Transcript 新興議題： 長照體系內譫妄評估與處置

長照體系內譫妄症
的評估與處置
台大醫院老年醫學部
陳人豪
8/23/2014
課程內容
• 譫妄症(delirium)
– 流行病學
– 致病機轉與病因
– 診斷與評估
– 預防與治療
• 長照體系內譫妄症
1
譫妄症
• 注意力和急性認知功能障礙的一種症候群
– 急性混亂狀態(acute confusional state)
– 典型的多因性(如同其他老年病症候群)
• 在臨床上常被忽略
2
譫妄症的流行病學
• 老年人譫妄症
– 社區盛行率: 1-2%
– 在急診的盛行率: 1/3 (但2/3被忽略)
– 在入住院時的盛行率: 14-24%
– 住院中的發生率: 6-56%
– 手術後的發生率: 15-53%
– 加護病房的發生率: 70-87%
– 護理之家/急性後期照護: 可高達60%
Inouye SK. N Engl J Med. 2006;354(11):1157-1165.
3
譫妄症的預後
• 急性後期機構
– 入住時的盛行率: 23%; 其中14%會完全恢復
– 入住後1個月仍有譫妄症: 51%
• 健康指標(health outcome)
– 有譫妄症的住院病人: 入住護理之家
– 急性後期機構病人: 日常生活功能恢復較差
– 急性後期機構病人: 併發症或再住院
– 死亡率
Lyons WL. J Am Med Dir Assoc. 2006;7(4):254–261.
4
「精神疾病診斷與統計手冊第五版」
診斷準則
A. 注意力 (引導、集中、維持及轉移能力降低)及清醒度
(對環境的定向力變差)的障礙
B. 該障礙在短時間內發展(通常是幾個小時到幾天) ，表
現出與之前在注意力與清醒度上的改變，且傾向在24
小時內呈現起伏的病程表現
C. 認知功能障礙（例如：記憶力缺損、無定向感、及語
言障礙、視覺空間能力或感官功能障礙)
D. A、C的障礙無法以已有的神經認知症(neurocognitive
disorder)來解釋，且並非發生在清醒程度嚴重變差(例
如：昏迷)
5
E. 從病史、理學檢查及實驗室檢查的結果顯示，該障礙
是由內科疾病、物質中毒或戒斷，暴露到毒素、或多
重病因所造成
6
「混亂評估法」(Confusion
Assessment Method, CAM)
• 由美國精神醫學會出版之「精神疾病診斷與統計手冊第
三版的修正版」發展出來篩檢譫妄症的工具
• 包括四個要件，病患一定要符合前兩個要件加上至少第
三或第四個要件其中之一，才能診斷譫妄症：
1. 急性發作的症狀且其病程時好時壞
2. 注意力不集中
3. 無組織的思考
4. 意識障礙
• 敏感度: 0.94-1.0，特異度: 0.90-0.95
Inouye SK, et al. Ann Intern Med. 1990:113(12):941-948.
7
譫妄症的嚴重度
• 混亂評估法-嚴重度(短 表)(CAM-Severity (CAM-S) short
form)
1. 急性發作的症狀且其病程時好時壞(無: 0; 有: 1)
2. 注意力不集中(無: 0; 輕微: 1; 顯著: 2)
3. 無組織的思考(無: 0; 輕微: 1; 顯著: 2)
4. 意識障礙(無: 0; 輕微: 1; 顯著: 2)
– 總分: 0-7
• Four different risk groups: None: 0, Low (mild): 1,
Moderate: 2, High (severe): 3-7 points
Inouye SK. Ann Intern Med. 2014;160(8):526-533.
8
譫妄症的臨床表現
可依精神活動型態分成四型
• 高活動型(hyperactive)
– 躁動(agitation)、增加警戒狀態(vigilance)
– 較易被察覺、較低的死亡率
• 低活動型(hypoactive)：最常見
– 嗜睡、精神活動功能減低
– 不易被察覺，常被忽略或誤診，或被不適當治療
– 預後較差
• 混合型(mixed)
– 表現上具有上述兩種形式的譫妄症
• 正常型
Liptzin B, et al. Br J Psychiatry. 1992;161:843-845.
9
致病機轉
• 十分複雜，至今仍不是很清楚
• 並無最後共通途徑，可能由數個病理機轉相互連結
– 神經傳導物質調控異常(neurotransmitter disturbance)
 膽鹼缺乏(acetylcholine deficiency)
 多巴胺(dopamine) 
 血清素(serotonin), γ-胺基酪酸(GABA)
– 壓力引起下視丘-腦垂腺-腎上腺軸過度活動(stress
related hypothalamic-pituitary-adrenal axis
overactivity)
• 細胞激素(cytokine) 
• 血漿酯酶(esterase)活性降低
Young J, et al. BMJ. 2007;334(7598):842-846.
10
前置因子(Predisposing factor)
•
•
•
•
•
認知功能障礙/失智症
多重疾病
功能障礙
年紀大
慢性腎臟病
•
•
•
•
•
營養不良
血清白蛋白偏低
憂鬱症
知覺障礙
物質濫用史
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誘發因子(Precipitating factor)
• 藥物及藥物改變(包括停
藥)
• 並發的各種疾病
• 電解質失調 或代謝異常
• 手術
• 疼痛控制不佳
•
•
•
•
•
中風
感染
留置管
約束
酗酒或娛樂性藥物的使
用
• 重大精神社會壓力源
12
譫妄症：多因性模式
Hazzard’s geriatric medicine and gerontology, 6th Ed.
13
造成譫妄症的原因
•
•
•
•
•
藥物(Drugs)
電解質失調(Electrolytes)
藥物戒斷(Lack of drugs)
感染(Infections)
感覺輸入減少(Reduced sensory input): 失明、失聰、
環境昏暗
• 顱內疾病(Intracranial disorder): 中風、腦膜炎、癲癇
• 尿滯留及糞石箝塞(Urinary retention, fecal impaction)
• 心臟疾病(Myocardial): 心肌梗塞、心律不整、心衰竭
14
譫妄症的評估
• 確立診斷
– 鑑別診斷: 譫妄症、失智症、憂鬱症
– 失智症是譫妄症的危險因子，反之亦然
• 確立可能造成譫妄症的原因，及會造成立即生命危險
的病因
15
Evaluation: Medical History
•
•
•
•
•
•
Baseline level of function
Changes in mental status
History for identifying acute organic illnesses
Drug reviews, including alcohol, benzodiazepine
Social habits
Review of systems
16
Evaluation: Physical Examination
• Vital signs and oxygen saturation
• General medical evaluation
– Signs of infections
– Signs of organ failure
– Suprapubic and rectal examination
• Neurological examination
– Mental status examination
– Speech, thought, perception, activity
17
Evaluation: Laboratory Tests
For most patients:
– CBC, blood sugar, renal and liver function tests,
electrolytes (Na, Ca), urinalysis, chest x-ray
– Consider ECG, cardiac enzymes, TSH, ABG, drug levels,
vitamin B12
For selected patients:
– Neuroimaging: head trauma or new focal neurologic
findings
– EEG and CSF study: seizure or signs of meningitis
18
Principles of Management
• Management of delirium requires
– Interdisciplinary effort by doctors, nurses, family
– Multifactorial approach because delirium usually
results from concurrent multiple factors
– Correction of all reversible contribution factors
– Avoidance of new precipitants
• Identify and treat predisposing and precipitating
factors promptly
19
• Avoid complications of delirium
– Remove unnecessary indwelling devices
– Monitor bowel and urinary output
– Achieve proper sleep hygiene and avoid sedatives
– Monitor for nosocomial complications, including
aspiration, pressure sores, UTI
• Optimize medication regimen
20
Nonpharmacologic Strategies
• Environment
– Provide quiet, well-fit surroundings
– Provide orienting stimuli (e.g., clocks, calendar,
familiar objects)
– Encourage family involvement
– Provide regular reorienting communication
– Limit room and staff changes
21
• Activities during daytime
– Cognitive activities
– Encourage early mobilization and rehabilitation
• Correct sensory deficits: eyeglasses, lighting, hearing
aids or cerumen removal
• Sleep
– Provide uninterrupted sleep time at night
– Normalize sleep-wake cycle
22
• Prevent dehydration
– Adequate intake of nutrition and fluids
– Feeding by hand if necessary
• Use sitters
• Avoid use of restraints and urinary catheters
• Avoid psychoactive drugs
23
Pharmacologic Strategies
• Remove offending and unnecessary drugs
• Reserve for patients at risk for interruption of essential
medical care or patients who pose safety hazard to
themselves or staff
• Start low doses and adjust until effect achieved
• Maintain effective dose for 2–3 days
24
Typical Antipsychotics
For acute agitation or aggression
• Haloperidol
– 0.25-0.5 mg po (peak effect: 4-6 hours) twice
daily with additional doses every 4 hours as
needed
– 0.25-0.5 mg im (peak effect: 20-40 minutes),
observe after 30 minutes and repeat the same
or twice the origin doses
– Titrate upward as needed (up to 3-5 mg/day)
• Goal: A manageable patient
• Observe for akathisia, extrapyramidal effects and
prolonged QTc
25
Atypical Antipsychotics
• Studied only in small uncontrolled studies
• Associated with increased risk of
– Stroke
– Mortality among older patients with dementia
• Observe for extrapyramidal effects and prolonged QTc
– Risperidone 0.5-1 mg/day po (qd-bid)
– Quetiapine 25-800 mg/day po (qd-bid)
– Olanzapine 2.5-10.0 mg po (qd)
26
Benzodiazepines
• Reserve for alcohol/benzodiazepine withdrawal
• Adjuncts to antipsychotics (agitation/insomnia)
– Lorazepam 0.5-1.0 mg po, with additional doses
every 4 hours as needed
27
Physical Restraint
• The highest relative risk of the precipitating factors for
delirium*
• Significant association with the severity of delirium†
• Misconceived reason for physical restraint use among
delirious patients to prevent injury
• Restraint reduction: not associated with falls
• Restraint free care: the standard of care
*Inouye
SK, et al. JAMA. 1996;275(11):852–857.
†McCusker J, et al. J Am Geriatr Soc. 2001;49(10):1327–1334.
28
Prevention of Delirium
• Primary prevention of delirium: the most effective
strategy to reduce delirium
• Avoid medications known to precipitate delirium
• Multicomponent approaches
• 40% risk reduction for delirium in hospitalized older
patients
29
Yale Delirium Prevention Trial
• To evaluate effectiveness of intervention protocols
targeted toward six risk factors
– Cognitive impairment
– Sleep deprivation
– Immobility
– Visual impairment
– Hearing impairment
– Dehydration
Inouye SK, et al. N Engl J Med. 1999;340(9):669-676.
30
Delirium in Long-term Care
• American Medical Directors Association (AMDA)
clinical practice guideline in 2008 for “delirium and
acute problematic behavior in the long-term care
setting”
– Recognition
– Assessment
– Treatment
– Monitoring
31
Recognition
Step 1: Identify the patient’s current behavior, mood,
cognition and function
• Review the history, observe the patient in various
situations, and identify and document pertinent details
about how the patient looks, thinks, and acts
• Assessment process should be coordinated among staff
from various disciplines involved
32
Key Elements in Evaluating
Mental Status
33
Step 2: Identify and clarify problematic behavior and
altered mental function
– Symptoms, current diagnoses, history and medications
• Review the patient’s medical, surgical, family and
social history; pertinent behavioral history; baseline
functional status; and any prior diagnostic work-up
and management
34
• Check available transfer information and any pertinent
consultation reports for related diagnoses (delirium,
dementia, bipolar disorder, or psychosis)
• Review current orders for treatments and medications
that address cognition, mood, problematic behavior, or
psychiatric disorders, and for medications with
anticholinergic properties or side effects, which are
known to adversely affect behavior and mental
function
35
 Define behavioral issues
– Nature and relevant factors
– Severity
– Course
 Identify delirium
– Require a high index of suspicion
– Should be considered in any patient who has a
change in behavior or mental function,
regardless of whether they also have dementia
– Use screening instruments (e.g., CAM)
36
Step 3: Assess the patient for individual risk factors for
problematic behavior and delirium
– Having dementia is the most common risk factor for
the development of delirium
• Avoid using indwelling urinary catheters and minimize
use of other medical devices (e.g., intravenous catheters)
that may restrict mobility or function
• Avoid using restraints
37
• Minimize the number and reduce the dose of
medications with central nervous system effects or
potential side effects
• Pay careful attention to fluid and electrolyte balance in
older patients who are taking diuretics; who have
diarrhea, pneumonia, or urinary tract infection; or
who are otherwise at risk for dehydration
• Identify and manage treatable causes of anemia
38
• Optimize sensory function (e.g., provide corrective
lenses for impaired vision, hearing aides)
• Optimize sleep (e.g., address reversible causes of sleep
impairment, minimize nighttime noises)
• Avoid unnecessary isolation or restriction (e.g., for
infection control purposes)
39
Assessment
Step 4: Determine the urgency of the situation and the
need for additional evaluation and testing
• Simply giving medications to try to control behavior, or
routinely requesting the immediate transfer of patients
to the emergency room or hospital, are often not helpful
• Some situations may require more urgent evaluation
and management
40
Assessment
Step 4: Determine the urgency of the situation and the
need for additional evaluation and testing
• Simply giving medications to try to control behavior, or
routinely requesting the immediate transfer of patients
to the emergency room or hospital, are often not helpful
• Some situations may require more urgent evaluation
and management
41
Situations Requiring Urgent
Evaluation
 Medical issues
– Markedly abnormal vital signs (systolic BP <90, PR
<50 or >120, RR>30, temp <35.5℃ or >38.3℃)
– New-onset respiratory distress, with increasing hypoxia
and dyspnea
– Signs of serious underlying condition possibly causing
delirium (e.g., symptoms of stroke)
 Psychiatric symptoms
– Escalating physically aggressive behavior or threats of
violence
– Intermittent or persistent change to self or others
42
Step 5: Identify the cause(s) of problematic behavior and
altered mental function
• A systematic approach
– A detailed description of current behavior, function
and mental status in proper context
– Careful physical assessment by nursing staff,
supplemented by a practitioner assessment and
pertinent laboratory testing as needed
43
• Consider unmet comfort needs, environmental issues
and nonspecific behavioral and psychological symptoms
of dementia (BPSD)
• Certain physical impairments (e.g., aphasia,
impairment of vision and hearing) may contribute to
behavioral symptoms
44
Step 6: Assess the patient for medical illnesses with or
without delirium
• Additional medical, neurological, psychological or
psychiatric assessment if above evaluations and tests do
not reveal a specific cause
• Stepwise approach may be more useful and costeffective than the simultaneous ordering of many tests
• Infections, particularly pneumonia and urinary tract
infection, are common in institutionalized elderly
45
Conditions That May Affect
Behavior and Mental Function
Acute or abrupt onset or condition change
• Medication-related adverse consequences
• Fluid and electrolyte imbalance
• Infections
• Hypoglycemia or marked hyperglycemia
• Acute renal failure, hypoxia, CO2 retention
• Cardiac arrhythmia, myocardial infarction or heart
failure
• Head trauma
• Stroke or seizure
• Pain, acute or chronic
46
• Urinary outlet obstruction
• Alcohol or drug abuse or withdrawal
• Postoperative state
Acute or abrupt onset or condition change
• Hypo or hyperthyroidism
• Neoplasm
• Nutritional deficiency (e.g., folate, thiamine, vitamin B12)
• Anemia
• Chronic constipation/fecal impaction
• Sensory deficits
47
Diagnostic Tests to Help Assess
Causes
48
 Almost any medication if time course is appropriate
49
Step 7: Consider possible psychiatric illnesses
• Consider psychiatric illness if the assessment does not
reveal a cause
– Psychosis from schizophrenia, schizoaffective
disorders, major depression, dementia, bipolar
affective disorders and mania
– Mood disorders
– Personality disorders
50
Step 8: Consider dementia-related causes
• Environmental triggers
• BPSD: restlessness, aggression, delusion, hallucinations,
repetitive vocalization, wandering
51
Treatment
Step 9: Establish a working diagnosis and validate
conclusions
• Identify the rationale for and goals of treatment
– Why is the patient’s behavior problematic?
– Why does the patient’s behavior require an
intervention?
– How was the likely cause determined?
– How will the proposed interventions address the
causes or factors contributing to the problematic
behavior in order to moderate it?
– How will the proposed interventions improve the
patient’s well-being and quality of life?
52
• Determine the need for transfer
– Many cases can be managed effectively in a facility,
to the patient’s benefit
– Hospitalization is only sometimes helpful and may
be traumatic for the patient
53
54
Step 10: Initiate a care plan for treatment
– A: What are the antecedents to the behavior?
B: What is the behavior?
C: What are the consequences of the behavior?
55
• Address key aspects of the patient’s care
– Risk assessment
– Cause identification and management
– Need for staff support and for informing the patient
and family
– Prevention and management of coexisting conditions
and complications
– Changes to the current treatment regimen
– Monitoring parameters
56
Step 11: Provide symptomatic and cause-specific
management
• Symptomatic interventions are often helpful in
combination with cause-specific approaches
– Prevent and manage complications and functional
problems
– Address relevant ethical issues
– Treat underlying causes
– Treat delirium and psychosis aggressively
– Address wandering and sleep disturbances
– Address apathy and mood disorders
– Address sexually inappropriate behavior
57
– Symptomatic (mostly nonpharmacologic) approaches to
addressing problematic behavior
 Address pain and discomfort
 Minimize sleep disruption
 Encourage independence to the extent of the patient’s
tolerance
 Provide activities for those with disruptive behavior
 Involve the patient daily routine in a calm, quiet
environment
 Use different approach to bathing, feeding and other
activities of daily living
58
Step 12: Use medications appropriately to address
problematic behavior
– Rational approach based on understanding mechanisms
of action and targeting medications to the identified or
likely underlying causes
– No magic bullets
– Risk and complications
 Short-half-life benzodiazepines (e.g., lorazepam):
oversedation, “rebound” effects after each dose
59
– Systematic approach
 Obtain and review the details of the situation (Steps
1-3)
 Determine the most likely causes
 Identify what the staff has already done, or could do,
to try to understand and address the situation
 Consider whether the patient’s behavior or condition
is presenting an imminent or high level of danger to
himself or herself or to others
60
– Antipsychotics
 Initiate treatment aggressively and taper the doses as
underlying causes are addressed and symptoms
stabilize or subside
 Make individualized decisions about the potential
benefits and risks
61
Monitoring
Step 13: Monitor and adjust interventions as indicated
– Monitor the patient’s progress periodically (Steps 1-8)
– Initiate or modify interventions (Steps 9-12)
– Document the patient’s course in enough detail
(treatment effect, diagnosis validity)
– Adjust medication doses on the basis of symptoms and
adverse consequences
62
– Review the situation, revisit the steps, reconsider the
diagnoses and interventions if problematic behavior or
altered mental function does not at least begin to
stabilize or improve within 72 hours of initiating
interventions
– May add another medication as an adjunct if a
maximum recommended dose or tolerated dose of one
medication is reached with partial improvement of
symptoms or improvement of one symptom but not
others
– Consider psychiatric consultation, but attending
physician must remain involved
63
Step 14: Review the effectiveness and continued
appropriateness of all medications
– After delirium have subsided, review the situation and
consider whether the underlying causes have improved or
resolved and intervention remain appropriate
– Once the cause of delirium has been identified and
managed effectively, it may be possible to taper or stop
any medications that were used to treat related
behavioral symptoms
64
– May be appropriate to reduce or stop the intervention(s),
at least for a trial period
– If symptoms endure or recur more than occasionally
while the patient is on a stable dose of
psychopharmacologic medications, reconsider the
diagnosis and appropriateness of current medication
regimen
– If symptoms are little or no different as the dose is
reduced, additional attempted dose reduction may be
indicated
65
Step 15: Prevent, identify and address any complications of
the conditions and treatments
– Fluid and electrolyte imbalance and pressure ulcers in a
patient with delirium
– Falling as a result of benzodiazepine, and other
psychopharmacologic medication use
– Hyperglycemia or cardiac events related to the use of
some atypical antipsychotics
– Oversedation as a side effect of benzodiazepine
66
Take Home Message
• Delirium, a geriatric syndrome
– Common among older persons
– Resulting in functional decline
– Associated with substantial morbidity/mortality
– Detected by using CAM
– Multi-factorial, with underlying causes usually
found by a comprehensive history, physical
examination, and focused laboratory studies
67
– Successful prevention and management
interventions include a multi-component
intervention
– The best management is prevention
– Physical restraints should not be used in patients
with delirium, and rarely should pharmacological
restraints be used
68
Reference
• 陳人豪：譫妄症。於臺灣老年學暨老年醫學會等主編
：老年醫學叢書系列：老年病症候群。臺北，臺灣老
年醫學會；2012：15-26。
• J Am Med Dir Assoc. Clinical Practice Guideline:
Delirium and Acute Problematic Behavior in the LongTerm Care Setting. 2008. 36p.
• Inouye SK. Delirium in older persons. N Engl J Med.
2006;354(11):1157-1165.
• Lyons WL. Delirium in postacute and long-term care. J
Am Med Dir Assoc. 2006;7(4):254-261.