老年常見精神疾病 振興醫院精神醫學部主治醫師 嚴烽彰

精神疾病的分類 以「現實感」的有無、好壞分 精神官能症 (Neurosis) 精神症 (Psychosis) 現實感佳 又稱輕型精神疾病 以焦慮症為大宗 精神症 (Psychosis) 現實感差 又稱嚴重型精神疾病 以精神分裂症、妄想症、躁鬱症、重鬱症併精神症狀、嚴重型器質性精神疾患、失智症併精神症狀、自閉症為主

老年常見的3’D’ Depression（憂鬱症） Dementia（失智症） Delirium（譫妄）

憂鬱症(I)—九大症狀 對事物不感興趣 情緒低落 食慾改變 睡眠障礙 心智活動改變 體力變差，容易有倦怠感，缺乏活力 無助、無望、無價值感，常自我責備、過多及不洽當的罪惡感 精神無法集中，或做事變得猶豫不決 反覆想到死亡，出現自殺的意念、威脅或行為

憂鬱症 (II) 九大症狀必須有五項以上 時間最短持續達兩個星期以上 影響其生活功能 終生盛行率－15％ 性別－女性是男性的兩倍 始能稱為重度憂鬱症 ICD categories: 296.3- 終生盛行率－15％ 性別－女性是男性的兩倍 好發年齡－20－50歲，平均約40歲

老年憂鬱症（I） 成因 源自年輕時即患有此症 對身體老化、功能退化、病痛不適的反應 心理上無法調適喪偶、兒女另立門戶、獨居（或家人安置於安養機構）、或面對死亡的陰霾 腦部病變，如腦梗塞、腦溢血、水腦、腦瘤、巴金森氏症等引發續發性憂鬱症

老年憂鬱症（II） 治療與處置 抗鬱劑 對續發性憂鬱症必須控制原發病兆 心理支持 團體治療 家族治療 活動治療 如血壓、跌倒預防 如老年懷舊團體 家族治療 如懇親大會 活動治療 如中秋烤肉、除夕圍爐、端午包粽

器質性精神疾病 又稱「器質性腦部症候群」 顧名思義即凡因身體疾病直接或間接引發精神症狀者 如為瞬間發作，合併意識混淆不清，無法清楚對答，並有下列症狀，且意識欠清晚間尤甚，則極可能「譫妄」 精神症狀所涉範圍極廣，端看受影響區域 思考障礙（如器質性妄想症） 知覺障礙（如器質性幻覺） 情緒、衝動調適障礙（如中風後憂鬱、情緒失禁） 認知行為障礙（如血管性失智）

Intensive Care Unit Syndrome ICU syndrome ICU psychosis Postoperative delirium Postcardiotomy delirium Cardiac psychosis Delirium

DSM-IV diagnostic criteria for delirium A. disturbance of consciousness B. a change in cognition or perceptual disturbance C. a short period of time and fluctuating course D. underlying medical causes

INCIDENCE OF DELIRIUM General surgical ward: 10~15% General medical ward: 15~25% SICU,CCU: 30% Surgery for hip fracture: 40~50% Postcardiotomy: 90% Severe burn: 20% AIDS: 30%

CLINICAL FEATURES(1) Fluctuating level of consciousness Poor orientation Delusions and hallucinations Behavioral anomalies Emotional disturbances Rapid onset and transient

CLINICAL FEATURES(2) Hallucinations and delusions: at least 40% Hallucinations: usually visual Delusions: often paranoid or persecution Sundowning

Subtypes of delirium(1) Hyperactive (increased psychomotor activity) adverse effects of anticholinergic drugs drug intoxication withdrawal states agitation, psychosis, and mood lability and may refuse to cooperate with medical care

Subtypes of delirium(2) Hypoactive (decreased psychomotor activity) less frequently recognized differs from the drowsiness hepatic or renal encephalopathy

Subtypes of delirium(3) 19% hypoactive 15% hyperactive 52% mixed 14% unclassified.

COURSE OF DELIRIUM Fluctuating course persist for days to weeks lucid interval in the midst of their delirium outcome longer hospital stays (12.1 D versus 7.2 D) institutionalized (16% versus 3%) higher chance of dying (8% versus 1%)

(1) Physiological Causes systemic infection Intracranial causes endocrine dysfunction electrolyte liver lung cardiovascular system kidney Drugs anticholinergic agents anticonvulsants antihypertensive agents H2-blocker steroids opiates sedatives poisons

(2)Premorbid Cognitive Status prior cognitive level age pharmacokinetics and pharmacodynamics structural brain disease and physiological processes associated with aging

(3)Sleep Deprivation sleep disturbance as a necessary diagnostic symptom of delirium rather than being a cause of the disturbance the result rather than the cause of cerebral dysfunction

(4)The ICU Environment sensory deprivation (for example, vision and hearing impairment or rooms without windows) sensory overload Social isolation immobilization unfamiliar surroundings

(5)Psychological Factors threat to life awe of medical procedures inability to communicate needs loss of personal control published research strongly points to underlying medical problems as the primary cause of delirium in the ICU

DIFFERENTIAL DIAGNOSIS Dementia: gradual onset,more than 1 month Depression: resemble a hypoactive delirium Functional psychosis: hyperactive delirium Anxiety: hyperactive delirium

MANAGEMENT (1) Identifying and treating the underlying causes of delirium (2) Use of nonpharmacologic measures to ameliorate symptoms (3) Initiation of pharmacologic therapy for severe agitation and behavioral dyscontrol

Nonpharmacologic interventions(1) maximizing the safety of the environment improve communication provide orientation avoiding extremes of sensory input or the stimulus deprivation

Nonpharmacologic interventions(2) Adequate control of pain Normal sleep-wake cycles Psychosocial support Physical restraints

Pharmacologic therapy Antipsychotics: haloperidol, 2~10 mg IM fewer anticholinergic and hypotensive side effects Benzodiazepines: alcohol or sedatives withdrawal Lorazepam, less affected by aging and liver disease

CONCLUSIONS(1) ICU syndrome does not differ from delirium “ICU syndrome” is potentially dangerous Hallmark features reduced level of consciousness disturbed cognition (memory, orientation, and language) perceptual disturbances

CONCLUSIONS(2) Main causes metabolic disturbances electrolyte abnormalities acute infection withdrawal or intoxication syndromes vascular disorders or lesions in the central nervous system

CONCLUSIONS(3) Identifying and treating the underlying causes of delirium prevention of delirium Identification of those high risk elderly minimization of medications close management of chronic illnesses Immunizations for influenza and pneumonia Family and community support systems

失智症(I) 記憶力衰退為主要症狀，其他認知功能障礙為輔 定向力 現實感 抽象思考 判斷力 運算能力

失智症(II) 盛行率 分類 ＞65歲，約5％severe dementia 15％mild dementia 阿茲海默症 (原發性)為最大宗 血管型失智症 (續發性)次之

Alzheimer’s disease Alzheimer’s disease is a progressive brain disorder that gradually destroys a person’s memory and ability to learn, reason, make judgments, communicate and carry out daily activities. Arch Neurol. 60(8):1119-22, (2003)

Amyloid cascade hypothesis

Nature Biotechnology 2000

失智症(III) 廣義上而言，「失智症」可謂是「器質型腦症候群」之一種疾病 常見精神方面的併發症亦相似 BPSD (Behavioral-Psychiatric Syndrome of Dementia) 行為方面 精神方面

BPSD－ 失智症的行為及精神症狀（I） 行為症狀 錯認行為 收集行為 虛談行為 重覆言談與行為 將熟悉的人誤認為他人 延續年輕時勤儉習慣，將物品收集回家 虛談行為 談論沒有發生的事情，或否認有發生的事情 重覆言談與行為 重覆講一樣的事物，或一直要求吃飯，洗澡或上廁所 也可能反果過來一直拒絕上述行為

BPSD－ 失智症的行為及精神症狀（II） 妄想 被偷妄念 不忠妄念 被害妄念 幻覺 視幻覺為主 情緒症狀 煩躁、激動、易怒、易哭泣難過 日夜顛倒，夜間不睡，入夜後意識不清，行為更加混亂 「黃昏症候群」

BPSD－ 失智症的行為及精神症狀（III） 治療與處置 抗鬱劑或抗精神藥物 對續發性失智症必須控制原發病兆 如高血壓、防再度中風、電解質監測 安全防護 跌倒預防、生理需求的滿足、個人清潔的維護 提供適度照明、安全環境 心理、情緒支持與安撫 行為引導 提供正確指引，如日曆、大時鐘 指令務必力求簡單、易懂