术后谵妄的病理生理机制及危险因素防治进展

<正>术后谵妄已然成为影响老年病人术后生活质量的一个重要并发症~([1]),有文献报道骨科手术术后谵妄发病率的可达51%,重症监护室中术后病人的发病率可高达82%~([2]),并且与年龄呈正相关。而术后谵妄的发生也会提高患者术后并发症、死亡率、延长住院时间及增加经济消耗~([3])。尽管目前不管是临床还是动物实验都有大量关于术后谵妄的研究,但并没有提出十分有效的诊断方法和治疗措施。本文对近几年术后谵妄发病病理生理机制及其危险因素和防治研究进展进行综述。     

心脏手术后ICU患者应用集束化护理对谵妄发生率的价值研究

目的研究将集束化护理应用于心脏手术后ICU患者,对其谵妄发生率的价值。方法将2018年4月到2019年7月在本医院接受心脏手术治疗的ICU患者纳入到研究中,共78例,根据随机抽签结果将所有患者分成对照组(n=39,常规护理)和实验组(n=39,集束化护理)。对比两组患者的护理满意度、谵妄发生率、谵妄持续时间、ICU治疗时间与住院时间。结果相比于对照组,实验组患者的护理满意度更高,其谵妄发生率、谵妄持续时间、ICU治疗时间与住院时间均更低,差异有统计学意义(P0.05)。结论将集束化护理应用于心脏手术后ICU患者的效果理想,能够降低患者的谵妄发生率,缩短其谵妄持续时间与ICU治疗时间,能够促进患者早日康复,患者更为满意,可在临床广泛推广应用。     

老年谵妄的临床研究新进展

谵妄在老年患者中较为常见.但由于病史不明、医生重视程度不足等原因,使许多谵妄患者未能被正确诊断、治疗.本文述及了谵妄的临床特点、病因、诊断、鉴别诊断和谵妄的处理等方面的研究进展.为临床工作中重视谵妄、正确诊断及治疗谵妄提供依据.     

基于ABCDE的集束化、个性化护理方案对老年急性A型主动脉夹层病人术后谵妄的影响

目的 探讨ABCDE集束化、个性化护理方案对老年急性A型主动脉夹层(ATAAD)病人术后谵妄的影响。方法 选取2018—2021年在我院行外科手术治疗并入住ICU的121例>60岁老年ATAAD病人为研究对象,其中2018—2019年入院的60例病人为对照组,2020—2021年入院的61例病人为干预组。对照组给予常规ABCDE集束化护理方案,干预组给予基于ABCDE集束化管理方案制定的针对老年病人的个性化术后护理方案。对比2组病人术后谵妄发生率、谵妄发生的时间点、谵妄持续时间、机械通气时间、ICU住院时间和总住院时间。结果 干预组谵妄的发生率及持续时间、机械通气时间、ICU住院时间均显著少于对照组,发生谵妄的时间点明显迟于对照组,差异有统计学意义(均P<0.05),2组间总住院时间差异无统计学意义(P>0.05)。结论 基于ABCDE集束化管理方案制定的针对老年病人的个性化术后护理方案能有效推迟老年ATAAD病人术后谵妄的发生,并降低术后谵妄的发生率及持续时间,缩短机械通气时间及ICU住院时间,值得在临床广泛推广应用。     

生物学标志物在心脏术后谵妄早期诊断及病情评估中的研究进展

谵妄是心脏术后常见并发症之一,多见于老年患者。术后谵妄的出现延长了患者的住院时间、增加了术后并发症的发生率及死亡率。通过对相关生物学标志物的研究有望协助术后谵妄的早期诊断及病情评估。本文回顾性分析近年相关文献,从基因、炎症因子、神经递质及神经细胞损伤产物方面对心脏术后谵妄相关生物学标志物的研究进展进行综述。     

术后谵妄患者的临床特点及危险因素

目的分析术后谵妄患者的临床特点,为非神经精神专科医生早期识别和处理谵妄提供参考。方法回顾分析术后谵妄患者的临床资料,与同期住院非手术谵妄患者比较。结果 35例谵妄患者中,术后谵妄组15例(42.9%)。年龄≥65岁者24例(68.6%),年龄65岁者11例(31.4%),平均年龄(70.2±11.3)岁。术后谵妄组平均年龄(70.9±13.1)岁,其中活动过多型9例、活动过少型3例、混合型3例,常见的谵妄诱因是术前禁食禁饮、术前使用阿托品、疼痛;非术后谵妄组20例,平均年龄(69.6±10.2)岁,其中活动过多型11例、活动过少型6例、混合型3例,常见的谵妄诱因是感染、酸碱平衡失常、中重度贫血。结论住院期间发生谵妄常见于老年。术后谵妄组与非术后谵妄组临床表现及预后相似,但术后谵妄与手术、阿托品药物及疼痛等相关,早期识别及处理得当,病程短、预后好。     

急性卒中后谵妄

谵妄是急性卒中的一种常见并发症,通常提示患者转归不良、病死率较高、住院时间较长以及痴呆风险增高.因此,急性卒中后谵妄的早期发现和干预具有重要意义.文章从卒中后谵妄的发病机制、危险因素、诊断评估、治疗和转归等方面进行了综述.     

《综合医院谵妄诊治中国专家共识（2021）》老年谵妄非药物护理部分解读

谵妄是老年住院病人最常见的并发症，严重威胁老年病人的身心健康和预后。非药物护理干预是预防和管理老年谵妄的重要手段。2021年，中华医学会神经心理与行为神经病学学组制定了《综合医院谵妄诊治中国专家共识(2021)》,其综合了国内外综合医院对谵妄诊治的经验，为临床实践中谵妄的诊治及预防提供了规范化的标准。本文将从老年谵妄的定义、评估、诊断和非药物护理干预相关内容等方面进行解读，以期为临床上开展老年谵妄非药物护理工作提供参考。     

老年发病的Gitelman综合征1例并文献复习

谵妄是老年住院病人最常见的并发症，严重威胁老年病人的身心健康和预后。非药物护理干预是预防和管理老年谵妄的重要手段。2021年，中华医学会神经心理与行为神经病学学组制定了《综合医院谵妄诊治中国专家共识(2021)》,其综合了国内外综合医院对谵妄诊治的经验，为临床实践中谵妄的诊治及预防提供了规范化的标准。本文将从老年谵妄的定义、评估、诊断和非药物护理干预相关内容等方面进行解读，以期为临床上开展老年谵妄非药物护理工作提供参考。     

老年住院患者发生谵妄的研究进展

谵妄是老年患者住院期间常见而严重的综合征,对患者、家庭和社会均带来严重的影响。本文就老年住院患者发生谵妄的流行病学、危险因素、发病机制、评估标准以及预防和治疗的新进展进行综述。     

Delir – Management im Krankenhaus: Diagnostik und Therapie

All states of confusion with acute onset and alteration of thinking, perception and awareness are defined as “delirium”. Delirium is a common problem in older patients admitted to the hospital. It is combined with a negative prognosis and complications (falls, infections, etc.). Diagnosis and management need special efforts. Delirium is mostly associated with an underlying disease. In the elderly patient, nearly every disease can be accompanied by delirium, and the fragile older patient is especially affected. Delirium should be evaluated using a systematic approach according to frequency and impact of possible causes. An accurate diagnosis can be challenging. Symptoms have to be distinguished from other cerebral alterations, such as preexisting dementia or depression. Due to the high prevalence, one should always be aware to the presence of delirium. With the treatment of the identified disease, there is generally a reduction of delirium. Often medical intervention in the acute state is necessary to prevent further alteration of the patient. Beside an adequate medical strategy, it is important to create a safe environment for the affected patient. The article gives suggestions for a systematic diagnostic and therapeutic strategy of delirium.     

Delirium predicts 12-month mortality

BACKGROUND: Delirium has not been found to be a significant predictor of postdischarge mortality, but previous research has methodologic limitations including small sample sizes and inadequate control of confounding. This study aimed to determine the independent effects of presence of delirium, type of delirium (incident vs prevalent), and severity of delirium symptoms on 12-month mortality among older medical inpatients. METHODS: A prospective, observational study of 2 cohorts of medical inpatients was conducted with patients 65 years or older: 243 patients had prevalent or incident delirium, and 118 controls had no delirium. Baseline measures included presence of delirium and/or dementia, severity of delirium symptoms, physical function, comorbidity, and physiological and clinical severity of illness. Mortality during the 12 months after enrollment was analyzed with the Cox proportional hazards model with adjustment for covariates. RESULTS: The unadjusted hazard ratio of delirium with mortality was 3.44 (95% confidence interval, 2.05-5.75); the adjusted hazard ratio was 2.11 (95% confidence interval, 1.18-3.77). The effect of delirium was sustained over the entire 12-month period after adjustment for covariates and was stronger among patients without dementia. Among patients with dementia, there was a weak, nonsignificant effect of delirium on survival. After adjustment for covariates, mortality did not differ between patients with incident and prevalent delirium, but among patients with delirium without dementia, greater severity of delirium symptoms was associated with higher mortality. CONCLUSIONS: Delirium is an independent marker for increased mortality among older medical inpatients during the 12 months after hospital admission. It is a particularly important prognostic marker among patients without dementia.     

Delirium concisely: condition is associated with increased morbidity, mortality, and length of hospitalization

Delirium is a common neuropsychiatric condition that affects 15% to 70% of elderly medical and surgical patients. It tends to be a transient disorder, although long-term complications are not uncommon. Medical comorbidity is the rule, and predisposing, as well as precipitating, factors are important to consider in its management. Major risk factors for delirium include advanced age, cognitive impairment, and chronic medical illness. Delirium is associated with several adverse outcomes including mortality, increased length of hospital stay, increased risk of dementia, and high rates of institutional placement. Delirium is distressing for patients, families, and staff. Nonpharmacologic-integrated intervention programs may improve outcome and may be incorporated into the overall medical management.     

The diagnosis of delirium among elderly patients presenting to the emergency department of an acute hospital

Delirium is prevalent among elderly people presenting to an emergency department (ED). However, despite the fact that delirium is associated with longer hospital stays, an increased rate of institutionalization and higher mortality (especially in the case of undiagnosed delirium), this condition often goes undiagnosed by ED doctors. We examined the rate of mental status assessment and the prevalence of delirium in the ED among patients older than 65 years in a large teaching hospital in Southern Israel via a retrospective chart review. Surprisingly we found no diagnosis of delirium in the medical charts of representative sample of 319 elderly people. Furthermore, only 12.5% of people received either an adequate or even a partially adequate mental status assessment by the ED doctors. We attribute these negative findings not to a low incidence of delirium but probably to a combination of a heavy workload along with a lack of adequate training of ED physicians. We suggest that part of the solution involves providing appropriate education to ED physicians as well as adding a geriatric consultant to the ED roster.     

Delirium in a sub-intensive care unit for the elderly: occurrence and risk factors

BACKGROUND AND AIMS: The objective was to study occurrence and risk factors of delirium in a new model of care, the Sub-Intensive Care Unit for the elderly (SICU), which is a level of care between that offered by ordinary wards and intensive care. METHODS: A prospective observational study of 401 consecutively admitted patients, 60+ years, in a four-bed SICU in the geriatric ward of a general hospital. Delirium was detected by the Confusion Assessment Method (CAM) at admission (prevalent) and during SICU stay (incident). Impaired function (Barthel Index) and/or IADL two weeks prior to admission identified disability, and additional Mini-Mental State Examination (MMSE) <18 at discharge identified probable dementia. RESULTS: Delirium was detected in 117 patients (29.2%). Of these 62 (15.5%) had delirium at admission and a further 55 developed delirium during their time in the SICU. Delirium occurred in 19 (11.4%) of the "robust" (no dementia or disability), 28 (24.1%) of the disabled and 70 (58.4%) of the demented patients (p<0.001). Prevalent delirium was found in 8 (4.8%), 11 (9.5%) and 43 (36.1%) (p<0.001) and incident in 11 (6.6%), 17 (14.7%) and 27 (22.7%) (p<0.001) of the robust, disabled, and demented patients respectively. Heavy alcohol use, maximum intake of 7 or more drugs, and the use of a bladder catheter were independently associated with delirium. CONCLUSIONS: Delirium was common in the SICU, and patients with probable dementia had the highest risk. They tended to have delirium at admission, whereas patients without dementia, although less at risk, were more prone to developing delirium during their stay in the SICU.     

Les syndromes confusionnels du sujet âgé hospitalisé: polymorphisme sémiologique et évolutif. Étude prospective de 183 patients

Using explicit criteria contained in the DSM III R, we collected in a prospective cohort study clinical features, outcome and risk factors from two cohorts of delirium in hospitalized elderly patients: 138 hospitalized in geriatric department and 45 patients admitted to an acute and comprehensive care hospital. The clinical features were assessed using a quantitative scale (developed by Derouesné). Delirium was unrecognized or misdiagnosed by physicians in 34% of the cases. The onset was known only two thirds of cases. The incidence of hyperactive type, prolonged hospital stay, poor outcomes (persistent delirium leading up to dementia) were highest in subjects admitted in comprehensive hospital. The etiology of delirium is complex and multifactorial. An underlying cause was identified in 80% of patients. The length or the worsening of delirium was significantly higher in patients with psychiatric or dementia comorbidity (OR: 0.2; IC 95%: 0.1–0.5). The prognosis was better in patients without psychoactive medications (OR: 0.2; IC 95%: 0.1–0.4) or with metabolic abnormalities or acute diseases and disorders (OR: 3.3; IC 95%: 1.5–7.6). The predisposing factors to the development of dementia were prior use of psychoactive medications and signs of prior cognitive impairment. This article suggests delirium in elderly patients is associated with several outcomes. The prognosis should be improved at admission by specific scale and an evaluation of predisposing and precipitating factors.     

Screening and detection of delirium in older ED patients: performance of the modified Confusion Assessment Method for the Emergency Department (mCAM-ED). A two-step tool

Delirium is frequent in older Emergency Department (ED) patients, but detection rates for delirium in the ED are low. To aid in identifying delirium, we developed and implemented a two-step systematic delirium screening and assessment tool in our ED: the modified Confusion Assessment Method for the Emergency Department (mCAM-ED). Components of the mCAM-ED include: (1) screening for inattention, the main feature of delirium, which was performed with the Months Backwards Test (MBT); (2) delirium assessment based on a structured interview with questions from the Mental Status Questionnaire by Kahn et al. and the Comprehension Test by Hart et al. The aims of our study are (1) to investigate the performance criteria of the mCAM-ED tool in a consecutive sample of older ED patients, (2) to evaluate the performance of the mCAM-ED in patients with and without dementia and (3) to test whether this tool is efficient in keeping evaluation time to a minimum and reducing screening and assessment burden on the patient. For this prospective validation study, we recruited a consecutive sample of ED patients aged 65 and older during an 11-day period in November 2015. Trained nurses assessed patients with the mCAM-ED. Results were compared to the reference standard [i.e. the geriatricians’ delirium diagnosis based on the criteria of the Text Revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR)]. Performance criteria were computed. We included 286 consecutive ED patients aged 65 and older. The median age was 80.02 (Q₁ = 72.15; Q₃ = 86.76), 58.7% of included patients were female, 14.3% had dementia. We found a delirium prevalence of 7.0%. In patients with dementia, specificity and positive likelihood ratio were lower. When compared to the reference standard, delirium assessment with the mCAM-ED has a 0.98 specificity and a 39.9 positive likelihood ratio. In 80.0% of all cases, the first step of the mCAM-ED, i.e. screening for inattention with the MBT, took less than 30 s. On average, the complete mCAM-ED assessment required 3.2 (SD 2.0), 5.6 (SD 3.2), and 6.2 (SD 2.3) minutes in cognitively unimpaired patients, patients with dementia and patients with dementia or delirium, respectively. The mCAM-ED is able to efficiently rule out delirium as well as confirm the diagnosis of delirium in elderly patients with and without dementia and applies minimal screening and assessment burden on the patient.     

The delirium index, a measure of the severity of delirium: new findings on reliability, validity, and responsiveness

OBJECTIVES: To assess the reliability, validity, and responsiveness of an instrument for measuring the severity of delirium, the Delirium Index (DI). DESIGN: Prospective cohort study, with repeated patient assessments at multiple points in the hospital, at 8 weeks after discharge, and at 6 and 12 months after admission. SETTING: The medical services of a primary acute-care hospital. PARTICIPANTS: Medical admissions aged 65 and older: 165 with delirium and dementia, 57 with delirium only, 55 with dementia only, and 41 with neither. MEASUREMENTS: Severity of delirium symptoms was measured using the DI. Delirium was diagnosed using the Confusion Assessment Method. Other measures included the Mini-Mental State Examination, Informant Questionnaire on Cognitive Decline in the Elderly, Barthel Index (BI), premorbid instrumental activities of daily living, Charlson Comorbidity Index, Clinical Severity of Illness scale (CSI), and the Acute Physiology Score (APS). RESULTS: The intraclass correlation coefficient of interrater reliability was 0.98. Two measures of fluctuation were significantly higher in patients with delirium than in those without delirium. At baseline, the DI was correlated with the BI, APS, and CSI in delirious patients with (correlation coefficient (r)=-0.43, 0.17, and 0.36, respectively) or without (r=-0.44, 0.39, 0.22, respectively) dementia. At 8 weeks, in delirious patients with and without dementia, internal responsiveness as measured by effect sizes was -0.60 and -0.74, respectively, and the standardized response mean for both groups was -0.64. Low to good levels of external responsiveness were found. CONCLUSION: The DI appears to be a reliable, valid, and responsive measure of the severity of delirium, in patients with delirium, with or without dementia.     

Delirium superimposed on dementia predicts 12-month survival in elderly patients discharged from a postacute rehabilitation facility

BACKGROUND: Delirium superimposed on dementia (DSD) is highly prevalent and associated with high mortality among hospitalized elderly patients, yet little is known about the effect of DSD on midterm mortality. The purpose of this study was to assess 12-month survival in patients with DSD and matched groups with dementia alone, delirium alone, or neither delirium nor dementia. METHODS: Among 1278 consecutively admitted elderly participants (aged > or =65 years) to our Rehabilitation Unit between January 2002 and May 2005, four matched samples of 47 participants each (DSD, dementia alone, delirium alone, or neither delirium nor dementia) were selected. Matching was based on age, gender, and reason for admission. Postdischarge 12-month survival was assessed in the four groups with Kaplan-Meyer analysis and compared with Cox proportional hazard regression models adjusted for confounders. RESULTS: Survival was significantly lower for DSD patients than for the other three groups. After adjustment for comorbidity and Barthel Index score before admission, patients with DSD had significantly higher mortality (hazard ratio, 2.3; 95% confidence interval, 1.1-5.5; p =.04) than did patients with neither delirium nor dementia. CONCLUSIONS: Demented patients who experienced delirium during hospitalization had a more than twofold increased risk of mortality in the 12 months following discharge than did patients with dementia alone, with delirium alone, or with neither dementia nor delirium.