林口長庚醫院

一般精神科

兒童及青少年精神科

楊緯聖

Delirium evaluation and treatment

Content

• Introduction

• Definition and evaluation

• Treatment and prevention

Delirium

Introduction

Mortality during admission, RR 2.19

Longer ventilator, SMR 1.79

Longer stay in ICU, SMR 1.38

Longer hospitalization, SMR 0.97

Afterward cognitive decline

暴力

躁鬱 躁動

焦慮

憂鬱失眠

妄想

幻覺思覺失調症

失智

身體抱怨多

厭食

自殺攻擊性

不配合治療

不配合復健沒有動力

Delirium

Definition and evaluation

DeliriumNeurobehavioral syndrome caused by dysregulation of baseline neuronal activity secondary to systemic disturbance

AwarenessAttention

Orientation Memory, LanguageVisuospatial ability

Perception

DepressionDysphoria

ManiaAnxiety

Violence self-harm

stereotype movement disorganized behaviourhallucinatory behaviour

reversed circadian rhythm

NeurocognitiveEmotional Behavioral Syndrome

Neuro-cognition

Emotional

Behavioral

Change From Baseline

Normal

Elderly

Comorbidities

Brain insults

Dementic

Delirium

Old age Previous delirium

Neurodegeneration / insults Immobility / ADL dependence

Visual / hearing impairment Comorbidities

Depression Alcohol

InfectionAcute illness

Drug Dehydration

Electrolyte disturbance Hypoxia

Pain Urine retention / constipation

Catheters Change of environments

Secondary toSystemic disturbance

Predisposing

Precipitating

DSM-5 definition

Focus

Sustain

Shift

Awareness

Attention / Awareness

Orientation

Memory

Language / Visuospatial

Perception

Cognition

Acute

Fluctuate

Course

NO SINGLE DETERMINANT HYPOTHESIS

Neuropathogenesis mechanism

Evaluation

DSM-5

You should have patience

Psychiatrist

Bed-side tool

CAM-ICU

Bed-side tool

ICDSC

Must include

精神狀態急性發作或改變 有 沒有

• 和病人平常的狀況相較，有證據顯示精神狀態的急性改變嗎？• (不正常的)行為在過去24小時有變動嗎？嚴重度增加或減少？• RASS, GCS, delirium scale

不注意 ≧8 4-7 0-3

• 8175141136

Either one

意識層次的改變 (RASS) 0 1 / -1 >1 / <-1

沒有組織的思考 4 correct 2-3 correct 0-1 correct

CAM-ICU

意識狀態水平改變

0 0幻覺及妄想

幻覺 1

+1～+4 1 妄想 1

-1～-3 1神經運動興奮或遲鈍

需要約束或鎮靜 1

-4, -5 STOP 明顯遲鈍 1

注意力不集中

難跟隨或遵循指令 1不恰當的言語或情緒

不恰當、不連貫或紊亂的言語 1

注意力容易被外界刺激轉移

1 對所處的事物出現不恰當的情緒 1

難以轉移注意力 1

醒 / 睡週期紊亂

一日總睡眠時數<4 小時 1

定向感障礙

時間錯誤 1 夜間常醒 1

地點錯誤 1 持續處於睡眠狀態 1

人物錯誤 1 症狀波動 24小時內變差 1

ICDSC

CAM-ICU

ICDSC

se 95-100% / sp 89-93% fast not depend on verbal response

se 99% / sp 64% easily administrated retrospectively evaluated no direct involvement subsyndromal item

Comparison

Sedation related delirium

Hyperactive vs. hypoactive delirium

Withdrawal vs. non-withdrawal delirium

Delirium

Treatment and prevention

Multimodal non-Pharmacological

Treatment

Reorientation program

Decrease night light exposure

Decrease night noise exposure

Increase day light exposure

Early mobilization

Visual and hearing aids

Relaxing music and warm drink

Day schedule

Avoid sleep interruption

Avoid daytime sleep

Antihistamine

Antiparkison drug

Atidepressants

Anticholinergics

Antiarrythmics

Antiepileptics

Antipsychotics

Statin

Cholinergic drugs: harmful, increased mortality

BZDs: for alcohol withdrawal

Pharmacotherapy

DC

ADDDextometomidine

Ramelteon

Steroid

Aspirin

Antibiotics

β – blockers

BZDs

CCB

Chemotherapy

Corticosteroid

Digitalis

NSAIDs

Opioids

PPIs

Pharmacotherapy for delirium treatment

Pharmacotherapy for delirium prevention

• Patel SB, Poston JT, Pohlman A, Hall JB, Kress JP. Rapidly reversible, sedation-related delirium versus persistent delirium in the intensive care unit. American journal of respiratory and critical care medicine. 2014;189(6):658-665.• Maldonado JR. Neuropathogenesis of delirium: review of current etiologic theories and common pathways. The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry. 2013;21(12):1190-1222.• Tomasi CD, Grandi C, Salluh J, et al. Comparison of CAM-ICU and ICDSC for the detection of delirium in critically ill patients focusing on relevant clinical outcomes. Journal of critical care. 2012;27(2):212-217.• Wu YC, Tseng PT, Tu YK, et al. Association of Delirium Response and Safety of Pharmacological Interventions for the Management and Prevention of Delirium: A Network Meta-analysis. JAMA psychiatry. 2019;76(5):526-535. • BMJ • DSM-5

Reference

Delirium

Thanks for your attention