長照體系內譫妄症 的評估與處置

1. 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

2. 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

3. 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

4. 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.

5. 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.

6. 「精神疾病診斷與統計手冊第五版」診斷準則 • 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 • 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 • 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) • 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)

7. 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

8. 「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.

9. 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.

10. 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.

11. 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.

12. 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 前置因子(Predisposing factor)

13. 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

14. 譫妄症：多因性模式 Hazzard’s geriatric medicine and gerontology, 6th Ed.

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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)

28. 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

29. Physical Restraint The highest relative risk of the precipitating factors for delirium* Significant association with the severity of delirium† Misconceived reasonfor physical restraint use among delirious patientsto 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.

30. 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

31. 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.

32. 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

33. 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

34. Key Elements in Evaluating Mental Status

35. 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

36. 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

37.  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)

38. 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

39. 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

40. 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)

41. 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

42. 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

43. 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

44. 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

45. 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

46. 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 cost-effective than the simultaneous ordering of many tests Infections, particularly pneumonia and urinary tract infection, are common in institutionalized elderly

47. 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

48. 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

49. Diagnostic Tests to Help Assess Causes

50.  Almost any medication if time course is appropriate