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內外科疾病最終表現, 不是原發性精神疾病
譫妄 = 急性大腦衰竭
譫妄是臨床預後不佳的指標
住院期間發生譫妄, 死亡率可能高達 21%~75%
Not a disease, it's a symptom !
短時間 Acute !
Attention 差
Fluctuating
意識障礙 + 認知功能改變
通常突然發作, 病程短, 多變化
Reversible
日夜顛倒, Disoriented, Visual hallucination
Delirium, acute encephalopathy, acute brain failure
Impairment of attention and cognition
Increase in morbidity, mortality, and hospital length of stay
Acute onset of attention deficits
and cognitive abnormalities, fluctuating in course
Delirium typically develops over days.
Disordered attention and acute fluctuating course
are the hallmarks of the condition,
fluctuate rapidly between hypoactive and hyperactive states
Sleep-wake cycles are often disrupted.
Tremor, asterixis, tachycardia, sweating, hypertension,
or emotional outbursts may be present.
Cause :
1. Primary intracranial disease
2. Systemic diseases secondarily affecting the CNS
3. Exogenous toxins (including prescribed pharmacotherapies)
4. Drug withdrawal and pain
5. Major trauma or surgery
DELIRIUM
看到 Delirium 先排除 酒精, BZD withdrawl 一定要問
Drug：最常見可以解決的譫妄原因
Electrolyte disturbance：注意脫水, 鈉離子不平衡, 甲狀腺異常
減藥（Lack of drugs）：評估停掉長期使用的鎮靜安眠藥
評估是否有控制不好的疼痛（Lack of analgesia）：
定時給藥, 局部用藥, 避免使用鴉片類止痛藥（特別是 Demerol）
Infection
視力聽力不佳（Reduced sensory input）：使用眼鏡, 助聽器
Intracranial disorders
Urinary and fecal disorders：尿液, 糞便滯留
Myocardial and pulmonary disorders
Delirium : Disoriented, Hallucination, sleep wake cycle abnormal
Dementia : Disoriented, Hallucination in late stage, sleep wake cycle normal
Rapid fluctuation of symptoms is common
in delirium but generally absent in depression.
Patients with depression are oriented and able to perform commands.
混亂評估量表 (Confusion Assessment Methods, 簡稱CAM)
最好的評估工具, 有3分鐘診斷會談(3D-CAM)版本, 值得非精神科採用
CAM 包含四項特徵, 須符合以下 1 & 2 + 3 or 4
(1) 急性意識狀態改變與病程起伏, 通常晚上症狀更為嚴重 (日落症候群)
(2) 注意力障礙：主要以「逆序記憶廣度測驗」測試
例如「3項逆序記憶廣度測驗」評估者說 (3-5-8) 病人須回答 (8-5-3)
患者若無法能完成「4項逆序記憶廣度測驗」，則算是注意力障礙
(3) 思考混亂 或 (4) 意識狀態改變：
思考混亂主要評估患者對 " 時, 地, 人 "的定向感
失去定向感（disorientation）的順序通常為 " 時 → 地 → 人 "
Treatment :
解決 Underlying cause, 越晚治療拖更久
Nonpharmacologic approaches to delirium are the standard of care.
In circumstances of risk of harm to self or others,
the use of antipsychotics may be indicated.
- Haloperidol
Antiphsychotic 也不能治療 delirium
重點還是在 Underlying cause, 只是減輕症狀
用到病人 delirium 改善快要好就要停藥
0.5-1 mg 打很少, 老人下手要更輕
5 - 10 mg PO, IM, or IV
with reduced dosing of 1 - 2 mg in older adults.
Repeat at 20- to 30-minute intervals as needed.
非必要少用, 須 slowly push, 注意心跳與血壓變化
三十分鐘後患者未鎮靜, 則再給一倍劑量
Haloperidol 在老年人常引起厲害的副作用 (如 EPS, 跌倒, 吸入性肺炎)
- Lorazepem :
not for delirium, but for maniac 來輔助照顧
一直用 BZD 會一直睡, 反而 Awareness 更差
BZD 絕對不能長效用, 甚至最好不要用
In younger patients, BZDs, such as lorazepam, 0.5 - 2.0 mg PO, IM, or IV,
may be used in combination with haloperidol.
Guidelines recommend avoiding BZDs in the elderly !
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