수면 장애 환자의 약물, 비약물 치료

강승걸 대한내과학회 2021 대한내과학회 추계학술대회 Vol.2021 No.2

Normative Study of the Literacy Independent Cognitive Assessment in Illiterate and Literate Elderly Koreans

강승걸,조성진,유승호,최성혜,한설희,심용수,고광필,정지향,이준영,이동우 대한신경정신의학회 2015 PSYCHIATRY INVESTIGATION Vol.12 No.3

ObjectiveaaThe aim of this study was to provide normative data on the Literacy Independent Cognitive Assessment (LICA) and to explore the effects of age, education/literacy, and gender on the performance of this test. MethodsaaEight hundred and eighty-eight healthy elderly subjects, including 164 healthy illiterate subjects, participated in this study. None of the participants had serious medical, psychiatric, or neurological disorders including dementia. Bivariate linear regression analyses were performed to examine the effects of age, education/literacy, and sex on the score in each of the LICA cognitive tests. The normative scores for each age and education/literacy groups are presented. ResultsaaBivariate linear regression analyses revealed that total score and all cognitive tests of the LICA were significantly influenced by both age and education/literacy. Younger and more-educated subjects outperformed older and illiterate or less-educated subjects, respectively, in all of the tests. The normative scores of LICA total score and subset score were presented according to age (60–64, 65–69, 70–74, 75–80, and ≥80 years) and educational levels (illiterate, and 0–3, 4–6, and ≥7 years of education). ConclusionaaThese results on demographic variables suggest that age and education should be taken into account when attempting to accurately interpret the results of the LICA cognitive subtests. These normative data will be useful for clinical interpretations of the LICA neuropsychological battery in illiterate and literate elderly Koreans. Similar normative studies and validations of the LICA involving different ethnic groups will help to enhance the dementia diagnosis of illiterate people of different ethnicities.

하지불안증후군 치료의 최신지견

강승걸 대한수면의학회 2018 수면·정신생리 Vol.25 No.1

Restless legs syndrome (RLS) is a sleep disorder characterized by an urge to move the legs or arms and uncomfortable paresthesia in the legs. Treatment of RLS can be various depending on the causes, severity, and frequency of the symptoms. In the case of secondary RLS, it is important to identify and manage the cause of RLS. Dopamine agonists have been used as firstline treatments for primary RLS treatment. However, due to augmentation, which is a common side effect of dopamine agonists, recent treatment guidelines are changing to prefer to anticonvulsants such as pregabalin and gabapentin. Iron, opioid, or benzodiazepine may be used when anticonvulsants or dopamine agonists are not adequately treated. Because RLS is a chronic disease, it is essential to establish a long-term treatment plan considering both efficacy and side effects. 하지불안증후군은 다리나 팔을 움직이고 싶은 충동과 사지의 불쾌한 이상감각을 주 증상으로 하는 수면장애이다. 하지불안증후군의 치료는 그 원인과 증상의 심각도, 빈도에따라 다양하게 접근 할 수 있으며 이차성 하지불안증후군의경우에는 원인 파악과 해결이 선행되어야 한다. 이제까지일차성 하지불안증후군의 치료에 도파민효현제가 일차치료제로 사용되어 왔으나, 우수한 효능에도 불구하고 약물의흔한 부작용인 증강현상으로 인해, 최근 치료 방침은 pregabalin과gabapentin등의 항경련제를 우선적으로 처방하는 것으로 변경되었다. 항경련제나 도파민효현제로 적절히치료되지 않는 경우에는 철분제제, 아편양제제, 벤조디아제핀 등이 사용될 수 있다. 하지불안증후군은 만성질환이기때문에 치료효과와 부작용을 고려한 장기적인 치료계획 수립이 중요하다.

노인 불면증의 약물치료

강승걸 대한노인정신의학회 2022 노인정신의학 Vol.26 No.1

Insomnia is a common disease in the elderly. It is caused by various etiologies and their combinations. Therefore, treatment should be tailored to the individual. Cognitive-behavioral therapy for insomnia (CBT-I) is the treatment of choice for chronic insomnia; however, hypnotics are commonly used as a primary treatment in the clinical practice. The hypnotics approved for insomnia management in Korea include zolpidem, eszopiclone, triazolam, doxepin, prolonged-release melatonin, and flurazepam. Although not approved, sedative antidepressants and antipsychotics are also frequently used. When prescribing hypnotics to elderly patients, the side effects and limitations of pharmacotherapy should be explained in advance, and the lowest effective dose and “as needed” prescription should be employed. Moreover, the adverse effects should be considered, including dependence, in the elderly. When reducing the medication dose, gradual tapering is safe and realistic considering the withdrawal symptoms. Even in long-term pharmacotherapy, the combination of sleep hygiene education and CBT-I should be considered to increase the effectiveness of and satisfaction from the insomnia treatment, and minimize the medication dose.

Glutathione S-Transferase (GST) 유전자 다형성과 항정신병약물로 유발된 하지불안증후군의 연관 연구

강승걸,박영민,김린,이헌정,Kang, Seung-Gul,Park, Young-Min,Kim, Leen,Lee, Heon-Jeong 대한수면의학회 2015 수면·정신생리 Vol.22 No.1

목 적 : 하지불안증후군(restless legs syndrome ; RLS)의 병인은 아직 불명확하지만, 유전적 질환으로 알려져 있다. 산화스트레스는 RLS, 지연성운동장애, 파킨슨병, 뚜렛장애 등의 운동장애에서 주요한 원인 중의 하나로 생각되고 있다. 본 연구에서는 조현병환자에서 항정신병약물에 의해 유발된 RLS 증상이 산화손상의 해독효소인 glutathione S-transferase (GST) 유전자의 다형성과 연관이 있는지를 밝히고자 하였다. 방 법 : International Restless Legs Syndrome Study Group의 진단기준으로 190명의 한국인 조현병 환자들을 대상으로 RLS에 대해서 평가하였다. 유전자형분석은 중합효소연쇄반응기법을 사용하여 GST-M1, GST-T1, GST-P1의 세 가지 단일염기다형성(single nucleotide polymorphism, SNP)에 대해서 시행되었다. 결 과 : RLS 증상군 96명과 무증상군 94명으로 피험자들을 분류하였다. GST-M1 (${\chi}^2=3.56$, p = 0.059), GST-T1 (${\chi}^2=0.51$, p = 0.476), GST-P1 (${\chi}^2=0.57$, p = 0.821)의 유전자형 빈도에 두 군간에 통계적으로 유의한 차이가 없었다. 유전자형에 따른 RLS 척도의 점수도 GST-M1 (t = -1.54, p = 0.125), GST-T1 (t = -0.02, p = 0.985), GST-P1 (F = 0.58, p = 0.560)의 세 가지 SNP에서 통계적으로 유의한 차이를 보이지 않았다. 결 론 : 본 연구의 결과 GST 유전자 다형성이 항정신병약물로 유발된 RLS 증상 발생의 민감성을 증가시킨다는 증거는 발견할 수 없었다. 산화손상과 관련된 다른 후보 유전자들에 대한 향후 연구가 필요할 것으로 사료된다. Objectives: The pathophysiology of restless legs syndrome (RLS) has not been fully elucidated. Oxidative stress might play a role in the development of RLS and other antipsychotic-induced side effects such as tardive dyskinesia. In the present study, we investigated whether the glutathione S-transferase (GST) gene polymorphisms are associated with antipsychotic-induced RLS in schizophrenia. Methods: We assessed antipsychotic-induced RLS symptoms in 190 Korean schizophrenic patients using the diagnostic criteria of the International Restless Legs Syndrome Study Group. The GST-M1, GST-T1 and GST-P1 loci were analyzed using PCR-based methods. Results: We divided the subjects into 2 groups: those with RLS symptoms (n = 96) and those without RLS symptoms (n = 94). There were no significant differences in the distributions of the GST-M1 genotypes (${\chi}^2=3.56$, p = 0.059), GST-T1 (${\chi}^2=0.51$, p = 0.476) and GST-P1 (${\chi}^2=0.57$, p = 0.821) between the 2 groups. Comparison of the RLS score among genotypes of the GST-M1 (t = -1.54, p = 0.125), GST-T1 (t = -0.02, p = 0.985) and GST-P1 (F = 0.58, p = 0.560) revealed no significant difference. Conclusion: These data suggest that GST gene polymorphisms do not confer increased susceptibility to RLS symptoms in schizophrenic patients. Future studies are necessary to evaluate the possible influences of other candidate genes involved in the reactive oxygen species system.

천식 환아의 폐기능과 수면무 호흡의 연관성: 예비연구

강승걸,이헌정,이승환,유영,정지태,김린,Kang, Seung-Gul,Lee, Heon-Jeong,Lee, Seung-Hwan,Yoo, Young,Choung, Ji-Tae,Kim, Leen 대한수면의학회 2009 수면·정신생리 Vol.16 No.2

목 적: 천식에서 수면무호흡증이 흔하다고 알려져 왔으나 야간 수면다원검사를 이용한 체계적인 연구는 거의 이루어지지 않았다. 본 연구의 성격은 천식 환아들에서 수면 중 무호흡-저호흡지수와 폐기능과의 연관성을 밝히기 위한 예비연구이다. 방 법: 천식으로 진단받은 19명의 남아와 12명의 여아들을 대상으로 하였으며 대상자들의 연령은 평균 8.2세였다. 야간 수면다원검사와 폐기능검사가 대상자들에게 시행되었다. 결 과: 31명의 천식 환아들 중에 21명(67.7%)이 소아의 수면무호흡증의 진단기준을 만족하였고, 평균 무호흡-저호흡지수는 시간당 1.7회였다. 무호흡-저호흡지수가 높을수록 폐기능이 저하되는 소견을 보였다($FEV_1$/FVC ratio: p=0.002, $FEV_1$%pred: p=0.047). 결 론: 본 연구의 결과는 소아 천식 환아들에서 수면무호흡증의 빈도가 매우 높을 가능성이 있으며 수면무호흡증의 중증도와 폐기능의 정도가 연관성이 있다는 것을 제시한다. 그러나, 향후 대조군과 천식군의 비교연구를 통하여 이에 대한 확인이 필요하다. Objective: It has been reported that the sleep apnea syndrome in the asthmatic patients is prevalent, however, the systematic study in this field using polysomnography has rarely been performed. The aim of this study is to investigate the relationship between the apnea-hypopnea index (AHI) and the pulmonary function in asthmatic children. Methods: This study enrolled 19 male and 12 female asthmatic children aged 6-13 years (average $8.2{\pm}1.7$ years old). Complete overnight polysomnography and pulmonary function test were performed for the participants. Results: Of the 31 asthmatic children, 21 (67.7%) met the diagnostic criteria of the pediatric sleep apnea and the average AHI was $1.7{\pm}1.5/h$. The children with higher AHI showed poorer pulmonary function ($FEV_1$/FVC ratio: p=0.002, $FEV_1$%pred: p=0.047). Conclusion: These results suggest that the prevalence of the pediatric sleep apnea could be very high among the asthmatic children and the severity of the sleep apnea correlates with the pulmonary function. However, the case-control study to compare the AHI between the asthma and control groups is absolutely necessary because few normative data are available for the children.

임상현장에서 하지불안증후군 환자의 수면다원검사결과의 특징과 약물처방현황

강승걸,남지혜,김하나,신홍범,Kang, Seung-Gul,Nam, Ji-Hye,Kim, Hana,Shin, Hong Beom 대한수면의학회 2013 수면·정신생리 Vol.20 No.1

목 적: 임상실제에서 하지불안증후군(restless legs syndrome, RLS) 환자들의 수면다원검사 결과의 특징과 약물치료의 현황을 자연적인 후향성 연구로 조사하는 것이다. 방 법: 임상적으로 RLS의 진단기준을 만족하며 수면다원검사를 시행 받고 치료받은 18세 이상 환자들의 의무기록을 검토하여 분석하였다. 대상자들에 대해 초진시 International Restless Legs Syndrome Study Group(IRLSSG)의 4가지 진단기준과 국제하지불안척도(International Restless Legs Scale, IRLS)를 평가하고 야간수면다원검사와 제안부동검사(suggested immobilization test, SIT)를 시행하였고, 도파민효현제로 한 달간 약물치료 후 IRLS를 재평가하였다. 결 과: 분석에 포함된 총 대상자수는 211명으로 남자가 94명(44.5%), 여자가 117명(55.5%)이었고 평균연령은 46.9세였다. 폐쇄성수면무호흡증이 136명(64.5%), PLMD가 53명(25.1%)에서 동반되어 다른 수면장애를 동반한 환자의 수는 185명(87.7%)이었다. 수면다원검사결과 수면효율은 78.0%, 수면중각성시간(wake after sleep onset)는 86.8분, N3는 3.4%였다. 평균 무호흡저호흡지수(apnea hypopnea index)는 시간당 12.4회, PLMS는 시간당 14.8회, SIT 중 PLMW는 시간당 41.2회였다. 수면중 총 각성지수는 시간당 21.6회였다. 전체 환자 중 ropinirole을 복용한 환자는 149명(70.6%), pramipexole을 복용한 환자수는 47명(22.3%)이었고 ropinirole은 평균 0.9 mg(용량범위 0.125~5 mg), pramipexole은 평균 0.5 mg(용량범위 0.125~4 mg)을 사용하였다. Ropinirole의 용량은 연령과 유의한 양의 상관관계를 보였고(r=0.25, p=0.002), IRLS와도 유의한 양의 상관관계를 보였다(r=0.23, p=0.038). IRLS는 초진시 24.9점에서 1달 뒤 13.4점으로 감소하였다. 결 론: 본 연구의 분석결과 임상적으로 RLS 진단이 가능한 환자 중에 다른 수면장애를 동반하는 경우가 대다수였다. PLMD에 해당되는 사람은 25.1%로 기존 보고보다 적었고 평균 PLMS도 시간당 14.8회로 높지 않았다. 사용하는 도파민효현제의 용량은 한국에서 허가용량으로 승인받은 용량보다 더 높은 경우가 많았다. 향후 이 주제에 대한 전향적이고 통제된 대규모의 연구가 필요하다. Objectives: The aim of this study is to evaluate the polysomnographic characteristics and prescription status of restless legs syndrome (RLS) patients in naturalistic setting. Methods: We reviewed medical record of the patients over 18 years olds who (i) satisfied the clinical RLS diagnostic criteria and (ii) had the polysomnography and got treatment related thereto. As a baseline, we evaluated the four diagnostic criteria of the International Restless Legs Syndrome Study Group (IRLSSG) and the International Restless Legs Scale (IRLS) of the subjects. Then the polysomnography and the suggested immobilization test (SIT) were conducted and, after one month of pharmacotherapy using dopamine agonist, the IRLS was evaluated again. Results: A total of 211 subjects participated in this analysis and 94 (44.5%) of them were male and the other 117 (55.5%) were female and the average age of the 211 subjects was $46.9{\pm}14.2$. Out of such 211 subjects, 136 subjects (64.5%) also had the obstructive sleep apnea (OSA), and 53 subjects (25.1%) also had the periodic limb movement disorder (PLMD). 185 subjects (87.7%) out of the 211 subjects had some other sleep disorders except RLS. The results of the polysomnography were as follows : 78.0% of sleep efficiency, 86.8 min of wake after sleep onset, and 3.4% of N3. More specifically, 12.4/h of the average apnea hypopnea index, 14.8/h of the periodic limb movement during sleep (PLMS), 41.2/h of the periodic limb movement during wake during SIT and 21.6/h of total arousal index during sleep. Out of the total subjects, 149 (70.6%) of them took the ropinirole and 47 (22.3%) of them took the pramipexole, and the average dosage of ropinirole was 0.9mg(dosage range 0.125-5 mg) while the average dosage of pramipexole was 0.5 mg (dosage range 0.125-4 mg). The dosage of the ropinirole showed a significant positive correlation with the age (r=0.25, p=0.002) and also with the IRLS (r=0.23, p=0.038). The IRLS at the baseline was 24.9 while the same was decreased down to 13.4 after one month. Conclusions: Analyzing the result of this study, a majority of clinical RLS subjects demonstrated comorbidity with some other sleep disorder such as the OSA or PLMD. 25.1% of the subjects showed a PLMD, which was less than in previous researches and the average PLMS was not very high as 14.8/h. The dosage of dopamine agonist taken was often a bit more than the amount recommended in Korea. A prospective research using a large scale controlled subjects will be necessary with respect to this topic.

폐쇄성수면무호흡증 의심환자에서 무호흡저호흡지수에 영향을 주는 임상적 신체적 요인 : 예비연구

강승걸,신승헌,이유진,정주현,강일규,박인숙,김찬우,예미경,황희영,김선태,박기형,김지언,Kang, Seung-Gul,Shin, Seung-Heon,Lee, Yu Jin,Jung, Joo Hyun,Kang, Il Gyu,Park, Insook,Kim, Peter Chanwoo,Ye, Mi Kyung,Hwang, Hee Young,Kim, Seon Tae,Par 대한생물정신의학회 2013 생물정신의학 Vol.20 No.2

Objectives The purpose of this study is to find the influential clinical and physical characteristics which affect apnea-hypopnea index (AHI) in suspected obstructive sleep apnea (OSA) patients. Methods We evaluated the comprehensive factors including sleep related symptoms, clinical scales, medical history, substance use, and anthropometric data of the 119 participants who complained of the symptoms of OSA. All the participants underwent attended-full night laboratory polysomnography. The correlation and multiple regression analysis were conducted to find the influential and predictive factors of AHI. Results A multiple linear regression model 1 showed that higher AHI was associated with higher body mass index (BMI)(p < 0.001) and higher frequency of observed apnea (p = 0.002). In multiple linear regression model 2, AHI was associated with higher BMI (p < 0.001) and loudness of snoring (p = 0.018). Conclusions The present preliminary results suggest that BMI and observed apnea are most influential factors that affect AHI in suspected OSA patients. In the future study we will design the prediction formula for the OSA and AHI, which is useful in the clinical medical field.

PER3 유전자다형성과 일중선호도의 연관성

강승걸,최태영,윤호경,박영민,김린,이헌정,Kang, Seung-Gul,Choi, Tae-Young,Yoon, Ho-Kyoung,Park, Young-Min,Kim, Leen,Lee, Heon-Jeong 대한수면의학회 2011 수면·정신생리 Vol.18 No.1

목 적: 일중선호도는 하루 중 어느 시간대에 각성도가 높고 활기찬 지에 대한 경향으로 아침형-저녁형이라고도 알려져있다. PER3 유전자는 일중선호도에 영향을 주는 것으로 알려져 왔다. 본 연구에서 우리는 젊고 건강한 피험자들에서 환경과 혼란요인들을 통제하고 PER3 유전자 다형성과 일중선호도간에 연관을 연구하였다. 방 법: 연구에 참여한 대상자는 299명의 의과대학생들(남자 299, 여자 191명)이며 평균연령은 22.9세였다. 일중선호도는 13개 문항의 Composite Scale for Morningness (CSM)로 측정하였다. PER3 VNTR(rs57875989)의 유전자형분석은 중합효소연쇄반응법을 사용하여 이루어졌다. 양측검정으로 유의수준은 p<0.05로 하였다. 결 과: 전체 대상자에 대한 CSM 점수는 31.90${\pm}$6.39 (평균${\pm}$표준편차)였다. 남녀간에 CSM 총점에 유의한 차이는 없었다. PER3 5R/5R에서 CSM 점수가 높은 경향을 보였으나, PER3 VNTR(rs57875989) 유전자형과 대립유전자에 따른 CSM 점수의 유의한 차이는 없었다. 결 론: 본 연구는 젊은 건강한 한국인에서 PER3 V- NTR과 일중선호도간의 연관을 입증하지 못했다. 향후 보다 대규모의 피험자들을 대상으로 PER3의 여러 유전자들에 대해 다형성과 일중선호도간의 연관에 대한 연구가 필요할 것으로 생각된다. Objective: Diurnal preference is an attribute reflecting whether people are alert and preferring to be active either early or late in the day. It also referred to as chronotype or morningness-eveningness trait. The PER3 genes have been known to influence diurnal preference. In this study, we have investigated the associations between the PER3 gene polymorphisms and diurnal preference in a healthy young population, controlling for the social and environmental confounding factors. Methods: The participants in this experiment included 299 unrelated medical college students (M=191, F=108), with a mean age of 22.9 years. Diurnal preference was measured by a single administration of the 13-item Composite Scale for Morningness (CSM). Genotyping of the PER3 VNTR (rs57875989) was performed using polymerase chain reaction. A two-tailed alpha of 0.05 was chosen. Results: The mean${\pm}$SD score on the CSM scale for all subjects was 31.90${\pm}$6.39. There was no significant difference in total CSM score between gender groups, although females showed a trend towards higher morningness score. Although PER3 5R/5R showed the tendency towards high CSM scores, there were no significant differences on CSM scores among genotypes and allele status of PER3 VNTR (rs57875989). Conclusions: We could not confirm that the PER3 VNTR is associated with diurnal preference in a Korean healthy young population. The future studies need to investigate the association between diurnal preference and other polymorphisms of PER3 gene in larger sample of Korean young healthy population.

Duloxetine-Induced Liver Injury in Patients with Major Depressive Disorder

강승걸,박영민,이헌정,Byungmun Yoon 대한신경정신의학회 2011 PSYCHIATRY INVESTIGATION Vol.8 No.3

Duloxetine is a balanced serotonin-norepinephrine reuptake inhibitor. Duloxetine-induced liver injury in patients with preexisting liver disease or chronic alcohol use is known. However, we have found that duloxetine can also induce liver injury in cases without those risk factors. We recommend that clinicians should monitor liver function carefully following duloxetine treatment.