目的 探討艾司唑侖聯(lián)合經(jīng)顱磁刺激（rTMS）治療老年慢性失眠的臨床效果。方法 前瞻性選取2018年10月—2020年10月遂寧市中心醫(yī)院收治的148例老年慢性失眠患者為研究對象，隨機數(shù)字表法將患者分為藥物組（n＝49）、rTMS組（n＝49）、聯(lián)合組（n＝50），藥物組給予艾司唑侖片，晚上入睡前口服1 mg，每天1次；rTMS組給予低頻rTMS，應(yīng)用YRD CCY-1型經(jīng)顱磁刺激器，取坐位，將其安放于四神聰、安眠、本神、百會、神庭穴位，刺激頻率1 Hz，刺激時間每個序列選定50 s，間歇5 s，連續(xù)治療1 500次脈沖，每天1次；聯(lián)合組給予艾司唑侖片＋低頻rTMS，艾司唑侖片用法用量同藥物組，低頻rTMS具體步驟同rTMS組。3組均治療1個月。對比3組臨床療效和不良反應(yīng)情況，對比3組患者治療前后匹茲堡睡眠質(zhì)量指數(shù)（PSQI）、多導(dǎo)睡眠圖（PSG）相關(guān)指標［睡眠潛伏期（SOL）、睡眠效率（SE）、快速眼動期（REM）］、情景記憶指標［聽覺詞語記憶測驗（AVMT），包括短延遲回憶、長延遲回憶、即刻記憶］、焦慮自評量表（SAS）、抑郁自評量表（SDS）、神經(jīng)遞質(zhì)［γ-氨基丁酸（GABA）、5-羥色胺（5-HT）、去甲腎上腺素（NE）］水平。結(jié)果 治療1個月后，聯(lián)合組治療總有效率為92.00%，藥物組和rTMS組治療總有效率分別為75.51%和71.43%，聯(lián)合組總有效率顯著高于藥物組和rTMS組（P＜0.05），藥物組和rTMS組治療總有效率比較差異無統(tǒng)計學(xué)意義（P＞0.05）。治療前3組患者睡眠質(zhì)量指標PSQI評分、SOL、SE、REM比較，差異無統(tǒng)計學(xué)意義（P＞0.05），治療1個月后3組患者睡眠質(zhì)量指標PSQI評分、SOL、SE、REM均較治療前明顯改善（P＜0.05）；治療1個月后聯(lián)合組PSQI評分顯著低于藥物組和rTMS組（P＜0.05），SOL顯著短于藥物組和rTMS組（P＜0.05），SE、REM顯著高于藥物組和rTMS組（P＜0.05）；治療1個月后藥物組SOL顯著短于rTMS組，SE、REM顯著高于rTMS組（P＜0.05）。治療前3組AVMT評分比較，差異無統(tǒng)計學(xué)意義（P＞0.05），治療1個月后3組AVMT評分各項水平均較治療前顯著提高（P＜0.05）；治療1個月后聯(lián)合組短延遲回憶、長延遲回憶、即刻記憶評分均高于藥物組和rTMS組（P＜0.05），且rTMS組各項指標顯著高于藥物組（P＜0.05）。治療前3組患者SAS、SDS評分比較，差異無統(tǒng)計學(xué)意義（P＞0.05）；治療1個月后3組患者SAS、SDS評分均較治療前顯著降低（P＜0.05）；治療1個月后聯(lián)合組患者SAS、SDS評分顯著低于藥物組和rTMS組（P＜0.05），治療1個月后藥物組和rTMS組患者SAS、SDS評分比較，差異無統(tǒng)計學(xué)意義（P＞0.05）。治療前3組患者血清GABA、5-HT、NE水平比較，差異無統(tǒng)計學(xué)意義（P＞0.05）；治療1個月后3組患者血清GABA、5-HT水平均較治療前顯著升高（P＜0.05），NE水平較治療前顯著降低（P＜0.05）；治療1個月后聯(lián)合組患者血清5-HT、GABA水平顯著高于藥物組和rTMS組（P＜0.05），NE水平顯著低于藥物組和rTMS組（P＜0.05）；治療1個月后藥物組和rTMS組血清5-HT、GABA、NE水平比較，差異均無統(tǒng)計學(xué)意義（P＞0.05）。3組不良反應(yīng)總發(fā)生率比較，差異無統(tǒng)計學(xué)意義（P＞0.05）。結(jié)論 艾司唑侖聯(lián)合rTMS治療老年慢性失眠效果確切，有利于調(diào)節(jié)神經(jīng)遞質(zhì)水平，改善睡眠質(zhì)量，減輕焦慮、抑郁程度，提高記憶功能，且安全性高。

Objective To investigate the effect of estazolam combined with repetitive transcranial magnetic stimulation (rTMS) in treatment of elderly patients with chronic insomnia. Methods A total of 148 elderly patients with chronic insomnia treated in Suining Central Hospital from October 2018 to October 2020 were prospectively selected as the research objects. The patients were randomly divided into drug group (n＝ 49), rTMS group (n＝ 49) and combined group (n＝ 50). Patients in the drug group were given Estazolam Tablets, 1 mg orally before going to sleep at night, once a day. Patients in the rTMS group were given lowfrequency rTMS and applied YRD CCY-1 transcranial magnetic stimulator. The sitting position was taken and placed at the acupoints of Sishencong, Anmian, Benshen,Baihui and Shenting. The stimulation frequency was 1 Hz. The stimulation time was selected for 50 s in each sequence, with an interval of 5 s. 1 500 pulses were treated continuously, once a day. Patients in the the combined group were given Estazolam Tablets + low-frequency rTMS. The usage and dosage of Estazolam Tablets were the same as those in the drug group, and the specific steps of low-frequency rTMS were the same as those in the rTMS group. All three groups were treated for one month. The clinical efficacy and adverse reactions of the three groups were compared. Before and after treatment, Pittsburgh sleep quality index (PSQI), polysomnography (PSG) related indexes [sleep latency (SOL), sleep efficiency (SE), rapid eye movement (REM)], episodic memory indexes [auditory word memory test (AVMT), including short delayed memory, long delayed memory, immediate memory], self rating anxiety scale (SAS), self rating depression scale (SDS), neurotransmitters[γ -aminobutyric acid (GABA), 5-hydroxytryptamine (5-HT), norepinephrine (NE)] levels. Results After one month of treatment, the total effective rate of the combined group was 92.00%, and that of the drug group and rTMS group were 75.51% and 71.43% respectively. The total effective rate of the combined group was significantly higher than that of the drug group and rTMS group (P<0.05). There was no statistical difference between the drug group and rTMS group (P>0.05). There was no significant difference in PSQI score, SOL, SE and REM among the three groups before treatment (P>0.05). One month after treatment, the PSQI score, SOL, SE and REM of the three groups were significantly improved compared with those before treatment (P<0.05). One month after treatment, the PSQI score of the combined group was significantly lower than that of the drug group and rTMS group (P<0.05), the SOL was significantly shorter than that of the drug group and rTMS group (P<0.05), and the SE and REM were significantly higher than that of the drug group and rTMS group (P<0.05). After one month of treatment, SOL in the drug group was significantly shorter than that in the rTMS group, and SE and REM were significantly higher than those in the rTMS group (P<0.05). There was no significant difference in AVMT scores between the three groups before treatment (P>0.05). After one month of treatment, the AVMT scores of the three groups were significantly higher than those before treatment (P<0.05). One month after treatment, the scores of short delayed memory, long delayed memory and immediate memory in the combined group were higher than those in the drug group and rTMS group (P<0.05), and the indexes in rTMS group were significantly higher than those in the drug group (P<0.05). There was no significant difference in SAS and SDS scores among the three groups before treatment (P>0.05). After one month of treatment, the scores of SAS and SDS in the three groups were significantly lower than those before treatment (P<0.05). After one month of treatment, the scores of SAS and SDS in the combined group were significantly lower than those in the drug group and rTMS group (P<0.05). There was no significant difference between the drug group and rTMS group (P>0.05). There was no significant difference in serum GABA, 5-HT and NE levels among the three groups before treatment (P>0.05). One month after treatment, the levels of serum GABA and 5-HT in the three groups were significantly higher than those before treatment (P<0.05), and the level of NE was significantly lower than those before treatment (P<0.05). After one month of treatment, the levels of serum 5-HT and GABA in the combined group were significantly higher than those in the drug group and rTMS group (P<0.05), and the levels of NE were significantly lower than those in the drug group and rTMS group (P<0.05). After one month of treatment, there was no significant difference in the levels of serum 5-HT, GABA and NE between the drug group and rTMS group (P>0.05). There was no significant difference in the total incidence of adverse reactions among the three groups (P>0.05). Conclusion Estazolam combined with rTMS is effective in the treatment of chronic insomnia in the elderly. It is beneficial to regulate the level of neurotransmitters, improve sleep quality, reduce the degree of anxiety and depression, improve memory function, and has high safety.

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