementia, and moderate-severe dementia groups according to their CDR score. The results revealed that, (1) the performance of patients with mild dementia on the tests of temporal orientation (TO), orientation to personal information (OPIP), recent and remote memory (RC & RM), verbal and nonverbal new learning (VL & NVL), semantic association of verbal fluency (VF), visual-spatial construction (VSC), reasoning, and manual dexterity with the right hand was significantly worse than that of healthy controls. The performance of patients with moderate-severe dementia on the tests of TO, OPIP, RC, RM, VL, NVL, digit repetition, auditory comprehension, calculation, reasoning, manual dexterity with both hands and bimanual coordination was worse than that of the healthy and mild dementia groups. The performance of the patients with moderate-severe dementia on the tasks of orientation to place and object naming was worse than that of healthy subjects. (2) The internal consistency, content validity, and criterion-related validity of the ARS were acceptable. There were ten factors, which could account for 78.91% variation, in the ARS. (3) On the basis of the results of the HCFE, the patients with mild dementia had no remarkable unawareness of their cognitive deficits. However, patients with moderate-severe dementia showed unawareness of deficits in the learning, short-term memory, remote memory, and spatial judgment domains. In non-cognitive functioning, on the basis of caregiver and psychologist evaluation, patients with mild dementia showed unawareness of deficits in the self-care domain, while patients with moderate-severe dementia showed unawareness of deficits in the self-care and daily-living function domains.
　　On the basis of these results showing that with the CDR, the neuropsychological assessment could reflect the deterioration of different neuropsychological functions in patients with DAT in terms of the course of the disease, we suggest that combining the CDR and neuropsychological assessment results could provide more complete information for rehabilitation and care. The Awareness Rating Scale seems to be useful for future study. However, some defects in the ARS should be revised. For example, some domains in the ARS cover fewer items, and some domains in the ARS have low criterion-related validity. Since our DAT patients in the middle-late stage had unawareness in general domains, but our DAT patients in the early stage were only evident of unawareness in the self-care functioning domain, it appears that these results partially support Frederiks (1985), and Joynt and Shoulson’s (1985) observations of patients with the early stage of DAT being unaware of their deficits. Finally, the results revealed that in using the ARS, there was bias, not only in patients’ self-reports but also in caregivers’ reports. In order to improve the accuracy in future research on unawareness, we suggest using the neuropsychological examination as the basis of the cognitive component, and using the caregiver and clinician’s evaluation as the basis of the non-cognitive component.

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