MRC Unit for Lifelong Health and Ageing, University College London, 33 Bedford Place, London WC1B 5JU, UK.
BMC Med. 2014 Oct 8;12:141. doi: 10.1186/s12916-014-0141-2.
Delirium is a common and serious problem among acutely unwell persons. Although linked to higher rates of mortality, institutionalisation and dementia, it remains underdiagnosed. Careful consideration of its phenomenology is warranted to improve detection and therefore mitigate some of its clinical impact. The publication of the fifth edition of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-5) provides an opportunity to examine the constructs underlying delirium as a clinical entity.
Altered consciousness has been regarded as a core feature of delirium; the fact that consciousness itself should be physiologically disrupted due to acute illness attests to its clinical urgency. DSM-5 now operationalises 'consciousness' as 'changes in attention'. It should be recognised that attention relates to content of consciousness, but arousal corresponds to level of consciousness. Reduced arousal is also associated with adverse outcomes. Attention and arousal are hierarchically related; level of arousal must be sufficient before attention can be reasonably tested.
Our conceptualisation of delirium must extend beyond what can be assessed through cognitive testing (attention) and accept that altered arousal is fundamental. Understanding the DSM-5 criteria explicitly in this way offers the most inclusive and clinically safe interpretation.
谵妄在急性病患者中是一个常见且严重的问题。尽管它与较高的死亡率、机构化和痴呆症发生率相关，但仍存在诊断不足的情况。有必要仔细考虑其现象学特征，以改善检测，从而减轻其一些临床影响。美国精神病学协会《精神疾病诊断与统计手册》（DSM - 5）第五版的出版为审视谵妄作为一种临床实体的潜在结构提供了契机。
意识改变一直被视为谵妄的核心特征；由于急性疾病导致意识本身在生理上受到干扰这一事实证明了其临床紧迫性。DSM - 5现在将“意识”操作化为“注意力改变”。应该认识到，注意力与意识内容相关，但觉醒对应于意识水平。觉醒降低也与不良后果相关。注意力和觉醒是层次相关的；在能够合理测试注意力之前，觉醒水平必须足够。
我们对谵妄的概念化必须超越通过认知测试（注意力）所能评估的范围，并承认觉醒改变是根本的。以这种方式明确理解DSM - 5标准提供了最具包容性且临床安全的解释。
