Department of Psychiatry, Yale School of Medicine, New Haven, CT.
Division of Geriatrics, Department of Internal Medicine, Saint Louis University School of Medicine, St. Louis, MO.
J Am Med Dir Assoc. 2017 Jul 1;18(7):629-631. doi: 10.1016/j.jamda.2017.03.004. Epub 2017 Apr 22.
Delirium is common in acute, postacute, and long-term care settings, and it can be difficult to recognize, especially without deliberate mental status evaluation. Because delirium typically presents with altered arousal and arousal can be assessed within a matter of seconds, routine assessment of arousal offers an efficient means of delirium screening. Nevertheless, impaired arousal often precludes formal assessment of attention and awareness, the cardinal features of delirium per the current Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Here we debate the relative merits of "ruling in" as delirious noncomatose patients with impaired arousal (inclusive approach) vs reserving delirium diagnosis to patients in whom diagnostic criteria can be elicited (restrictive approach). Inclusivism provides efficiency and may prevent missing or delaying delirium diagnosis. The restrictive approach challenges the utility of ruling such patients in as delirious and advocates for identifying mental states that directly inform clinical care. Both positions, however, firmly emphasize the value of routine clinical assessment of arousal.
谵妄在急性、亚急性和长期护理环境中很常见，而且很难识别，特别是在没有刻意进行精神状态评估的情况下。由于谵妄通常表现为意识状态改变，而意识状态可以在几秒钟内进行评估，因此常规评估意识状态是一种有效的谵妄筛查方法。然而，意识受损通常会妨碍对注意力和意识的正式评估，而这是当前《精神障碍诊断与统计手册（第五版）》中谵妄的主要特征。在这里，我们对以下两种方法进行了辩论：对于意识受损的非昏迷患者（包容性方法），将其诊断为谵妄；或者仅对能够引出诊断标准的患者做出谵妄诊断（限制性方法）。包容性方法提供了效率，并可能防止遗漏或延迟谵妄的诊断。而限制性方法则对将此类患者诊断为谵妄的做法提出了质疑，并主张识别直接为临床护理提供信息的精神状态。然而，这两种方法都坚决强调了常规临床评估意识状态的价值。
