376.4 📋 章末速蚘 Summary

376.4.1 🔑 䞀句話瞜結

Delirium (acute confusional state) = DSM-5: (1) disturbance in attention + awareness + (2) develops short period (hours-days) + fluctuates + (3) cognitive disturbance + (4) not better explained by other NCD + (5) evidence of physiological cause (medical/drug/withdrawal/multifactorial); hallmark = inattention; subtypes — hyperactive 25% (agitation, easier to recognize) + hypoactive 50% (lethargic withdrawn — OFTEN MISSED, WORST PROGNOSIS) + mixed 25%; epidemiology — ~ 20% hospitalized older adults + 50-80% ICU patients + 30% post-surgical elderly + 70% post-hip fracture + 90% terminal illness; predisposing factors — age > 65 + pre-existing dementia (most important) + prior delirium + multi-comorbidity + severe illness + functional impairment + sensory impairment (visual, hearing) + depression + substance use + frailty; precipitating factors — medications #1 cause (anticholinergics oxybutynin/scopolamine/diphenhydramine/TCAs + benzodiazepines + opioids especially meperidine accumulates normeperidine + sedatives + steroids + antiparkinsonian) + infection (UTI elderly, pneumonia, sepsis, COVID-19) + metabolic (hypoglycemia, hyperglycemia, hyponatremia, hypercalcemia, uremia, hepatic) + withdrawal (alcohol DTs, BZD, opioid) + hypoxia/hypercapnia + stroke/TBI/SDH/seizure + surgery (post-op, hip fracture, cardiac surgery) + ICU factors (sleep deprivation, sensory overload/deprivation, immobilization, restraints, multiple medications) + pain undertreated + urinary retention + constipation + dehydration + malnutrition; assessment — CAM (Confusion Assessment Method): (1) acute onset + fluctuating + (2) inattention + (either) (3) disorganized thinking OR (4) altered LOC; CAM-ICU for ICU/intubated; baseline collateral history critical; labs (electrolytes, glucose, Ca, Mg, LFTs, ammonia, TFTs, B12, UA + culture, CXR, ECG, drug levels, toxicology, blood cultures if febrile); selective imaging (CT head for focal deficit/trauma/stroke), LP (meningitis suspected), EEG (NCSE suspected); delirium vs dementia distinction — delirium acute + fluctuating + inattention hallmark + altered LOC + often reversible; dementia insidious + progressive + memory hallmark + clear LOC + usually not reversible; delirium superimposed on dementia common in high-risk hospitalized older adults; management — non-pharmacologic FIRST-LINE — HELP program (Hospital Elder Life Program, Inouye 1999 NEJM, reduces incidence ~ 40%): reorientation (clocks, calendars) + sleep enhancement (non-pharm) + mobilization + visual + hearing aids + hydration + family involvement + avoid restraints; environmental quiet/well-lit day + dark night + familiar objects; medical optimization identify + treat underlying cause(s) + discontinue/minimize culprit drugs + treat infection + correct electrolytes + manage pain (acetaminophen first, minimize opioids, AVOID meperidine in elderly) + bowel/bladder regularity + adequate hydration/nutrition + sleep hygiene + melatonin; pharmacologic LAST RESORT for severe agitation/danger to self+others/distress/interfering with medical care — low-dose haloperidol 0.5-1 mg PO/IM/IV or atypical antipsychotics (quetiapine 12.5-50 mg preferred for PD/DLB, risperidone 0.25-1 mg, olanzapine 2.5-5 mg) — AVOID benzodiazepines (paradoxical worsening — EXCEPT for alcohol/BZD withdrawal) + AVOID anticholinergics; QT prolongation check + EPS/NMS/parkinsonism + mortality BBW dementia + lowest dose shortest duration; dexmedetomidine (α2 agonist) ICU sedation alternative to propofol/BZDs — less delirium (MIDEX, PRODEX, SEDCOM, MENDS, DESIRE); alcohol withdrawal delirium (DTs) 48-96 hr after last drink — BZDs first-line (lorazepam, diazepam) + thiamine before glucose + magnesium + phenobarbital alternative + ICU for severe + mortality 5-15% untreated; ICU delirium — minimize BZDs + dexmedetomidine + ABCDEF bundle + daily SAT/SBT + early mobilization; MIND-USA 2018: antipsychotics did NOT change delirium duration/outcome → reinforces non-pharm primary; consequences — prolonged hospital stay 5-10 days + ↑ mortality 2-3x at 1 year + ↑ institutionalization + accelerated cognitive decline + accelerated dementia trajectory + ↑ healthcare costs + may persist months; prevention — multicomponent non-pharm HELP + geriatric consultation + avoid high-risk meds + pre-op optimization + early mobilization + sleep promotion + adequate analgesia non-opioid first。

376.4.2 💊 治療粟芁

  • non-pharmacologic FIRST-LINE (HELP program)reorientation (clocks, calendars, communication) + sleep enhancement non-pharm (dim lights, quiet, no daytime naps) + early mobilization + glasses + hearing aids + hydration + nutrition + family involvement + avoid restraints + minimize tethers (catheters, IVs, monitors)
  • medical optimizationidentify + treat underlying cause(s) (infection, electrolytes, withdrawal, drugs); discontinue/minimize culprit drugs (anticholinergics, BZDs, opioids minimize meperidine NEVER); acetaminophen first for pain; bowel + bladder regularity (laxatives, bladder scan); adequate hydration/nutrition
  • pharmacologic LAST RESORT for severe agitationhaloperidol 0.5-1 mg PO/IM/IV q4-6h (low dose elderly, ECG for QT, watch EPS); atypical antipsychotics — quetiapine 12.5-50 mg HS preferred for PD/DLB + risperidone 0.25-1 mg + olanzapine 2.5-5 mg; AVOID benzodiazepines (paradoxical worsening — EXCEPT alcohol/BZD withdrawal) + AVOID anticholinergics + AVOID meperidine in elderly
  • ICU sedationdexmedetomidine 0.2-1.4 ÎŒg/kg/h (less delirium vs propofol/BZDs); minimize BZDs; daily SAT (spontaneous awakening trial) + SBT (spontaneous breathing trial); early mobilization; ABCDEF bundle
  • alcohol withdrawal delirium (DTs)lorazepam 2-4 mg IV q15-30 min PRN OR diazepam 5-10 mg IV q5-10 min PRN (titrated to symptom-triggered CIWA-Ar) + thiamine 500 mg IV TID × 3 days BEFORE glucose + magnesium + glucose + multivitamin + phenobarbital alternative + ICU for severe (mortality 5-15% untreated)
  • catatonia (delirium mimic)lorazepam challenge 1-2 mg IV often diagnostic + therapeutic; ECT for refractory
  • prevention (HELP program reduces incidence ~ 40%)multicomponent non-pharm + geriatric consultation + avoid high-risk meds (Beers criteria, anticholinergic burden) + pre-op optimization + early mobilization + sleep promotion + adequate analgesia + melatonin 3-5 mg HS may help

376.4.3 🎯 盧醫垫的考前提醒

  1. Delirium DSM-5 criteria (memorize): (1) disturbance in attention + awareness + (2) develops hours-days + fluctuates + (3) cognitive disturbance + (4) not better explained + (5) physiological cause — hallmark INATTENTION (most characteristic feature)
  2. Subtypes: hyperactive 25% (agitation, easier to recognize) + hypoactive 50% (lethargic withdrawn — OFTEN MISSED + WORST PROGNOSIS) + mixed 25%; screen all admitted older adults with CAM
  3. CAM (Confusion Assessment Method): (1) acute onset + fluctuating + (2) inattention + (either) (3) disorganized thinking OR (4) altered LOC; CAM-ICU for intubated/ICU patients
  4. Common precipitants (mnemonic ABCDEFG-H): A anticholinergics (oxybutynin, scopolamine, diphenhydramine, TCAs) + B benzodiazepines + C cardiovascular (digoxin, diuretics, β-blockers) + D drugs/dehydration + E ENT (antihistamines) + F furosemide (electrolytes) + G GI (H2 blockers, antiemetics) + H hormones (steroids)
  5. Delirium vs dementia distinction: delirium (acute + fluctuating + inattention hallmark + altered LOC + often reversible) vs dementia (insidious + progressive + memory hallmark + clear LOC early + usually not reversible); delirium superimposed on dementia common in hospitalized older adults
  6. Management — non-pharmacologic FIRST-LINE (HELP program reduces ~ 40%): reorientation + sleep enhancement + mobilization + sensory aids + hydration + family + avoid restraints + minimize tethers
  7. Medical optimization: identify + treat underlying cause(s) + discontinue/minimize culprit drugs + treat infection + correct electrolytes + manage pain (acetaminophen first) + bowel/bladder regularity
  8. Pharmacologic LAST RESORT for severe agitation: low-dose haloperidol 0.5-1 mg or atypical antipsychotics (quetiapine 12.5-50 mg preferred for PD/DLB) — AVOID benzodiazepines (paradoxical) EXCEPT for alcohol/BZD withdrawal; AVOID meperidine + anticholinergics in elderly
  9. ICU delirium specific: dexmedetomidine over BZDs (less delirium — MIDEX, PRODEX, SEDCOM, MENDS, DESIRE) + ABCDEF bundle + daily SAT/SBT + early mobilization; MIND-USA 2018: antipsychotics did NOT change duration/outcome → reinforces non-pharm primary
  10. Alcohol withdrawal delirium (DTs) 48-96 hr after last drink: severe autonomic + hallucinations + seizures possible + mortality 5-15% untreated → BZDs first-line (lorazepam, diazepam) symptom-triggered CIWA-Ar + thiamine 500 mg IV TID BEFORE glucose (Wernicke prevention) + magnesium + ICU for severe; delirium → ↑ mortality 2-3x at 1 year + accelerated cognitive decline — prevention is key