Delirium in old age
Introduction
Introduction to old age The common cognitive disorder in the elderly in psychopathology is seniledelirium, also known as acute ambiguity. Transient organic brain syndrome characterized by attention, feeling, thinking, memory, mental exercise, and sleep cycle disorders, often associated with physical illness, severe infectious diseases, toxic diseases, and organic diseases of the brain At the time of surgery or after surgery. When the elderly suffer from acute diseases, they often use fever and pain instead of fever to become the main symptom. It is not only the manifestation of systemic and brain organic lesions, but also aggravates the patient's condition and burdens the family. Give medical staff the complexity of treatment and care. Old age sputum plays an important role in judging brain dysfunction and the severity of the primary disease. basic knowledge Sickness ratio: 0.05% Susceptible people: the elderly Mode of infection: non-infectious Complications: acne malnutrition oral ulcer
Cause
Age of sputum
Physical factors (35%):
(1) Decreased physiological function: With the increase of age, the cells and interstitial cells of the body gradually become aging, the morphology of human tissues and the physiological functions of various system organs are gradually aging, so that the functions of various internal organs are affected, and the adaptability is reduced. , reduced resistance, and poor body stability, etc., these are the causes of disturbance of consciousness, especially the incidence of sputum in the elderly is significantly higher than the reasons for young people, such as complications after fracture surgery, pain and drug use induced In addition to the above reasons, Williams-Russo et al found that 41% of the 60 patients with bilateral knee arthroplasty had paralysis, because the elderly not only had physiological dysfunction, but also often had superposition of physical or psychological factors. Role, so it is more prone to dysfunction such as paralysis.
(2) Physical illness: Any disease that affects cerebral blood flow or cerebral oxygen supply, and diseases that cause metabolic disorders in the body may cause paralysis, such as cardiovascular disease affecting the blood supply to the brain, respiratory tract Insufficient brain oxygen supply caused by diseases, and the effects of certain metabolites caused by hypoxia in the brain on the brain, ammonia metabolism disorders caused by liver diseases, azotemia caused by kidney diseases, disorders of glucose metabolism caused by endocrine diseases, etc. For example, hypertensive encephalopathy, severe anemia, water and electrolyte disorders and B vitamin deficiency, and even infectious diseases such as influenza can cause brain dysfunction. The occurrence of sputum often depends on the severity of physical diseases and brain damage to physical diseases. The degree of tolerance.
Brain organic factors (25%):
Due to the gradual aging of the brain cells of the elderly, the blood output of the heart gradually decreases, so that the blood supply to the elderly is reduced year by year, and the cerebral physiology is reduced due to cerebral atherosclerosis, etc., and the ability to adjust and adapt to decline is reduced. Extremely sensitive, this is one of the most important reasons for the high incidence of sputum in the elderly. In addition, direct damage to the brain organs will undoubtedly cause serious disturbance of brain function. At this time, although the coma showing severe dysfunction is more common, The state is also very common, such as cerebrovascular disease, intracranial infection, craniocerebral trauma, brain tumor, brain parasitic disease, epilepsy, etc., can cause varying degrees of paralysis, especially the nighttime paralysis of patients with vascular dementia is more representative .
Trauma or irritation (15%):
Under the influence of traumatic stimulation, the elderly are more prone to convulsions than young people due to the weakening of the cerebral cortex. Common strong mental stimuli, such as the sudden death of a loved one, sudden intimidation, natural disasters, environmental changes, etc. Sexual psychosis, a snoring emotional outburst after an unpleasant life event in life, can also occur in a state of paralysis, in addition, an acute onset of mental illness, such as sudden illusion delusion state, acute mania or depression in the elderly People can also be accompanied by a state of paralysis.
Drug factors (10%):
Adverse reactions or poisoning of drugs are one of the causes of senile convulsions. It is generally believed that the incidence of adverse drug reactions increases with age, and target organs including the brain are less tolerant to drugs. Liver and kidney dysfunction, drugs easily accumulate in the body, therefore, the incidence of convulsions in the elderly is significantly higher than young adults.
(1) Any toxic sputum caused by excessive drug dose, such as sedatives, hypnotics, atropine poisoning, etc., may affect the function and metabolism of the central nervous system.
(2) Drug-dependent patients with withdrawal medication symptoms can also be expressed as sputum, such as the sudden withdrawal of drugs when the sleeping pills are dependent, long-term smoking of the elderly, sudden withdrawal of smoking can also occur in the withdrawal state, alcohol-dependent patients ring There are sputum in wine, and people with long-term drinking can have tremor convulsions. It has been reported that diazepam and ethanol have cross-resistance. Diazepam has specific effects on early withdrawal symptoms, but it is harmful when tremor is twitching. And sodium salicylate, digoxin, lidocaine, cimetidine, metoclopramide, antibiotics (penicillin), antihypertensives, anesthetics, laxatives, antineoplastics, antihistamines, Antipyretic drugs can cause sputum, heavy metals, carbon monoxide, organic phosphorus and other toxic encephalopathy, the elderly are prone to behave, and its occurrence depends on the degree of poisoning and the body's stress state.
(3) Adrenal cortex hormones, anti-Parkinson's disease drugs, antipsychotic drugs.
The cause of convulsions is also an important factor that cannot be ignored. Especially in the elderly, insomnia, sensory blockage, excessive sensory stimulation, environmental psychological changes, etc. often induce or aggravate sputum, thus avoiding or reducing the occurrence of these factors. Great advantage.
Pathogenesis
Consciousness is the highest form of human reality that reflects reality. The sobriety of consciousness activities depends on the excitability of the cerebral cortex and brainstem reticulum activation system to ensure people's ability to recognize and detect the surrounding environment and their own state, in any adverse factors. Under the action, it leads to brain dysfunction, and the understanding and reflection of the self and the surrounding environment, the mental activity is generally inhibited. In recent years, it is recognized that the occurrence of senile sputum is mainly due to the body's metabolic disorder, cerebral hypoxia, brain Insufficient energy supply, toxin action; water and electrolyte and acid-base balance disorders, stress response, changes in central neurotransmitters, inhibition of cholinergic activity, acute mental stimulation can cause damage to the lower thalamus and elevated levels of circulating corticosterone The normal physiological metabolic function of the brain is disordered. In addition, the body's disease causes the brain's energy demand to increase, and the brain's energy supply is the main mechanism for the occurrence of paralysis.
From the perspective of neuropathology and physiology, local lesions of the brain, such as the occipital lobe, the base of the temporal lobe and the apical and posterior part of the medial hemisphere, and the anterior frontal lobe are all related to the occurrence of sputum. Degenerative changes and a decrease in acetylcholine synthesis are also prone to paralysis.
Prevention
Senile prevention
is preventable, and clinical experience shows that 30% - 40% of cases are preventable.
1. Prevention should be started before surgery to find out the cause of postoperative delirium and try to correct it.
2. Early postoperative activities, avoiding physical constraints as much as possible.
3 Try to take steps to avoid applying drugs that have a significant effect on the mind.
4. Avoid depriving patients of sleep.
5. Communicate with patients and let relatives communicate with patients as much as possible.
6. Patients with poor eyesight or hearing should be given glasses and hearing aids as soon as possible.
7. During the day, the indoor lights are turned on and turned off at night, mimicking the normal sleep awakening cycle, and the least nights disturb the patient's sleep.
8. Correct hypoxemia, maintain hydroelectric balance, and adequate nutritional support.
9. Adequate analgesia, but must be strictly tested to avoid adverse reactions. Dobutin is forbidden, and the right amount of morphine, fentanyl, and hydrocodone can be used. Epidural analgesia did not show a lower incidence of postoperative delirium than intravenous analgesia.
Complication
Senile complication Complications, acne malnutrition, oral ulcers
Hemorrhoids, respiratory infections, urinary tract infections, malnutrition, oral ulcers, corneal ulcers and other complications.
Symptom
Symptoms of senile sputum common symptoms conscious disturbance, slow response, suspicion, anxiety, insomnia, sleepiness, self-orientation, hallucination
In the senile period, the patient's consciousness is reduced, and his mental activity is generally suppressed. It is often manifested by decreased perceptual clarity, slow response, increased sensory threshold, dull expression, and awkwardness. It is difficult to concentrate on the surrounding things. He talks, the examiner often needs to ask questions loudly and slowly, the patient can notice that the examiner is talking to him, the thinking is slow and incoherent, if asked, the answer is simple, and the questions are not relevant, the content is disorderly. Difficulties in understanding, poor judgment, patients can not correctly identify morning or afternoon, day or night, do not know the age and season, can not estimate the length of time spent, patients do not know where they are, can not correctly answer is in the hospital, at home, Still in a hotel, or can not correctly identify the surrounding people, that is, time, people, location disorder, memory disorders are often accompanied by fiction, self-discipline disorder when serious, such as their gender, age, occupation can not be identified, sometimes accompanied by a large number The illusion, illusion, mainly horror visual illusion, its content is mostly vivid and vivid Sexual situations, such as insects, beasts, etc., and the illusion of fragments, when the patient can not recognize true and false, so extreme anxiety, nervousness, fear, emotional reaction, excitement, screaming, running, impulsive behavior, lack of behavior Purpose and directivity, showing uncoordinated psychomotor excitement, patient's thinking activities are disorderly, speech is incoherent, or muttering to himself, often appearing on the basis of illusions and illusions, the suspicion is more common .
Another characteristic of senile convulsions is the volatility of symptoms. Patients sometimes appear dull, slow, distracted, and less active; sometimes they are noisy, restless, lack of purpose and repetitive; sometimes they show Consciousness disorder disappears completely, is in a state of waking, and several states can alternately appear. Symptoms of fluctuations often have the characteristics of being light and heavy, even during the day as normal people, and at night there is aggravation, when the consciousness is restored, the patients experience in the disease All forgotten or partially forgotten.
Examine
Elderly sputum examination
Blood, urine, regular abnormalities, abnormal blood sugar and electrolytes.
Electroencephalogram, head CT, and MRI have important reference value for the diagnosis of sputum.
Diagnosis
Diagnosis of senile senile
Diagnostic criteria
When you are suspicious, you must have a deep understanding of the state of consciousness and intelligence, as well as the corresponding physical examination of the body and other physical examinations and positive findings of laboratory tests. You should also master other relevant factors for comprehensive analysis, and based on the second edition of Chinese Mental Illness. Diagnostic criteria (CCMD-II) for diagnosis.
Diagnostic criteria:
1. The sensory threshold is increased, the response to external stimuli is weakened, the perception clarity is lowered, and the perception of the surrounding environment is blurred.
2. Pay attention to the transfer (especially active attention), and the ability to concentrate and maintain attention is diminished.
3. Orientation disorders, including time, location, people and self-disorientation.
4. At least one of the following symptoms:
(1) Illusions or hallucinations.
(2) Understand difficulties or mistakes, or inconsistent speech, or disintegration of the structure of the mind, or answer questions that are not relevant.
(3) psychomotor excitement or delay, or nervous syndrome.
(4) sleep awakening rhythm disorder, insomnia or lethargy.
(5) Instantly remember and recall difficulties.
5. The onset is urgent, the symptoms last for a short time, usually several hours to several days, and the weight and frequency often fluctuate within 1 day. After the condition is relieved, the experience in the disease is often partially or completely forgotten.
In the diagnosis of sputum, it is necessary to find abnormal changes related to the cause from the medical history, physical examination or laboratory examination. In addition to the above diagnostic criteria, cognitive function and attention measurement are also required. Under normal circumstances, the elderly can only do some Simple bedside neuropsychological examination, for example:
Cognitive function and attention measurement:
(1) Orientation: date, day of the week, time, location of the patient, familiar person's name and occupation.
(2) Near-memory memory: Describe the illness, cause and condition, the date of hospitalization and recent events, recall after 5 minutes, 3 words and 3 things (digital memory).
(3) Attention.
(4) Abstract thinking: the definition of words, the similarities of concepts and the identification of different points.
(5) Dynamics of thinking: The vocabulary is fluently measured, requiring the patient to say as many words as possible within 1 minute, and the quota is 30 words within 1 minute.
Differential diagnosis
The elderly are identified with dementia and pseudo-dementia (aged depression) caused by various causes, fluctuating cognitive and attentional disorders of acute attacks, accompanied by visual hallucinations, sleep-wake cycle disorders and incitement Uneasy or slow behavior, the diagnosis can be determined, but it is difficult to determine the diagnosis in the elderly because of:
1 acute convulsions in the elderly often occur on the basis of dementia, the clinical symptoms of the former are covered by the latter;
2 The acute confusion of the elderly is often the symptom of affective psychosis;
3 The history of illness and the course of illness are often unknown in the elderly;
410%20% of the elderly have acute physical confusion and have not found physical diseases and organic factors that affect brain function;
5 EEG is less valuable for the diagnosis of sputum: because the EEG of healthy elderly people also has a slow wave, but repeated EEG examination is helpful for identification. In the elderly, more common dementia Multi-infarct dementia caused by cerebrovascular disease, Alzheimer's disease dementia caused by primary brain degeneration, in addition, pernicious anemia, neurosyphilis, frontal lobe tumor, normal pressure hydrocephalus, Huntington's disease, Parkinson's disease, Pick disease, etc. can cause degeneration of the brain and cause dementia. This type of dementia starts slowly, gradually increases, no fluctuations and reversals, with intelligent obstacles as the main performance, based on medical history, physical examination and laboratory. Auxiliary examination can be differentiated from senile sputum. In addition, senile sputum should be differentiated from severe mental illness, especially when psychomotor excitability is the main manifestation. It is easy to ignore the examination of directional dysfunction. Identification with depression, generally based on medical history, combined with mental state and physical examination, and various auxiliary examinations, can be identified.
