老年髋部骨折后发生谵妄的研究现状  

The current status of delirium after elderly hip fracture

作　　者：王晓伟[1] 孙天胜[1] 刘智[1] 张建政[1] 李连华[1] 

机构地区：[1]北京军区总医院骨科,100700

出　　处：《中华骨科杂志》2016年第13期871-875,共5页Chinese Journal of Orthopaedics

摘　　要：谵妄是老年髋部骨折术后最常见的并发症之一，其致死率、致残率均较高，但相对于下肢深静脉血栓、肺栓塞、心力衰竭等疾病，谵妄尚未得到大家足够的重视。本文就髋部骨折后谵妄的定义、诊断、发生率、预后、预防、治疗等方面进行综述，希望可以更好地认识及了解谵妄。谵妄是一种急性精神障碍，以意识、注意力、知觉、思考能力、记忆力、心理活动、情感以及睡眠-觉醒周期的共同紊乱为特征，而且这些改变很难用老年痴呆来解释。虽然诊断谵妄的方法较多，但最常用的是意识状态评估法（confusion assessment method, CAM），即主要依靠患者的意识及认知功能对谵妄进行诊断及评估。老年髋部骨折后谵妄发生率较高，最高可达61%。导致谵妄发生的机制尚不明确，学说众多，目前认为谵妄是由多种因素共同作用的结果，影响因素主要有高龄、认知功能损害、疼痛、睡眠节律失常等，涉及学说主要有神经递质学说、中枢炎性假说、应激反应学说、睡眠-觉醒周期障碍学说等。关于谵妄对髋部骨折术后死亡率的影响，目前尚没有统一结论，但可以肯定的是谵妄患者术后功能恢复差，独立生活能力差，需要更长卧床时间，更多人进行护理。对谵妄应以预防为主，尽可能纠正低氧血症，减轻疼痛，避免水电解质紊乱，改善睡眠节律，避免使用阿片类药物，同时采用包括骨科、麻醉科、老年科等在内的多学科协作模式可能会减少谵妄的发生率。而谵妄一旦发生，应首选非药物治疗，如保持呼吸道通畅、充足的营养支持、纠正水电解质紊乱、贫血和低白蛋白血症、保证充足睡眠和精神支持、创造优良的病区环境等；一旦病情加重，出现躁动、幻觉、注意力不集中等症状，可使用药物治疗来减轻其发病症状，首选氟哌啶醇。Delirium is a common complication after elderly hip fracture, and is associated with high rates of mortality and morbidity. There is no enough attention for delirium compared to deep vein thrombosis, pulmonary embolism, heart failure, etc. This paper reviews the definition, diagnosis, incidence, prognosis, treatment and other aspects of delirium in order to better under？stand delirium clinically. Delirium is an acute mental disorder of consciousness, attention, perception, thinking ability, memory, mental activity, and emotion. It is characterized by the disorder of sleep or wakefulness, and these changes are difficult to explain by dementia. The confusion assessment method （confusion assessment method, CAM） is generally accepted as the current diagnos？tic tools for delirium, and mainly depends on the patient＇s consciousness and cognitive function. The mechanisms of delirium are unclear, and it is influenced by many factors, such as agedness, cognitive impairment, pain, sleep rhythm disorders, and theories mainly include neurotransmitter theory, the central inflammatory response theory, the theory of stress response, sleep wake cycle, et al. The delirium is difficult to explain by using single, liner factor, but is elaborated by many various factors. However, the influ？ences of delirium on outcome for hip fracture are unclear, and it is definite that these patients have poor functional recovery, poor independent living ability, longer time in bed, demand for more care. The prevention should be implemented as mainly measures for delirium. Elimination of risk factors, including correct hypoxia, reduce pain, avoid water electrolyte disorders, improve sleep rhythm, and avoid using of opioids should be tried. In addition, adequate analgesia and appropriate anesthesia should used, and some inappropriate drugs should be avoided. Multidisciplinary cooperation mode, including doctors from orthopedics, anesthesiolo？gy, and geriatric department should be conducted to reduce the incidence of delirium as far as

关 键 词：髋部骨折 老年痴呆 骨折后 谵妄 睡眠-觉醒周期 水电解质紊乱 认知功能损害 独立生活能力 

分 类 号：R683[医药卫生—骨科学]