Family Medicine Residency Program, University of Ottawa, Ottawa, Canada.
Palliat Support Care. 2012 Mar;10(1):59-62. doi: 10.1017/S1478951511000599.
Despite the high prevalence of delirium in palliative care settings, this diagnosis is frequently missed, particularly in patients with hypoactive delirium. These patients are also commonly misdiagnosed with depression because of the overlap in symptoms between the two diagnoses. Failure to promptly diagnose delirium can have significant ramifications in terms of delirium reversal, subsequent patient involvement in end-of-life decision making, and the recognition and treatment of other symptoms.
We report a case of a 63-year-old French-speaking woman admitted to our inpatient palliative care unit with colorectal cancer and a history of depression. This case report highlights the major challenges associated with making the diagnosis of delirium in a patient with a complex medical history, including depression.
The patient presented with symptoms of depressed mood and fluctuation in psychomotor activity, but failed to respond to an increase in her fluoxetine treatment in addition to methylphenidate and treatment of her hypothyroidism. A psychiatric assessment in her own language detected features of inattention and confirmed a diagnosis of delirium that was multifactorial, secondary to a combination of posterior reversible encephalopathy syndrome (PRES), hypothyroidism, hepatic dysfunction, and medication.
Subsyndromal delirium may present with mood lability, and as delirium and depression can coexist, clinicians should perform a delirium screen for all patients presenting with symptoms of depression, preferably in the patient's first language. Cognitive testing can be particularly helpful in distinguishing delirium, especially hypoactive delirium, from depression.
尽管在姑息治疗环境中谵妄的患病率很高，但这种诊断常常被忽视，尤其是在患有低活动度谵妄的患者中。这些患者也常被误诊为抑郁症，因为两种诊断的症状存在重叠。未能及时诊断谵妄可能会对谵妄逆转、随后患者参与临终决策以及识别和治疗其他症状产生重大影响。
我们报告了一例 63 岁的法语女性患者，因结直肠癌和抑郁症病史入住我们的住院姑息治疗病房。该病例报告强调了在具有复杂病史（包括抑郁症）的患者中诊断谵妄所面临的主要挑战。
患者表现出情绪低落和精神运动活动波动的症状，但在增加氟西汀治疗（同时还使用哌醋甲酯和治疗甲状腺功能减退症）后仍未改善。用她的母语进行的精神科评估检测到注意力不集中的特征，并确认了谵妄的诊断，该诊断是多因素的，继发于后部可逆性脑病综合征（PRES）、甲状腺功能减退症、肝功能障碍和药物治疗的组合。
亚综合征性谵妄可能表现为情绪波动，并且由于谵妄和抑郁症可能同时存在，因此临床医生应该对所有出现抑郁症状的患者进行谵妄筛查，最好使用患者的第一语言进行。认知测试在区分谵妄，特别是低活动度谵妄与抑郁症方面特别有帮助。
