老年人髋部骨折术后谵妄的诊断和治疗

Diagnosis and treatment of postoperative delirium of elderly hip fracture patients

目的探讨结合量化评估方法对老年髋部骨折术后谵妄的围手术期诊疗。方法前瞻性研究65岁以上的老年髋部手术患者(2005年8月至2007年7月)。入选病例161例。将入选患者随机分为围手术期综合干预组(83例)和对照组(78例)。入院后每天采用精神错乱鉴定方法对所有患者进行评估,并作为诊断谵妄发生及病程结束的依据。对确诊谵妄的患者,再进行谵妄严重程度(DRS)测评,记录首、末次DRS评分和谵妄持续时间。对综合干预组患者进行谵妄危险因素控制和预防性治疗,并根据上述评分对治疗方案进行评价,随时进行调整。对照组患者则应用常规骨科处理方案。结果综合干预组平均住院时间为(12.80±2.15)d,少于对照组的(13.73±2.12)d (P<0.01);谵妄发生率为12例(14.46%),低于对照组19例(24.36%,P<0.01);谵妄严重程度为首次DRS评分17.33±3.31,低于对照组20.58±4.18(P<0.05);谵妄持续平均时间为(2.08±1.08)d,少于对照组的(3.32±1.53)d(P<0.05)。治疗后DRS评分,综合干预组为8.08±2.84,低于对照组11.05±3.31(P<0.05);治疗后与治疗前相比,综合干预组DRS减分为9.25±2.18,对照组为9.25±2.18(P>0.05)。结论对老年髋部骨折术后患者,通过使用精神错乱鉴定方法诊断,DRS评价严重程度,并指导围手术期的治疗和危险因素控制,可有效降低谵妄的发生率,缩短谵妄的持续时间,减轻谵妄的严重程度,缩短住院时间。

Objective To explore the diagnosis and management of postoperative delirium of elderly hip frac- ture patients with quantization assessment by confusion assessment method（CAM） and delirium rating scale（DRS）. Methods One hundred and sixty-one patients, aged 65 years and over, from Aug 2005 to July 2007 were enrolled and randomly assigned to comprehensive management group and conventional orthopedic management （control） group. Daily assessment was based on patient interview with the CAM. DRS was used to measure symptoms during the prodromal phase after the onset of delirium. The scores of DRS by first and last assessment and the duration of delirium were recorded. Results The mean length of hospital stay of the patients receiving comprehensive manage- ment was shorter than that of controls （12.80±2. 15） d vs （13.73±2. 12） d, P〈0.01]. A lower proportion of patients recciving comprehensive intervention were delirious postoperatively than that of the controls （12/83, 14.46% vs 19/78, 24.36%, P〈0.01）. The first DRS scores in the comprehensive intervention patients and controls were 17.33±3.31 and 20.58±4.18, respectively （P〈0.05） ; delirium duration was （2.08±1.08） d and （3.32±1.53） d, respectively （P〈0.05） and the last DRS scores were 8.08±2.84 and 11.05±3.31, respectively （P〈0.05） ; the decrease in score of DRS was 9. 25±2.18 and 9.25±2.18, respectively（P〉O. 05）. Conclusion Postoperative delirium can be successfully prevented and treated by control of risk factors with daily CAM and DRS assessment, which can reduce days of delirium and incidence of delirium, and shorten length of hospital stay.