简介
谵妄是指精神状态出现的急性波动性改变，伴有注意障碍、思维混乱和意识水平的改变。[1]Inouye SK, Schlesinger MJ, Lydon TJ. Delirium: a symptom of how hospital care is failing older persons and a window to improve quality of hospital care. Am J Med. 1999;106:565-573.http://www.ncbi.nlm.nih.gov/pubmed/10335730?tool=bestpractice.com它是一种可能危及生命的病理状态，特点为高发病率和死亡率。指南介绍了谵妄的识别、危险因素及治疗。[2]Barr J, Fraser GL, Puntillo K, et al; American College of Critical Care Medicine. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41:263-306.http://www.learnicu.org/SiteCollectionDocuments/Pain,%20Agitation,%20Delirium.pdfhttp://www.ncbi.nlm.nih.gov/pubmed/23269131?tool=bestpractice.com[3]Neto AS, Nassar AP Jr, Cardoso SO, et al. Delirium screening in critically ill patients: a systematic review and meta-analysis. Crit Care Med. 2012;40:1946-1951.http://www.ncbi.nlm.nih.gov/pubmed/22610196?tool=bestpractice.com
阅读更多
后遗症
在医院内，经诊断伴发谵妄的患者死亡率是患有类似疾病但无谵妄患者的两倍，并且在诊断后一个月内死亡率最高可增加 14%。[4]Cole MG, Primeau FJ. Prognosis of delirium in elderly hospital patients. CMAJ. 1993;149:41-46.http://www.ncbi.nlm.nih.gov/pubmed/8319153?tool=bestpractice.com在美国，谵妄在住院病例中的发生率为每年 20% 至 25%，[5]Brown TM, Boyle MF. Delirium. BMJ. 2002;325:644-647.http://www.bmj.com/cgi/content/full/325/7365/644http://www.ncbi.nlm.nih.gov/pubmed/12242179?tool=bestpractice.com是最常见的住院相关并发症。[6]US Department of Health and Human Services. 2004 CMS Statistics. Washington, DC: Centers for Medicare and Medicaid Services, 2004:34. (CMS Publication No 03445)谵妄在重症监护病房内较常见，常出现在机械通气患者中。对于危重患者，谵妄可导致住院时间延长及死亡率上升。[7]Cavallazzi R, Saad M, Marik PE. Delirium in the ICU: an overview. Ann Intensive Care. 2012;2:49.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3539890/http://www.ncbi.nlm.nih.gov/pubmed/23270646?tool=bestpractice.com研究显示，谵妄在急诊科老年患者中的患病率为 12%。[8]Han JH, Wilson A, Vasilevskis EE, et al. Diagnosing delirium in older emergency department patients: validity and reliability of the delirium triage screen and the brief confusion assessment method. Ann Emerg Med. 2013;62:457-465.http://www.ncbi.nlm.nih.gov/pubmed/23916018?tool=bestpractice.com然而尽管患者经常出现谵妄，但由于谵妄症状的波动性以及医护人员缺乏足够的重视，因此谵妄经常被忽视。谵妄还会导致躯体功能和认知能力下降、康复治疗预后不佳、被收容照看以及重新入院接受治疗的风险增加。[1]Inouye SK, Schlesinger MJ, Lydon TJ. Delirium: a symptom of how hospital care is failing older persons and a window to improve quality of hospital care. Am J Med. 1999;106:565-573.http://www.ncbi.nlm.nih.gov/pubmed/10335730?tool=bestpractice.com[9]Kiely DK, Bergmann MA, Murphy KM, et al. Delirium among newly admitted postacute facility patients: prevalence, symptoms, and severity. J Gerontol A Biol Sci Med Sci. 2003;58:441-445.http://www.ncbi.nlm.nih.gov/pubmed/12730254?tool=bestpractice.com[10]Murray AM, Levkoff SE, Wetle T, et al. Acute delirium and functional decline in the hospitalized elderly patient. J Gerontol. 1993;48:M181-M186.http://www.ncbi.nlm.nih.gov/pubmed/8366260?tool=bestpractice.com[11]Marcantonio ER, Simon SE, Bergmann MA, et al. Delirium symptoms in post-acute care: prevalent, persistent, and associated with poor functional recovery. J Am Geriatr Soc. 2003;51:4-9.http://www.ncbi.nlm.nih.gov/pubmed/12534838?tool=bestpractice.com[12]van den Boogaard M, Schoonhoven L, Evers AW, et al. Delirium in critically ill patients: impact on long-term health-related quality of life and cognitive functioning. Crit Care Med. 2012;40:112-118.http://www.ncbi.nlm.nih.gov/pubmed/21926597?tool=bestpractice.com尽管一般观点认为谵妄具有可逆性，但研究显示，谵妄的症状在发病后可持续数周至数月。[13]Roche V. Southwestern Internal Medicine Conference. Etiology and management of delirium. Am J Med Sci. 2003;325:20-30.http://www.ncbi.nlm.nih.gov/pubmed/12544081?tool=bestpractice.com老年住院患者常出现持续性谵妄，并且与不良预后有关。[14]Cole MG, Ciampi A, Belzile E, et al. Persistent delirium in older hospital patients: a systematic review of frequency and prognosis. Age Ageing. 2009;38:19-26.http://ageing.oxfordjournals.org/content/38/1/19.longhttp://www.ncbi.nlm.nih.gov/pubmed/19017678?tool=bestpractice.com
分类
精神疾病诊断与统计手册 (DSM-5) 指出，患者必须表现出以下全部 4 项特征才能被诊断为谵妄。[15]American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 5th ed., (DSM-5). Washington, DC: American Psychiatric Publishing; 2013.
注意力障碍（即对环境的认识清晰度下降）明显，伴集中、保持或转移注意力的能力下降。这种意识障碍可能较轻微，最初仅表现为嗜睡或注意力分散，临床医生和/或家人常常会认为其与原发性疾病有关而不予重视。
认知改变（例如，记忆缺失、定向障碍、语言障碍）或出现之前存在或目前存在的痴呆无法解释的知觉障碍。
这种障碍在短期内（通常为数小时至数日）出现，表现为急性起病，一天当中症状往往会出现波动。
来自病史、体格检查或实验室检测结果的证据表明，这种障碍由全身疾病状态、物质中毒或物质戒断直接导致。注意力和认知的改变不应发生在觉醒水平严重降低（例如，昏迷）的情况下。
目前谵妄一般分为三种临床亚型。[16]Potter J, George J. The prevention, diagnosis and management of delirium in older people: concise guidelines. Clin Med. 2006;6:303-308.http://www.ncbi.nlm.nih.gov/pubmed/16826866?tool=bestpractice.com[17]Gupta N, de Jonghe J, Schieveld J, et al. Delirium phenomenology: what can we learn from the symptoms of delirium? J Psychosom Res. 2008;65:215-222.http://www.ncbi.nlm.nih.gov/pubmed/18707943?tool=bestpractice.com[18]Meagher DJ, Leonard M, Donnelly S, et al. A longitudinal study of motor subtypes in delirium: frequency and stability during episodes. J Psychosom Res. 2012;72:236-241.http://www.ncbi.nlm.nih.gov/pubmed/22325705?tool=bestpractice.com其中包括：
活动过度型谵妄 — 该型患者一般处于高度觉醒状态，并伴有坐立不安、激越、幻觉和不适当行为
活动减退型谵妄 — 该型患者一般具有嗜睡、肢体活动减少、语无伦次和缺乏兴趣的表现
混合型谵妄 — 同时具有活动过度型和活动减退型的体征和症状。
术语“亚综合征谵妄”是指部分消退或不完整形式的谵妄。
流行病学
谵妄在社区中的患病率预计为 1% 至 2%；对于年龄在 85 岁以上的患者，这一数字则上升至 14%。[13]Roche V. Southwestern Internal Medicine Conference. Etiology and management of delirium. Am J Med Sci. 2003;325:20-30.http://www.ncbi.nlm.nih.gov/pubmed/12544081?tool=bestpractice.com在所有老年病患中，谵妄的患病率高达 30%。[19]Royal College of Physicians. Prevention, diagnosis and management of delirium in older people. June 2006. http://www.rcplondon.ac.uk (last accessed 27 July 2017).https://www.rcplondon.ac.uk/guidelines-policy/prevention-diagnosis-referral-and-management-delirium-older-people老年住院患者的患病率在 10% 至 40% 之间。[5]Brown TM, Boyle MF. Delirium. BMJ. 2002;325:644-647.http://www.bmj.com/cgi/content/full/325/7365/644http://www.ncbi.nlm.nih.gov/pubmed/12242179?tool=bestpractice.com在住院患者中，谵妄在急诊科患者的患病率为 14% 至 24%，术后患者的患病率为 15% 至 53%，重症监护患者则为 70% 至 87%。[20]Inouye SK. Delirium in hospitalized older patients. Clin Geriatr Med. 1998;14:745-764.http://www.ncbi.nlm.nih.gov/pubmed/9799477?tool=bestpractice.com[21]Pisani MA, McNicoll L, Inouye SK. Cognitive impairment in the intensive care unit. Clin Chest Med. 2003;24:727-737.http://www.ncbi.nlm.nih.gov/pubmed/14710700?tool=bestpractice.com[22]Neufeld KJ, Thomas C. Delirium: definition, epidemiology, and diagnosis. J Clin Neurophysiol. 2013;30:438-442.http://www.ncbi.nlm.nih.gov/pubmed/24084176?tool=bestpractice.com
病理生理学
谵妄的病理生理机制尚不明确。神经影像学研究显示存在脑部多个不相关区域功能障碍，这些区域包括前额叶、皮层下结构、丘脑、基底神经节、舌回、梭状回和颞顶皮层。[23]Singer GG, Brenner BM. Fluid and electrolyte disturbances. In: Kasper DL, Fauci AS, Longo DL, et al. eds. Harrison's Principles of Internal Medicine, 16th ed. New York, NY: McGraw Hill; 2005:252-263.[24]Choi SH, Lee H, Chung TS, et al. Neural network functional connectivity during and after an episode of delirium. Am J Psychiatry. 2012;169:498-507.http://www.ncbi.nlm.nih.gov/pubmed/22549209?tool=bestpractice.com
脑电图 (EEG) 研究结果也表明皮层活动弥漫性放缓。
谵妄发病也与神经递质、炎症和慢性应激有关。例如，使用抗胆碱能药物的患者谵妄发生率显著增高，表明胆碱能神经递质缺乏与谵妄发生有关。[25]Trzepacz P, van der Mast R. The neuropathophysiology of delirium. In: Lindesay J, Rockwood K, Macdonald A, eds. Delirium in old age. Oxford, UK: Oxford University Press; 2002:51-90.针对手术患者的研究已证实术后发生谵妄的患者体内胆碱能系统与免疫系统之间存在互动功能障碍。[26]Cerejeira J, Nogueira V, Luís P, et al. The cholinergic system and inflammation: common pathways in delirium pathophysiology. J Am Geriatr Soc. 2012;60:669-675.http://www.ncbi.nlm.nih.gov/pubmed/22316182?tool=bestpractice.com
多巴胺能药物过量也会引起谵妄，明显例证为多巴胺拮抗剂（例如，抗精神障碍药物）的保护性作用。其它的神经递质也可能与谵妄有关，包括去甲肾上腺素、血清素、γ-氨基丁酸、谷氨酰胺和褪黑激素。
另有证据表明白介素 1 和 2、TNF-α 和干扰素等细胞因子也与谵妄的发生相关。[27]Cerejeira J, Lagarto L, Mukaetova-Ladinska EB. The immunology of delirium. Neuroimmunomodulation. 2014;21:72-78.http://www.ncbi.nlm.nih.gov/pubmed/24557038?tool=bestpractice.com
此外，继发于疾病或外伤的慢性应激所诱发的慢性皮质醇增多症也可能会导致谵妄。[28]Inouye SK. Delirium in older persons. N Engl J Med. 2006;354:1157-1165.http://www.ncbi.nlm.nih.gov/pubmed/16540616?tool=bestpractice.com
