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paliatiuri mzrunveloba nevrologiuri daavadebebis
dros
progresirebadi nevrologiuri daavadebebi: epidemiologiuri da
klinikuri suraTi
progresirebadi gaxangrZlivebuli nevrologiur mdgomareobebis (PLNTC –
progressive long-term neurological conditions) uamravi tipi arsebobs. am TavSi
ganvixilavT mxolod 4 daavadebas: gafantuli sklerozi (MS) da
parkinsonis daavadeba (PD) (romlebic ufro metadaa gavrcelebuli),
motoruli neironis daavadeba (MND) da hantingtonis daavadeba (HD) (romlebic SedarebiT iSviaTia). mag. did britaneTSi, ojaxis eqims SeiZleba
Sexvdes saSualod sami pacienti gafantuli skleroziT pacientTa mTlian
nakadSi, maSin roca motoruli neironis daavadebiT pacientis
momarTvianoba daaxloebiT 1/10 sixSiriTaa.
am TavSi yuradReba gamaxvilebulia “avadobasa” da “gavrcelebaze”.
“avadoba” – esaa daavadebis axali SemTxvevebis ricxvi weliwadSi, xolo
“gavrceleba” gulisxmobs am daavadebis mqone pacientebis ricxvs drois
garkveul monakveTSi.
gafantuli sklerozi
epidemiologia
gafantuli sklerozi (MS) yvelaze gavrcelebuli nevrologiuri
paTologiaa axalgazrda asakSi. igi ufro xSiria qalebSi, vidre
mamakacebSi (Sefardeba 2/1). daavadeba, rogorc wesi, Tavs iCens sicocxlis
mesame an meoTxe aTwleulSi.
did britaneTSi gafantul sklerozze monacemTa baza ar arsebobs. uxeSi
gaTvlebiT, did britaneTSi daaxloebiT 85 000 adamiania daavadebuli
gafantuli skleroziT. msoflioSi gavrceleba daaxloebiT 2 500 000-ia.
did britaneTSi yovelwliurad daaxl. 2500 pacienti diagnostirdeba
gafantul sklerozze.
gafantuli sklerozis gavrceleba msoflioSi araTanabaria. daavadebis
sixSire izrdeba ekvatoridan moSorebiT regionebSi (rogorc CrdiloeTiT
ise samxreTiT). mag. inglisisaTvis es niSnavs rom 1000 sul mosaxleze
gafantuli skleroziT avadoba ufro metia CrdiloeT SotlandiaSi, vidre
londonSi. ufro farTo masStabiani magaliTi rom moviyvanoT, daavadeba
ufro xSiria kanadaSi vidre romelime ekvatorul qveyanaSi, mag. indoeTSi.
daavadebis ganviTarebis riski moicavs mravali faqtoris, mag. genetikuri
da garemo faqtorebis urTierTqmedebas. es imiT dasturdeba, rom Tu Tqven
sacxovreblad gadaxvalT dabali riskis qveynidan (mag. indoeTidan) maRali
riskis qveyanaSi (mag. kanadaSi), gafantuli skleroziT daavadebis riski am
SemTxvevaSi damokidebulia Tqvens asakze. rac ufro naklebia migrantis
asaki, miT metia Sansi, rom mas eqneba iseTive mimRebloba rogoric im
qveynis mosaxleobas, sadac moxda migracia, da piriqiT.
gafantuli sklerozis riski did britaneTSi saSualod 700 mosaxleze 1-ia.
daavadebis risks zrdis ojaxuri anamnezic. Tu Tqvens pirveli rigis
naTesavs (mag. mSobels, da-Zmas, Svils) aqvs gafantuli sklerozi, maSin
TqvenTvis riski 1/40-zea. xolo Tu daavadeba aReniSneba meore rigis
naTesavs (mag. biZaSvilebi/mamidebi/biZebi/ZmisSvilebi), maSin es riski
mcirdeba 1/100-mde. gafantuli sklerozi warmoadgens xangrZliv
progresirebad nevrologiur mdgomareobas, romliTac pacienti xSirad
mravali wlis manZilze cxovrobs. mTlianobaSi, es daavadeba sicocxlis
mosalodnel xangrZlivobas mxolod umniSvnelod amcirebs, Tumca es
mocemuloba individualuri da farTod cvalebadia.
jer kidev ucnobia konkretulad ra garemo faqtorebi iwvevs gafantul
sklerozs. arsebobs sxvadasxva kvlevebis monacemebi, romlebic erTmaneTsac
ki Zlier ewinaaRmdegeba. savaraudo trigerebSi moiazreba individis asaki
ebStein-baris virusiT inficirebis periodSi da klimatiT inducirebuli
vitamin D-s deficiti.
gafantuli sklerozis paTofiziologia
miCneulia, rom gafantuli sklerozis ganviTarebas safuZvlad udevs
adamianis organizmis imunuri sistemis ujredebis mimarTva sakuTari
neironebis mimarT nervul sistemaSi. amas autoimunuri reaqcia ewodeba. am
SemTxvevaSi Semtev ujredebs warmoadgens T limfocitebi. es ukanasknelni
aRweven cns-Si da azianeben neironebis Semomgarsvel mielinis garss. am
process ewodeba demielinizacia. mielinis garsis dazianebis Semdeg
Zneldeba nervuli impulsis gadacema neironis gaswvriv. es niSnavs, rom
nervuli impulsi veRar midis daniSnulebis adgilas. mag. Tu dazianda
qveda kidurebis mamoZravebeli kortikaluri nervuli gza, maSin cxadia rom
siaruli gaZnelebuli iqneba, xolo Tvalis nervis dazianebisas gauaresdeba
mxedveloba.
gafantuli sklerozis adreul stadiebze SesaZloa moxdes remielinizacia,
anu aRdges dazianebuli mielinis garsi. Tumca, aRdgenili mielinis garsi
xSirad ufro Txelia winamorbedTan SedarebiT da ise kargad mainc ver
atarebs nervul impulss, rogorc Tavdapirveli mielinis garsi. droTa
ganmavlobaSi ziandeba mielinis maproducirebeli ujredebic
(oligodendrocitebi) da mielinis garsis aRdgena saerTod aRar xdeba.
mielinis garsisgan daucveli nervi (aqsoni) SemdgomSi iRupeba. im
SemTxvevaSi Tu ziandeba aqsonis mcire nawili, cns-s aqvs saSualeba
moaxdinos impulsebis gadamisamarTeba, Tumca Tu dazianeba moicavs ufro
did ares, gadamisamarTeba veRar xerxdeba da mocemuli nervuli gza
sabolood iblokeba.
gafantuli sklerozis tipebi
umravles SemTxvevaSi gafantul sklerozs sawyis etapze axasiaTebs
remisiul-recidiuli mimdinareoba, rac niSnavs, rom nevrologiur deficits
aqvs gardamavali xasiaTi: grZeldeba ramodenime kvira (recidivi), Semdeg ki
alagdeba (remisia). advilia imis warmodgena, Tu ra xdeba am dros
paTofiziologiuri TvalsazrisiT.
recidivis periodSi adgili aqvs demielinizaciis process. rogorc ki
moxdeba remielinizacia, dgeba remisiis periodi. klinikuri cdebis
Catarebisas TvalsaCinoebis mizniT, miRebulia, rom recidivad iTvleba 24
saaTze meti xangrZlivobis Seteva, romlis drosac sxeulis temperatura
normaluria, xolo imisaTvis rom Setevebi CavTvaloT calkeulad, maT
Soris naTeli intervali sul mcire 30 dRe unda iyos.
Setevebis simwvave, sixSire da recidivebs Soris intervali Zalian
cvalebadia da misi winaswar gansazRvra SeuZlebelia. pacientebis
umravlesobas gafantuli sklerozis recidiul-remisiuli formiT
aReniSnebaT saSualod 1 an 2 recidivi weliwadSi. wlebis manZilze es
modeli SeiZleba Seicvalos gafantuli sklerozis mudmivad
progresirebadi formiT. am dros recidivebis sixSire klebulobs, Tumca
invalidobis xarisxi matulobs. am formas ewodeba meoradad
progresirebadi gafantuli sklerozi.
sxvadasxva kvlevebis monacemebis mixedviT, im pacientebs, romelTac
Tavdapirvelad aReniSnebaT gafantuli sklerozis recidiul-remisiuli
forma, meoradad progresirebadi forma uviTardebaT daaxloebiT 10
weliwadSi. Tumca pacientebis nawilSi es daavadeba Tavidanve
progresirebadi formiT mimdinareobs. amas ewodeba pirveladad
progresirebadi gafantuli sklerozi. es pacientebi SedarebiT ufros
asakSi (saSualod 40 weli) avaddebian. da bolos, gafantuli sklerozis
kidev erTi tipia keTilTvisebiani forma, romlis drosac Setevebi msubuqia
da maT Soris naTeli periodi zogjer wlebis manZilze grZeldeba.
gafantuli sklerozis simptomebi
simptomebi gafantuli sklerozis dros damokidebulia imaze, Tu nervuli
sistemis romel nawilSi xdeba demielinizacia. mag. am dros xSirad
ziandeba optikuri nervi (II wy.), romelic Tavis tvins gadascems vizualur
informacias. es, rogorc wesi, erT Tvals exeba xolme da iwvevs
mxedvelobis gauaresebas, rac mtkivneulad aRiqmeba pacientis mier.
umeteswilad gansakuTrebiT ziandeba ferebis aRqma. sxva SemTxvevebSi, Tu
demielinizacia moxda wonasworobis centrSi (naTxemSi), adgili aqvs
siarulis gaZnelebas, metyvelebis darRvevas da koordinaciis problemebs.
tvinis im nawilis dazianeba, romelic akontrolebs mgrZnobelobas, iwvevs
gabuJebis an CxvletiT SegrZnebebs. Tumca, es simptomebi mxolod mwvave
SemTxvevebSi vlindeba da Tu pacienti mogvmarTavs ara-mwvave periodSi,
klinikaSi es simptomebi SeiZleba verc aRmovaCinoT.
gafantuli sklerozis sxva simptomebi moicavs nawlavisa da Sardis buStis
funqciis moSlas, mexsierebis problemebs, depresiasa da pirovnebis
cvlilebebs. aseve xSiria daRla (sisuste), romelic aRiniSneba pacientebis
daaxl. 75%-Si. mravali pacienti gafantuli skleroziT aRniSnavs
daRlilobas, rogorc mTavar problemas. daRlilobis es tipi gansxvavdeba
im daRlilobisagan, romelic gvxvdeba depresiis dros. gafantul
sklerozTan dakavSirebuli daRliloba xSirad uaresdeba sicxis,
datvirTvis gavleniT da dRis gvian monakveTSi, amasTan, igi xSirad ixsneba
mciredi dasvenebiT. depresiasTan asocirebuli daRliloba ufro
araspecifiuria da dakavSirebulia depresiis sxva simptomebTan, mag. Zilis
darRvevebTan. am simptomTa umravlesoba fluqtuirebs daavadebis sawyis
stadiaze, Tumca gafantuli sklerozis progresirebasTan erTad simptomebi
da Sesabamisad, invalidobac myardeba da mudmiv iers iZens.
gafantuli sklerozis diagnozi
pacientebi gafantuli sklerozis pirveladad progresirebadi formiT
xSirad mimarTaven eqims siarulis gaZnelebis gamo. es ukanaskneli xSirad
Zalian SeumCnevlad da nela viTardeba, ris gamoc pacienti, rogorc wesi,
axdens adaptacias da raRac doneze inarCunebs xolme funqciur aqtivobas.
am pacientebSi mZime nevrologiuri deficitebi xSirad vlindeba
poliklinikaSi an ojaxis eqimTan gasinjvisas.
gafantuli sklerozis diagnozze eWvis mitana xdeba pacientis anamnezisa
da klinikuri gasinjvis safuZvelze, Tumca gamokvlevebis Catareba mainc
aucilebelia. amJamad kvlevis standarts warmoadgens magnitur-birTvuli
rezonansi (MRI). xdeba Tavis tvinis da zogjer zurgis tvinis gamokvlevac.
gafantuli sklerozi tipiurad iwvevs Tavis tvinis TeTri nivTierebis
dazianebas, upiratesad parkuWebis garSemo. gadoliniumiT kontrastireba
saSualebas iZleva gamovavlinoT 4-6 kviraze naklebi asakis folaqebi. es
axalgazrda folaqebi, romlebic kargad krefs kontrasts, 5-10-jer ufro
xSirad gvxvdeba klinikuri recidivebis ricxvTan SedarebiT. am mizezis
gamo, maTi arseboba miiCneva mxolod surogat markerad klinikuri
kvlevebis Catarebis dros. klinikuri TvalsazrisiT, wesiT maTi arseboba
unda CaiTvalos diagnozis damadastureblad, Tumca raime eWvis SemTxvevaSi
SesaZloa gakeTdes lumbaluri punqcia oligoklonuri antisxeulebis
aRmosaCenad. am ukanasknelTa aRmoCena SesaZlebelia sxva nevrologiuri
daavadebebis drosac, Tumca pacientebis 95%-s klinikurad dadasturebuli
gafantuli skleroziT es antisxeulebi yovelTvis aqvT cerebrospinalur
siTxeSi.
zogjer aseve keTdeba eleqtruli testebi (gamowveuli potencialebi), rac
gulisxmobs nervSi an nervebSi impulsis gamtareblobis siCqaris
gansazRvras. demielinizacia iwvevs impulsis gatarebis Senelebas da
amgvarad, zrdis gamtareblobis dros. sisxlis analizebis Catareba saWiroa
im daavadebebis gamosaricxad, romlebic SeiZleba axdendes gafantuli
sklerozis mimikrias.
gafantuli sklerozis sawyisi mkurnaloba
gafantuli sklerozis sawyisi mkurnaloba gulisxmobs pacientisaTvis
diagnozis ganmartebas. sasurvelia, rom es saqme mivandoT nevrologiuri
gundis iseT wevrs, romelic gamocdilia msgavs sakiTxebSi da SeuZlia
dawvrilebiT upasuxos yvela kiTxvaze. mravali pacienti miiCnevs, rom
gafantuli sklerozis meddis CarTva adreul etapze maTTvis mniSvnelovan
daxmarebas warmoadgens. gafantuli sklerozis zogierT centrSi tardeba
kursebi saRamoobiT, romlis mizania miawodos pacientsa da misi ojaxis
wevrebs informacia gafantuli sklerozisa da misi bunebis Sesaxeb, aseve
gaaTviTcnobieros isini daavadebis sxvadasxva aspeqtebSi.
sawyis etapze recidivebis kupireba xdeba steroidebiT. es ukanasknelni
iniSneba oraluri formiT mzardi doziT (meTilprednizolonis tabletebi).
meTilprednizoloni aCqarebs gamojanmrTelebas calkeuli recidivebis
dros, Tumca saboloo gamosavalze gavlenas ver axdens. mas aseve aranairi
efeqti ara aqvs xangrZlivi kursiT invalidobis xarisxze. sxvadasxva
kvlevebis mixedviT gamovlenili iqna ramodenime medikamenti, romlebic
ramdenadme cvlis daavadebis kurss, esenia: interferoni, CAMPATH
(Alemtuzumab), natalizumabi da metoqsantroni. es wamlebi gamoiyeneba
daavadebis progresirebis SesaCereblad, rac gulisxmobs recidivebis
sixSirisa da invalidobis xarisxis Semcirebas. did britaneTSi es wamlebi
xelmisawvdomia specializirebul gafantuli sklerozis klinikebSi,
zogjer am wamlebis mopoveba SeiZleba klinikur kvlevebSi CarTvis gziT.
idealurma mkurnalobam wesiT unda SeaCeros recidivebi, Seaferxos
daavadebis progresireba da aRadginos invalidobis nebismieri forma.
Tumca, samwuxarod, aseTi medikamenti jerjerobiT ar arsebobs.
gafantuli sklerozis dros aseve xSirad gamoiyeneba simptomuri
mkurnaloba. magaliTad, tkivili SeiZleba moixsnas Cveulebrivi
tkivilgamayuCeblebiT, rogoricaa paracetamoli and aass-ebi
(arasteroiduli anTebis sawinaaRmdego saSualebebi), anda ufro naklebad
gamoyenebadi tkivilis kupirebis saSualebebiT, mag. antikonvulsantebi da
antidepresantebi. Sardis buStis problemebi yvelaze kargad imarTeba
specialuri konsultantis mier. es SeiZleba gulisxmobdes medikamentebs an
kaTeterizacias. zogierT SemTxveveaSi kaTeterizacia SeiZleba gakeTdes
TviTon pacientis mier dReSi ramdenjerme, Sardis buStis efeqturad
daclis mizniT, Tanac ise rom Tavi avaridoT permanentul kaTeters.
depresiis marTva xSirad xdeba antidepresantebiT (tabletirebuli forma)
da fsiqologiuri mxardaWeriT, Tu amis saSualeba arsebobs lokalurad.
daRlilobis moxsna zogjer SesaZlebelia medikamenturi saSualebebiT,
Tumca yvelaze kargad igi imarTeba ufro pragmatuli midgomiT. am
midgomaSi igulisxmeba yvela mxaris (pacientis, pacientze mzrunvelis,
damqiraveblis) ganaTleba, raTa moxdes yoveldRiuri saqmianobisadmi
morgeba maqsimaluri moqnilobiT. magaliTad, SeiZleba Zalian didi
sargeblis momtani aRmoCndes SuadRis Zili, Tumca zog pacients SeiZleba
dasWirdes darwmuneba da gamxneveba amis misaRebad. aseve, damqiravebelic
SeiZleba daTanxmdes amaze, Tu kargad avuxsniT mis mniSvnelobasa da
sargebels.
gafantuli sklerozis umravles stadiaze, udidesi mniSvnelobda aqvs
specialuri Terapevtis CarTvas, fizioTerapevts, okupaciuri Terapevtis da
metyvelebisa da enis Terapevtis CaTvliT. magaliTad, fizioTerapevts
SeuZlia daexmaros pacients damoukidebeli siaruli unaris SenarCunebaSi,
sanam es SesaZlebelia da Semdgom, daavadebis raRac etapze urCios
sagoravebliani savarZeli. okupaciuri Terapevtis roli mdgomareobs
pacientis saxlis mowyobaSi, raTa maT ufro usafrTxod icxovron maTTvis
Cveul garemoSi. metyvelebisa da enis Terapevti xSirad monawileobs
ylapvis unaris SefasebaSi.
motoruli neironis daavadeba (mnd)
mnd-s epidemiologia
gafantuli sklerozisagan gansxvavebiT, mnd iSviaTi paTologiaa. avadoba
daaxl. 1.5-2-ia 100 000 sul mosaxleze, xolo gavrceleba ki – 5-7 / 100 000-ze.
mamakacebi 2-jer ufro xSirad avaddebian vidre qalebi. mnd upiratesad
vlindeba ufros asakSi, asakis piki diagnostirebisas 55-57 welia. Tumca
zogjer SeiZleba gamovlindes sicocxlis meore dekadaSic.
mnd-iT avadoba 50-150-jer ufro maRalia dasavleT wynari okeanis regionSi,
msoflios danarCen regionebTan SedarebiT. savaraudod es ukavSirdeba
mcenareTa (mag. cikadebis) TeslSi arsebul toqsinebs. daavadebis 5%-Si
mizezi genetikuri gadacemaa. erTaderTi mutacia, romelic dRemde aris
dadgenili, ukavSideba superoqsid-dismutazas gens, romelic autosomur
dominanturi tipiT gadaecema.
mnd rogorc wesi, sicocxlis xangrZlivobas amoklebs. mosalodneli
sicocxlis xangrZlivoba diagnozis dasmidan saSualod 2 welia, Tumca es
monacemic farTod varirebs individebs Soris.
mnd-s paTofiziologia
mnd-s dros xdeba motoruli neironebis gadagvareba. lokalizacia farToa
da moicavs Tavis tvinis qerqs, tvinis Reros, zurgis tvinsa da
kortikospinalur traqts. neironebis degeneraciis mizezi ucnobia. am dros
aRdgenis process adgili ara aqvs, ase rom gafantuli sklerozisgan
gansxvavebiT, daavadeba dasawyisidanve uwyvetad progresirebadia. mnd-s
dros ar ziandeba nervuli sistemis nawilebi, romlebic ganagebs nawlavisa
da Sardis buStis funqcias, mgrZnobelobiT da Tvalis mamoZravebel
sistemas.
mnd-s tipebi
mnd-s yvelaze gavrcelebuli tipia gverdiTi amiotrofuli sklerozi (gas)
(ALS – amyotrophic lateral sclerosis). am formis mnd-s dros ziandeba rogorc zeda, aseve qveda motoruli neironi. zeda motoruli neironi warmoadgens
motorul gamtar gzas Tavis tvinidan zurgis tvinamde, xolo qveda
motoruli neironi ki qmnis gamtar gzas zurgis tvinidan kunTebamde.
amgvarad, gas-is dros kompleqsuradaa warmodgenili rogorc zeda, ise
qveda motoruli neironis problemebi.
sxva SemTxvevaSi, SesaZloa gvqondes mxolod zeda motoruli neironis
dazianeba. am mdgomareobas hqvia “pirveladi gverdiTi sklerozi”. aseve
SeiZleba Segvxvdes sufTad qveda motoruli neironis daavadeba, romlis
drosac rogorc wesi warmodgenilia metyvelebisa da ylapvis problemebi.
mnd-is simptomebi
mnd-iT daavadebul pacientebs uviTardebaT sxvadasxva simptomebis mTeli
speqtri. xSirad maT aqvT sisuste kidurebSi da siarulis gaZneleba. xSirad
es CaiTrevs mxolod erT fexs daavadebis dasawyisSi. meore xSiri simptomia
xelis moxmarebis gaZneleba, es exeba ufro natifi moZraobebis Sesrulebas,
rogoricaa mag. Rilis Sekvra. SesaZloa daziandes metyveleba da pacienti
amCnevs, rogor Seunelda da gaurkveveli gaxda metyveleba, anda gauWirda
artikulacia. pirvel simptomebad SeiZleba gamovlindes ylapvis
problemebi, rac vlindeba sakvebis gadacdeniT. daavadebis
progresirebasTan erTad Cndeba axali simptomebic. SesaZloa es swrafad
moxdes, mag. ramodenime kviris ganmavlobaSi. sxva SemTxvevaSi, daavadeba
SesaZloa progresirebdes ufro nela, ramodenime Tvis manZilze. mnd ar
azianebs mxedvelobas, mgrZnobelobiT sistemasa da Sekavebis funqcias. mnd-s
dros SesaZloa daziandes kognituri da mexsierebis sferoebi, Tumca
xSirad misi diferencireba Zneldeba metyvelebis moSlis gamo.
rogorc wesi, am dros irRveva respiratoruli funqcia. pacientebs
uviTardebaT orTopnoe (sunTqvis gaZneleba woliT mdgomareobaSi). xSirad
ziandeba Ramis sunTqvis faza, ramac SeiZleba gamoiwvios sisxlSi CO2-is
donis mateba. Sesabamisad, es iwvevs Ramis Zilis ciklis moSlas da dRisiT
Zilianobas, an Tavis tkivils.
mnd-s diagnozi
mnd warmoadgens fatalur mdgomareobas da amitom swor diagnozs arsebiTi
mniSvneloba eniWeba. diagnostikis oqros standartad miCneulia farTod
aRiarebuli el eskorialis kriteriumebis Skala. TumcaRa, am ukanasknels
ufro kvlvevebsa da klinikur gamocdebSi iyeneben da Sesabamisad, klinikur
praqtikaSi maTi Sesruleba iSviaTad xdeba.
praqtikaSi diagnozi ismeba nervis gamtareblobis kvlevebiTa da
eleqtromiografiiT, sadac vlindeba mnd-s damaxasiaTebeli niSnebi. aseve
gamoiyeneba neirovizualizaciuri kvlevebi, sisxlis analizi da SesaZloa
lumbaluri punqciac, raTa gamoiricxos sxva daavadebis arseboba. xSiria
diagnostikis problemebi, gansakuTrebiT im pacientebSi, romelTac
gamoxatuli aqvT mxolod zeda an mxolod qveda motoruli neironis
dazianebis niSnebi, da ara maTi kompleqsi.
mnd-s diagnozis ganmarteba pacientisTvis sakmaod problemuria da
moiTxovs am daavadebis mxriv gamocdilebis mqone nevrologis CarTvas.
saWiroa winaswari (proviziuli) sqemis qona, romelic SeTanxmebuli unda
iqnas pacientTan; moxdes Tu ara gagzavna specialur TerapevtTan, CaerTos
Tu ara pacientis marTvaSi mnd-s movlis koordinatori, moxdes Tu ara
mimarTva respiratoruli marTvis gundTan, Tu moxdes yvela
zemoTCamoTvlili RonisZiebebis kombinacia. pacientis Sefaseba (kontroli)
rogorc wesi sakmaod swrafad unda xorcieldebodes, nevrologis an mnd-s
gundis sxva gamocdili wevris mier. mraval qveyanaSi axla arsebobs
specializebuli mnd-s klinikebi, romelsac xelmZRvanelobs erTi an ori
nevrologi centridan, metyvelebisa da enis TerapevtTan, dietologTan,
fizioTerapevtTan da paliatiuri mzrunvelobis eqimTan an eqTanTan erTad.
amgvari multidisciplinaruli gundis arsebobis SemTxvevaSi SesaZlebeli
xdeba mnd-iT daavadebuli pacientisTvis sicocxlis xarisxis gaumjobeseba
da maqsimalurad gaxangrZliveba.
mnd-s sawyisi mkurnaloba
dReisaTvis erTaderTi licenzirebuli preparati mnd-s mkurnalobisTvis
aris riluzoli. igi amcirebs glutamatis gamoTavisuflebasa da xels
uSlis neironis dazianebas in vitro. igi ufro moqmedebs daavadebis kursze, da ar warmoadgens simptomatur preparats: naCvenebia, rom riluzoli
axangrZlivebs sicocxles ramodenime TviT iseT pacientebSi, romelTac ar
aReniSnebaT bulbaruli (metyvelebisa da ylapvis) problemebi. rogorc
wesi, preparati kargad gadaitaneba. mravali nevrologi am wamals niSnavs
pacientisTvis imedis misacemad, vidre raime fizikuri sargeblis motanis
TvalsazrisiT.
ukanaskneli kvlevebiT naCvenebi iqna, rom mnd-s garkveul SemTxvevebSi
arainvaziuri ventilaciis gamoyenebiT SesaZlebelia gavzardoT sicocxlis
xangrZlivoba da metic, gavuumjobesoT sicocxlis xarisxi rogorc
pacients, ise mis momvlels. sunTqviTi moculoba rogorc wesi, fasdeba
specialuri sunTqviTi testebiT, xSirad amas akeTeben specializirebul
klinikebSi. arainvaziuri ventilatorebi portatulia da saWiroebs saxis
niRabs. mravali pacienti Tavdapirvelad arainvaziur ventilators iyenebs
mxolod RamiT, an mxolod roca aqvT sunTqvis ukmarisobis SegrZneba,
Tumca zogierTs uwevs am aparatis gamoyeneba 24 saaTis ganmavlobaSi.
mnd-s dros kidev erTi gasaTvaliswinebeli sakiTxia kveba. daavadebis
nebismier stadiaze SeiZleba moiSalos ylapvis funqcia. ylapvis Sefasebas
axdens da mkurnalobas marTavs metyvelebis specialisti da enis Terapevti.
sawyis etapze SeiZleba sakmarisi iyos dietis modificireba, mag. rbili an
naxevrad Txevadi sakvebiT, Tumca sabolood mainc saWiro xdeba damatebiTi
enteraluri kveba. rogorc wesi, es miiRweva PEG zondis CasmiT (kangavliTi
gziT, muclis kedlidan kuWSi), rac ylapvis saWiroebas xsnis. arsebobs
zondis Casmis ori meTodi: endoskopiuri an radiologiuri. zondi
gamoiyeneba kaloriebis, anda sakvebi nivTierebebisa da siTxeebis Sevsebis
mizniT. mnd-s specializirebul dawesebulebebSi amgvari zondis Casmas
ZiriTadad ganixilaven daavadebis iseT etapze, roca pacienti SedarebiT
kargad grZnobs Tavs, vinaidan daavadebis gvian stadiaze, roca pacientis
mdgomareoba saeWvoa, zondireba ufro sariskoa.
mnd-Ti daavadebuli pacientebi, iseve rogorc gafantuli sklerozis
SemTxvevaSi, saWiroeben multidisciplinaruli samedicino gundis CarTvas.
daavadebis Zlier cudi prognozisa da xSirad mdgomareobis swrafad
damZimebis gamo, multidisciplinaruli gundis eqimebi xSirad Zalian
aqtiurad arian CarTuli yoveli pacientis marTvaSi, daavadebis
diagnozidan sikvdilamde.
parkinsonis daavadeba
parkinsonis daavadeba (pd) pirvelad aRwera jeims parkinsonma triadiT,
romelic moicavda tremors, rigidobas da bradikinezias.
epidemiologia
pd-iT avadoba daaxloebiT udris 300 / 100 000 sul mosaxleze. avadoba
asakis matebasTan erTad izrdeba. ZiriTadad igi vlindeba 50 wlis zemoT
asakSi. pacientebis 2/3 70 welze ufrosi asakisaa. pd-Ti daavadebis zogadi
riski udris 2%-s mamakacebisaTvis da 1.3%-s qalebisaTvis. zogierTi kvlevis
mixedviT, kavkasiuri rasa ufro xSirad avaddeba afroamerikelebTan
SedarebiT, Tumca am mosazrebis damadasturebeli monacemebi ar arsebobs.
pd-s uniformuli diagnostikuri kriteriumebi mwiria, riTac SeiZleba
aixsnas avadobis gansxvavebuli monacemebi sxvadasxva qveyanaSi.
arsebobs kvlevebi, romlebiTac Sefasebulia mwvelobisa da alkoholis
moxmarebis kavSiri pd-s ganviTarebasTan. am kvelvebis monacemebis mixedviT,
mweveloba SesaZloa xels uSlides pd-s ganviTarebas. populaciuri
kvlevebi uCvenebs, rom pd ufro xSiria industriul regionebSi, vidre
qalaqgareT; aseve, igi ufro xSiria CrdiloeT amerikasa da evropaSi,
Soreul aRmosavleTTan SedarebiT.
pd zogjer memkvidreobiTia. pd-s gamomwvevi pirveli geni dadgenil iqna 1997
wels; mas Semdeg kidev ramodenime aseTi iqna aRmoCenili. maTgan zogi
dominanturia, zogi ki recesiuli saxiT gadaecema.
pd-is paTofiziologia
pd-s dros niSandoblivia Tavis tvinis Savi nivTierebis kompaqtur nawilSi
(pars compacta substantia nigra) dofamin-Semcveli ujredebis degeneracia.
ujredTa kargva aseve xdeba tvinis Reros sxva pigmentirebul birTvebSi,
autonomiur birTvebsa da piramiduli ujredebis SreSi.
pd-is gamovlineba
klasikurad, pd warmodgenilia tremoris, rigidobisa da bradikineziis
triadiT, rac pirvelad aRwera jeims parkinsonma. daavadebis dasawyisSi
simptomebi rogorc wesi, calmxrivia. retrospeqtulad, anamnezis SekrebiT,
pacientma SeiZleba gaixsenos, rom diagnozis dasmamde ramodenime wliT
adre awuxebda sxvadasxva msgavsi simptomebi, mag. SeboWiloba, saxsrebis
tkivili, weris gaZneleba da kidurSi moZraobis unaris mzardi daqveiTeba.
am simptomebs xSirad SecdomiT afaseben, rogorc arTrits, an miaweren
daberebas. mosvenebiTi tremoris arseboba (anu, tremori, romelic
warmodgenilia mosvenebiT mdgomareobaSi da qreba mizanmimarTuli
moZraobis dawyebisas) xSirad aZlevs klinicists pd-s diagnozis dasmis
safuZvels. dgomis dros poza Cveulebriv moxrilia, xolo siaruli – nela
da barbaciT. metyveleba SesaZloa gaxdes monotonuri da Cumi. saxis
mimikebi da Tvalebis moZraoba mcirdeba. es niSnebi SeiZleba Tavdapirvelad
sustad iyos gamoxatuli.
pd-s progresirebasTan erTad simptomebic mZimdeba. siaruli Zalian neldeba
da SesaZloa ganviTardes gaSeSebac. es ukanaskneli gulisxmobs normaluri
siarulis SeCerebas da gagrZelebis SeuZleblobas. wonasworobis dacva
Zneldeba da SeiZleba gvqondes davardnis epizodebic. SesaZloa gaWirdes
ylapva. kognituri cvlilebebi Tavidan xSirad vlindeba rogorc
halucinaciebi. es ukanaskneli rogorc wesi vizualuria da saSiSi ar aris.
ufro mogvianebiT stadiaze SeiZleba ganviTardes demencia.
pd-s dros xSiria Zilis moSla. pacientebs uviTardebaT REM Zilis (REM –
rapid eye movement) fazis darRvevebi, rac ganapirobebs mkveTr sizmrebs,
ZilSi yvirils da zogjer partniorze Tandasxmas RamiT. rogorc wesi, amas
pacientebi nebiT ar hyvebian, Tu specialurad ar CavekiTxebiT.
pd-sTan dakavSirebuli sxva xSiri problemebi moicavs aseve Sekrulobas,
kanis cximianobas, xasiaTis cvlilebebs (gansakuTrebiT depresias),
seqsualur disfunqcias, urologiur problemebs, ylapvis problemebsa da
autonomiur disregulacias.
pd-s diagnozi
pd ZiriTadad klinikurad diagnostirdeba. diferenciuli diagnozi unda
gatardes esenciur tremors, medikamentiT inducirebul parkinsonizmsa da
vaskulur parkinsonizms Soris.
zogjer diagnostikisTvis gamoiyeneba ioflupani. igi warmoadgens birTvul
samedicino neirovizualizaciis meTods, romelic sazRvravs dofaminis
xelaxla aTvisebas Tavis tvinSi.
pd-s sawyisi marTva
did britaneTSi, pd-s sawyisi marTva gulisxmobs diagnozis axsnas da
detalebis ganmartebas, aseve mxardaWeras informaciuli TvalsazrisiT,
rasac uzrunvelyofs parkinsonis daavadebis sazogadoeba. Tavidan xSirad
wamlis daniSvna araa saWiro. simptomebis progresirebasTan erTad, roca
ukve Zneldeba yoveldRiuri saqmianobis Sesruleba, dRis wesrigSi dgeba
medikamenturi Terapiis dawyebis sakiTxi. medikamenturi Terapiis mTavar
RerZs warmoadgens levodopa. igi inSneba iseT preparatTan erTad, romelic
iZleva levodopis nawlavSi Sewovis saSualebas misi metabolizebis gareSe.
ramodenime wlis Semdeg, pacientebs xSirad uviTardebaT problemebi
levodopas mimarT, rac gamoixateba wamlis koncentraciuli pikis swrafad
miRwevaSi, ris Semdegac misi done swrafad vardeba; es iwvevs
gadaWarbebuli mobilobis (diskineziebis) da aramobilobis (gaSeSebis)
periodebis monacvleobas. mkurnalobis kidev erTi meTodia dofaminis
agonistebi, romlebic zogjer damatebiTi Terapiis saxiT iniSneba
levodopasTan erTad. arsebobs monacemebi, rom Tuki am preparatebs
Tavidanve davniSnavT, levodopasTan dakavSirebuli problemebi cota gvian
warmoiSveba. Tumca mxolod es medikamentebi araa sakmarisad Zlieri
imisaTvis, rom marTos daavadebis simptomatologia. ZiriTadad, dofaminis
agonistebi iniSneba rogorc pirveli rigis preparatebi im pacientebSi,
romelTac SedarebiT axalgazrda asakSi daewyoT simptomebi. sxva
medikamentebi moicavs amantadins, romelic iniSneba susti bradikineziis da
rigidobis dros da antiqolinergul saSualebebs axalgazrda
pacientebisaTvis tremoriT.
bolo dros inergeba pd-s mkurnalobis neiroqirurgiuli meTodebi. es
ukanasknelni moiazreba ufro bolo stadiaSi myofi pacientebisaTvis. did
britaneTSi am meTodebTan dakavSirebiT arsebobs mkacri gaidlainebi,
romlebic mowodebulia NICE-s (National Institute for Health and Clinical Excellence) mier.
hantingtonis daavadeba
hantingtonis daavadeba (hd) warmoadgens autosomur dominantur
mdgomareobas. igi iwvevs moZraobis moSlilobebsa da kognitur
cvlilebebs. hd progresirebadi daavadebaa da iwvevs naadrev sikvdils.
hd-s epidemiologia
hd genetikurad determinirebuli, autosomur-dominanturi mdgomareobaa. es
niSnavs, rom daavadebuli adamianis STamomavlobis naxevars aqvs am
daavadebis ganviTarebis Sansi. hd SeiZleba Segvxvdes sporaduladac, Tumca
Tu dawvrilebiT gamovikiTxavT anamnezs, aRmoCndeba rom pacients mSobeli
adre gardaecvala, anda aris naSvilebi. did britaneTSi hd-s gavrceleba 4-
10-ia 100 000 sul mosaxleze.
cnobilia, rom hd-s iwvevs arastabiluri trinukleotiduri ganmeoreba me-4
qromosomaze. yvela daavadebul individSi am ganmeorebaTa ricxvi 35-s
aRemateba. ganmeorebebis raodenoba mocemul pacientSi ganapirobebs
daavadebis gamovlenis asaks. hd-s axasiaTebs anticipacia, rac niSnavs, rom
Semdgom TaobebSi misi gamovlenis asaki SeiZleba sul ufro Semcirdes.
trinukleotiduri ganmeoreba akodirebs cilas, romelsac ewodeba
hantingtini.
hd-s paTofiziologia
hd-s paTofiziologia Zalian variabeluria. umravles SemTxvevebSi bolo
stadiaze xdeba bazaluri gangliebis nawilebis (kudiani birTvisa da
CenCos), aseve qerqisa da subkortikaluri struqturebis atrofia.
sainteresoa isic, rom asimptomur pacientebs SeiZleba hqondeT
gavrcelebuli paTologiuri cvlilebebi Tavis tvinSi, xolo simptomebis
mqone pacientebs SesaZloa piriqiT, umniSvnelo cvlilebebi aReniSnebodeT.
hd-s simptomatologia
samwuxarod, hd xSirad emarTeba pacients ojaxuri anamneziT, rac imas
niSnavs, rom pacientma mSvenivrad icis, ra diagnozi unda dausvan. daavadeba
SeiZleba gamovlindes nebismier asakSi, bavSvobidan dawyebuli
moxucebulobis asakiT damTavrebuli. umravles SemTxvevebSi daavadebis
sawyisi gamovlenis asaki 30-dan 50 wlamde meryeobs.
pacientebis 2/3 Tavdapirvelad aRniSnavs motorul problemebs, ZiriTadad
qoreis saxiT. es ukanaskneli gulisxmobs uneblie talRisebr (grexviT)
moZraobebs kidurebSi da/an tanSi. amas SeiZleba Tan axldes bradikinezia
da rigidoba. daavadebis progresirebasTan erTad viTardeba mzardi
imobiloba, davardnebi, aseve Zneldeba metyveleba da ylapva. SesaZloa
problemuri gaxdes wonis kargvac, rac gamowveulia rogorc Tavad qoreiT,
ise ylapvis gaZnelebiT.
pacientebis danarCen 1/3-Si sawyisi simptomebi moicavs kognitur problemebs.
Tavidan vlindeba gaRizianebadoba, apaTia, mousvenroba da xasiaTis
cvlilebebi. TavisTavad, es gavlenas axdens samsaxurze, Semosavalsa da
ojaxur urTierTobebze. xSiria depresia, ramac SeiZleba miiyvanos pacienti
TviTdazianebamde. aseve SeiZleba aSkarad iqnas gamoxatuli demencia.
hd-s diagnozi
hd-s diagnozi ZiriTadad genetikuria. anu, diagnozi ismeba pacientis dnm-is
analiziT. es analizi rogorc wesi keTdeba genetikuri konsultaciis
mixedviT genetikosis an nevrologis mier, romelic specifiurad
dainteresebulia da muSaobs hd-s ganxriT. rogorc yvela genetikuri
diagnozis dros, am drosac diagnozs aqvs farTo qveteqsti ojaxuri
TvalsazrisiT. 50 wlis qvemoT pacientebSi aucileblad unda gamoiricxos
vilsonis daavadeba, romelic aseve SeiZleba gamovlindes moZraobis
anomaliebiTa da kognituri cvlilebebiT. vilsonis daavadeba viTardeba
spilenZis metabolizmis darRvevis Sedegad da misi diferenciuli diagnozi
aucileblad unda gakeTdes bioqimiuri testirebiT.
hd-s sawyisi mkurnaloba
hd-s paTognomuri mkurnaloba ar arsebobs. moZraobis aSlilobebs SeiZleba
vumkurnaloT tetrabenaziniT an sxva nevrologiuri medikamentebiT.
depresiis mkurnaloba unda moxdes simZimis Sesabamisad. fsiqozis
SemTxvevaSi SeiZleba saWiro gaxdes neiroleptikebi. diagnozis dasmidanve
saWiroa multidisciplinaruli gundis CarTva, rac Cveulebriv moicavs
nevrologs, fizioTerapevts, okupaciur Terapevts, metyvelebisa da enis
Terapevts da dietologs. yvela zemoTCamoTvlili gaerTianebulia
specializirebul hd-s klinikebSi. fsiqiatrisa da paliatiuri
mzrunvelobis CarTva xSirad saWiro xdeba daavadebis adreul etapze, rac
moicavs sazogadoebriv CarTulobas, gadavadebuli da xangrZlivi movlis
uzrunvelyofas.
daskvna
PLTNC mdgomareobebi Zlier gansxvavdeba erTmaneTisgan simptomatologiis,
progresirebis siCqarisa da sicocxlis xangrZlivobaze gavlenis mxriv. am
TavSi Cven mokled mimovixileT gafantuli sklerozis, parkinsonis
daavadebis, motoruli neironis daavadebisa da hantingtonis daavadebis
epidemiologia, paTofiziologia da diagnostikis meTodebi. am daavadebebs
mravali ganmasxvavebeli niSnebi gaaCnia, Tumca maT saerTo aqvT
problemebis mTeli speqtri, romlis winaSec dgebian daavadebuli
pacientebi. sxva PLTNC mdgomareobebis msgavsad, am pacientebsac sWirdebaT
multidisciplinaruli midgoma daavadebis paliatiur stadiaze,
invalidobis xarisxisa da tanjvis Sesamcireblad.
paliatiuri mzrunvelobis gamowvevebi
paliatiuri mzrunveloba gaxangrZlivebuli mdgomareobebis dros
tradiciulad da istoriuladac, paliatiuri mzrunveloba exeboda mxolod
kibos bolo stadiaze myof pacientebs. rogorc Cans, aman ganapiroba
ganmtkiceba ideisa, rom paliatiuri mzrunveloba exeba mxolod sicocxlis
bolo Tveebs an kvirebs. Tumca axla ukve farTodaa aRiarebuli, rom
praqtikaSi kuraciuli mkurnalobidan paliatiur mzrunvelobaze gadasvla
mkveTrad sulac ar xdeba, gansakuTrebiT es exeba pacientebs
gaxangrZlivebuli mdgomareobebiT. pacientze mzrunvelobis es ori saxe
(kuraciuli da paliatiuri) SesaZloa paralelurad arsebobdes xangrZlivi
drois manZilze, Tumca pacientis saWiroebisa da situaciis mixedviT,
aqcenti inacvlebs an icvleba romelime maTganis sasargeblod.
adreul stadiaze paliatiuri mzrunvelobis mimarTvasTan dakavSirebuli
erT-erTi problemaa amgvari midgomis Sefaseba da misi mniSvnelobis
sworad gageba, aseve gansazRvra imisa, Tu rodis unda vurCioT pacients,
mimarTos paliatiuri mzurnvelobis specialists rCevisTvis. miuxedavad
farTod miRebuli azrisa, rom paliatiur mzrunvelobas didi roli
akisria mZime daavadebis adreul stadiaze, praqtikaSi amgvari tipis
mzrunveloba xSirad pacients miewodeba daavadebis gvian etapze. amis
mizezebi mravalgvaria, SesaZloa es nawilobriv gamowveuli iyos
daavadebis, sikvdilisa da jandacvis mimarT kulturul an socialur
damokidebulebebze, anda aseve prognostikaciis sakiTxebze. pacientebi,
romelTac aqvT ara kibo aramed sxva letaluri kondicia, SesaZloa
gansakuTrebiT iqnan invalidizirebuli, ara paliatiuri mzrunvelobis da
misi saWiroebis arcodnis gamo maTi eqimebis mxriv, aramed TviTon
daavadebis moulodneli da winaswar ganusazRvreli mimdinareobis gamo.
paliatiuri mzrunvelobisa da mxardaWeris saWiroeba
progresirebadi gaxangrZlivebuli nevrologiuri
mdgomareobebis dros: mokle mimoxilva
am TavSi mocemulia mokle mimoxilva paliatiuri mzrunvelobisa da
mxardaWeris saWiroebebze, aseve im problemebze, romlebic aqvT pacientebs
progresirebadi gaxangrZlivebuli nevrologiuri mdgomareobebiT, aseve
maTi ojaxis wevrebsa da megobrebs, romlebic uSualod monawileoben
yoveldRiur movlaSi. rogorc zemoT aRvniSneT, Cven ZiriTadad yuradRebas
vamaxvilebT oTx yvelaze gavrcelebul progresirebad mdgomareobaze,
esenia: motoruli neironis daavadeba, parkinsonis daavadeba, gafantuli
sklerozi da hantingtonis daavadeba; Tumca arsebobs sxva mravali msgavsi
daavadebac, romelTa drosac warmoiSveba msgavsi an gansxvavebuli
problemebi, ris gamoc SeiZleba maTi gaerTianeba PLTNC-ebTan erTad erTi
qolgis qveS. kerZod, am TavSi mimovixilavT im gaidlainebs, romlebic
ukanasknel xans gaxda xelmisawvdomi inglisis paliatiuri mzrunvelobis
erovnuli sabWos mier Catarebuli programis Sedegad. es ukanaskneli
ikvlevda paliatiuri, reabilitaciuri da nevrologiuri mzrunvelobis
modelebs sxvadasxva PLTNC-mdgomareobebis SemTxvevaSi. am gaidlainebis
ganxilvamde, moviyvanT ramodenime mTavar epidemiologiur maxasiaTeblebs
da mokled SevexebiT politikur mimarTulebebs, romlebic Camoyalibda
did britaneTSi am sakiTxTan dakavSirebiT.
mokle epidemiologiuri monaxazi
did britaneTSi amJamad sikvdilis ZiriTadi mizezi qronikuli daavadebebia;
inglisSi daaxloebiT 15 milioni adamiani saWiroebs gaxangrZlivebul
movlas qronikul mdgomareobaTa gamo. aseTi mosaxleobis ricxvi kidev
ufro gaizrdeba momavalSi, sicocxlis saSualo xangrZlivobis matebis
gamo. rogorc wesi, qronikuli mdgomareobebi xangrZlivad grZeldeba, an
aqvT rekurentuli xasiaTi da ar ikurneba. isini yovelTvis progresirebadi
araa da xSirad ar qmnis sikvdilis mkveTr saSiSroebas, Tumca
progresirebis SemTxvevaSi isini saboloo jamSi amokleben sicocxlis
xangrZlivobas.
NHS Healthcare Workforce –is monacemebis mixedviT:
did britaneTSi daaxloebiT 10 milion adamians aqvs PLTNC, rac Seadgens mwvave hospitaluri miRebis 20%-s;
350 000 adamians did britaneTSi esaWiroeba daxmareba yoveldRiuri
saqmianobis Sesasruleblad, nevrologiuri mizezebis gamo;
850 000 adamiani aris nevrologiuri pacientis momvleli;
daavadebulTa saWiroebebi kompleqsuri da variabeluria, ZiriTadi aqcenti
modis yoveldRiur saqmianobebze, rac SeiZleba wlebis manZilze
gagrZeldes. saWiroebebi cvalebadobs mdgomareobisda mixedviT, mcire
saWiroebebidan dawyebuli uwyveti paliatiuri mzrunvelobis saWiroebiT
damTavrebuli, rac sicocxlis bolo etapze xorcieldeba. paliatiuri
mzrunvelobis erovnuli sabWo gamohyofs mTel rig mTavar maxasiaTeblebs
(saWiroebebis TvalsazrisiT), romlebic ganasxvavebs nevrologiur
mdgomareobebs “tipiuri” kibos SemTxvevebisgan:
- umravles SemTxvevebSi, PLTNC-s axasiaTebs ufro xangrZlivi da
cvalebadi mimdinareoba;
- umravles PLTNC-s axasiaTebs remisiebi da recidivebi, ris gamoc
xSirad Znelia gansazRvro, imyofeba Tu ara pacienti sicocxlis
bolo etapze;
- simptomebi PLTNC-s dros Zalian gansxvavebuli da kompleqsuria,
romelTac xSirad Tan axlavs kognituri, qceviTi da komunikaciis
problemebi, fizikur simptomebTan erTad, rogoricaa tkivili da
invalidobis sxvadasxva tipebi.
politika: koteqsti da gamowvevebi did britaneTSi
nevrologiuri mdgomareobebis paliatiuri mzrunvelobis mxriv mravali
politikuri mimarTulebani iqna aRebuli bolo wlebis manZilze did
britaneTSi. kerZod, arsebobs zogadi paliatiuri mzrunvelobis principebis
gadmotanisa da gamoyenebis tendencia yvela mdgomareobisa da garemos
SemTxvevaSi, nacvlad imisa, rom fokusi gakeTebuliyo specializirebul
paliatiur mzrunvelobaze. paliatiuri mzrunvelobis erovnuli sabWos
mixedviT, zogadi paliatiuri mzrunvelobis principebi moicavs:
- sicocxlis xarisxze fokusis aRebas;
- “mTliani pirovnebisadmi” midgomas;
- mzrunvelobas, romelic moicavs aramxolod pacients, aramed mis
axloblebsac;
- arCevanisa da avtonomiuri uflebebis pativiscemas;
- Ria urTierToebebze koncentrirebas.
sicocxlis bolo etapis strategia inglisSi gansazRvravs sicocxlis
bolo etapis saorganizacio sakiTxebs, rac moicavs Semdeg safexurebs:
- im adamianebis identifikacia, romlebic uaxlovdebian sicocxlis
saboloo etaps da saboloo etapze mzrunvelobis upiratesi formebis
ganxilvis dawyeba;
- mzrunvelobis dagegmva: saWiroebebis da pacientis arCevanis Sefaseba,
maTi mixedviT paliatiuri mzrunvelobis modelis SerCeva da misi
regularuli gadamowmeba;
- mzrunvelobis koordinacia;
- maRalxarisxiani servisis uzrunvelyofa yvela adgilmdebareobisTvis;
- sicocxlis ukanaskneli dReebis marTva;
- mzrunveloba gardacvalebis Semdeg;
- pacientis axloblebis Tanadgoma, rogorc misi avadmyofobis
periodSi, ise gardacvalebis Semdeg.
Tanadgomisa da paliatiuri mzrunvelobis saWiroebani: monacemTa mokle
mimoxilva
Tanadgomisa da paliatiuri mzrunvelobis saWiroebebi PLTNC-Ti
daavadebul pacientebSi SesaZloa warmoiSvas diagnozis dasmidanve, Tumca
daavadebis xangrZlivi kursi (mag. gafantuli skleroziT, parkinsonis
daavadebiT da hantingtonis daavadebiT pacientma SeiZleba icocxlos 15-dan
25 wlamde) ganapirobebs siZneleebs, rac gamoixatebaSi imaSi, rom Znelia
gansazRvra, rodis gavakeToT aqcenti ufro paliatiur mzrunvelobaze, da
ara daavadebis mkurnalobaze. Tumca amisgan gansxvavebiT, motoruli
neironis daavadebiT pacientma SeiZleba mxolod ramodenime Tve icocxlos,
amasTan mdgomareoba am drois manZilze swrafad uaresdeba, rac moiTxovs
paliatiuri mzrunvelobis swraf reagirebas da CarTvas. yvela SemTxvevaSi
SesaZloa saWiro gaxdes reabilitaciuri da Terapiuli jgufebis
intensiuri CarTva simptomebis marTvasa da sxva araklinikur paliatiur
mzrunvelobasTan erTad. PLTNC-ebs axasiaTebs motoruli, sensoruli da
kognituri funqciebis daqveiTeba, rac iwvevs progresirebad invalidobas
da gareSe pirze damokidebulebas. miuxedavad zemoTCamoTvlili saerTo
maxasiaTeblebisa rac Tan axlavs daavadebis progresirebas, pacientebs
SeiZleba hqondeT mravalferovani individualuri saWiroebebi. mag.:
sxvadasxva mdgomareobebis damaxasiaTebeli simptomebi, aseve erTidaigive
mdgomareobis simptomebi farTod varirebs individualur SemTxvevebSi,
garda amisa pacients SeiZleba ganuviTardes mravali gansxvavebuli
simptomebi droTa ganmavlobaSi. zogierTi simptomi xSirad Seqcevadia,
Tumca zogi maTgani mxolod nawilobriv ganicdis ukuganviTarebas da mas
Caenacvleba sxva axali simptomi an simptomTa jgufi. es garveulwilad
aZnelebs xangrZlivi paliatiuri mzrunvelobis dagegmvas. aseT pacientebs
bolo stadiaze warmodgenili aqvT rigi problemebi, romlebic arTulebs
da problematurs xdis rogorc paliatiur mzrunvelobis ganxorcielebas,
ise am ukanasknelis dagegmvas sicocxlis bolo etapze: eTikurad,
praqtikulad da klinikuradac. es xdeba rigi fizikuri, kognituri da
emociuri problemebis gamo, romelic Tavs iCens sicocxlis bolo
stadiaze, aseve problematuria komunikaciis, kvebaze gadawyvetilebis
miRebis, sicocxlis SemanarCunebeli teqnologiebis gamoyenebis da ojaxze
mzrunvelobis sakiTxebi.
motoruli neironis daavadeba
motoruli neironis daavadeba (mnd) warmoadgens iSviaT progresirebad
daavadebas, romelic xSirad swrafad ganviTarebadia da iwvevs
sicocxlesTan SeuTavseblobas. daavadebas iwvevs nervuli sistemis
dazianeba yvela doneze. misi gamomwvevi mizezebi ZiriTadad ucnobia. mcire
SemTxvvebSi gamovlenilia genetikuri faqtorebi. daavadeba iwvevs kraniuli
da ConCxis kunTebis damblas. daavadebis simZime vrceldeba rogorc
pacientze, ise mis axloblebze. umravles SemTxvevebSi inteleqti
gardacvalebamde SenarCunebulia, miuxedavad imisa rom invalidoba swrafad
progresirebs da pacienti mTlianad damokidebuli xdeba momvlelze. mnd-Ti
pacientebis gadmocemiT isini ganicdian egzistenciur kriziss, romelic
gamowveulia sicocxlis yvela aspeqtis kontrolis dakargviT: organizmis,
socialuri da komunikaciuri, rac gulisxmobs imasTan Seguebas, rom
daxmareba sxvisgan unda miiRon.
pacientebis daaxloebiT naxevarSi sicocxlis mosalodneli xangrZlivoba
diagnozis dasmidan 3 welia, Tumca zogierT SemTxvevebSi es periodi
ramodenime Tves Seadgens. zogierT pacients aReniSneba “bulbaluri
dasawyisi”, romelic moicavs metyvelebis gauaresebas (dizarTria), ylapvis
gaZnelebas (disfagia), an orives. sxva SemTxvevebSi SeiZleba sawyisi
simptomebi iyos zeda an qveda kiduris sisuste. bulbaluri dasawyisi,
SedarebiT xandazmul asakTan da cud sunTqvis maCveneblebTan erTad ufro
cudi prognozis maCvenebelia. qvemoT CamoTvlilia simptomebi, romlebic
rogorc wesi uviTardebaT mnd-Ti pacientebs.
mnd-s simptomebi:
sisuste da atrofia
fascikulaciebi da kunTovani krampebi
spastiuroba
dizarTria
disfagia da nerwyvdena
dispnoe
paTologiuri sicili an tirili
fsiqikuri aSlilobebi
Zilis darRvevebi
tkivili
sqeli lorwovani sekretebi
hipoventilacia
Sekruloba
mnd-Ti pacientebs SeiZleba ganuviTardeT undobloba eqimis mimarT
diagnozis dasmis dros (radgan daavadebis pirveli niSnebis gamovlenidan
isini ramdenime Tvis manZilze ar mimarTaven eqims), zogierT SemTxvevaSi ki
eZeben sxva, maTTvis misaReb diagnozs. sabolood, diagnozis gaazrebis
Semdgom maT uviTardebaT Zlieri SiSi. Sesabamisad, diagnozis ganmartebis
dros kargi komunikaciuri unarCvevebi aucilebelia, rac xSirad
gansazRvravs paliatiuri mzrunvelobis Semdgom efeqturobas da karg
damokidebulebas samedicino gunds, pacientsa da ojaxs Soris.
gafantuli sklerozi
gafantuli sklerozi yvelaze gavrcelebuli mademielinizirebeli
daavadebaa, anu paTologia, romelic azianebs nervuli sistemis mielinis
garss. rogorc wesi, mas axasiaTebs moulodneli remisiul-recidiuli
mimdinareoba, rasac mosdevs progresirebadi gauareseba terminalur
stadiamde, amasTan, yoveli momdevno recidivis Semdeg gamojanmrTeleba
arasrulia. igi warmoadgens nevrologiuri invalidobis yvelaze xSir
mizezs axalgazrda zrdasrulebSi, amasTan, igi ufro xSiria qalebSi,
vidre mamakacebSi. iseve rogorc mnd-s SemTxvevaSi, aqac gamomwvevi mizezi
ucnobia, Tumca daavadebis ganviTarebaSi moiazreba sxvadasxva genetikuri
da garemo faqtorebi. gafantuli skleroziT gamowveuli dazianebani
moicavs tvinis farTo areals lokalizaciis TvalsazrisiT da Sesabamisad,
simptomatikac Zalian mravalferovania. yvela pacients safexurebrivad
uviTardeba da umZimdeba daavadeba sxvadasxva simptomebiT, rac moicavs
sisustes, spastiurobas, tremors, moZraobis unaris daqveiTebas,
daRlilobas, mxedvelobis problemebs da Sardvis funqciis moSlas.
zogierT pacients SesaZloa hqondes ylapvis problemebi, aseve zogierT
SemTxvevaSi Zlier problematuria tkivili, romlis simZimec
dakavSirebulia demielinizaciis xarisxTan. iSviaTad aRiniSneba emociuri
gamoxatvis moSlilobani, rac ganapirobebs imas, rom pacients uWirs
emociebis kontroli, an ver gamoxatavs emocias im saxiT, romelic sworad
Seesabameba mis Sinagan mdgomareobas. xSir SemTxvevaSi pacientebs Zalian
uWirT im simptomebis gadatana, romlebic ase vTqvaT, sxvebisTvis
“SeumCnevelia”: amgvari tipis uxSiresi problemaa daRliloba. diagnozis
dasmidan 15 wlis Semdeg, pacientebis 1/3-dan 2/3-mde sWirdebaT daxmareba
siarulis dros, rac ganapirobebs samuSaoze uaris Tqmas, xolo zog
SemTxvevaSi ki pacienti sawolze xdeba mijaWvuli. iseve rogorc mnd-s
SemTxvevaSi, gafantuli sklerozis drosac daavadebis simZime da misgan
gamowveuli invalidoba Zalian Zneli gadasatania rogorc pacientis, ise
misi axloblebisTvis, miuxedavad imisa, rom daavadebis kursi ufro
xangrZlivia. rogorc parkinsonis daavadebis SemTxvevaSi (romelsac qvemoT
ganvixilavT), gafantuli sklerozis drosac sikvdilianoba dakavSirebulia
Tanmxleb infeqciasTan an komorbiduli daavadebis, mag. gulis
paTologiebis arsebobasTan.
parkinsonis daavadeba
parkinsonis daavadeba (pd) sakmaod gavrcelebuli PLTNC paTologiaa,
romelic, monacemebis mixedviT, aReniSneba 500 adamianidan erTs did
britaneTSi, amasTan, gavrceleba asakis matebasTan erTad izrdeba.
daavadebis paTofiziologia ukavSirdeba dofamin-maproducirebeli
ujredebis gamofitvas (kvdomas), rac ganapirobebs daavadebis kargad
nacnobi motoruli simptomatikis ganviTarebas: mosvenebis tremori,
rigiduloba da bradikinezia. daavadebis mimdinareobis manZilze gaCenili
aramotoruli simptomatikac, mag. depresia da mousvenroba, Zilis
darRvevebi, autonomiuri disfunqcia (rac iwvevs mag. Sardvis problemebs an
impotencias) da mravalgvari variabeluri tkivilis simptomebi aseve iwvevs
invalidobas da Rrma, xagrZliv stress. daavadeba progresirebs adreuli,
Sualeduri da saboloo stadiebiT, amasTan terminaluri faza ufro
gaxangrZlivebulia. miRebulia, rom daavadebis saboloo stadiad iTvleba
etapi, romlis drosac warmodgenilia ori an meti simptomi qvemoT
CamoTvlilTagan:
- medikamenturi mkurnaloba araefeqturia;
- medikamenturi mkurnalobis reJimebi sul ufro da ufro rTuldeba;
- “ukontaqtobis” periodebi (“off” periods); - diskineziebi;
- moZraobis problemebi da davardnebi;
- ylapvis problemebi;
- fsiqiatriuli niSnebi (depresia, mousvenroba, halucinaciebi, fsiqozi);
- damoukideblobis SezRudva;
- kontrolis da winaswar gansazRvris naklebi SesaZlebloba mTliani
daavadebis suraTSi.
pd-s dros sikvdilianobis uSualo mizezia Tanmxlebi infeqcia an
komorbiduli mdgomareoba, da ara TviTon daavadebis pirdapiri Sedegebi.
hantingtonis daavadeba
hantingtonis daavadeba (hd) genetikurad determinirebuli paTologiaa,
romelic iwvevs fizikuri, kognituri da emociuri statusis progresul
gauaresebas, ise rom pacienti Rrma invalidizaciamde midis. daavadebuli
adamianis Svilebs daavadebis damemkvidrebis 50% Sansi aqvT. hd ZiriTadad
viTardeba mogvianebiT, zrdasruli asakis Sua periodSi, Tumca aRwerilia
iSviaTi SemTxvevebi bavSvebSic.
daavadebis niSnebisa da simptomebis naTel klinikur gamovlinebas SesaZloa
win uswrebdes mcire anomaliebi (mag. mousvenroba), romelic ramodenime
wlis ganmavlobaSi grZeldeba da rCeba yuradRebis miRma. letaluri
gamosavali dgeba naTeli klinikuri gamovlinebidan daaxloebiT 10-20 wlis
Semdeg da iseve rogorc parkinsonis daavadebisa da gafantuli sklerozis
SemTxvevaSi, mas iwvevs meoradi infeqcia. daavadebas axasiaTebs
progresirebadi demencia da damaxasiaTebeli uneblie moZraobebi, romelsac
qorea ewodeba, aseve qceviTi anomaliebi. es ukanaskneli moicavs mkveTr da
uecar afeTqebebs sibrazis an agresiis saxiT, romelTa winaswarmetyveleba
da Sesabamisad, gamklaveba axloblebs uWirT. zog SemTxvevaSi igi
dakavSirebuli kriminalur faqtebTanac. zogjer piriqiT, hd-Ti daavadebul
pacientebs aReniSnebaT mkveTri apaTia da uinteresoba garSemo samyaros
mimarT, anda aqvT faruli depresia. suicidis sixSire hd-is dros 4-jer
maRalia janmrTel mosaxleobasTan SedarebiT. hd iTvleba erT-erT yvelaze
gamanadgurebel mdgomareobad, da aramarto misi ojaxuri tipis gamo.
ojaxis wevrebi, romlebic xSirad uSualod monawileoben pacientis
movlaSi, potenciurad TviTonac am daavadebis ganviTarebis riskis qveS
arian.
diagnozis ganmarteba: paliatiuri mzrunvelobis midgoma komunikaciis
sakiTxebSi PLTNC-ebis dros
PLTNC diagnozis ganmarteba yovelTvis dakavSirebulia sirTuleebTan
rogorc pacientis, ise misi axloblebisTvis. paliatiuri mzrunvelobis
sxvadasxva dargebis mier komunikaciur praqtikaSi SemuSavebulia cudi
ambis miwodebis principebi, romlebic, sworad Sesrulebis SemTxvevaSi,
qmnis im safuZvels, romelzec eyrdnoba pacientsa da ojaxze mzrunvelobis
mTeli Semdgomi sistema.
usiamovno informaciis miwodebisas mniSvnelovania:
1. saubari martivad da gasagebad;
2. pacientis rwmenisa da codnis donis gansazRvra (raTa gaadvildes
misTvis faqtebis axsnis ukeTesi gzis moZebna);
3. gaxsovdeT, rom Sokisa da SiSis zemoqmedebis qveS myofi pirovneba
ganicdis Zlier depresias;
4. mieciT pacients neba da dro reaqciisaTvis. ar SezRudoT misi emociebi
(xmiT tirili, moTqma) didaqtikuri saubriT. did Secdomas warmoadgens
rTuli axsna-ganmartebebis micema pacientis martiv SekiTxvebze.
gaxsovdeT, zogjer maT mxolod sakuTari grZnobebis gamoxatva surT;
5. gaiTvaliswineT iseTi reaqciebi, rogoricaa Soki, tirili, sicili,
rwmenis dakargva, pesimizmi, Caketiloba, Zlieri agzneba. swored aseT
SemTxvevaSia aucilebeli agrZnobinoT pacients mxardaWera;
6. misceT pacients dro informaciis gasaanalizeblad, darToT neba
imoqmedos survilisamebr da daTanxmdes mkurnalobas Zaldautaneblad.
eqimisa da pacientis urTierToba dafuZnebulia simarTlis Tqmaze. misi
xelSewyoba gapirobebulia gulaxdilobiT, xolo tyuili ki misi rRvevis
garantiaa.
arasodes moatyuoT pacienti;
moerideT windauxedav gulwrfelobas.
`cudi ambis~ miwodebis ZiriTadi principebi:
I. Sesaferisi fizikuri garemoTi uzrunvelyofa:
mniSvnelovania ganmartoveba
saubari auCqareblad, pauzebis gareSe
pacientTan saubris periodSi iyoT Tavisufali sxva saqmeebisgan.
II. dadgena imisa, Tu ra icis pacientma da risi codna surs:
miusadagoT informacia pacientis SegrZnebebs;
gansazRvroT ZiriTadi problemebi, nerviulobis sagani;
esaubroT martivi eniT, Jargonebis gareSe.
III. saubris dawyeba Tavisufali SekiTxvebiT:
`Tqveni azriT, ra SeiZleba yofiliyo arsebuli simptomebis
mizezi?~
`rogor grZnobdiT Tavs operaciis Semdeg?~
`aRniSnuli avadmyofoba grZeldeba dausruleblad? nerviulobT
sakuTar Tavze?~
PLTNC diagnozis ganmartebisas yvelaze mniSvnelovani punqtia klinikuri
gundis mier pacientis da misi axloblebis ndobis mopoveba da Ria
urTierTobebis damyareba, aseve informaciis maqsimaluri gaziareba, raTa
Semdgomi strategia dagegmili iqnas maqsimalurad pacientis interesebis
gaTvaliswinebiT, mocemuli situaciis moqnilad marTvis CaTvliT. am gziT
SesaZlebelia mkveTri krizisebis Tavidan acileba. imisaTvis, rom eqimTan
viziti nayofierad CaiTvalos, aucilebelia piraduli garemos Seqmna,
mosmenis survilis gamoxatva, naklebad CarTva maT saubarSi da Tbili,
TanagrZnobiTi damokidebuleba. qvemoT mocemulia sloanisa da kolegebis
mier mowodebuli rekomendaciebi mnd-s diagnozis gamJRavnebis dros, rac
praqtikaSi iqna gamocdili:
1. ar daumaloT informacia pacients, Tu mas surs misi miReba;
2. ar misceT pacients informacia, Tu mas ar surs misi miReba;
3. winaswar SeafaseT pacientis mosalodneli reaqcia da imoqmedeT
adeqvaturad mis sapasuxod.
am etapze vlindeba mniSvnelovani gansxvavebebi, rac ukavSirdeba
kulturul da eTikur sakiTxebs, aseve pacientis socialur klass da
ganaTlebas, an religiur Sexedulebebs. yvelasTvis erTi modeli ar
gamodgeba, amitom es faza erT-erTi yvelaze rTuli gadasalaxia
klinicistis mxridan.
diagnozis ganmartebis sworad SerCeuli modeli pirdapir moqmedebs
pacientisa da misi ojaxis wevrebis momaval SesaZleblobebze -
gaumklavdnen im problemebsa da dilemebs, rac warmoiSveba PLTNC daavadebebis mimdinareobis dros. gansakuTrebiT es exeba hantingtonis
daavadebas. misi ojaxuri tipi gulisxmobs imas, rom diagnozs eniWeba
Sorsmimavali mniSvneloba, romelic vrceldeba ojaxis wevrebzec. rogorc
wesi, ojaxSi Cndeba dilema, mouaron mSobels, romelsac aqvs am daavadebis
dasawyisi da paralelurad gadawyviton, gaukeTon Tu ara Svilebs
diagnostikuri testi hantingtonis daavadebaze. roca ojaxSi aris gayris an
calke cxovrebis situacia, es sakiTxebi kidev ufro mZimdeba.
o’braienis kvlevis monacemebis mixedviT, romelic moicavda mnd-Ti
daavadebuli 50 pacientis TviTSegrZnebis aRweras, aRmoCnda rom pacientebis
umravlesoba poulobda pozitiur elements diagnozis ganmartebaSi, radgan
igi swor axsnas aZlevda im simptomebsa da problemebs, rac hqondaT maT am
xnis ganmavlobaSi. umravlesoba aRniSnavda, rom erCivna diagnozis
ganmarteba moesmina eqimis mxridan pirdapiri, Tumca TangrZnobis
gamomxatveli saxiT, vinme axlobelTan erTad. mnd-Ti daavadebuli
pacientebis SemTxvevaSi, diagnozis ganmartebis Semdeg zogierTi aRniSnavda
SiSis grZnobas sikvdilis procesis mimarT, gansakuTrebiT aSinebdaT
“moxrCobis” SesaZlebloba. Sesabamisad rekomendirebuli iyo, rom aseTi
pacientebisaTvis, aseve maTTvis, romelTa forsirebuli amosunTqvis
moculoba 50%-ze dabla ecemoda, SeeTavazebinaT dawvrilebiTi axsna-
ganmarteba terminaluri fazis Sesaxeb, sicocxlis tipiuri bolo etapis
aRweriT, rac umravlesi pacientebis SemTxvevaSi gulisxmobs komas da mSvid
gardacvalebas.
yvela SemTxvevaSi, PLTNC-Ti daavadebul pacientebs surT hqondeT mudmivi
sando mxardaWerisa da informaciis wyaro saxlSi dabrunebis Semdeg.
diagnozis ganmartebisas zedmeti informaciis miwodeba SesaZloa mravali
adamianisTvis Zlier stresuli aRmoCndes. Tumca, informaciis wyarosa da
kontaqtis naklebobis SemTxvevaSi, diagnozis ganmartebis Semdgomi periodi
SeiZleba analogiurad mZime aRmoCndes pacientisa da misi ojaxisaTvis.
daavadebaTa asociaciebis roli (mag. hantingtonis daavadebis asociacia an
motoruli neironis daavadebis asociacia) Zalian mniSvnelovania am
daavadebebis marTvaSi, radgan maT aqvT kargad damuSvebuli, lakonuri
beWdviTi informaciuli masala pacientebisaTvis, aseve gamocdili rCevebi
da rekomendaciebi maTTvis, rogor moiZion daxmareba da nebismier kiTxvaze
pasuxi. aseve Zalian mniSvnelovania uSualo muSa personalis, mag.
klinikuri meddebis CarTuloba, radgan swored isini axorcieleben
pacientis vizitebsa da monitorings saxlis pirobebSi. mzrunvelobis es
uwyveti tipi pacientebisa da maTi ojaxebisaTvis gadamwyveti
mniSvnelobisaa, radganac igi warmoadgens diagnozis Semdgom xangrZlivi
paliatiuri mzrunvelobis safuZvels.
fsiqosocialuri saWiroebani PLTNC mdgomareobebis dros: Rirsebisa da
mniSvnelobis SenarCuneba
diagnozis ganmartebidan dawyebuli fsiqosocialuri saWiroebebi
warmoiSveba PLTNC-iT pacientis daavadebis mTeli kursis manZilze.
fsiqosocialuri daxmarebis uzrunvelyofa gulisxmobs mraval aspeqts,
rac moicavs: pacientisa da ojaxis Tanadgomas, informirebas da maTTvis
Rirsebisa da mniSvnelobis grZnobis SenarCunebas, raTa maT garkveulwilad
Tavad moaxerxon gamklaveba problemebisadmi da CaerTon situaciis
marTvaSi. igi aseve moicavs gardacvalebasa da glovasTan dakavSirebul
sxvadasxva sulier, religiur, emociur da socialur sakiTxebs, romlebic
yovelTvis Tan axlavs inkurabelur daavadebas. fsiqosocialuri daxmarebis
uzrunvelyofas aqvs uzarmazari dadebiTi gavlena pacientisa da misi
ojaxis zogad mdgomareobaze, rac grZeldeba glovis periodSic. Tumca,
PLTNC-s fsiqosocialuri aspeqtebi naklebadaa Seswavlili. mnd-s
SemTxvevaSi naCvenebia, rom pacientebi, romelTac dakmayofilebuli aqvT
fsiqosocialuri saWiroebani, ufro kargad umklavdebian sakuTar
mdgomareobas, ufro naklebad aReniSnebaT depresia da aqvT sicocxlis
xarisxis ufro maRali maCveneblebi, im SemTxvevebSic ki, roca gvaqvs ufro
xandazmuli asaki da mZime statusi daavadebis mxriv. piriqiT, rodesac
fsiqosocialuri mxare Seuvsebelia, saxezea tanjvis, SiSis, uimedobis
gancda da naCqarevi sikvdilis survili.
fsiqosocialuri saWiroebebis Sevseba xdeba paliatiuri mzrunvelobis
mTavari muSa jgufis mier (es SesaZloa iyos medda, socialuri muSaki,
fsiqologi an eqimi, romlebic muSaoben calke an erTad
multidisciplinaluri gundis saxiT). am personals unda hqondes saWiro
unar-Cvevebi imisaTvis, rom imuSavos rTul da zogjer problemur
situaciebSi ojaxuri TvalsazrisiT. maT unda hqondeT unari, daxmareba
gauwion rogorc pacients, ise ojaxs mocemuli situaciisadmi SeguebaSi da
CarTon isini mniSvnelovani gadawyvetilebebis miRebaSi mimdinare
mzrunvelobis dagegmvis Sesaxeb, gansakuTrebiT rodesac miviwevT
terminaluri fazisken. fsiqosocialuri daxmarebisaTvis aucilebeli
Tvisebaa kargi komunikacis, aseve mosmenis, gulwrfeli interesis, zrunvisa
da TanagrZnobis gamoxatvis unari. personals, romelic muSaobs pacientTan
da mis ojaxTan, esaWiroeba gansakuTrebuli midgomebis da faseulobebis
Camoyalibeba sakuTar TavSi, rogoricaa: ara-gankiTxva; urTierToba
pacientTan da mis ojaxTan rogorc partniorebTan; pacientis uflebebis
pativiscema, rac niSnavs, rom mas SeuZlia moiqces Tavisi survilisa da
gadawyvetilebis mixedviT, misi SesaZleblobebisda mixedviT.
galaherisa da monros mier Catarebul kvlevaSi mnd-Ti daavadebul
pacientebze fsiqosocialuri mzrunvelobis Sesaxeb, yuradReba
gamaxvilebulia Semdeg sakiTxebze, romlebic aucilebelia
gaTvaliswinebuli iqnas yoveli pacientisa da ojaxis Sefasebisas:
- individualuri pacientis gageba;
- daavadebis zegavlena ojaxSi pacientis rolsa da ojaxur
urTierTobebze;
- ojaxis wevrebis piradi istoriebi;
- ojaxis sasicocxlo ciklTan dakavSirebuli sakiTxebi da maTi aRqma
pacientisa da ojaxis mier;
- adre arsebuli daavadeba an krizisuli situacia ojaxSi da rogor
moxda masTan gamklaveba;
- sxva susti (mowyvladi) individebi ojaxSi;
- ojaxis fizikuri da socialuri resursebi.
mTavari sayuradRebo sakiTxi amgvari Sefasebis Catarebisas aris is, Tu
ramdenad sworad esmis msmenels pacientisa da misi axloblebis mier
gadmocemuli azri da dagegmili perspeqtivebi. msmenelma aseve unda
gaiTvaliswinos isic, rom monaTxrobi ojaxur movlenebze warmoadgens
dinamiur, “cocxal” ambebs, romlis drosac am movlenebze ojaxis reaqcia
da maTi aRqma iseve mniSvnelovania, rogorc TviTon masSi arsebuli
“faqtebis” Sinaarsi. ufro metic, Sexedulebebi da Rrmad gamjdari rwmena
garkveuli movlenebis Sesaxeb SesaZloa swrafad Seicvalos droTa
ganmavlobaSi, amitom kargi fsiqosocialuri damxarebis
uzrunvelyofisaTvis saWiroa moxdes gegmebis Tavidan ganxilva da
gadafaseba, gansakuTrebiT es exeba im SemTxvevas, roca pacientis
mdgomareoba swrafad mZimdeba. hd-Ti daavadebul pacientebze Catarebulma
kvlevam aCvena, rom mzrunvelobis koordinatorebs (romelTac ar
moeTxovebaT klinikuri gamocdilebis qona) ekisrebaT Zalian didi roli
informaciis miwodebis, daxmarebis centrebisaTvis mimarTvis, emociuri da
moraluri mxardaWeris uzrunvelyofis da mimdinare mzrunvelobis gegmebis
mudmivi ganxilvisa da Sefasebis mxriv.
tkivilis marTvis mTavari principebi PLTNC mdgomareobebis dros
aq mxolod mokled da zogadad ganvixilavT tkivilis marTvis principebs,
radgan dawvrilebiT igi mocemulia Semdeg nawilSi.
rogorc zemoT aRvniSneT, tkivili damaxasiaTebelia yvela PLTNC mdgomareobisTvis. gansakuTrebiT xSiria tkivili gafantuli sklerozisa
da motoruli neironis daavadebis dros, igi aRiniSneba 50%-dan 75%-mde
SemTxvevebSi – es monacemi kibos zogierTi SemTxvevebis monacemebze ufro
maRalia. tkivilis ganviTarebas mravali mizezi aqvs, Tumca xSirad igi aris
neiropaTiuri an kunTovani genezis. neiropaTiuri tkivili – esaa tkivili,
romelic gamowveulia nervul sistemaSi arsebuli paTologiis Sedegad, mag.
periferiuli nervis, dorsaluri fesvis gangliis an dorsaluri fesvis, an
cns-is dazianebis mizeziT. mxolod bolo ramodenime welia, rac tkivili
aRiarebuli iqna rogorc mniSvnelovani problema PLTNC mdgomareobis dros. Tanamedrove klasikuri ganmartebis mixedviT tkivili aris:
- individualuri SegrZneba;
- Sedgeba emociuri da sensoruli komponentebisgan;
- aqvs temporaluri maxasiaTeblebi;
- aqvs SeuzRudavi sazRvrebi.
PLTNC-ebis dros umTavresad saxezea tkivilis qronikuli forma.
gansxvavebiT mwvave tkivilisgan, romelic normaSi warmoiSveba qsovilis
dazianebis Sedegad, qronikuli tkivili mudmivia da rCeba qsovilis
aRdgenis Semdeg, an SeiZleba ganviTardes dazianebis ararsebobis dros.
qronikuli tkivili dakavSirebulia nevrologiuri disfunqciis rTul
meqanizmebTan da xSirad rTulia misi sruli aRmofxvra mxolod
medikamentebis saSualebiT. aseT tkivils esaWiroeba kompleqsuri da
mravalmxrivi midgoma mkurnalobis TvalsazrisiT, radgan igi ufro Rrma
zegavlenas axdens pacientis zogad mdgomareobaze, vidre mwvave tkivili:
qronikuli tkivili xSirad moqmedebs xasiaTze, iwvevs pirovnebis
cvlilebebs da aseve cvlis socialur urTierTobebs. arsebobs aseve
urTierTkavSiri tkivilis gancdasa da mis asociaciebs Soris, romelic
individualurad aRiqmeba pacientis mier. magaliTad, Tu pacientisTvis
tkivili asocirebulia mzardi invalidobis an ucnobisadmi SiSis
gancdasTan, aseTi tkivili ufro Zneli samarTavia da SesaZloa TandaTan
ufro gauaresdes. pacientebSi aranamkurnalebi tkiviliT xSirad viTardeba
Tanmxlebi depresia, Zilis darRvevebi, daRliloba, qveiTdeba zogadi
fizikuri da mentaluri funqcia. qronikuli tkivilis, gansakuTrebiT ki
neiropaTiuri tkivilis mkurnaloba saWiroebs farmakologiuri da ara-
farmakologiuri meTodebis kombinirebas. zogierT pacientSi SeiZleba
Zlier efeqturi aRmoCndes damatebiTi fizioTerapiuli an alternatiuli
mkurnalobis meTodebi, mag. refleqsologia an masaJi. farmakologiuri
mkurnalobis saWiroebisas unda vimoqmedoT janmo-s mier mowodebuli
tkivilis marTvis samsafexuriani sqemiT. es samsafexuriani sqema
aRiarebulia rogorc yvelaze usafrTxo da efeqturi gaidlaini, romelic
safuZvlad udevs tkivilis kontrols. meTodi gulisxmobs, rom
mkurnalobas viwyebT martivi araopioiduri analgetikebiT, romelsac
SeiZleba daematos adiuvanturi saSualebebi saWiroebis SemTxvevaSi
(pirveli etapi), romlis araefeqturobis SemTxvevaSi gadavdivarT sust
opioidebsa da saWiroebis SemTxvevaSi adiuvantebze (meore etapi), xolo
sabolood ki mesame etapze, romelic moicavs opioidur analgetikebs,
romelTa titraciac xdeba frTxilad, mzardi dozebiT sanam tkivili ar
gayuCdeba. am etapzec, saWiroebis SemTxvevaSi ixmareba adiuvanturi
(damatebiTi) saSualebebi. janmo-s mier mowodebul rekomendaciebSi
gansakuTrebuli yuradReba eniWeba analgetikebis oralurad daniSvnis
upiratesobas regularuli intervalebiT, amasTan mkurnalobis sqema unda
eqvemdebarebodes mudmiv gadaxedvas. analgeziuri mkurnalobis swori doza
da kombinacia aris is, romelic srulad axdens tkivilis kupirebas
mocemul pacientSi.
janmos tkivilis marTvis 3-safexuriani sqema
msubuqi (1-3 qula) saSualo (4-6 qula) mZime (7-10 qula) acetaminofeni a/kodeini morfini aspirini a/hidrokodoni fentanili aass-ebi a/oqsikodoni hidromorfoni +/- adiuvantebi tramadoli levorfanoli +/- adiuvantebi metadoni oqsikodoni oqsimorfoni +/- adiuvantebi
movla sicocxlis bolo etapze da misi dagegmva PLTNC mdgomareobebis
dros
rogorc ukve aRvniSneT, mnd-Ti daavadebul pacientebSi gardacvaleba xdeba
sunTqvis ukmarisobis Sedegad, maSin roca sxva mdgomareobebis dros
sikvdilis uSualo mizezia Tanmxlebi infeqcia, rasac amwvavebs
progresirebadi daavadebis Sedegad gamowveuli organizmis sisuste da
aramdgradoba.
mnd-s dros, sunTqvis ukmarisoba SeiZleba ganviTardes sakmaod swrafad da
amis gamo, gardacvalebac moxdes SedarebiT moulodnelad. Sesabamisad,
aucilebelia rom gadawyvetilebebi pacientisa da misi ojaxis mxridan
winaswar iqnas miRebuli imis Sesaxeb, Tu ra unda movimoqmedoT an
saerTod vimoqmedoT Tu ara respiratoruli ukmarisobis SemTxvevaSi. axali
teqnologiebis SemotanasTan erTad, rogoricaa mag. arainvaziuri
ventilacia da kangavliTi endoskopiuri gastrostomiT (PEG) kveba (PEG –
percutaneous endoscopic gastrostomy), mnd-s terminaluri faza SesaZlebelia
mniSvnelovnad gavaxangrZlivoT, Tumca es meTodebi naklebad moqmedebs
TviTon terminaluri fazis modelze. gasaTvaliswinebelia isic, rom
zogierT pacients urCevnia daTanxmdes amgvar Carevebze, rac maT kidev
ramdenime Zvirfas dRes, kviras Tu Tves Sematebs, Tumca yvelasTvis igive
arCevani misaRebi araa. terminaluri fazis dawyebamde misi marTva unda
daigegmos winaswar, SesaZloa ramodenime kviriT an TviT adrec ki, raTa
gaziarebuli iqnas informacia, ra aris pacientisTvis ukeTesi an rogor
urCevnia TviTon pacients da mis ojaxs.
zogierT pacients SeiZleba mtkiced ar surdes teqnologiuri Carevebis
warmoeba bolo stadiaze, radganac miaCniaT, rom es ubralod gardauvali
Sedegis gadavadebaa. am SemTxvevebSi, rodesac eqimi darwmundeba rom
pacients SeuZlia miRebuli informaciis sworad aRqma da analizi, ris
Sedegadac iRebs igi mocemul gadawyvetilebas, pacients SeuZlia misces
eqims werilobiTi dasturi sicocxlis SemanarCunebeli Terapiebis
uaryofis Sesaxeb. am dokuments, Tuki igi Sefasebulia validurad, aqvs
iuridiuli Zala 2005 wlis mentaluri unaris aqtis mixedviT (didi
britaneTi). nebismier SemTxvevaSi, sikvdilis procesis detaluri aRweriT
SeiZleba Zalian SevaSinoT pacienti da misi ojaxi. mag. mnd-Ti pacientebis
umravlesobas eSinia moxrCobiT sikvdilis, Tumca kvlevebiT
dadasturebuli iqna, rom es SiSi metwilad usafuZvloa. pacientebsa da maT
ojaxs aseve kargad unda ganvumartoT opioidebis (mag. morfinis) roli
simptomebis marTvaSi, avuxsnaT, rom mocemuli standartebis Sesabamisad
gamoyenebisas opioidebi ar aCqareben sikvdils da SeiZleba maTi mzardi
dozebiT gamoyeneba saTanado adiuvantur TerapiebTan erTad, tkivilisa da
sxva simptomebis kargi kontrolis mizniT. qvemoT CamoTvlilia tipiuri
medikamentebi, romlebic gamoiyeneba terminalur fazaSi:
- analgetikebi – tkivilis mosaxsnelad, mag. morfini;
- anqsiolitikebi (trankvilizatorebi) / sedaciuri saSualebebi –
sunTqvis ukmarisobisa da stresis mosaxsnelad, mag. midazolami;
- anti-sekreciuli preparatebi – respiratorul traqtSi sekretebis
Sesamcireblad, mag. hioscinis hidrobromidi;
- antiemetikuri preparatebi – gulisrevisa da Rebinebis mosaxsnelad,
mag. ciklizini.
zogierT pacients SeiZleba hqondes specifikuri problemebi, romlebic
moiTxovs maTi ojaxis eqimis an kerZo specialistebis Carevas. erT-erTi
magaliTia sulieri stresi. PLTNC mdgomareobebis dros gansakuTrebul
problemas qmnis komunikaciis unaris dakargva pacientebSi. gansakuTrebiT
es exeba mnd-sa da hd-s. invalidobis xarisxi aseT pacientebSi ukiduresad
mZimea. Tumca, pacientTan xSiri yofna da misi simptomebis mogvarebis
mcdeloba aadvilebs terminaluri fazis marTvas. kargi movla gulisxmobs
klinikuri gundis erTad muSaobas imisaTvis, rom kritikulad iqnas
Sefasebuli is miznebi da amocanebi, rac dgas dRis wesrigSi mocemuli
pacientisa da misi ojaxisaTvis. kiTxvebi, rogoricaa mag. “ratom vakeTebT
amas?” an “risi miRwevis imedi gvaqvs am konkretuli gegmiT Tu TerapiiT?” -
yovelTvis unda iqnas dasmuli imisaTvis, rom klinikuri qmedeba morgebuli
iyos maqsimalurad individualurad, pacientis interesebis
gaTvaliswinebiT, da ar iyos nakarnaxevi biosamedicino moTxovnebiT an
rutinuli klinikuri praqtikis wesebiT. sicocxlis bolo stadiaze
movlisa da Tundac mkurnalobis zogadi da mTavari mizania, swrafad da
efeqturad movaxdinoT reagireba im saWiroebebze, romlebic SeiZleba
warmoeSvas pacients da mis axloblebs, raTa miRweuli iqnas maqsimaluri
komforti da sicocxlis xarisxi SesaZleblobis farglebSi. qvemoT
CamoTvlilia ZiriTadi principebi, romlebic safuZvlad udevs terminaluri
etapis marTvas nebismieri mdgomareobis SemTxvevaSi:
- mimdinare mkurnalobis reJimis Sefaseba da arasaWiro wamlebis
Sewyveta;
- saWiroebis SemTxvevaSi, iniSneba medikamenti kanqveS misaRebad
SeTanxmebuli protokolis mixedviT, tkivilis, aforiaqebis,
gulisreva-Rebinebisa da respiratorul traqtSi sekreciebis
mosaxsnelad;
- xdeba gadawyvetilebis miReba arasaWiro Carevebis Sewyvetis Sesaxeb,
rac moicavs mag. sisxlis analizebs, intravenuri siTxeebis Seyvanas
da vitaluri niSnebis monitorings;
- pacients, ojaxsa da momvlelebs Soris Camoyalibebuli unda iqnas
gasagebi ena komunikaciisTvis;
- dgindeba pacientis, ojaxisa da momvlelTa aRqmisunarianoba
pacientis mdgomareobis mimarT;
- fasdeba pacientis, ojaxisa da momvlelTa religiuri da sulieri
saWiroebani;
- ojaxsa da momvlelebs eZlevaT Sesabamisi werilobiTi informacia;
- ojaxis eqims acnobeben pacientis mdgomareobis Sesaxeb;
- unda moxdes Semdgomi movlis gegmis ganmarteba da ganxilva
ramdenadac es SesaZlebelia, pacientTan an mis ojaxTan, anda sxva
momvlelebTan erTad.
simptomebis marTva nevrologiur paliatiur mzrunvelobaSi
nevrologiur mdgomareobebs axasiaTebT mravali saerTo simptomi,
romlebic Rrma zemoqmedebas axdens pacientis sicocxlis xarisxze. karg
simptom-kontrols ganapirobebs dawvrilebiTi anamnezis Sekreba,
yuradRebiT gasinjva da Sesabamisi gamokvlevebis Catareba, rac saSualebas
aZlevs eqims gaakeTos daavadebis SesaZlo procesebis mTliani monaxazi da
Seafasos, rogor zegavlenas axdens igi pirovnebasa da mis momvlelebze.
Ria diskusia pacientTan (da mis momvlelebTan, roca amas mdgomareoba
saWiroebs) Zlier mniSvnelovania da Terapiuli efeqtic aqvs; igi
gulisxmobs axsna-ganmartebis micemas problemis SesaZlo mizezze da
moicavs mkurnalobis ama Tu im sqemis ormxriv ganxilvas maTi plusebisa da
minusebis gaTvaliswinebiT. am TavSi mocemulia rigi problemebi, romlebic
rogorc wesi gvxvdeba PLTNC mdgomareobebis dros da maTi marTvis xerxebi,
rac efuZneba avtorebis klinikur gamocdilebas da xelmisawvdom
gamoqveynebul monacemebs am sakiTxze.
siarulis gaZneleba
siarulis gaZnelebis mizezi mravalgvaria da saWiroebs srulyofil
Sefasebas da menejments. saWiroa mxedvelobaSi iqnas miRebuli Semdegi
faqtorebi:
- sisuste fexebSi SeiZleba iyos distaluri an proqsimaluri;
- spastiuroba iwvevs SeboWilobas da zambarisebur siaruls, aseve
fexis TiTebiT iatakis daWeras (rac iwvevs davardnebs);
- parkinsonis daavadebiT pacientebs tipiurad axasiaTebT neli siaruli
moxrili posturiT da mokle nabijebiT, davardnis tendenciiT;
- ataqsia, farTo dgoma da aramyari nabijebi miuTiTebs naTxemis
dazianebis niSnebze, romelsac xSirad Tan axlavs nistagmi da
dizarTria, anda mgrZnobelobis dakargva periferiuli mgrZnobelobis
dazianebis gamo, mag, polineiropaTiis dros. am ukanasknelis dros
SeiZleba siaruli ufro gaZneldes sibneleSi, Tu dazianeba moicavs
Rrma mgrZnobelobasac;
- frontaluri wilis daavadebam SeiZleba gamoiwvios apraqsia, rac
ganapirobebs siarulis qerqul darRvevas, rasac xSirad Tan axlavs
Seukavebloba an demencia;
- sxvadasxva mizeziT gamowveulma tkivilma aseve SeiZleba xeli
SeuSalos pacients gadaadgilebaSi.
mkurnalobis mizani am SemTxvevaSi aris pacientisaTvis usafrTxoebis da
damoukideblobis unaris SenarCuneba, ramdenadac es SesaZlebelia.
aucilebelia pacientis dawvrilebiTi gamokvleva fizioTerapevtis mier.
sisuste
sisuste xSirad Tan axlavs nevrologiuri daavadebis bolo stadiebs. qveda
kidurebSi sisusteze miuTiTebs dakiduli terfi, fexis wamokvris
tendencia, skamidan adgomis gaZneleba da siarulisas Zalian advilad
daRla. sisuste aseve Zlier invalidizacias iwvevs zeda kidurebSi, rac
gamoixateba maTraxisebri (dakiduli) mklavebiT (rodesac ziandeba
proqsimaluri kunTebi) an natifi moZraobebis darRveviT (distaluri
kunTebis dazianebisas), mag. pacients ar SeuZlia boTlis gaxsna, gasaRebis
gadatrialeba da xelidan uvardeba sagnebi.
damxmare mowyobilobebis Semotana pacientis cxovrebaSi cota safrTxilo
sakiTxia, radgan man SesaZloa es aRiqvas mdgomareobis gauaresebis
dadasturebad eqimis mxridan; Tumca amJamad arsebuli saSualebebi Zalian
moxerxebulia pacientis komfortisaTvis. yavarjnebisa da sagoravebeli
savarZelis garda, es SeiZleba iyos msubuqi wonis danebi da misTana
saojaxo xelsawyoebi, aseve moZravi Sxapis kabina an distanciuri marTvis
sistemebi.
tkivili
gafantuli sklerozis garda, gaxangrZlivebuli nevrologiuri
mdgomareobebiT pacientebis umravlesobaSi tkivili xSirad ar moiazreba
umTavres problemad. Tumca, xSirad igi ignorirebulia pacientis mier, Tu
ar CavekiTxebiT specialurad, maT SesaZloa arc aRniSnon igi. arsebobs
tkivilis gamomwvevi ramodenime SesaZlo etiologiuri faqtori, aseve
pacients SeiZleba aReniSnebodes erTdroulad ramodenime tkivilis
sindromi. gafantuli sklerozis dros, mwvave da qronikuli tkivilis
sindromebi gvxvdeba pacientebis 30-80%-Si, xolo motoruli neironis
daavadebis dros ki - 73%-Si, monacemebis mixedviT.
kunT-saxsrovani tkivili
moZraobis SezRudvam SeiZleba gamoiwvios saxsrebis SeboWiloba da
potenciurad mtkivneuli kontraqturebi. amas garda, saxsrebis garSemo
kunTovani tonusis daqveiTebis gamo xdeba moZraobis diapazonis gazrda,
ramac SeiZleba gamoiwvios amovardnilobebi. yvelaze xSirad es xdeba mxris
saxsarSi. am dros mniSvnelovani roli eniWeba fizioTerapias, romelic
afasebs moZraobis diapazons. fizioTerapia uzrunvelyofs adeqvaturi da
efeqturi damxmare saSualebebis miwodebas, aswavlis pacients (mis
momvlels) pasiur moZraobebs, rac xels uSlis kontraqturebis
ganviTarebas, aseve sxvadasxva varjiSebs. am dros SeiZleba efeqturi iyos
farmakologiuri an sxva ara-farmakologiuri meTodebis gamoyenebac.
- adgilobrivad siTbos an eleqtruli kangavliTi nervuli
stimulaciis gamoyeneba (TENS – transcutaneous electrical nerve stimulation); - xSirad efeqturia paracetamoli da sxva aass-ebi;
- lokalurad aass-is gelis gamoyeneba;
- mwvave tkivilis dros, Tu zemoT CamoTvlili saSualebebi
araefeqturia, SeiZleba zogjer saWiro gaxdes opioidebi. SeiZleba
sakmarisi iyos susti opioidebis daniSvna, mag. kodeini
paracetamolTan kombinaciaSi, mag. ko-kodamoli 30/500 dReSi 4-jer,
magram Tu igi araefeqturia, maSin unda dainiSnos ufro Zlieri
opioidi. dozis titraciis TvalsazrisiT mosaxerxebelia xanmokle
moqmedebis opioidi, mag. morfinis xsnari, romelic aseve SeiZleba
miRebuli iqnas mosalodneli mtkivneuli Setevebis dawyebamde
naxevari saaTiT adre. Tu tkivili mudmivad grZeldeba, maSin
SesaZloa saWiro gaxdes neli gamoTavisuflebis opioidebi. ylapvis
gaZnelebis dros gansakuTrebiT efeqturia opioidebis, mag.
buprenorfinis an fentanilis transdermuli mwebavi safenebi.
nawolebi
pacientebis invalidobis zrdasTan erTad maTi moZraobis diapazoni
mcirdeba, radgan ufro da ufro met dros atareben savarZelSi an sawolSi,
amasTan xSirad arc SeuZliaT damoukideblad pozis Secvla. kanze zewolis
adgilebze yuradRebis miqceva aucilebelia. zewolis adgilebSi
ganviTarebuli wylulebi (nawolebi) aris tkivilisa da stresis gamomwvevi
mTavari mizezi, ris gamoc pacientebi saWiroeben analgetikebs, janmos
samsafexuriani analgetikebis sqemis mixedviT. aseve yuradReba unda mieqces
tansacmelsa da pacientis moTavsebas sawolSi. Camoyalibebuli nawolebis
dros SesaZloa efeqturi iyos topikuri opioidebi.
nevropaTiuli tkivili
es gansakuTrebiT problemuria gafantuli sklerozis dros; igi moicavs
mtkivneul paroqsizmul simptomebsa da dizesTezias wvis SegrZnebiT.
centraluri tkivili, romelic viTardeba cns-Si gafantuli sklerozis
folaqebiT tkivilis gamtari gzebis dazianebis Sedegad, warmodgenilia
pacientebis daaxloebiT 33%-Si.
nevropaTiuli tkivilis dros naCvenebia Semdegi medikamentebi:
- tricikluri antidepresantebi: tkivilis gasakontroleblad
sakmarisia ufro dabali dozebis daniSvna, vidre misi rogorc
antidepresantis gamoyenebis dros, mag. amitriptilini 10-50 mg RamiT.
gverdiTi movlenebi moicavs piris simSrales da sedacias, romelic
SeiZleba sasargebloc ki iyos pacientisTvis;
- antiepilefsiuri preparatebi: tradiciulad, karbamazepini
gamoiyeneboda trigeminaluri nevralgiis dros. ufro mogvianebiT
daiwyes gabapentinis da pregabalinis gamoyeneba nevropaTiuri
tkivilis dros. rogorc wesi, isini kargad gadaitaneba pacientis mier
da maTi upiratesobaa naklebi urTierTqmedeba sxva wamlebTan;
- opioidebi: opioidebis efeqturoba naCvenebia nevropaTiuri tkivilis
dros, Sesabamisad SeiZleba vifiqroT opioidebis CarTvaze, Tu
zemoTCamoTvlili meTodebi araefeqturia;
- kanabinoidebis mag. oraluri dronabinolis roli tkivilis
kontrolSi jer kidev daudgenelia, Tumca zogierTi kvlevis
monacemebiT, igi efeqturia centraluri genezis tkivilis dros.
zogierTi pacienti, gansakuTrebiT gafantuli skleroziT pacientebi
zogjer iyeneben kanafs, amtkiceben ra, rom igi exmareba maT tkivilisa
da spazmis moxsnaSi. Tumca, preparatis legaluri statusidan
gamomdinare, misi daniSvna eqims xSirad ar SeuZlia.
kunTovani spazmi da krampebi
am SemTxvevaSi SesaZloa saWiro gaxdes arafarmakologiuri da
farmakologiuri meTodebis kombinirebulad gamoyeneba.
- aucilebelia spastiurobis Sefaseba da misi marTva sxvadasxva
specialistis mier;
- mtkivneuli krampebis dros SeiZleba efeqturi aRmoCndes daWimvebi da
fizioTerapia;
- zogierTi pacienti aRniSnavs qininis efeqturobas, 200-300 mg. RamiT;
- sistemuri kvlevebiT naCvenebia antispazmuri preparatebis / kunTovani
relaqsantebis SesaZlo efeqturoba, Tumca maTi efeqturobisa da
alternatiuli saSualebebi moicavs:
baklofeni 5-20 mg 3-jer dReSi;
trizanidini 2-24 mg dReSi, 3-4-jerad gayofili doziT;
diazepami 5 mg RamiT, dozis zrdiT 10 mg-mde 4-jer dReSi;
klonazepami 1-4 mg RamiT;
dantroleni 25-100 mg 4-jer dReSi.
maTi gamoyeneba SezRudulia arasasurveli gverdiTi efeqtebis gamo,
rogoricaa mag. kunTovani sisuste (risi Sansic SeiZleba ufro meti iyos
baklofenisa da dantrolenis SemTxvevaSi), Zilianoba da piris simSrale
(tizanidini). dantroleni moqmedebs periferiulad kunTovan SekumSvaze da
amgvarad iwvevs kunTovan sisustes. arsebobs aseve monacemebi
hepatotoqsiurobaze.
- mtkivneuli tonuri spazmebis dros SeiZleba kargi efeqti mogvces
antiepilefsiurma preparatebma, mag. gabapentinma da karbamazepinma;
- TENS-ma SeiZleba kargi Sedegi mogvces tkivilisa da kunTovani
spazmebis dros (nervis kangavliTi eleqtruli stimulacia).
spastiuroba
spastiuroba Cveulebrivi simptomia gafantuli sklerozis dros da
vlindeba pacientebis 40-60%-Si, Tumca igi aseve aRiniSneba sxva
gaxangrZlivebuli nevrologiuri mdgomareobebis dros, rodesac saxezea
zeda motoruli neironis dazianeba. igi ganapirobebs tkivils, SeboWilobas
da kunTovan spazms, rac sabolood iwvevs moZraobis da yoveldRiuri
saqmianobis mniSvnelovan SezRudvas, anu amcirebs pacientis siarulis,
gadaadgilebis, aseve damoukideblad dabanis da Cacmis unars. spastiurobis
xarisxi SeiZleba dRiTidRe cvalebadobdes, misi gamwvaveba SeiZleba
gamoiwvios mtkivneulma stimulma, mag. nawolebma, Sekrulobam.
aranamkurnalebma spastiurobam SeiZleba mogvces kontraqturebis
ganviTareba, romelic kidev ufro zrdis tkivilis xarisxs, higienasa da
yoveldRiur aqtivobebTan dakavSirebul problemebs, igi aseve zrdis
dawylulebisadmi midrekilebas.
arsebiTi mniSvneloba eniWeba gundur muSaobas; mxedvelobaSi unda iqnas
miRebuli sakiTxebi rogoricaa mag. daRlilobis marTva, specializirebuli
mowyobilobebis da fsiqologiuri mxardaWeris uzrunvelyofa, mag. sxeulis
suraTis, seqsualobis da ojaxSi rolebis cvlilebebis gamo.
fizioTerapevts SeuZlia daxmareba gauwios pacients loginSi mdebareobis,
aqtiuri da pasiuri varjiSebis da mobilobis Sefasebis sakiTxebSi. amas
garda, mkurnaloba mimarTuli unda iyos nawolebis, saSarde infeqciebis da
da Sekrulobis prevenciisken. spastiurobis mosaxsnelad gamoiyeneba
farmakologiuri saSualebebic, Tumca daniSvnamde preparati sifrTxiliT
unda iqnas Sefasebuli; arsebobs Semdegi midgomebi, romelTa roli da
efeqturobac jer kidev ganxilvas saWiroebs:
- spastiurobis dros SesaZloa raRac efeqti hqondes antispazmur
saSualebebs (ix. zemoT); Tumca man SeiZleba ufro aSkarad
gamoavlinos dainteresebuli kunTebis sisuste da daRliloba da
Sesabamisad, gaauaresos pacientis gadaadgilebis unari da mobiloba;
- intraTekaluri baklofeni Teoriulad efeqtur alternativas
warmoadgens difuzuri mwvave spastiurobis dros, radganac igi
gverds uvlis hematoencefalur bariers da ZiriTadad
koncentrirdeba motoruli neironebis doneze, cns-Si mcire difuziiT.
Tavdapirvelad keTdeba intraTekaluri testi bolusiT. dadebiTi
Sedegis miRebis SemTxvevaSi xdeba intraTekaluri Seyvanis aparatis
implantacia. dRiuri doza SeiZleba vcvaloT saWiroebisda mixedviT
manam, sanam ar miiRweva mudmivi bazisuri efeqti. naCvenebia, rom
baklofenis mudmivi intraTekaluri infuzia amcirebs spastiurobas
da spazmebs da amgvarad aumjobesebs zogad funqcias da sicocxlis
xarisxs;
- botulinis toqsinis inieqciebi efeqturi saSualebaa fokaluri
spastiurobis mosaxsnelad da aqvs kargi funqciuri Sedegi. dadebiTi
Sedegis SemTxvevaSi, SeiZleba misi ganmeoreba 3-4 Tvis intervalebiT;
- zogjer SeiZleba naCvenebi iyos periferiuli nevrotomiis gakeTeba,
fokaluri spastiurobis an distoniis mosaxsnelad;
- kanabinoidebi SesaZloa aRmoCndes efeqturi kunTis spastiurobisa da
tkivilis Sesamcireblad, radgan isini moqmedeben kanabinoidur
receptorebze (CB1) cns-Si. Catarebuli kvlevebi miuTiTebs, rom
gafantuli skleroziT pacientebSi es preparatebi amcireben rogorc
spastiurobas, ise masTan dakavSirebul tkivils. Tumca, jer kidev
kiTxvis qveS rCeba kanabinoidebis upiratesobis sakiTxi arsebul
konvenciur medikamentebTan SedarebiT, romlebic gamoiyeneba
tkivilisa da spastiurobis samkurnalod. garda amisa, mxedvelobaSia
misaRebi uaryofiTi gverdiTi efeqtebi, mag. Tavbrusxveva, romelic
SeiZleba sakmaod Semawuxebeli iyos.
moZraobis darRvevebi
moZraobis darRvevebi umTavresad vlindeba parkinsonis daavadebisa da
hantingtonis daavadebis dros da iyofa or jgufad:
1. moZraobis Semcireba (bradikinezia, akinezia);
2. hiperkinezuli uneblie moZraobebi, mag. tremori, distonia, qorea,
mioklonusi, tikebi. qvemoT mocemulia calk-calke maTi marTvis
sqemebi.
tremori
- mosvenebis tremori warmoadgens kardinalur simptoms parkinsonis
daavadebis dros. misi Semcireba SeiZleba dofaminerguli
preparatebis maRali dozebis saSualebiT;
- aseve efeqturi SeiZleba iyos antiqolinerguli saSualebebi, mag.
benzheqsoli, Tumca maT SeiZleba gamoiwvion cnobierebis Secvla
(konfuzia);
- SesaZloa efeqturi iyos botulinis toqsinis inieqcia winamxris
kunTebSi (metwilad momxrelebSi). uaryofiTi efeqtebi moicavs
gamSleli kunTebis fokalur sisustes, rac aZnelebs mtevnebSi natifi
moZraobebis Sesrulebas. procedura saWiroebs daaxloebiT 1 kviras
Sedegis misaRebad da Sedegi grZeldeba 3-4 Tve;
- aRwerilia aseve botulinis toqsinis inieqciebis gamoyeneba qveda ybis
tremoris dros;
- iSviaTad, mwvave tremoris an distoniis dros ganixileba qirurgiuli
Carevis sakiTxi, rac moicavs Talamotomias, palidotomias da tvinis
Rrma stimulacias (DBS – deep brain stimulation).
distonia
- gaxangrZlivebuli kunTovani SekumSvebi iwvevs grexviT da
paroqsizmul (ganmeorebiT) moZraobebs an anomaluri posturis
ganviTarebas, SeiZleba iyos lokaluri an generalizirebuli;
- levodopam SeiZleba moxsnas an piriqiT, gaamwvavos distonia;
- monacemebis mixedviT, botulinis toqsinis inieqciebiT mkurnalobis
efeqti cvalebadia, Tumca igi SeiZleba efeqturi aRmoCndes
mtkivneuli terfis distoniis dros;
- damtkicebulia botulinum A da botulinum B-s inieqciebis dadebiTi
efeqti cervikaluri (kisris) distoniis dros.
blefarospazmi warmoadgens fokaluri distoniis formas, romelic
Tavdapirvelad gamoixateba arakontrolirebadi xamxamiT, Semdeg ki gadadis
quTuToebis uneblie, mZlavr moxuWvaSi. igi SeiZleba warmoadgendes
problemas progresuli supranuklearuli dambliT, an parkinsonis
daavadebiT pacientebSi. botulinis toqsinis inieqcia Tvalis irgvliv
kunTebSi SesaZloa funqciurad dadebiTi Sedegis momtani aRmoCndes,
zogjer saWiro xdeba antiqolinerguli preparatebis damateba, SeiZleba
aseve quTuToebis damWeris gamoyenebac.
qorea
- krTomiTi fsevdo-mizanmimarTuli moZraobebi, gansakuTrebiT
gamoxatulia hantingtonis daavadebis dros;
- qoreisa da masTan erTad fsiqiatriuli simptomebi hantingtonis
daavadebis dros SesaZloa vmarToT neiroleptikebiT, mag.
haloperidoli, flufenazini;
- atipiur neiroleptikebs eqstrapiramiduli movlenebis ganviTarebis
ufro naklebi riski gaaCnia, Tumca maT SesaZloa gamoiwvion wonis
mateba, mag. klozapini, olanzapini;
- naCvenebia, rom tetrabenazini, romelic amcirebs dofaminis
koncentracias nervis daboloebebSi, amcirebs qoreis intensivobas,
Tumca siarulis gaZnelebis an parkinsonizmis dros misi daniSvna
aramizanSewonilia.
respiratoruli problemebi
qoSini
qoSini progresirebadi nevrologiuri daavadebiT pacientebSi SeiZleba
gamowveuli iyos ramodenime mizeziT:
1. qveda sasunTqi gzebis infeqcia: es ukanaskneli SeiZleba ganviTardes
sasunTqi kunTebis sisustis gamo, rac iwvevs gulmkerdis eqskursiis
SezRudvas sunTqvis dros, amoxvelebis, sekretebis amowmendis
gaZnelebas da Sereul aspiracias;
2. filtvis arteriebSi emboliebi, rac gamowveulia pacientis naklebi
moZraobiT;
3. sasunTqi kunTebis sisuste – gansakuTrebuli problemaa mnd-s dros,
rasac kidev ufro amZimebs arasulfasovani kveba. procesSi SeiZleba
CarTuli iyos rogorc diafragmis, ise neknTaSua kunTebi;
4. Tanmxlebi gulis an filtvis paTologia.
mkurnaloba damokidebulia gamomwvev mizezze. Tu dadgindeba, rom mizezia
sasunTqi gzebis infeqcia, maSin iniSneba Sesaferisi antibiotiki da
SesaZloa damatebiT fizioTerapiac. umjobesia, rom nevrologiuri
daavadebis bolo stadaze pacientebs gaukeTdeT gripis virusis
sawinaaRmdego acra. Tu xelisSemwyob faqtorad moiazreba aspiracia, maSin
ganxiluli unda iqnas da SeirCes kvebis alternatiuli meTodebi.
hipoventilaciiTa da hipoqsiiT gamowveul simptomebs kargad xsnis
arainvaziuri ventilacia (ix. qvemoT). aseve kargi efeqtis SeiZleba
aRmoCndes qvemoT CamoTvlili simptomuri midgomebi:
- sawolSi moTavseba – wamomjdar mdgomareobaSi baliSebiT an sxva
damWeri saSualebebiT garSemo;
- saxeze sufTa haeris nakadi, mag. ventilatoriT an Ria fanjridan;
- sunTqviTi savarjiSoebi, moduneba da sityvieri damSvideba;
- bolo dros Catarebul koxreinis kvlevaSi naCvenebi iqna, rom
siarulis maSvelebi, kunTis neiro-eleqtruli stimulacia da
gulmkerdis kedlis vibracia efeqturad moqmedebs qronikuli
daavadebis bolo stadiaze myof sxvadasxva tipis pacientebSi, Tumca
kvlevebis umetesi nawili Catarebuli iyo pacientebSi filtvis
qronikuli obstruqciuli daavadebiT.
farmakologiuri mkurnalobis reJimebi
- qoSinis mosaxsnelad efeqturia opioidebi, mag. oraluri morfini,
dasawyisSi 2-5 mg 4 saaTSi erTxel, titracia saWiroebis Sesabamisad;
- benzodiazepinebi Svelis qoSinTan dakavSirebul aRelvebasa da
panikas, mag. diazepami 2-5 mg Zilis win / dReSi samjer, an lorazepami
0.5-1 mg, romelic SeiZleba mivceT enis qveS mwvave Setevis dros. unda
gaviTvaliswinoT, rom es preparatebi Tavidan unda mivceT mcire
dozebiT da titracia unda movaxdinoT frTxilad, radgan pacients
isedac daqveiTebuli aqvs respiratoruli funqcia.
- seleqtiuri serotoninis ukumitacebis inhibitorebi (SSRI-ebi) efeqturi da usafrTxo preparatebia panikisa da aRelvebis
mosaxsnelad da SeiZleba gamoyenebuli iyos xangrZlivad.
sunTqvis (ventilaciuri) ukmarisoba
mnd-Ti daavadebul pacientebSi daavadebis progresirebasTan erTad ufro
da ufro matulobs sasuTqi kunTebis sisuste. pacientebis nawils eqimTan
vizitisas ukve aReniSneba respiratoruli ukmarisoba. miuxedavad imisa, rom
simptomebi vlindeba maSin, rodesac forsirebuli amosunTqvis moculoba
(FEV) ecema 50%-ze dabla, es formulireba mainc cvalebadia da zogierT
pacients SeiZleba ganuviTardes respiratoruli ukmarisoba iseT
maCvenebelzec ki, rodesac sasicocxlo moculoba (VC – vital capacity) 75%-is
tolia (respiratorul ukmarisobad iTvleba, rodesac arteriul sisxlSi
an yuris bibiloSi pCO2>6.5 kPa). es SeiZleba ganviTardes mosvenebiTi
qoSinis an orTopnoes ararsebobis drosac ki. sasicocxlo moculoba
respiratoruli funqciis Sesafaseblad sando maCvenebels ar warmoadgens,
gansakuTrebiT pacientebSi bulburi simptomebiT, amitom gamoiyeneba sxva
maCveneblebi, mag. nazaluri haeris nakadis wneva.
mnd-s dros respiratoruli ukmarisobis erT-erT pirvel niSans
warmoadgens Zilis darRvevebi. hipoventilacia Tavdapirvelad viTardeba
REM Zilis dros, rodesac damxmare sasunTqi kunTebi naklebad aqtiuria da
ventilaciis procesi ZiriTadad damokidebuli xdeba diafragmis
moZraobaze, xolo am ukanasknelis funqcia ki mwoliare mdgomareobaSi
klebulobs. hipoventilaciisa da masTan dakavSirebuli Jangbadis
desaturaciis epizodebma Ramis ganmavlobaSi SeiZleba gamoiwvios
ganmeorebiTi gamoRviZebebi. Ramis hiperkapniis ganviTareba SemdgomSi iwvevs
daqveiTebul koncentraciis unars, Zilianobas, dilis Tavis tkivils,
gulisrevas, gaRizianebadobas, anoreqsiisa da depresiis ganviTarebas.
pacients SesaZloa aReniSnebodes dispnea daZabvisas an laparakis dros. Tu
eWvi arsebobs hipoqsiaze, pacientTan saubris Semdgom igi unda gavagzavnoT
ftiziatrTan respiratoruli funqciis srulyofilad SefasebisTvis.
dReRamuri arteriuli Jangbadis saturaciis sazomi mowyobiloba SesaZloa
saxlis pirobebSic iqnas gamoyenebuli, esaa patara zomis aparati, romelic
magrdeba TiTze. Sedegebi Semdgom SeiZleba gadacemuli iqnas
respiratoruli samedicino jgufisTvis diliT.
hipoventilaciiT gamowveuli simptomebi mniSvnelovnad umjobesdeba
arainvaziuri dadebiTi wneviT ventilaciis (NIPPV – non-invasive positive pressure
ventilation) meTodiT. aRniSnuli meTodi iyenebs ventilaciur sistemebs
niRbiT, romlebic uzrunvelyofs wyvetilad inspiratoruli dadebiTi
wneviT haeris nakadis miwodebas (mag. “NIPPY”, B & D Electromedical, UK), an bi-fazur dadebiTi wnevis aparatebs, romlebic uzrunvelyofs sxvadasxva
faziT (doniT) dadebiTi wneviT haeris nakadis miwodebas rogorc
CasunTqvis, ise amosunTqvis dros (BiPAP). arsebobs mravali sxvadasxva
tipis arCevani sasunTqi aparatebis gamoyenebisas, nazaluri niRbidan
dawyebuli mTliani saxis niRbiT da nazaluri burTulakebiT
damTavrebuli, Tumca am dros arsebobs gawiTlebis an wylulebis gaCenis
saSiSroeba. arsebobs aseve mcire zomis portatuli aparatebi. NIPPV
aparatebis gamoyeneba garkveul sazrianobas da codnas moiTxovs, amitom
pacientebi SeiZleba Tavad ver gaumklavdnen maT marTvas, riTac
momvlelebs sazrunavi kidev ufro ematebaT. pacientebs gamoxatuli
bulburi simptomatikiT SesaZloa hqondeT NIPPV aparatTan dakavSirebuli
problemebi, radgan maT uviTardebaT obstruqciis epizodebi, rac
dakavSirebulia xmovani iogebis disfunqciasTan, aseve aqvT aspiraciis
ufro meti riski.
rodesac mosalodnelia respiratoruli problemebi, mag. pacientebSi mnd-
iT, aucileblad adridanve unda daviwyoT pacientTan erTad am sakiTxis
ganxilva, raTa mivceT mas dro mosafiqreblad da gadasawyvetad, surT Tu
ara da ra tipis RonisZieba undaT rom iqnas miRebuli maT konkretul
SemTxvevaSi respiratoruli problemebis warmoqmnisas. erT-erTi
randomizebuli klinikuri gamocdis Sedegebma aCvena, rom saSualo
gadarCenis maCvenebeli izrdeboda daaxloebiT 7 TviT pacientebSi kargi
bulbaluri funqciiT, romlebSic gamoyenebuli iyo arainvaziuri
ventilaciis meTodi, sicocxlis xarisxis gaumjobesebisaken mimarTul
RonisZiebebTan erTad. saWiroebis dadgenis Semdeg, pacientebi xSirad
iwyeben arainvaziuri ventilaciis gamoyenebas RamiT, Tumca daavadebis
progresirebasTan erTad, maT SesaZloa dRis periodebSic daiwyon misi
gamoyeneba. am SemTxvevaSi mosalodnelia ventilatorze mzardi
damokidebulebis ganviTareba, amitom pacients unda ganvumartoT
mkurnalobis arsebuli SezRudvebi.
invaziuri ventilacia traqeostomiT sasunTq gzebs icavs sekretebiT
daxSobisgan da Sesabamisad, SeuZlia sicocxlis gaxangrZliveba daavadebis
progresirebisas. did britaneTSi es ukanaskneli iSviaTad keTdeba da
dakavSirebulia rTul eTikur sakiTxebTan. rodesac mnd-Ti daavadebul
pacients utardeba aqtiuri ventilacia, dadasturebuli diagnoziT an mis
gareSe, ventilatorisgan damoukidebloba iSviaTad miiRwva. Sesabamisad,
Zalian mniSvnelovania, rom ventilaciisa da zogadad, sicocxlis bolo
stadiaze mzrunvelobis sakiTxebi ganxiluli iqnas pacientTan da mis
axloblebTan erTad manamde, sanam warmoiSveba gadaudebeli mdgomareoba,
xolo miRebuli gadawyvetilebebi dawvrilebiT unda iqnas asaxuli
werilobiT dokumentaciaSi.
xvela
xvela xSirad susti da araproduqtiulia da SeiZleba ganviTardes ylapvis
mcdelobis dros. xvelisa da moxrCobis epizodebi xSiria mnd-Ti
daavadebul pacientebSi, Tumca igi iSviaTad ukavSirdeba xilul
respiratorul infeqcias. mkurnaloba mimarTuli unda iyos gamomwvevi
mizezis winaaRmdeg. rezistentuli da Semawuxebeli xvelis dros SeiZleba
efeqturi aRmoCndes opioidebi.
klinikuri marTva moicavs Semdgom midgomebs:
- arsebuli infeqciis gamovlena da Sesabamisi mkurnaloba;
- fizioTerapiis CarTva; pacientebsa da maT momvlelebs SeiZleba
vaswavloT meTodebi, romlebic exmareba amosunTqviT moZraobebSi
xvelis dros;
- portatuli, saxlis pirobebSi gamosadegi gamwovi aparati sekretebis
mosacileblad;
- meqanikuri Caberva-amoqaCvis aparati (“xvelis maSveli”), zrdis
amosunTqviTi nakadis siCqares da xels uwyobs sekretebisa da
lorwovani sacobebis amowmendas;
- Tu arsebobs apiraciis saSiSroeba, unda vifiqroT kvebis
alternatiul meTodebze;
- xvela SeiZleba gamoiwvios mJava refluqsma – SegiZliaT daniSnoT
metoklopramidi, protonuli tumbos inhibitorebi;
- Tu aris sqeli naxveli, romelic aZnelebs amoxvelebas, SegiZliaT
gamoiyenoT:
mariliani xsnari nebulaizeriT sekretebis gasaTxeleblad, an
haeris damatenianebeli;
karbocisteini 250-750 mg samjer dReSi.
- Ramis xvelis dros zogjer efeqturia lokaluri anesTetikis miReba
nebulaizeriT.
moxrCoba (laringospazmi) / respiratoruli distres sindromi
laringospazmis, xvelis paroqsizmebisa da inspiratoruli stridoris
epizodebi Tanmxlebi apnoeTi rogorc wesi mxolod ramodenime wami
grZeldeba, Tumca SesaZloa Zalian SemaSinebeli iyos pacientisTvis. es
epizodebi SeiZleba ganviTardes rogorc dRisiT ise Ramis manZilze da
SesaZloa misi trigeri gaxdes gastro-ezofaguri refluqsi an mavne qimiuri
nivTierebebisa da kvamlis SesunTqva. epizodebis prevencia SeiZleba
movaxdinoT antisekretoruli da prokinetikuri medikamentebiT, romlebic
iniSneba yoveli Wamis win, aseve Zilis win kvebisagan Tavis SekavebiT. mwvave
situaciaSi SeiZleba efeqturi aRmoCndes wamojdoma, mklavebis daWera
sxeulis stabilizaciisTvis da sunTqvis Seneleba. Tu respiratoruli
distresi grZeldeba, SesaZloa mdgomareoba gavaumjobesoT lorazepamis
micemiT enis qveS.
ylapvis problemebi
mnd-Ti daavadebuli pacientebis daaxloebiT 80%-Si sabolood viTardeba
mZime bulbaluri disfunqcia, Tumca ylapvis problemebi aseve
warmodgenilia gafantuli sklerozis, parkinsonis daavadebisa da
hantingtonis daavadebis mogvianebiT stadiebze. ReWva da ylapva Zneldeba
da xdeba damRleli, rasac Tan axlavs xSiri gadacdena (moxrCoba),
regurgitacia da sakvebis mikvra saylapavze. mnd-Ti pacientebis daaxloebiT
21%-Si aRiniSneba malnutricia. zogierT maTganSi amis mizezia disfagia,
Tumca nerwyvis dena da Wamis neli tempi aseve iwvevs socialur
diskomforts. sisuste xelebSi aseve xels uSlis Wamis process da
sakvebisa da siTxis miRebis TvalsazrisiT pacients sxvaze damokidebuls
xdis.
menejmenti moicavs Semdeg midgomebs:
- saWiroa enisa da metyvelebis Terapevtis CarTva, raTa Sefasebuli
iqnas ylapvis problemebis mizezebi, pacients gavacnoT usafrTxo
ylapvis meTodebi da miRebul iqnas gadawyvetileba gastrostomiuli
milis Cadgmaze, dietologTan erTad mWidro TanamSromlobiT;
- sakvebis teqsturisa da konsistenciis Secvla (sakvebis daqucmaceba,
siTxeebis gasqeleba da a.S.);
- posturisa da Tavis poziciis Secvla SesaZloa dadebiTi Sedegis
momtani iyos, mag. Wama wamomjdar mdgomareobaSi win gamoSverili
nikapiT, rac icavs sasunTq gzebs;
- alternatiuli kvebis meTodebis ganxilva.
kveba gastrostomiiT umjobesia dainiSnos wonis dakargvis prevenciis
mizniT, aseve aspiraciis riskis Sesamcireblad. gastrostomiiT kvebaze
saubari unda warimarTos da gadawyvetileba miRebuli unda iqnas
daavadebis adreul etapze. proceduris Catarebas maSin, roca pacients ukve
daqveiTebuli aqvs respiratoruli funqcia, meti riski axlavs Tan. PEG
zondis Cadgmidan momdevno erTi Tvis manZilze sikvdilis riski mcirea im
SemTxvevaSi, rodesac filtvis sasicocxlo moculoba (VC) metia 50%-ze.
gastrostomiuli zondebi SeiZleba Caidgas endoskopiurad (PEG zondi), an
radiologiuri kontroliT (RIG zondi). gastrostomiuli zondis
radiologiurad Cadgma xSirad ufro kargad gadaitaneba, radgan am dros
sedacia mcired an saerTod araa saWiro, Sesabamisad, igi aris arCevis
meTodi respiratoruli disfunqciiT pacientebSi. naCvenebia, rom PEG zondiT kveba amcirebs wonis dakargvis Sanss da aumjobesebs sicocxlis
xarisxs mnd-Ti daavadebul pacientebSi.
sialorea (nerwyvis dena)
sialorea (nerwyvis gaZlierebuli dena) xSiri simptomia sxvadasxva PLTNC mdgomareobebis dros, gansakuTrebiT parkinsonis daavadebis (70-80%-Si) da
mnd-s (20-30%-Si) dros. nerwyvi gamomuSavdeba ybisqveSa, enisqveSa da ybayura
jirkvlebis mier, romlebsac ainervirebs parasimpaTikuri nervuli sistema.
ybisqveSa da enisqveSa jirkvlebi gamoimuSaveben nerwyvis ZiriTad nawils,
romelic ufro blantia. ybayura jirkvlebi gamoimuSavebs Txel serozul
sekretebs, rac ufro metad xorcieldeba Wamisa da smis procesSi. fiqroben,
rom muskarinuli M3 receptoris neirotransmiter acetilqoliniT
stimulacia iwvevs salivacias. Tumca, nerwyvis nakadi SeiZleba
gaZlierebuli iqnas aseve simpaTikuri inervaciiTac, romelic zrdis
nerwyvis sadinarebis garSemo arsebuli kunTovani boWkoebis SekumSvas.
sialoreis mizezi ZiriTadad aris iSviaTi da gaZnelebuli ylapva, rasac
Tan axlavs saxisa da piris aparatis daqveiTebuli nervkunTovani
kontroli. pacientebs SeiZleba uWirdeT nerwyvis gadaadgileba pirSi.
situacia ufro rTuldeba parkinsonis daavadebis dros, radgan amas emateba
pirRiaobisken midrekileba da moxrili postura. zogadad, nerwyvis
gamomuSaveba parkinsonis daavadebis dros mcirdeba. Tumca zogjer
arsebobs SemTxvevebi, rodesac viTardeba autonomiuri disfunqcia, rac
iwvevs saylapavismier disfagia da nerwyvis hipersekrecia. garda amisa,
hipersekrecia SeiZleba gamoiwvios anTebiTma procesmac (mag. kbilis kariesi
da gingiviti, gastro-ezofaguri refluqsi) da zogierTma medikamentmac (mag.
klozapinma). nerwyvis dena mniSvnelovnad moqmedebs pacientis sicocxlis
xarisxze, iwvevs kanis gaRizianebas, infeqciebs, cud suns piridan,
aspiracias, sircxvilis grZnobas da mzard damokidebulebas.
arafarmakologiuri midgomebi
SesaZloa efeqturi aRmoCndes Semdgomi midgomebi calkeulad an
medikamentebTan erTad kombinaciaSi gamoyenebisas:
- enisa da metyvelebis Terapevtis CarTva, romelic aswavlis pacients
sxvadasxva xerxebs nerwyis denisa da ylapvasTan dakavSirebiT, mieces
instruqcia rom ufro xSirad gadaylapos nerwyvi da gamoiyenos
broSis magvari aparati, romelic regularul intervalebSi xmovani
signaliT axsenebs pacients rom nerwyvi unda gadaylapos. sustad
gamoxatuli daavadebis dros es meTodi sakmaod efeqturia;
- vaswavloT pacients Tavis Weris stabilizacia, uzrunvelvyoT Tavis
sazurgiani sagoravebeli etli;
- saxlis pirobebis gamwovi aparati.
farmakologiuri mkurnaloba
klinikur praqtikaSi gamoiyeneba Semdegi medikamentebi:
1. antiqolinerguli preparatebi:
am preparatebis gamoyeneba SezRudulia maTi gverdiTi efeqtebis
gamo, rac moicavs Sekrulobas, dizorientacias (konfuzia), piris
simSrales, Sardis Sekavebas, mxedvelobis gabundovanebas da
Tavbrusxvevas. isini ukunaCvenebia pacientebSi kardialuri
ariTmiebiT, daxurulkuTxovani glaukomiT da prostatis
hipertrofiiT. kvlevebis umetesoba am preparatebze Catarebulia
bavSvebSi, mag. cerebruli dambliT.
arCevis preparatebia:
I. hioscinis hidrobromidis mwebavi safenebi, 1 mg 72 saaTSi
erTxel, SeiZleba gamoviyenoT 1-dan 3 safenamde, titracia
reaqciis Sesabamisad. kvlevebiT naCvenebia maTi efeqturoba
bavSvebSi nerwyvis deniT. SesaZloa problematuri iyos
lokaluri gaRizianeba da qavili safenis mikvris adgilze;
II. atropini: bulbaluri mnd-Ti an parkinsonis daavadebiT, aseve
progresuli supranuklearuli dambliT pacientebSi naCvenebia
rom nerwyvis denis xarisxi rogorc obieqturi ise subieqturi
SefasebiT ukve 1 kviraSi klebulobs. rogorc wesi, gamoiyeneba
(Tumca es forma aralicenzirebulia) atropinis 0.5%-iani Tvalis
wveTebi (0.5 mg) dReSi 2-4-jer enis qveS;
III. glikopirolati: es preparati hematoencefalur barierSi ver
aRwevs, amitom ufro mcire centraluri efeqtebi aqvs. igi
yvelaze metadaa gamokvleuli sxva antiqolinergul preparatebs
Soris, Tumca arsebobs mxolod erTi randomizebuli, ormagad
brma placebo-kontrolirebuli kvleva, romelSic naCvenebia
nerwyvis denis mniSvnelovani gaumjobeseba subieqturi SefasebiT,
Tumca am kvlevaSi pacientebis 30%-ma preparati Sewyvita. misi
gamoyeneba SeiZleba Semdegi formebiT:
kanqveSa infuzia, 1.2 mg 24 saaTis manZilze;
tabletebi, 1 an 2 mg. mozrdilebSi 0.5 mg dReSi 1-3-jer, titracia maqsimum 8 mg-mde/dReSi;
glikopirolatis inhalacia nebulaizeriT.
IV. sxva antiqolinerguli preparatebi, romlebic aseve SeiZleba
efeqturi iyos, moicavs:
benztropini
benzheqsoli
ipratropiumis bromidis sprei enis qveS.
V. amitriptilini: dabali dozebiT, mag. 10-25 mg RamiT. man SeiZleba
xeli Seuwyos sekretebis Semcirebas, gaaumjobesos Zili da
moxsnas SfoTva.
2. beta blokerebi:
antiqolinerguli preparatebis uefeqtobis SemTxvevaSi, an rodesac
sekretebi Zlier blantia, SeiZleba vcadoT mag. propranololi 10
mg. dReSi samjer, Tumca man SeiZleba gaamwvavos daRliloba.
botulinis toqsini
es neirotoqsini, romelic gamomuSavdeba clostridia botulinum-is mier,
ablokirebs acetilqolinis gamoTavisuflebas qolinerguli
neirosekretoruli sinafsebidan da amgvarad xels uSlis sanerwyve
jirkvlis stimulacias. inieqciebi keTdeba ybayura da/an ybisqveSa
jirkvlebSi. am sakiTxTan dakavSirebiT mravali kvlevaa Catarebuli,
dadebiTi Sedegebia miRebuli Ria da randomizebuli
kontrolirebuli kvelvebiT.
oTxi randomizebuli kontrolirebuli kvlevis Sedegebma aCvena, rom
A tipis botulinis toqsinis gamoyeneba pacientebSi parkinsonis
daavadebiT, mnd-Ti, multisistemuri atrofiiT da kortikobazaluri
degeneraciiT mniSvnelovnad amcirebs nerwyvis gamomuSavebas
rogorc subieqturi, ise obieqturi analizis mixedviT. aseve
umjobesdeboda ojaxuri da socialuri stresisa da sircxvilis
maCveneblebi.
Tumca botulinis toqsinis efeqturobaze monacemebi cvalebadobs
sxvadasxva pacientTa jgufebSi, mag. gafantuli skleroziT
pacientebSi B tipis botulinis toqsinis gamoyenebisas aRiniSna rom
dadebiTi efeqtis xangrZlivoba ufro naklebi iyo, xolo blanti
nerwyvis gamomuSavebis maCvenebeli ufro maRali, parkinsonis
daavadebiT pacientebTan SedarebiT.
botulinis toqsinis inieqciebi ZiriTadad kargad gadaitaneba, ise
rom pacientebis 80%-ze meti rCeba kmayofili mkurnalobiT da
gamoxataven inieqciebis gagrZelebis survils. uaryofiTi gverdiTi
movlenebi rogorc wesi msubuqi xasiaTisaa da moicavs piris
simSrales, gardamaval gripismagvar simptomebs, diskomforts
inieqciis adgilas da nerwyvis gasqelebas. Tumca, arsebobs
gardamavali ylapvis gaZnelebis riski. naCvenebia, rom es inieqciebi
iseve efeqturia rogorc skopolamini, Tumca gaaCnia ufro naklebi
uaryofiTi efeqtebi am ukanasknelTan SedarebiT. jer kidev arsebobs
gaurkvevlobebi optimalur dozasTan dakavSirebiT, Tumca naCvenebia,
rom A tipis botulinis toqsinis 75 MU (mikroerTeulis) inieqcia
yovel ybayura jirkvalSi ufro efeqturia, vidre dabali dozebi.
aseve arsebobs debatebi eqoskopiis kontroliT proceduris
Catarebaze, Tumca es ukanaskneli albaT ufro mniSvnelovania
ybisqveSa jirkvlebSi inieqciis SemTxvevaSi, maTi ufro naklebad
misadgomi anatomiuri lokalizaciis gamo. rogorc weis, dadebiTi
efeqti grZeldeba 3-dan 8 Tvemde da SeiZleba proceduris
ganmeorebac.
radioTerapia
xSirad efeqturia ybayura jirkvlis dasxiveba, Tumca doza,
romelic saWiroa sanerwyve jirkvlis atrofiis misaRwevad,
cvalebadobs individualur SemTxvevebSi. tipiurad, pacients jer
sTavazoeben radioTerapias mxolod erT mxares, xolo mniSvnelovani
efeqtis ararsebobis SemTxvevaSi, sTavazoben meore mxares
dasxivebasac. uaryofiTi movlenebi moicavs kanis wvas, romelic
SesaZloa gagrZeldes ramodenime kvira alagebamde. qserostomia
(piris simSrale) SeiZleba gagrZeldes ramodenime Tvidan ramodenime
wlamde. dasxivebul adgilas arsebobs mogvianebiT avTvisebiani
procesis ganviTarebis momatebuli riski proceduris Catarebidan 10-
15 wlis Semdeg, Tumca es ukanaskneli mniSvnelovan faqtors ar
warmoadgens im pacientebisTvis, romelTa prognozic xanmoklea.
aseve arsebobs ybis ZvalSi osteonekrozis ganviTarebis riski.
qirurgiuli Careva
mwvave sialoreis SemTxvevaSi, romelic ar emorCileba farmako- da
radioTerapias, SeiZleba ganvixiloT qirurgiuli Carevis varianti.
procedurebi moicavs:
- transtimpanuri nevreqtomia: es SedarebiT martivi qirurgiuli
Carevaa, xorcieldeba Sua yuridan midgomiT da ar saWiroebs
generalur anesTezias, Tumca SeiZleba aman imoqmedos gemovnebis
funqciaze. nervis boWkoebi rogorc wesi regeneracias ganicdis 6-18
TveSi;
- ybisqveSa an ybayura jirkvlis amokveTa;
- ybisqveSa an ybayura jirkvlis sadinaris gadanacvleba.
tipiuri procedura gulisxmobs ybayura jirkvlis sadinaris gadakvanZvas
da ybisqveSa jirkvlis amokveTas, an misi sadinris gadanacvlebas. Tumca, es
ukanaskneli Zalian seriozuli operaciaa da iwvevs Seuqcevad piris
simSrales, aseve sialocelesa da kbilis kariesis ganviTarebis risks.
garda amisa, ybisqveSa jirkvlis amokveTis Semdeg rCeba garegani nawiburi
da saxis kunTebis sisustis potenciuri riski.
metyveleba
mraval pacientSi SeiZleba ganviTardes vokalizaciis gaZneleba, Cumi
saubridan dawyebuli dizarTriisa da anarTriis CaTvliT. metyvelebis
Seneleba (gabundovaneba), romelic gamowveulia enis moZraobis
disfunqciiT, rogorc wesi vlindeba disfagiis ganviTarebamde. menejmenti
gulisxmobs rCevebis micemas da axsnas, Tu rogor unda movaxdinoT
metyvelebis optimizacia ise, rom igi gaxdes gasagebi, aseve xmis gaZliereba
(tonis momateba) SeiZleba efeqturi aRmoCndes im pacientebisaTvis,
romelTac aqvT kargi artikulacia, magram susti xma sasunTqi kunTebis
sisustis gamo. daavadebis progresirebasTan erTad unda ganvixiloT
metyvelebis alternatiuli meTodebis Semotanis sakiTxi, mag. werilobiTi,
komunikaciuri mowyobilobebi (“Lighwriter”), CamrTvelebi da skaneruli
sistemebi, anbaniani dafebi da individualuri komunikaciuri ruqebi.
partniors an momvlels SesaZloa jer kidev esmodes pacientis metyveleba,
magram ufro farTo komunikaciisaTvis aucilebelia enisa da metyvelebis
Terapevtis adreuli CarTva, raTa Camoyalibebuli iqnas komunikaciis
alternatiuli saSualebebi.
Sekruloba
Sekruloba xSiri simptomia nevrologiuri daavadebis bolo stadiaze da
mas mravali mizezi gaaCnia. xelisSemwyob faqtorebad miiCneva sisuste, maT
Soris muclis kunTebis Zalis daqveiTeba da gaWinTvis SeuZlebloba,
umoZraoba, medikamentebis, gansakuTrebiT antiqolinerguli preparatebis
efeqti, naklebi narCeni moculobis dieta da dehidratacia. igi aseve
SeiZleba iyos autonomiuri disfunqciis niSani, rasac axasiaTebs kuWis
daclis dayovneba myari masisagan da msxvili nawlavis peristaltikis
daqveiTeba Wamis Semdeg. Sekrulobis prevencia Zalian mniSvnelovania, rac
xorcieldeba adeqvaturi hidrataciiT, balansirebuli dietiT da
laqsativebiT (gamaTxiereblebiT).
menejmenti moicavs Semdgom meTodebs:
- pirvel rigSi unda aRmoifxvras gamomwvevi mizezi, anu Sewydes im
preparatis miReba romelic iwvevs Sekrulobas da dainiSnos
Sesabamisi dieta;
- adeqvaturi hidrataciis uzrunvelyofa;
- laqsativebi – efeqturia stimulantisa da gamaTxeleblis kombinacia,
mag:
ko-dantrameri an kondantruzati (5-10 ml 2-jer dReSi, titracia
saWiroebisda mixedviT);
sena da laqtuloza (5-10 ml 2-jer dReSi);
movikoli (1-2 paketiT erTxel dReSi, mzardi doziT dReSi 8
paketamde).
- ganavlis Seukavebloba SeiZleba ganviTardes normaluri
mgrZnobelobis dakargvis gamo, Tumca mkurnalobam unda gamoricxos
rogorc gauvaloba, ise faRaraTi;
- pacients aseve SeiZleba vurCioT mimarTos raionis eqTnis samsaxurs.
Sardvis problemebi
Sardvis problemebi aRiniSneba gafantuli skleroziT daavadebuli
pacientebis 50-75%-Si, Tumca igi aseve xSiria parkinsonis daavadebis dros.
hantingtonis daavadebis bolo stadiaze pacientebma aseve SeiZleba
dakargon nawlavis da Sardis buStis kontrolis unari. Sardis
buStismierma problemebma SeiZleba gamoiwvios socialuri izolacia,
seqsualuri problemebi da daqveiTebuli TviTSefaseba, iseve rogorc
meoradi janmrTelobis problemebi, mag. saSarde traqtis infeqciebi.
yvelaze xSiri problemaa gadaudebeli moTxovnileba Sardvaze, rac xSirad
asocirebulia xSir SardvasTan da Sardis SeukaveblobasTan gadaudebeli
moTxovnilebis gamo. simptomebis simwvave qveda kidurebSi arsebuli
piramiduli paTologiis xarisxis pirdapirproporciulia, rac miuTiTebs
spinaluri dazianebis xarisxze. SesaZloa efeqturi iyos Semdegi
medikamentebi:
- antiqolinerguli an gluvi kunTebis relaqsanti preparatebi, mag.
propanTelini, oqsibutinini;
- antiqolinerguli antidepresantebi – imipramini, amitriptilini;
- intranazaluri desmopresini SeiZleba kargi Sedegis momtani iyos
Sardvis gaxSirebisa da Seukaveblobis dros, amasTan, igi kargad
gadaitaneba.
garda amisa, pacientebisTvis SeiZleba sasargeblo aRmoCndes raionis eqTnis
samsaxurSi viziti an Seukaveblobis specialistTan mimarTva Sefasebisa da
rCevebisaTvis. unda SevTavazoT specialuri leibebisa da zewrebis
gamoyeneba.
Sardvis Sekaveba an dayovneba SeiZleba gamoiwveuli iyos Sardis buStis
kunTovani kedlis daqveiTebuli an ararsebuli SekumSvis gamo. zogjer
efeqturia am dros beTaneqoli, Tumca xSirad saWiro xdeba kaTeterizacia.
im SemTxvevaSi Tu pacienti jer kidev sakmaod mobiluria da damoukidebeli
moqmedebis unari gaaCnia, SeiZleba umjobesi iyos ganmeorebiTi TviT-
kaTeterizaciis gakeTeba, rac amcirebs saSarde traqtis infeqciebis risks
simptomebis moxsnamde.
kognituri da xasiaTTan dakavSirebuli problemebi
SfoTva
SfoTva mraval pacients aReniSneba da gansakuTrebiT Semawuxebelia RamiT.
mniSvnelovania pacientis damSvideba, praqtikuli mxardaWera da simptomebis
kontrolze yuradRebis gamaxvileba. pacientebisTvis SesaZloa sasargeblo
aRmoCndes fsiqologiuri mxardaWera, mag. kognituri da qceviTi
(bihevioruli) meTodebi, an saWiro gaxdes farmakologiuri Careva. xanmokle
moqmedebis benzodiazepinebi, mag. temazepami 10-20 RamiT xsnis SfoTvas da
xels uwyobs CaZinebas. panikuri Setevebi dRis manZilze SeiZleba moixsnas
lorazepamiT 0.5-1 mg, SeiZleba mivceT enis qveS. Tu SfoTva mainc grZeldeba
dRis manZilze, arCevis preparatia ufro xangrZlivi moqmedebis
benzodiazepini, mag. diazepami 5 mg RamiT, an SSRI. citaloprams aqvs is
upiratesoba, rom arsebobs wveTebis formiTac, ase rom SesaZlebelia dozis
neli titracia.
depresia
sevda, depresia da mwuxareba xSirad aRiniSneba pacientebSi PLTNC mdgomareobebiT, rasac kidev ufro amwvavebs gaurkveveli prognozi, mzardi
damokidebuleba da xSirad ojaxSi rolis dakargva. aman SeiZleba
gamoiwvios yovlismomcveli uimedobis grZnoba da TviTfaseulobis
dakargva. pacientebs iseve rogorc maT axloblebs unda gaewioT rogorc
praqtikuli ise fsiqologiuri mxardaWera. SeiZleba ganvixiloT
konvenciuri antidepresantebis, mag. SSRI-ebis daniSvnis sakiTxi. aseve
efeqturi SeiZleba iyos amitriptilini da mirtazepini.
demencia
demencia parkinsonisa da hantingtonis daavadebis gviani stadiebis
damaxasiaTebeli simptomia, romelic mniSvnelovan stress iwvevs pacientis
momvlelebSi. garda amisa, gafantuli skleroziT pacientebis daaxloebiT
50%-s aseve aReniSneba raRac xarisxiT gamoxatuli kognituri problemebi.
frontotemporaluri demencia gvxvdeba mnd-Ti daavadebuli pacientebis
daaxloebiT 5%-Si. Tavidan pacients SeiZleba aReniSnebodes Senelebuli
qceva da rTuli davalebebis Sesrulebis, aseve gadawyvetilebis miRebis
gaZneleba. procesis progresirebasTan erTad SeiZleba pacients
ganuviTardes xisti qceva da gaxdes arakontaqturi (Senelebuli).
pacientebis met nawilSi (20-40%-Si) aRiniSneba ufro sustad gamoxatuli
kognituri problemebi, romelic ufro xSiria pacientebSi upiratesad
bulburi simptomebiT, kidurebis problemebiT pacientebTan SedarebiT.
sufTa fsiqozi nevrologiuri daavadebis bolo stadiaze iSviaTia, Tumca
igi xSirad aRiniSneba hantingtonis daavadebis dros. misi moxsna
SesaZlebelia antifsiqozuri preparatiT, mag. resperidoniT. bihevioruli
simptomebis dros hantingtonis daavadebis SemTxvevaSi aseve kargi efeqtisaa
olanzapini, haloperidoli da buspironi.
emociuri labiloba
es ukanaskneli aRiarebuli simptomia PLTNC-Ti pacientebSi, gansakuTrebiT
igi aRiniSneba gafantuli sklerozis dros. garda amisa, zog pacients aqvs
spontanuri, paTologiuri sicilisa da tirilis epizodebi (fsevdobulburi
efeqti), miuxedavad normaluri tonusisa, ramac SeiZleba gamoiwvios Zlieri
stresi. igi aRiniSneba gafantuli skleroziT pacientebis daaxloebiT 10%-
Si da mnd-ti pacientebis daaxloebiT 50%-Si.
arCevis preparatebia:
- SSRI-ebi – isini efeqturia ufro mcire dozebiT gamoyenebisas, vidre
gamoiyeneba depresiis dros;
- amitriptilini an misi msgavsi tricikluri antidepresanti;
- arsebobs aseve monacemebi deqstrometorfanis da qinidinis gamoyenebis
Sesaxeb.
Zilis darRvevebi
nevrologiuri daavadebis bolo stadiaze pacientebs xSirad aReniSnebaT
Zilis darRvevebi, romelic xSirad sakmaod mwvavea, Tumca arasaTanadodaa
Sefasebuli da araefeqturad namkurnalebi. insomnia SeiZleba gamowveuli
iyos tkiviliT, SfoTviT, depresiiT, xveliT Warbi sekretebis gamo da
hipoqsiiT, romelic iwvevs RamiT xSir gamoRviZebas da dRisiT Zilianobas.
dRisiT Warbi Zilianoba SeiZleba problemad iqces, gansakuTrebiT
parkinsonis daavadebisa da gafantuli sklerozis dros, amasTan, mizezi
SeiZleba iyos TviTon daavadeba an medkamentebi. SeiZleba efeqturi iyos
stimulantis daniSnva, mag. modafinili 200 mg erTxel dReSi.
daRliloba
daRliloba xSirad aRiniSneba PLTNC-Ti pacientebSi da warmoadgens mZime
problemas. potenciuri xelisSemwyobi faqtorebi moicavs Zilis darRvevas,
noqturias, qronikul tkivils, medikamentebs (mag. antidepresantebs da
spastiurobis mosaxsnel preparatebs), depresias da problemis
gamklavebisaTvis SerCeul cud strategias. aucilebelia Rrma Sefaseba
mTlianobaSi da energiis SenarCunebis swavleba, aseve damxmare
saSualebebisa da mowyobilobebis uzrunvelyofa.
seqsualuri disfunqcia
pacientebi xSirad malaven seqsualur problemebs, miuxedavad imisa, rom igi
mniSvnelovan stress iwvevs maTSi da mxolod SeiZleba upasuxon
delikaturad dasmul kiTxvebs imis Taobaze, Tu ra gavlenas axdens
daavadeba maT partniorul urTierTobebze. fizikuri faqtorebi, romlebic
xels uwyobs seqsualur disfunqcias, moicavs menjis kunTebis sisustes,
spastiurobas, zogad daRlilobas, autonomiuri nervuli sistemis
moSlilobebs da medikamentebis efeqtebs. garda amisa, Tanabrad
mniSvnelovania aseve fsiqologiuri faqtorebi, romlebic ukavSirdeba
depresiasa da SfoTvas, sxeulis suraTis Secvlas da rolis cvlilebebs
ojaxsa Tu partniorul urTierTobebSi.
menejmenti moicavs Semdgom midgomebs:
- ganmarteba, fsiqologiuri mxardaWera da konsultacia, rac zogjer
saWiroebs specializirebul samsaxurebSi mimarTvas;
- fizikuri simptomebis optimaluri menejmenti, tkivilisa da
spastiurobis CaTvliT;
- medikamentebis, mag. antidepresantebis, beta blokerebis
racionalizacia;
- sildenafilis an intrakavernozuli papaverinis gamoyeneba.
sxva nevrologiuri simptomebi
pacientebs nevrologiuri daavadebis bolo stadiaze SeiZleba
aReniSnebodeT uamravi simptomi romelic dakavSirebulia maT
daavadebasTan. eseni moicavs aramyar dgomas, Tavis simsubuqis SegrZnebas,
cnobierebis cvlilebas, mxedvelobis problemebs, rogoricaa optikuri
nervis nevropaTia gafantuli sklerozis dros, Tavbrusxvevas, yurebSi
xmaurs da epilefsiur sindromebs. saWiroa am simptomebis srulyofili
Sefaseba da saTanado mkurnaloba. mgrZnobelobis daqveiTeba zrdis kanis
wylulebis da infeqciis risks, amitom mniSvnelovania kanis kargi movla da
pacientis ganaTleba am mxriv.
autonomiuri disfunqcia sul ufro da ufro metad moiazreba, rogorc
mravali nevrologiuri mdgomareobis damaxasiaTebeli niSani, romlebic
moicavs multisistemur atrofias, parkinsonis daavadebas, gafantul
sklerozs da motoruli neironis daavadebas. oflianobis tipebi, romlebic
sakmaod Semawuxebelia da xSirad aRiniSneba parkinsonis daavadebis dros,
ZiriTadad dakavSirebulia autonomiur disfunqciasTan, aseve gamorTvis
periodebsa (off periods) da diskineziebTan. aqsialuri hiperhidrozi xSirad
vlindeba, rogorc kompensatoruli movlena kidurebSi daqveiTebuli
simpaTikuri funqciis dros, rodesac aRiniSneba xelisgulis Semcirebuli
oflianoba. autonomiuri disfunqcia aseve aRwerilia mnd-s mwvave
SemTxvevebSi.
komunikaciis problemebi
komunikaciis problemebi mudmivad warmoiSveba ukurnebeli seniT
daavadebuli pacientis movlisas sicocxlis bolo stadiaze. politikuri
mimarTulebebi bolo dros yuradRebas amaxvilebs komunikaciaze
jandacvisa da socialur sferos Soris, aseve ayalibebs saukeTeso
komunikaciis gagebas praqtikaSi. efeqturi komunikacia paliatiuri
mzrunvelobis midgomis mTavari principia. es pirvel rigSi gulisxmobs Ria
da TanagrZnobiT komunikacias, romelic vrceldeba pacientebze,
araformalur momvlelebsa da profesiul kolegebze. qvemoT mocemulia
gaxangrZlivebuli (nevrologiuri) mdgomareobebis erovnuli samsaxuris
mier mowodebuli rekomendaciebi efeqturi komunikaciis Sesaxeb:
- kargi praqtikis magaliTebis gaziareba;
- samsaxurebs Soris komunikaciuri kavSirebis gaumjobeseba;
- momxmarebelTa CarTva sakomunikacio sakiTxebSi da cvlilebaTa
wamowyeba;
- praqtikosi eqimisTvis rekomendaciis gaweva specializirebuli unar-
Cvevebisa da codnis SeZenisaTvis, rac daexmareba mas pacientTan, mis
ojaxTan da kolegebTan urTierTobaSi.
organizaciuli midgoma aucilebelia imisaTvis, rom kargi praqtikis
individualuri magaliTebi gavrceldes da miRebuli iqnas saerTo
praqtikaSi. aseve unda iTqvas isic, rom praqtikosi eqimis qcevis tipi
mniSvnelovn rols TamaSobs maTi komunikaciis unarSi, kerZod, igulisxmeba
maTi piradi kultura garemos Seqmnis mxriv, monawile pirovnebebi, TviTon
praqtikosi eqimis religiuri mrwamsi da misi damokidebuleba sikvdilis
mimarT. komunikaciis TvalsazrisiT zemoT CamoTvlili aspeqtebi ufro
mniSvnelovania, vidre eqimis specialuri ganaTleba an komunikaciuri unar-
Cvevebis codna.
komunikaciis problema exeba jandacvis yvela sferos da socialur
samsaxurebs, miuxedavad maTi rolisa Tu praqtikis garemosi. cudi
komunikacia iSviTadaa ganpirobebuli konkretulad praqtikosi eqimis
mizeziT. igi ufro gamowveulia komunikaciisadmi midgomis arsebuli
samedicino modeliT, romelSic fokusireba keTdeba daavadebis
paTologiur kurssa da anamnezis Sekrebaze, xolo ufro farTo
individualuri saWiroebani da pacientis perspeqtivebi yuradRebis miRma
rCeba.
profesionalTa mxridan rTuli saubrisTvis Tavis arideba SeiZleba
gamowveuli iyos ramdenime mizeziT:
- isini SezRuduli arian sakuTari samuSao ganrigiT;
- danaSaulis (pasuxismgeblobis) SiSi;
- sakuTar ZalebSi naklebi TviTrwmena;
- drois naklebobis SegrZneba;
- cudi organizaciuli unar-Cvevebi;
- SiSi pacientis mxridan iseTi reaqciisa, romelsac hgoniaT rom ver
gaumklavdebian;
- sakuTari SezRudvebis SegrZneba;
- SegrZneba imisa, rom maT ara aqvT uflebamosileba pasuxi gascen
dasmul kiTxvebs.
paliatiuri mzrunvelobis calke dargad CamoyalibebasTan erTad, igi
yovelTvis eZiebda efeqtur meTodebs imisaTvis, rom daxmareboda pacientsa
da mis ojaxs rTuli gadawyvetilebebis miRebaSi; rTuli saubrebis
warmoebisa da profesiuli SiSis mosaSoreblad saWiro iyo naTeli da
pirdapiri meTodebis Camoyalibeba komunikaciuri TvalsazrisiT. qvemoT
CamoTvlilia is unar-Cvvevebi, romlebic unda gaaCndes praqtikos eqims
kargi komunikaciisaTvis:
praqtikos eqims unda SeeZlos
- uzrunvelyos iseTi saxis mzrunveloba, romelic xelmisawvdomia
komunikaciuri TvalsazrisiT SezRuduli adamianebisaTvis;
- unda icodes im potenciuri komunikaciuri siZneleebis Sesaxeb,
romelic warmoiSveba praqtikaSi, aseve barieris gadasalaxad saWiro
unar-Cvevebi, rac ganapirobebs efeqtur ormxriv komunikacias;
- unda icodes stresis Sefasebis mTeli rigi meTodebi, romelTac
gansakuTrebuli mniSvneloba eniWeba SezRuduli verbaluri an
kognituri SesaZleblobebis dros;
- Caataros pacientisa da misi ojaxis Sesabamisi paliatiuri
mzrunvelobis globaluri Sefaseba maTi fizikuri, fsiqologiuri,
socialuri, sulieri da informaciuli saWiroebebis TvalsazrisiT;
- unda esmodes da icodes, rodis da rogor mimarTos rCevisaTvis
specializirebuli paliatiuri mzurnvelobis samsaxurs da/an sxva
organizaciebs, imisaTvis rom daakmayofilos pacientis saWiroebebi;
- aRiaros sakuTari codnis an unar-Cvevebis nakleboba da gaakeTos
Sesabamisi gadamisamarTeba.
komunikaciis garTuleba ukavSirdeba mTel rig mizezebs:
- drois nakleboba;
- eqimis codnis an unar-Cvevebis simwire;
- pacientis saWiroeba da misi mdgomareoba mocemul etapze;
- garemo;
- gaugebroba da aRqmis sxvadasxvaoba.
es CamonaTvali arasrulia, Tumca igi zogadad asaxavs im siZneleebs rac
realurad gvxvdeba praqtikaSi.
komunikaciis problemebi gaxangrZlivebuli nevrologiuri mdgomareobebis
dros
PLTNC-Ti pacientebis movla mTel rig problemebs ukavSirdeba
komunikaciis TvalsazrisiT, rogorc eqimis, ise socialuri muSakisa da
pacientis momvlelebis mxriv. es xSirad moicavs saWiroebaTa mTel nusxas,
romelSic CarTulia mravali samsaxuri. efeqturi profesiuli komunikacia
arsebiTi mniSvnelobisaa koordinaciis gaumjobesebis da Sesabamisi movlis
uzrunvelyofis mxriv. PLTNC-Ti pacientebs Tavidan normaluri verbaluri
da weriTi unarebi aqvT, Tumca daavadebis progresirebasTan erTad maTi
unarebi uaresdeba. individualuri pacientis, misi ojaxisa da momvlelebis
daxmareba yovldRiuri movlis dagegmvasa da modifikaciaSi saWiroebisda
mixedviT saWiroebs kreatiul da Rrma midgomas. qvemoT moyvanilia
ZiriTadi fizikuri faqtorebi, romlebic warmoiSveba sxvadasxva
nevrologiuri mdgomareobis dros da xdeba komunikaciis garTulebis
mizezi:
- kognituri gauareseba: nevrologiuri daavadebebiT gamowveuli
potenciuri kognituri cvlilebebi moicavs Senelebul procesings,
xanmokle mexsierebisa da mentaluri SesaZleblobebis daqveiTebas,
aseve mTavar Temaze koncentraciis siZneles saubris dros;
- tuCebis funqcia: tuCebisa da loyis kunTebi SeiZleba daziandes
motoruli neironis daavadebis an insultis dros. kunTis funqciis
cvlilebebi aZnelebs sityvis sworad warmoTqmas, rac Znelad
gasagebs xdis pacientis saubars;
- rbili sasis da xaxis funqcia: iseve rogorc tuCebis SemTxvevaSi,
rbili sasa da xaxac monawileobs warmoTqmuli bgerebis formirebaSi.
rodesac maTi funqcia ziandeba, Sesabamisad irRveva bgerebic da
metyveleba xdeba bundovani da gaurkveveli;
- enis funqcia: enis funqciis daqveiTeba gansakuTrebuli problemaa
gverdiTi amiotrofuli skleroziT pacientebSi. igi iwvevs
warmoTqmuli bgerebis Semcirebas, amitom daavadebis
progresirebasTan erTad, metyveleba ufro da ufro dabinduli da
gaugebari xdeba;
- xorxis funqcia: metyvelebis unars gansazRvravs xorxi da xmovani
iogebi. xmovani iogebis sisuste xSiri problemaa da igi
mniSvnelovnad arRvevs komunikaciis unars. zeda da qveda motoruli
neironis disfunqciam SeiZleba gamoiwvios xmovani iogebis moZraobis
unaris daqveiTeba, rac ganapirobebs xmis tembris, tonisa da bgeris
xangrZlivobis cvlilebas;
- respiratoruli funqcia: respiratoruli sistemis funqciis
daqveiTebam SesaZloa imoqmedos pacientis komunikaciis unarzec.
laparakisaTvis saWiroa filtvis sasunTqi moculobis garkveuli
done. respiratoruli funqciis daqveiTebam SeiZleba Secvalos xmis
toni, riTmi, intonacia da siZliere. infeqciiT gamowveuli
respiratoruli disfunqciis dros SeiZleba gvqondes komunikaciis
problemebi. zurgis tvinSi garkveuli ubnebis disfunqciis an
dazianebis gamo, rac iwvevs zeda an qveda motoruli neironis
gamoTiSvas, qveiTdeba sasunTqi Zala da pacients uWirs sakmarisi
moculobis amosunTqvis warmoeba, imisaTvis rom misi xma gasagebi
iyos, an ver ambobs erTi-or sityvaze mets erT amosunTqvaze;
- sxeulis poza: sxeulis poza aseve moqmedebs pacientis komunikaciis
unarze. cudi (mouxerxebeli) pozis gamo pacients SeiZleba fizikurad
ar SeeZlos xmis amoReba, anda uWirdes im pozis didxans SenarCuneba,
romelic mas komunikacias uadvilebs. pozis gamo zemoaRniSnuli
fizikuri problemebi SeiZleba kidev ufro gauaresdes;
- daRliloba: daRliloba xSirad Tan axlavs progresirebad
nevrologiur daavadebebs. Tanmxlebi simptomebi, mag. disfazia imdenad
Rlis pacients, rom maT komunikaciaSi CarTvis energia aRar aqvT;
- paTologiuri sicili da tirili: fizikuri problemebis an daavadebis
gamo zogierTi nevrologiuri mdgomareobis dros SeiZleba
Seicvalos nevrologiuri funqcia, rac iwvevs arakontrolirebad
sicils an tirils, rac arTulebs komunikacias.
zemoT CamoTvlili faqtorebi moqmedebs pacientis komunikaciis unarze, ris
gamoc isini ver axerxeben maTi saWiroebebis gadmocemas, xdebian
asocialurebi da kargaven damoukideblobas.
saukeTeso praqtikis saxelmZRvanelo principebi
kargi komunikaciis principebi yvela situaciisaTvis saerToa. Tumca isini
damokidebulia pacientis smenis, mxedvelobis da metyvelebis unarze. es
unarebi gansxvavdeba yoveli konkretuli pacientisaTvis PLTNC mdgomareobebis SemTxvevaSi, amitom saWiroa individualuri da kreatiuli
midgomis Camoyalibeba komunikaciuri TvalsazrisiT yoveli konkretuli
pacientis mimarT. qvemoT moyvanilia komunikaciis is mTavari principebi,
romlebic gamoiyeneba zogadad sicocxlis bolo stadiaze:
- iyaviT gulwrfeli da pirdapiri;
- gamoikiTxeT pacientis faseulobebi da miznebi;
- daexmareT pacients arCevanis gamokveTaSi misi faseulobebisa da
miznebis mixedviT;
- xeli SeuwyeT SekiTxvebs pacientis mxridan;
- hkiTxeT Tqvens Tavs, “ras vizamdi, es rom Cemi ojaxis wevri iyos?”
- gamoyaviT dro mosasmenad;
- ar aaridoT Tavi rTul saubars, aramed eZieT daxmareba sxva
kolegebis mxridan, Tu mocemuli sakiTxi aRemateba Tqvens
kompetencias an SesaZleblobebis farglebs;
- iyaviT mzad saubris dawyebisaTvis.
gunduri muSaoba da koordinacia
qronikuli daavadebiT pacientebs uamrav specialistTan aqvT Sexeba mTeli
avadmyofobis manZilze. PLTNC-s dros warmoSobili sirTuleebi moiTxovs
efeqtur da koordinirebul profesiul komunikacias. centraluri muSakis
CarTva, romelsac aqvs sruli monacemebi da Canaweri pacientis Sesaxeb,
metad moxerxebulia, radgan igi amcirebs arasaWiro ganmeorebebs,
gvexmareba komunikaciis gaRmavebaSi da Tavidan gvacilebs uxerxuli
gaugebrobebis warmoSobas. dokumentaciis saerTo bazis SemoReba, romelic
gankuTvnilia profesionalebisa da momvlelebisTvis, xels uwyobs saubris
Semdgom gagrZelebas da ar exeba erTidaigive Temas komunikaciis dros.
arsebuli literatura miuTiTebs, rom efeqturi TanamSromlobisTvis
gundebs esaWiroebaT TviT-analizis, TanagrZnobis da moqnilobis unari,
rac gansazRvravs naTeli mimarTulebis aRebas da qmnis mSvid, megobrul
garemos arsebuli problemebis gamovlenisa da maTze diskusiisTvis.
rodesac komunikacia gansakuTrebiT rTuldeba, SegiZliaT CarToT
procesSi eqsperti praqtikosi, romelsac gaaCnia gamocdileba am mxriv.
enisa da metyvelebis TerapevtTan adreuli mimarTva SeiZleba saWiro iyos
zogierTi gaxangrZlivebuli nevrologiuri mdgomareobis adreul stadiaze,
raTa pacientma da misma ojaxma miiRos rCevebi da maTTan erTad
gansazRvrul iqnas momavali strategiebi, Tu ra unda gakeTdes
metyvelebisa da komunikaciis mkveTrad gauaresebis SemTxvevaSi.
diagnozis gamxela
diagnozis gamxelasTan dakavSirebulma kvlevebma aCvena, rom eqTnebi
yovelTvis winaaRmdegi iyvnen diagnozis damalvisa naTesavebis moTxovniT,
radgan miiCnevdnen, rom didxans motyueba SeuZlebelia da amasTan, mas aqvs
stresuli Sedegebi pacientisa da misi ojaxisTvis. naTesavebis ZiriTadi
motivacia iyo gardacvalebaze saubris SiSi da pacientze mZime zegavlenis
moxdenis saSiSroeba, risganac maT surdaT sayvareli adamianis dacva.
istoriulad cnobilia paternistuli midgoma, romelic bolo dros
gadawyvetilebis miRebis uflebisa da eTikuri sakiTxebis ganviTarebasTan
erTad Seicvala. Tumca arsebobs garkveuli principebi, romlebic unda
iqnas daculi diagnozis an prognozis gamxelis dros:
- gamxela mgrZnobiare da pozitiuri meTodiT;
- pirovnebis drouli da saTanado mxardaWera;
- informaciis adreuli gaziareba;
- profesionalTa da momvlelTa urTierTTanamSromloba pacientis
dasaxmareblad.
mzrunvelobis dagegmva sicocxlis bolo stadiaze
mzrunvelobis dagegmva sicocxlis bolo stadiaze prevenciuli jandacvis
mniSvnelovani nawilia da moiTxovs mgrZnobiare da mizanSewonil midgomas,
rogoricaa mag. 4-safexuriani dagegmvis procesi bolo stadiaze (ix.
cxrili). Tumca mas ewinaaRmdegeba realobis gamocda: 10 barieri bolo
stadiaze mzrunvelobis dagegmvisas:
4-safexuriani dagegmvis procesi bolo stadiaze
1. Temis warmodgena 2. diskusiisaTvis xelis Sewyoba 3. bolo etapze strategiis
gansazRvra da dokumentacia 4. dokumentebis regularuli
ganxilva da saWiroebis mixedviT ganaxleba
realobis gamocda: 10 barieri bolo stadiaze mzrunvelobis dagegmvisas
1. pacientisa da provaideris sizarmace
2. drois SezRudvebi 3. varaudebi 4. uaryofa da gadadeba 5. ararealuri molodini
6. gadadeba krizisis dadgomamde 7. diskomforti paliatiuri
mzrunvelobis dagegmvisas
8. dokumentaciis nakleboba
9. kulturuli da jandacvis
sistemis mxridan barierebi
10. pacientis mzaoba
mzrunvelobis dagegmva SeiZleba garTuldes iseT situaciaSi, rodesac
pacients uWirs metyveleba. arsebobs mravali damxmare meTodi Sefasebis
Casatareblad, mag. invalidobis distres meTodi, romlis meSveobiTac
SeiZleba Sefaseba CavataroT ufro sistemuri da detaluri formiT. Tumca,
nebismieri meTodi sifrTxiliT unda iqnas gamoyenebuli da mudmivad unda
iqnas gadaxedili, raTa damowmdes maTi Sesabamisoba da sandooba mocemul
situaciaSi.
SesaZleblobis/unaris Sefaseba
did britaneTSi miRebuli mentaluri SesaZleblobis aqti (Mental Capacity Act
– MCA) miznad isaxavda paliatiuri mzrunvelobis xarisxis gaumjobesebas im
pacientebisTvis, romelTac ar SeeZloT damoukideblad gadawyvetilebis
miReba an sakuTari mzrunvelobis dagegmvaSi monawileobis miReba. es
sakiTxi gansakuTrebiT mwvaved dgas gaxangrZlivebuli nevrologiuri
mdgomareobebis dros, rodesac daavadeba iwvevs pacientis mentaluri
unaris daqveiTebas imdenad, rom mas aRar SeuZlia gadawyvetilebis miReba
sakuTar mdgomareobasTan dakavSirebiT. rodesac saxezea mentaluri unaris
cvlileba, praqtikosi eqimis roli pacientTan efeqturi komunikaciis xelis
Sewyobis mxriv matulobs (rac SemdgomSi aadvilebs gadawyvetilebis
miRebas). es ukanaskneli SeiZleba moicavdes Semdeg midgomebs:
- saubris dagegmva dasvenebis periodis Semdeg, an dRis garkveul
monakveTSi, roca pacientTan komunikaciis SesaZlebloba yvelaze
maRalia;
- dRis manZilze drois daxuruli monakveTis gamonaxva, romelic
saSualebas miscems eqims saubari waiyvanos pacientisTvis misaRebi
tempiT;
- saubris uzrunvelyofa Sesaferis garemoSi, xelisSemSleli mizezebis
gamoricxviT;
- komunikaciis gamaadvilebeli strategiis gamoyeneba da daxmareba
gadawyvetilebis miRebaSi, romelic maqsimalurad pasuxobs konkretuli
pacientis saWiroebebs.
mentaluri SesaZleblobis aqtis mixedviT, pacients ar gaaCnia sakuTar
Tavze gadawyvetilebis miRebis mentaluri unari, Tu mas ar ZaluZs:
- gadawyvetilebis miRebisaTvis saWiro informaciis gageba (aRqma);
- informaciis damaxsovreba;
- informaciis awon-dawona an misi gamoyeneba gadawyvetilebis miRebis
procesSi, an
- sakuTar gadawyvetilebaze komunikacia (saubriT, niSnebis eniT an sxva
saSualebebis gamoyenebiT).
amgvar situaciaSi praqtikosma eqimma unda gadawyvitos, unda CaiTvalos Tu
ara pacienti informaciis miRebis unaris armqoned, romelic exeba
gadawyvetilebis miRebas, an gaarkvios, SeuZlia Tu ara pacients am
informaciis gageba, Tu mas mivawvdiT misTvis gasagebi ganmartebiT da im
formiT, romelis maqsimalurad Seefereba mis situacias (mag. martivi enis,
vizualuri an sxva saSualebebis gamoyenebiT). im SemTxvevaSic ki, rodesac
pacients mxolod mcire droiT SeuZlia informaciis damaxsovreba
gadawyvetilebis miRebis Sesaxeb, es ar niSnavs imas, rom pacienti unda
CaiTvalos gadawyvetilebis miRebis unaris armqoned. eqimma unda scados
gadawyvetilebis Taobaze informaciis gadacema iseTi saxiT, rom
paralelurad miwodebuli iqnas informacia ama Tu im gadawyvetilebis
miRebis SemTxvevaSi realurad mosalodneli Sedegebis warmoSobis Sesaxeb,
an im Sedegebze, rac mohyveba gadawyvetilebis miuReblobas.
SesaZleblobisda mixedviT, procesSi CarTuli unda iqnan aseve pacientis
ojaxis wevrebi da momvlelebic.
mentaluri SesaZleblobis aqts udidesi mniSvneloba eniWeba sicocxlis
bolo stadiaze gadawyvetilebebis miRebis procesSi. rodesac arsebobs
eWvi, rom pacients ar aqvs gadawyvetilebis miRebis mentaluri unari, vinme
sxvam unda miiRos gadawyvetileba pacientis magivrad, oRond pacientis
interesebis maqsimalurad gaTvaliswinebiT. “interesebis maqsimalurad
gaTvaliswineba” gulisxmobs gadawyvetilebis miRebas sxvis magier, rodesac
eqimi an mzrunvelobis jgufi adasturebs, rom es gadawyvetileba aris
yvelaze optimaluri varianti pacientisaTvis, mocemuli garemoebebis
gaTvaliswinebiT. rodesac sakiTxi dgeba pacientis interesebis
gaTvaliswinebiT gadawyvetilebis miRebaze, logikurad unda
ganxorcieldes Semdgomi etapebi:
1. im pirTa dadgena, romlebic unda iqnan CarTuli gadawyvetilebis
miRebis procesSi da mTavari pasuxismgebelis gamovlena;
2. SeTavazebuli midgomis da mkurnalobis sxva variantebis zustad
dadgena;
3. sxvadasxva sakiTxebis mxedvelobaSi miReba diskusiisaTvis
momzadebisTvis;
4. mTavar xelmZRvanel pirebTan Sexvedra SeTavazebuli midgomis
ganxilvisaTvis;
5. miRebuli gadawyvetilebis naTlad registracia da dokumentacia.