重癥監(jiān)護(hù)病房患者認(rèn)知功能評(píng)定工具的研究進(jìn)展

吳野環(huán)，張一，姚秋近，陳超，王涯，張瑜

重癥監(jiān)護(hù)病房患者認(rèn)知功能評(píng)定工具的研究進(jìn)展

吳野環(huán)，張一，姚秋近，陳超，王涯，張瑜

[摘要]譫妄和認(rèn)知障礙在重癥監(jiān)護(hù)病房(ICU)中經(jīng)常出現(xiàn)。對(duì)于譫妄，美國(guó)重癥醫(yī)學(xué)臨床實(shí)踐指南推薦5個(gè)篩查用量表：ICU精神錯(cuò)亂評(píng)定法(CAM-ICU)、重癥監(jiān)護(hù)譫妄篩查表(ICDSC)、譫妄認(rèn)知測(cè)試(CTD)、護(hù)士用譫妄量表(Nu-DESC)和譫妄分級(jí)量表(DRS)。其中，CAM-ICU和ICDSC信度、效度、敏感性及特異性等最好，CTD和Nu-DESC次之，DRS最差。認(rèn)知障礙的篩選和評(píng)定工具包括簡(jiǎn)易精神狀態(tài)檢查(MMSE)、簡(jiǎn)短精神狀態(tài)檢查(AMSE)、約翰-霍普斯金認(rèn)知評(píng)定量表。約翰-霍普斯金認(rèn)知評(píng)定量表是比較適合重癥監(jiān)護(hù)病房的量表之一，操作簡(jiǎn)單，內(nèi)容全面，有較高的信度與效度。

[關(guān)鍵詞]重癥監(jiān)護(hù)病房；認(rèn)知功能；評(píng)定；綜述

[本文著錄格式]吳野環(huán)，張一，姚秋近，等.重癥監(jiān)護(hù)病房患者認(rèn)知功能評(píng)定工具的研究進(jìn)展[J].中國(guó)康復(fù)理論與實(shí)踐, 2015, 21(11): 1287-1289.

CITED AS: Wu YH, Zhang Y, Yao QJ, et al. Toolsof cognitivefunction assessment used in intensivecareunit (review) [J]. Zhongguo Kangfu LilunYu Shijian, 2015, 21(11): 1287-1289.

許多重癥監(jiān)護(hù)病房(intensivecareunits, ICU)幸存患者在出院后常常遭受認(rèn)知損害，進(jìn)而導(dǎo)致肢體障礙、睡眠障礙以及心理壓力[1-2]。這些患者需要長(zhǎng)期被照顧或需要使用一些輔助設(shè)備，從而導(dǎo)致生活質(zhì)量下降，并給家人或親屬帶來很大的心理壓力[3]。在ICU，譫妄非常常見，可達(dá)80%以上[4]，它能導(dǎo)致更嚴(yán)重的認(rèn)知損害，使老年患者一半以上發(fā)展為癡呆[2,5-6]。床邊精神狀態(tài)評(píng)估是每個(gè)患者評(píng)估的重要組成部分。目前關(guān)于譫妄的評(píng)估和量表研究比較多，下面就譫妄和認(rèn)知障礙在ICU中常用的量表進(jìn)行闡述。

1　譫妄

譫妄(delirium)在ICU中是一個(gè)非常嚴(yán)重的問題，它與患者的住院時(shí)間及死亡率息息相關(guān)[7-8]。譫妄篩查對(duì)臨床至關(guān)重要。2013年，美國(guó)重癥醫(yī)學(xué)臨床實(shí)踐指南推薦5個(gè)篩查工具。

ICU精神錯(cuò)亂評(píng)定法(Confusion Assessment Method Intensive Care Unit, CAM-ICU)基于精神疾病統(tǒng)計(jì)診斷手冊(cè)(The Diagnostic and Statistical Manual of Mental Disorders, DSM)Ⅲ版譫妄定義開發(fā)，主要評(píng)估其4個(gè)特點(diǎn)：急性發(fā)作、注意力不集中、意識(shí)水平的變化、思維紊亂[9-10]。其敏感性0.86，特異性0.93，測(cè)試時(shí)間<5min。Brummel等應(yīng)用CAM-ICU量表評(píng)定譫妄[11]，敏感性和特異性較好。

重癥監(jiān)護(hù)譫妄篩查表(Intensive Care Delirium Screening Checklist, ICDSC)是基于DSM-Ⅳ版譫妄定義修訂，納入8個(gè)特點(diǎn)：意識(shí)水平的變化、注意力不集中、定向障礙、幻覺妄想精神障礙、精神運(yùn)動(dòng)多動(dòng)缺陷障礙、言語增多和情緒障礙、睡眠-覺醒周期紊亂、癥狀變化[12]。其敏感性0.99，特異性0.64，每個(gè)項(xiàng)目評(píng)分分0、1分兩個(gè)結(jié)果，總分8分，≥4分即可診斷，測(cè)試時(shí)間不定。

譫妄認(rèn)知測(cè)試(Cognitive Test for Delirium, CTD)是基于DSM-Ⅲ譫妄定義開發(fā)，包括定向、注意力、記憶力、理解力和反應(yīng)性5個(gè)方面[12-13]。敏感性0.947，特異性0.988，每個(gè)項(xiàng)目評(píng)分0～6分，總分30分，≤11分即可診斷，測(cè)試時(shí)間10～15 min。

護(hù)士用譫妄量表(Nursing Delirium Scale, Nu-DESC)是基于DSM-Ⅳ譫妄定義開發(fā)，包括定向障礙、異常行為、交流、幻覺及精神運(yùn)動(dòng)缺陷[14]。其敏感性0.83，特異性0.81，每個(gè)項(xiàng)目評(píng)分為0～2分，≥2分即可診斷譫妄，測(cè)試時(shí)間1 min。測(cè)試時(shí)間短，敏感性及特異性相對(duì)較高，適合護(hù)理人員使用。

譫妄分級(jí)量表(Delirium Rating Scale, DRS)包含13個(gè)關(guān)于患者譫妄嚴(yán)重性的項(xiàng)目和3個(gè)診斷項(xiàng)目，敏感性0.92，特異性0.93，每個(gè)項(xiàng)目評(píng)分0～3分，總分46分，≥15分即可診斷，測(cè)試時(shí)間不定。

在這5個(gè)量表中，信度、效度、敏感性及特異性等指標(biāo)檢測(cè)，CAM-ICU和ICDSC表現(xiàn)最好，CTD和Nu-DESC次之，DRS最差。

2013年美國(guó)重癥醫(yī)學(xué)臨床實(shí)踐指南推薦在ICU中使用CAM-ICU和ICDSC篩查譫妄[4]，兩個(gè)量表具有A級(jí)證據(jù)[15]。Meta分析提示，CAM-ICU具有很高的特異性，適合診斷譫妄，而ICDSC具有很強(qiáng)的敏感性，更能排除譫妄[16-17]。

2　簡(jiǎn)易精神狀態(tài)檢查

簡(jiǎn)易精神狀態(tài)檢查(Mini-Mental State Examination, MMSE) 是1975年由Folstein編制，適用于老年認(rèn)知障礙的一種篩查工具[18]。它是目前最具影響的認(rèn)知障礙篩選工具之一。MMSE共19項(xiàng)，包括時(shí)間定向、地點(diǎn)定向、語言即刻記憶、注意、計(jì)算、短程記憶、物體命名、語言復(fù)述、閱讀理解、語言理解、言語表達(dá)、圖形描畫[19-20]。MMSE的敏感性76%～81%[21-23]，特異性82%[24]。因其不能排除年齡、學(xué)歷及疾病時(shí)間等因素的影響，敏感性不可能很高。

其優(yōu)點(diǎn)為：①對(duì)病情惡化有很高敏感性；②大部分項(xiàng)目對(duì)認(rèn)知障礙敏感；③能區(qū)分癡呆的兩種類型[21]。Jackson等用MMSE觀察53例重癥患者3～8 d，發(fā)現(xiàn)MMSE可以對(duì)譫妄進(jìn)行篩查，但建議聯(lián)合其他量表一起使用[25]。Radtke等在ICU術(shù)后認(rèn)知障礙的研究中使用MMSE評(píng)價(jià)患者認(rèn)知功能，提示其對(duì)ICU患者認(rèn)知障礙的篩查有一定意義[26]。目前該量表主要適用于老年患者，癡呆、腦卒中、多發(fā)性硬化等神經(jīng)系統(tǒng)疾病患者，很少應(yīng)用于ICU患者[27]。

3　簡(jiǎn)短精神狀態(tài)檢查

簡(jiǎn)短精神狀態(tài)檢查(Abbreviated Mental Status Examination, AMSE) 1988年由Merigian等根據(jù)Dick編寫的應(yīng)用于急診科患者30項(xiàng)檢查精神狀態(tài)發(fā)展而來[28]。AMSE主要包括10個(gè)項(xiàng)目，分為時(shí)間定向、地點(diǎn)定向、計(jì)算力，記憶力以及執(zhí)行功能5方面內(nèi)容，每個(gè)項(xiàng)目0～1分，總分10分，8分以上為正常者。此量表為認(rèn)知障礙篩查量表，使用比較方便，一般在5 min左右完成，非常適合在急診科和ICU中使用。目前國(guó)內(nèi)無漢譯版本[29]。

Merigian等的研究表明，此量表與格拉斯哥昏迷量表(Glasgow Coma Scale, GCS)相關(guān)性極高，對(duì)認(rèn)知障礙的篩查比GCS敏感，是用于ICU的很好篩查工具[28]。

4　約翰-霍普斯金認(rèn)知評(píng)定量表

約翰-霍普斯金認(rèn)知評(píng)定量表(the Johns Hopkins Adapted Cognitive Exam)由Lewin和他的團(tuán)隊(duì)以MMSE和Addenbrooke認(rèn)知檢查(Addenbrooke'sCognitiveExam,ACE)兩個(gè)量表為基礎(chǔ)開發(fā)的[30]，特別適用于ICU患者認(rèn)知障礙的篩查，國(guó)外研究，其信度為0.99，效度為0.83[1,3,31]，比MMSE高出許多。內(nèi)容主要包括定向力、言語、模仿能力、注意力與計(jì)算力以及記憶力5方面，總分100分，包括定向力30分，言語21分，模仿能力6分，注意力與計(jì)算力22分，記憶力21分[32]。目前國(guó)外已經(jīng)廣泛應(yīng)用于臨床ICU[33]，國(guó)內(nèi)尚無中文譯本。

5　結(jié)語

目前臨床上越來越多的醫(yī)生開始關(guān)注認(rèn)知障礙，但往往關(guān)注病情相對(duì)穩(wěn)定時(shí)患者的認(rèn)知障礙，臨床應(yīng)用的大部分認(rèn)知功能評(píng)價(jià)量表也針對(duì)于此。適用于ICU或急診科患者認(rèn)知功能的評(píng)價(jià)量表極少，約翰-霍普斯金認(rèn)知評(píng)定量表是其中之一，它能應(yīng)用于ICU或急診科對(duì)認(rèn)知障礙的篩查或評(píng)估，國(guó)外研究顯示有很好的信度和效度，值得進(jìn)一步研究。

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·綜述·

Toolsof CognitiveFunctionAssessment Usedin IntensiveCareUnit (review)

WU Ye-huan, ZHANGYi, YAOQiu-jin, CHENChao, WANGYa, ZHANGYu
Department of Neurosurgery, TheFirst People'sHospital of Changzhou, Changzhou, Jiangsu213003, China

Abstract:Delirium and cognitiveimpairment arecommon in theintensivecareunits(ICU). The Confusion Assessment Method Intensive Care Unit (CAM-ICU), Intensive Care Delirium Screening Checklist (ICDSC), Cognitive Test for Delirium (CTD), Nursing Delirium Scale(Nu-DESC) and Delirium Rating Scale(DRS) arerecommended to assessdelirium. CAM-ICU and ICDSC arethebest in thereliability, validity, sensitivity and specification. Mini-Mental State Examination (MMSE), Abbreviated Mental Status Examination (AMSE), the Johns HopkinsAdapted Cognitive Exam areused commonly for cognitiveimpairment, and Johns HopkinsAdapted Cognitive Exam isone of thesuitablescalesfor ICU asit issimple, comprehensive, andwithhigher reliability andvalidity.

Keywords:intensivecareunits; cognitivefunction; assessment; review

(收稿日期：2015-04-07修回日期：2015-07-07)

作者簡(jiǎn)介：作者單位：常州市第一人民醫(yī)院神經(jīng)外科，江蘇常州市213003。吳野環(huán)(1986-)，男，漢族，黑龍江明水縣人，碩士，醫(yī)師，主要研究方向：顱腦創(chuàng)傷及腦血管病的康復(fù)評(píng)定與治療。通訊作者：張一。E-mail: zhangyizhe1975@aliyun.com。

DOI:10.3969/j.issn.1006-9771.2015.11.011

[中圖分類號(hào)]R749

[文獻(xiàn)標(biāo)識(shí)碼]A

[文章編號(hào)]1006-9771(2015)11-1287-03