【導(dǎo)讀】長照體系內(nèi)譫妄癥。注意力和急性認知功能障礙的一種癥候群。在臨床上常被忽略。–有譫妄癥的住院病人:?–急性後期機構(gòu)病人:?由美國精神醫(yī)學(xué)會出版之「精神疾病斷與統(tǒng)計手冊第。包括四個要件，病患一定要符合前兩個要件加上至少第?；靵y評估法-嚴重度(短表)(CAM-Severity(CAM-S)short. 十分複雜，至今仍不是很清楚。並無最後共通途徑，可能由數(shù)個病理機轉(zhuǎn)相互連結(jié)。,γ-胺基酪酸?血漿酯酶活性降低。藥物及藥物改變(包括停。電解質(zhì)失調(diào)或代謝異常。酗酒或娛樂性藥物的使。重大精神社會壓力源。尿滯留及糞石箝塞。確立可能造成譫妄癥的原因，及會造成立即生命危險

　　

【正文】 opriately 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 plications ? Shorthalflife benzodiazepines (., lorazepam): oversedation, “rebound” effects after each dose 59 – Systematic approach ? Obtain and review the details of the situation (Steps 13) ? 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 18) – Initiate or modify interventions (Steps 912) – 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 remended 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 plications 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 – Multifactorial, with underlying causes usually found by a prehensive history, physical examination, and focused laboratory studies 67 – Successful prevention and management interventions include a multiponent 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：譫妄癥。於臺灣老年學(xué)暨老年醫(yī)學(xué)會等主編：老年醫(yī)學(xué)叢書系列：老年病癥候群。臺北，臺灣老年醫(yī)學(xué)會； 2020： 1526。 ? J Am Med Dir Assoc. Clinical Practice Guideline: Delirium and Acute Problematic Behavior in the LongTerm Care Setting. 2020. 36p. ? Inouye SK. Delirium in older persons. N Engl J Med. 2020。354(11):11571165. ? Lyons WL. Delirium in postacute and longterm care. J Am Med Dir Assoc. 2020。7(4):254261.