ICU患者谵妄的危险因素及护理的研究新进展

谵妄是一种急性脑功能障碍的临床综合征,尤其是ICU患者谵妄的发生率比较高。本文对ICU谵妄患者的危险因素、护理人员对谵妄评估量表的临床应用情况及ICU谵妄患者的预防及护理进行综述,旨在为今后ICU谵妄患者的管理与研究提供参考依据。     

中国版脑卒中简明ICF核心要素量表在老年人群中的效度

目的进一步验证中国版脑卒中简明ICF核心要素量表在老年人群中的有效性。方法选择42例年龄50～78岁,平均(64.45±7.50)岁的脑卒中患者,使用中国版脑卒中简明ICF核心要素量表的第一部分——身体功能,以及第三部分——活动与参与中的行为表现(即活动和参与的一级限定值),美国国立卫生院卒中评定量表(NIHSS)、简易智能精神状态检查量表(MMSE)、Fugl-Meyer运动评定量表(FM)、运动功能评估量表(MAS)、日常生活活动能力评定Barthel指数(BI)、改良的Rankin量表(mRS)、世界卫生组织残疾评定量表(WHO-DAS2.0)进行评估后,对评估结果作相关性分析。结果中国版脑卒中简明ICF核心要素量表与NIHSS、MMSE等量表的Spearman相关系数绝对值在0.353～0.723。结论在老年人群中,中国版脑卒中简明ICF核心要素量表与临床常用的脑卒中评定量表之间有着中等以上相关性,该量表是可靠有效的临床评估工具。     

膝关节损伤评定量表的简介及应用

评估膝关节损伤和指导治疗方案的评定量表有多种,医疗结果研究36项简表用于评估整体健康状况;西安大略大学麦克马斯特大学骨关节炎指数、膝关节损伤及骨关节炎评分和国际膝关节文献委员会主观量表是评估膝关节的常用量表;而膝关节的吕斯霍尔姆评分和辛辛那提膝关节量表主要用来评估膝关节韧带损伤;前十字韧带生活质量评分是前十字韧带损伤病人自评的量表;滕纳尔活动水平分级和马克思活动水平分级联合膝关节量表能更全面和准确的评估病情,进而有效指导膝关节损伤康复和选择有效临床干预手段。     

奥氮平与氟哌啶醇治疗老年谵妄的随机对照研究

目的探讨非典型抗精神病药物奥氮平与传统抗精神病药物氟哌啶醇治疗老年谵妄的疗效和安全性。方法收集在我院住院的老年谵妄患者196例,随机分为奥氮平组(80例)、氟哌啶醇组(76例)和对照组(40例),3组分别治疗7 d,治疗前后用简明精神病评定量表、临床总体印象量表严重程度评定疗效,用副反应量表评定不良反应和安全性。结果奥氮平组、氟哌啶醇组和对照组治疗的显效率分别为83.75%、80.26%和27.5%,差异有统计学意义(P0.01),奥氮平与氟哌啶醇组比较,差异无统计学意义(P0.05)。奥氮平组不良反应发生率为18.75%,氟哌啶醇组为55.26%,2组比较差异有统计学意义(P0.01)。结论奥氮平治疗谵妄患者疗效与氟哌啶醇相当,但副作用少,耐受性好,且安全有效,可替代传统抗精神病药用于谵妄治疗。     

老年营养风险指数对老年高血压住院患者发生谵妄的预测价值

目的谵妄是一种老年住院患者常见的并发症,尤其在患有高血压的老年患者中较为常见。本研究拟探讨老年营养风险指数(GNRI)在老年高血压住院患者谵妄风险评估中的预测价值。方法选取2016年3月—2017年1月于四川大学华西医院老年科住院且年龄≥70岁的197例高血压患者进行前瞻性研究。入院48 h内对患者进行营养评估和谵妄相关危险因素评估,从住院当天至住院第13天每隔一天对患者进行谵妄评估,通过多因素logistic回归分析GNRI与谵妄之间的相关性,采用受试者工作特征曲线分析GNRI对老年高血压住院患者发生谵妄的预测价值。结果最终有33例患者发生谵妄,多因素logistic回归分析结果显示GNRI是老年高血压住院患者发生谵妄的独立危险因素(OR 7.257,95%CI 1.520～34.638),受试者工作特征曲线提示GNRI预测谵妄的曲线下面积为0.757(95%CI 0.653～0.861,P<0.001)。结论 GNRI作为一种方便快捷的指标,可初步用于老年高血压住院患者谵妄风险的评估。     

A control study of delirium superimposed on dementia treatment between Naloxone joim Quetiapine and Quetiapine alone

目的 探讨纳洛酮联合喹硫平与单用喹硫平治疗痴呆叠加谵妄的疗效与疗效指数.方法 符合DSM-4痴呆叠加谵妄(DSD)诊断标准的住院病人70例,随机分成治疗组(纳洛酮联合喹硫平)35例和对照组(喹硫平)35例,前瞻性观察治疗15天,采用谵妄量表(DSS)在治疗前及治疗3、6、9、12、15天进行评分.采用简易智力状态量表(MMSE)、日常生活评定量表(ADL)及临床疗效总评量表(CGI)在治疗前和治疗15天后进行评分.结果 治疗组与对照组治疗DSD均有效,疗效指数高(CGI-GI分别为1.46±0.51、1.66±0.48,CGI-EI分别为3.24±0.83、2.83±0.84).治疗组在治疗3、6、9、12、15天DSS评分增加分与对照组比较差异有统计学意义(P＜0.05或＜0.01),治疗后MMSE增加分和CGI-EI增加分与对照组比较差异亦有统计学意义(P＜0.05).结论 在治疗痴呆叠加谵妄时,纳洛酮联合喹硫平较单用喹硫平控制谵妄症状快,疗效指数高,可提高认知功能.     

高龄老年住院患者谵妄发生的危险因素

目的 观察高龄老年住院患者谵妄的发生情况,对相关危险因素进行分析。方法 选择2018年2月至2020年2月于徐州医科大学附属医院老年科住院的365例年龄≥80岁的患者为研究对象。应用老年综合评估(CGA)评估患者入院时情况,采用意识模糊评估表(CAM)评估患者入院后7 d内谵妄的发生情况,并将患者分为谵妄组(43例)和非谵妄组(322例)。采用SPSS 24.0统计软件进行数据分析。根据数据类型,分别采用t检验或χ²检验进行组间比较。采用logistic回归分析谵妄发生的独立危险因素。结果 365例老年患者中有43例发生谵妄,发生率为11.8%。谵妄组患者的居家环境、居住方式、多重用药率、抑郁症、营养不良发生率、多病共存发生率、衰弱状态、简易智能状态检查量表(MMSE)评分、老年综合征发生情况及入院时血清中枢神经特异蛋白100β(S100β)水平与非谵妄组相比,差异均有统计学意义(P<0.05)。多因素logistic回归分析显示,年龄(OR=2.683,95%CI 1.005～4.019,P<0.05)、营养状况(OR=2.212,95%CI 1.1...     

老年髋部骨折围术期谵妄的早期干预

目的探讨老年髋部骨折围术期谵妄的早期干预方法和疗效。方法将128例老年髋部骨折患者随机分为干预组(63例)和对照组(65例),入院后每天使用谵妄评定方法中文修订版(CAM-CR)对所有患者进行评估,确诊为谵妄后再进行谵妄分级量表评定(DRS-R-98),记录首次、末次DRS-R-98评分和谵妄持续时间。干预组在术前、术中及术后均进行谵妄危险因素的干预,并结合上述量化评分进行预防性治疗和及时调整治疗方案。对照组进行常规骨科处理。结果干预组谵妄发生率〔15.87%(10例)〕低于对照组率(30.76%(20例),P0.05〕;干预组平均住院时间为(11.28±2.54)d,少于对照组〔(14.15±2.18)d,P0.01〕;干预组首次DRS评分为(18.25±3.42)分,低于对照组〔(21.27±3.64)分,P0.05〕;干预组谵妄持续平均时间为(2.06±1.03)d,少于对照组〔(3.42±1.57)d,P0.05〕;治疗后干预组的末次DRS评分低于对照组(P0.05);随着年龄增长谵妄发生率逐渐增加(P0.05)。结论对老年髋部骨折围术期谵妄的早期干预可结合量表评估早期诊断和量化治疗,早期控制谵妄危险因素,酌情预防性用药,高龄患者更应早期筛查和干预。早期干预可降低围术期谵妄的发生率、严重程度和持续时间,缩短平均住院时间。     

冠状动脉旁路移植术后患者发生谵妄的相关因素

目的观察并分析影响冠状动脉旁路移植术(coronary artery bypass grafting,CABG)术后发生谵妄的相关因素分析。方法选取我院收治的300例CABG患者,根据《谵妄评估量表》将患者分为谵妄组50例,对照组250例,分析患者发生谵妄的相关危险因素。结果术后谵妄患者出现睡眠-觉醒周期紊乱44例(88.00%),情感易变性43例(86.00%),精神运动性激越47例(94.00%),夜间谵妄加重30例(60.00%)。另有短时间记忆力减退32例(64.00%)、长时间记忆力减退23例(46.00%)、注意力不集中33例(66.00%)等临床表现。采用组间单因素分析,得出CABG术后患者发生谵妄危险因素为年龄≥70岁、脑梗死、既往脑出血、手术持续时间、使用芬太尼和重症监护病房观察时间。采用Logistic回归分析,因变量为CABG术后患者是否发生谵妄,自变量为年龄、脑梗死和重症监护病房观察时间。结果表明上述因素均能对术后患者发生谵妄产生严重影响。结论影响CABG术后发生谵妄的危险因素有年龄≥70岁、脑梗死、既往脑出血、手术持续时间、使用芬太尼和重症监护病房观察时间等,应在术前再次评估具有危险因素的患者,为术后患者谵妄发生率的降低提供思路。     

心血管系统病人应用焦虑抑郁筛查量表的研究进展

综述心血管系统病人应用焦虑抑郁筛查量表的信度、效度、敏感度、特异度、简便性,评估量表的应用价值。随着医学模式向社会-心理-生物医学模式转变和双心医学的不断发展,人们开始关注心血管疾病病人焦虑、抑郁等心理问题。评定量表作为筛查心理障碍的重要工具,对识别双心病人和评估其心理障碍严重程度有重要作用。     

Characteristics associated with delirium persistence among newly admitted post-acute facility patients

BACKGROUND: Delirium is costly, common, and may persist for weeks or months. Therefore, the adverse impact of delirium on loss of independence may occur in the post-acute setting rather than in the hospital. The purpose of this study is to describe the rate of delirium persistence and identify baseline patient characteristics that are associated with delirium persistence at 1 month among newly admitted post-acute facility patients who were admitted with delirium. METHODS: Patients were recruited from 4 Boston area skilled nursing facilities specializing in post-acute care (PAC). Assessment instruments included the Confusion Assessment Method Diagnostic Algorithm, the modified Delirium Symptom Interview, the Memorial Delirium Assessment Scale (MDAS), and the Blessed Dementia Rating Scale (BDRS). Multiple logistic regression analyses were used to identify patient characteristics associated with delirium persistence (at 1 month). RESULTS: Nearly 51% of the 85 delirious patients enrolled in this study had delirium at their 1-month follow-up assessment. Four patient factors associated with delirium persistence were identified: older age (> or =85 years), severe delirium at PAC admission (MDAS score >15), prehospital cognitive impairment based on proxy report [BDRS], and the presence of all 8 modified Delirium Symptom Interview symptoms at PAC admission. Our model has very good predictive power (area under the receiver operating characteristic = 0.85). CONCLUSIONS: Delirium is persistent in the post-acute setting. If verified in further research, the risk factors found in this study could be used to identify patients who are likely to have delirium after 1 month, and may prove useful in developing and targeting interventions of care.     

Delirium in an acute geriatric unit: clinical aspects

Delirium is a common event in geriatric hospitalized patients. A prospective study was performed in order to characterize predictors, features and outcome in an acute geriatric care unit in a general hospital in Israel. The tools used to detect delirium were the Confusion Assessment Method (CAM) and the Delirium Rating Scale (DRS), supported by clinical observation by an experienced geriatrician. Results showed an occurrence of 18%; risk factors were polypharmacy and poor nutritional status. Age, education, ethnic origin, pre-morbid cognition and ADL status did not show any statistical correlation with the occurrence of delirium. Delirious patients experienced longer hospital stays, more complications, high mortality rate, cognitive and functional decline. It is very difficult to prove the correlation between reduction of brain reserve and appearance of delirium, but as we have observed in other systems (cardiovascular, renal, etc.), it seems reasonable to presume that the same mechanism is involved in cognitive function. Our conclusions are that the diagnosis of delirium may be misleading by a psychiatric overwhelming presentation, and should be considered not as a transient event, but as a marker for cognitive and functional decline in the future, and therefore these patients should be looked after once discharged.     

Delirium is independently associated with poor functional recovery after hip fracture

OBJECTIVE: To evaluate the role of delirium in the natural history of functional recovery after hip fracture surgery, independent of prefracture status. DESIGN: Prospective cohort study. SETTING: Orthopedic surgery service at a large academic tertiary hospital, with follow-up extending into rehabilitation hospitals, nursing homes, and the community. PARTICIPANTS: One hundred twenty-six consenting subjects older than 65 years (mean age 79 +/- 8 years, 79% women) admitted emergently for surgical repair of hip fracture. MEASUREMENTS: Detailed assessment at enrollment to ascertain prefracture status through interviews with the patient and designated proxy and review of the medical record. Interviews included administration of standardized instruments (Activities of Daily Living (ADL) Scale, Blessed Dementia Rating Scale, Delirium Symptom Interview) and assessment of ambulation, and prefracture living situation. Medical comorbidity, the nature of the hip fracture, and the surgical repair were obtained from the medical record. All subjects underwent daily interviews for the duration of the hospitalization, including the Mini-Mental State Examination and Delirium Symptom Interview, and delirium was diagnosed using the Confusion Assessment Methods algorithm. Patients and proxies were recontacted 1 and 6 months after fracture, and underwent interviews similar to those at enrollment to determine death, persistent delirium, decline in ADL function, decline in ambulation, or new nursing home placement. RESULTS: Delirium occurred in 52/126 (41%) of patients, and persisted in 20/52 (39%) at hospital discharge, 15/52 (32%) at 1 month, and 3/52 (6%) at 6 months. Patients aged 80 years or older, and those with prefracture cognitive impairment, ADL functional impairment, and high medical comorbidity were more likely to develop delirium. However, after adjusting for these factors, delirium was still significantly associated with outcomes indicative of poor functional recovery 1 month after hip fracture: ADL decline (odds ratio (OR) = 2.6; 95% confidence interval (95% CI), 1.1- 6.1), decline in ambulation (OR = 2.6; 95% CI, 1.03-6.5), and death or new nursing home placement (OR = 3.0; 95% CI, 1.1-8.4). Patients whose delirium persisted at 1 month had worse outcomes than those whose delirium had resolved. CONCLUSIONS: Delirium is common, persistent, and independently associated with poor functional recovery 1 month after hip fracture even after adjusting for prefracture frailty. Further research is necessary to identify the mechanisms by which delirium contributes to poor functional recovery, and to determine whether interventions designed to prevent or reduce delirium can improve recovery after hip fracture.     

Time trends of delirium rates in the intensive care unit

BackgroundEffects of clinical practice changes on ICU delirium are not well understood.ObjectivesDetermine ICU delirium rates over time.MethodsData from a previously described screening cohort of the Pharmacological Management of Delirium trial was analyzed. Richmond Agitation-Sedation Scale (RASS) and Confusion Assessment Method for the ICU (CAM-ICU) were assessed twice daily. We defined: Any delirium (positive CAM-ICU at any time during ICU stay) and ICU-acquired delirium (1st CAM-ICU negative with a subsequent positive CAM-ICU). Mixed-effects logistic regression models were used to test for differences.Results2742 patient admissions were included. Delirium occurred in 16.5%, any delirium decreased [22.7% to 10.2% (p < 0.01)], and ICU-acquired delirium decreased [8.4% to 4.4% (p = 0.01)]. Coma decreased from 24% to 17.4% (p = 0.04). Later ICU years and higher mean RASS scores were associated with lower odds of delirium.ConclusionsDelirium rates were not explained by the measured variables and further prospective research is needed.     

Delirium in long-term care setting: Indicator to severe morbidity

We aimed to investigate the incidence and characterize predictors associated with delirium in elderly demented and functionally dependent LTC patients. Data collection included: demographic, clinical, functional, nutritional and cognitive data as well as blood counts and chemistry analysis. The tools used to detect delirium were the Confusion Assessment Method (CAM) and the Delirium Rating Scale (DRS), supported by clinical observation. The occurrence of delirium was 34%. The predominant primary etiologies for delirium were infections (58%), following by metabolic abnormalities (36%), and adverse drug effects (18%). The mean duration of delirium was 15.74 days (2-96 days). Independent predictors influencing duration of delirium were low plasma albumin level, high number of comorbid diseases, male gender, advanced age and presence of CVD. Complete resolution of the delirium was found in 33% (30/92), with persistence in 12% (11/92), and no change in 8% (7/92) of the patients. Forty-eight percent (44/92) of the patients died. Most deaths (50%) were in the first month. The main cause of death was infection related (70%), of which bronchopneumonia was predominant (39%), followed by sepsis (32%). Independent predictors of death were infection, advanced age, low plasma albumin level, dehydration and CHF. The early recognition, identification, correction and treatment of underlying conditions especially in very demented, uncooperative and functionally dependent patients may influence their outcome. Any changes in cognitive and functional status are critical in monitoring LTC patients.     

Dysgraphia in elderly delirious medical inpatients

BACKGROUND AND AIMS: Dysgraphia is a recognized clinical finding in delirium, but few studies have evaluated handwriting, and results have been inconsistent. In particular, handwritten signatures, which may be a motor automatism, have not been previously evaluated in delirious patients. The aim was to assess abnormalities of signature and spontaneous writing in delirious patients and to investigate their clinical utility in the detection of delirium. METHODS: Secondary analysis of data was collected from a prospective observational study of acutely ill inpatients 70 years or older. Mini-Mental State Examination, Confusion Assessment Method, Delirium Rating Scale, Activities of Daily Living, and APACHE II were administered to each subject, their signatures were evaluated from the consent form, and their handwriting from the spontaneous sentence written as part of the MMSE. RESULTS: The signatures of patients with delirium were significantly more impaired than those without (Chi-square= 14.749, df=1, p<0.0001). The sensitivity of the signature for delirium as defined by CAM was 0.54, with specificity of 0.88. Handwriting abnormalities of omission (p=0.018), illegibility (p=0.034) and spelling (p=0.035) were significantly more common in delirious patients than others (Chi-square with Fisher's Exact tests. This difference was mainly attributable to the fact that a large number of delirious patients were unable to provide any response to the handwriting questions. CONCLUSIONS: An abnormal signature may be an indicator of delirium. People with delirium have handwriting problems, which may be partly caused by cognitive impairment but also by disorders of motor function.     

The Delirium Interview as a new reference standard in studies on delirium assessment tools

Background

The reference standard in studies on delirium assessment tools is usually based on the clinical judgment of only one delirium expert and may be concise, unstandardized, or not specified at all. This multicenter study investigated the performance of the Delirium Interview, a new reference standard for studies on delirium assessment tools allowing classification of delirium based on written reports.

Methods

We tested the diagnostic accuracy of our standardized Delirium Interview by comparing delirium assessments of the reported results with live assessments. Our reference, the live assessment, was performed by two delirium experts and one well-trained researcher who registered the results. Their delirium assessment was compared to the majority vote of three other independent delirium experts who judged the rapportage of the Delirium Interview. Our total pool consisted of 13 delirium experts with an average of 13 ± 8 years of experience.

Results

We included 98 patients (62% male, mean age 69 ± 12 years), of whom 56 (57%) intensive care units (ICUs) patients, 22 (39%) patients with a Richmond Agitation Sedation Scale (RASS) < 0 and 26 (27%) non-verbal assessments. The overall prevalence of delirium was 28%. The Delirium Interview had a sensitivity of 89% (95% confidence interval [CI]: 71%–98%) and specificity of 82% (95% CI: 71%–90%), compared to the diagnosis of an independent panel of two delirium experts and one researcher who examined the patients themselves. Negative and positive predictive values were 95% (95% CI: 86%–0.99%), respectively, 66% (95% CI: 49%–80%). Stratification into ICU and non-ICU patients yielded similar results.

Conclusion

The Delirium Interview is a feasible reference method for large study cohorts evaluating delirium assessment tools since experts could assess delirium with high accuracy without seeing the patient at the bedside.     

Validation and psychometric properties of the Delirium Motor Subtype Scale in elderly hip fracture patients (Dutch version)

The Delirium Motor Subtype Scale (DMSS) was developed to capture all the previous different approaches to delirium motor subtyping into one new instrument and emphasize disturbances of motor activity rather than associated psychomotoric symptoms. We investigated reliability and validity of the DMSS Dutch version. Elderly patients who had undergone hip fracture surgery received the DMSS and the Delirium Rating Scale Revised-98 (DRS-R-98). A diagnosis of delirium was defined according to the Confusion Assessment Method (CAM). Among 146 patients, 46 (32%) patients were diagnosed with delirium (mean age 86.3 years; SD 5.2). The internal consistency of the DMSS was acceptable (Cronbach's alpha = 0.72). If an item was removed at random the internal consistency of the scale remained the same. Similarly the concurrent validity of DMSS was good (Cohen's kappa = 0.73) while for each motor subtype the Cohen's kappa ranged from 0.58 to 0.85. The sensitivity and specificity of DMSS to detect each subtype ranged from 0.56 to 1 and from 0.88 to 0.98, respectively. This study suggests that the Dutch version of the DMSS is a reliable and valid instrument. The DMSS has scientific validity that could allow for greater precision in further research on motor subtypes.     

Clinical practice guidelines for the management of delirium in older people in Australia

Delirium is a common and serious condition which is often overlooked or misdiagnosed in older people. In 2006, the first set of national clinical practice guidelines for the management of delirium in older people were developed. This paper provides an abbreviated version of the guideline document which includes recommendations for the detection of delirium (diagnosis and screening), assessment and prediction of risk factors for delirium, prevention of delirium and interventions to manage people with delirium. The guidelines reflect the available evidence base and highlight the limited high level research in delirium care, particularly in the areas of symptom management and screening for delirium.