Hewer Walter, Thomas Christine
Klinik für Gerontopsychiatrie, Klinikum Christophsbad, Faurndauerstr. 6-28, 73035, Göppingen, Deutschland.
Klinik für Psychiatrie und Psychotherapie für Ältere, Klinikum Stuttgart, Stuttgart, Deutschland.
Z Gerontol Geriatr. 2017 Feb;50(2):106-114. doi: 10.1007/s00391-016-1176-0. Epub 2017 Jan 25.
Psychiatric symptoms in dementia and delirium are associated with a substantially reduced quality of life of patients and their families and often challenging for professionals. Pharmacoepidemiological surveys have shown that, in particular, patients living in nursing homes receive prescriptions of psychotropic agents in significant higher frequency than recommended by current guidelines. This article focuses on a critical appraisal of this gap from the point of view of German healthcare services.
Narrative review with special reference to the German dementia guideline from 2016 and recently published practice guidelines for delirium in old age in German and English language.
The indications for use of psychotropic agents, especially antipsychotics, are defined narrowly in the German dementia guideline. According to this guideline for several psychopathological symptoms evidence based recommendations cannot be given, currently. For delirium several practice guidelines related to different treatment settings have been published recently. Comparable to the German dementia guideline they recommend general medical interventions and nonpharmacological treatment as first line measures and the use of psychotropic agents only under certain conditions. These guidelines differ to some extent regarding the strength of recommendation for psychopharmacological treatment.
The guidelines discussed here advocate well-founded a cautious prescription of psychotropic agents in patients with dementia and delirium. This contrasts to everyday practice which is characterized by significantly higher prescription rates. This gap may explained partially by a lack of evidence-based recommendations regarding certain psychopathological symptoms. Most notably, however, epidemiological data disclose an unacceptable rate of hazardous overtreatment with psychotropic agents, especially in long-term care of persons with dementia. In this situation counteractive measures by consequent implementation of the principles of good clinical practice in geriatrics are required urgently.
痴呆和谵妄中的精神症状会显著降低患者及其家人的生活质量，并且常常给专业人员带来挑战。药物流行病学调查显示，特别是住在养老院的患者，其精神药物的处方频率显著高于现行指南的推荐频率。本文从德国医疗服务的角度对这一差距进行批判性评估。
进行叙述性综述，特别参考2016年德国痴呆指南以及最近以德语和英语发表的老年谵妄实践指南。
德国痴呆指南对精神药物尤其是抗精神病药物的使用指征定义狭窄。根据该指南，目前对于几种精神病理症状无法给出基于证据的建议。对于谵妄，最近已经发布了一些与不同治疗环境相关的实践指南。与德国痴呆指南类似，它们推荐一般医疗干预和非药物治疗作为一线措施，仅在特定条件下使用精神药物。这些指南在精神药物治疗推荐强度方面存在一定差异。
本文讨论的指南大力提倡对痴呆和谵妄患者谨慎开具精神药物处方。这与以显著更高处方率为特征的日常实践形成对比。这种差距部分可能是由于缺乏关于某些精神病理症状的循证建议。然而，最值得注意的是，流行病学数据揭示了精神药物过度治疗的发生率令人无法接受，尤其是在痴呆患者的长期护理中。在这种情况下，迫切需要通过在老年医学中切实贯彻良好临床实践原则来采取应对措施。
