Leonard Maeve, Agar Meera, Mason Colin, Lawlor Peter
Midwestern Regional Hospital, Limerick, Ireland.
J Psychosom Res. 2008 Sep;65(3):289-98. doi: 10.1016/j.jpsychores.2008.05.018.
The objective of this study is to provide an expert review of delirium in the context of palliative care.
Based on a primary selection criterion, firstly, studies were included for review if the population studied either had a diagnosis of advanced cancer or was receiving palliative care; alternatively, in the absence of data derived from these populations, studies conducted in other populations were included. Secondly, from the studies meeting the primary selection criterion, we selected those that examined specific standard outcome measures. Thirdly, we selected studies and literature reviews that identified delirium research issues.
Delirium occurs commonly in the context of palliative care where it is likely to cause heightened distress for patients, carers, and families alike, and make interpretation of pain and other symptoms extremely difficult. There is a profound dearth of rigorous studies on delirium in this setting. Ambiguous terminology, varying definitions in internationally recognized classification systems, and failure to use validated assessment tools lead to wide-ranging incidence and prevalence of delirium episodes in such populations. Episodes are usually multifactorial in origin and may portend poor prognosis by preceding death in many cases. Despite this, many are often at least partially reversible with relatively low-burden interventions. The patient's disease status, previous quality of life, and prior expressed wishes regarding goals of care should all be taken into account. Antipsychotics are the pharmacotherapeutic agents most commonly used to control symptoms despite limited evidence either supporting their efficacy or examining their adverse event profile. Often, symptomatic control alone is indicated. In cases with refractory symptoms, deeper or "palliative" sedation may be required.
Further research is needed regarding delirium recognition, phenomenology, the development of low-burden instruments for assessment, family education, predictive models for reversibility, and evidence-based guidelines on the appropriate use of palliative sedation.
本研究的目的是在姑息治疗背景下提供关于谵妄的专家综述。
基于主要选择标准，首先，如果所研究的人群患有晚期癌症诊断或正在接受姑息治疗，则纳入研究进行综述；或者，在缺乏来自这些人群的数据的情况下，纳入在其他人群中进行的研究。其次，从符合主要选择标准的研究中，我们选择那些检查特定标准结局指标的研究。第三，我们选择确定谵妄研究问题的研究和文献综述。
谵妄在姑息治疗背景下很常见，这可能会给患者、护理人员和家庭带来更大的痛苦，并使对疼痛和其他症状的解读极其困难。在这种情况下，关于谵妄的严格研究严重匮乏。术语不明确、国际认可的分类系统中定义不同以及未使用经过验证的评估工具导致此类人群中谵妄发作的发生率和患病率范围广泛。发作通常是多因素起源的，并且在许多情况下可能在死亡之前预示着不良预后。尽管如此，许多发作通常至少可以通过负担相对较轻的干预措施部分逆转。应考虑患者的疾病状况、先前的生活质量以及先前表达的关于护理目标的愿望。抗精神病药物是最常用于控制症状的药物治疗剂，尽管支持其疗效或检查其不良事件概况的证据有限。通常，仅需对症治疗。对于症状难治的病例，可能需要更深层次的或“姑息性”镇静。
需要进一步研究谵妄的识别、现象学、低负担评估工具的开发、家庭教育、可逆性预测模型以及关于姑息性镇静适当使用的循证指南。
