A 疫学・診断
1.疫学
2.診断
B 治療
1.薬物療法
2.非薬物療法
文献

1.疫学

せん妄は終末期がん患者の52-88%にみられる最も多い神経精神疾患である[72]。

2.診断

1)原因[73, 74]

・薬物(オピオイド、睡眠薬、抗精神病薬、抗コリン薬など)

・感染症

・脱水

・頭蓋内病変

・アルコールや他の薬物からの離脱

・低酸素血症・高二酸化炭素血症

・代謝異常(腎機能異常・肝機能異常、高血糖・低血糖、高カルシウム血症・低ナトリウム血症などの電解質異常、高浸透圧血症)

・血液学的異常(貧血、播腫性血管内凝固)

2)診断・評価

・米国精神医学会診断基準(DSM-IV)

下記のすべてを満たす場合、せん妄の診断がつくとしている。

(1)意識障害:ボーっとしていて周囲の状況をよくわかっていない。

(2)認知機能・知覚の異常:見当識障害、幻覚、妄想など。

(3)日内変動:1日の中で症状のむらがある。夜間に悪化。

(4)原因となる薬物、あるいは身体要因が存在する。

・Confusion Assessment Method(CAM)[75]

簡便なスクリーニングツール。(1)+(2)+(3)か(4))を満たせばせん妄と診断。

(1)急性発症かつ症状の変動

(2)注意力の低下

(3)思考の解体

(4)意識レベルの変容

・Memorial Delirium Assessment Scale(MDAS)[76]

せん妄の重症度判定に有用。以下の10項目について0(なし)、1(軽度)、2(中等度)、3(重度)で評価。7点以上で98%の感度、96%の特異度でせん妄の診断がつく[77]。日本語版の信頼性・妥当性も検証済み[78]。

(1)意識障害

(2)見当識障害

(3)短期記憶障害

(4)順唱・逆唱の障害

(5)注意の集中と注意の転換の障害

(6)思考障害

(7)知覚障害

(8)妄想

(9)精神運動抑制もしくは精神運動興奮

(10)睡眠覚醒リズムの障害

せん妄の原因に対する治療が先決である。ベンゾジアゼピン系薬や抗コリン薬など鎮静作用のある薬物の中止、睡眠薬から抗精神病薬への変更、オピオイドローテーションなどによりせん妄が改善することが少なくない。

1.薬物療法

ランダム化比較試験により抗精神病薬(ハロペリドール ✚✚✚、クロルプロマジン ✚✚✚)のベンゾジアゼピン系薬(ロラゼパム)に対する優位性が示されており[79]、ハロペリドールが最も広く使われている[72, 80, 81]。

非定型抗精神病薬であるオランザピン ✚✚✚ やリスペリドン ✚✚✚ はせん妄に対しハロペリドールと同等の効果を示す[82]。クエチアピン ✚ とハロペリドールを比較した質の高いランダム化比較試験はない[82]。クエチアピンはICU患者においてプラセボと比較してせん妄の改善を早めることが示されているが[83]、がん患者における質の高いランダム化比較試験はない。

低用量のハロペリドール(<3 mg/日)は非定型抗精神病薬と比較して錐体外路症状の頻度を増加させないが、高用量(>4.5 mg/日)ではその頻度が高くなる[82]。

症状が軽い場合は抗精神病薬を頓用で使用

・haloperidol錠(0.75 mg) 1錠 内服、注射剤(5 mg/A) 0.5A 皮下注・点滴

・risperidone液(0.5 mg) 1包 内服

・olanzapine錠(2.5 mgまたは5 mg) 1錠 内服、または口腔内崩壊錠(5 mg) 1錠 内服

・quetiapine錠(25 mg) 1錠 内服

・上記の投与量で開始し、効果に応じて漸増。

・症状が強い場合、夜間せん妄が強い場合は眠前定期投与を開始。

・定期投与に加え、不穏時は眠前1回分を1時間あけて3回まで追加。それ以上必要な場合は定時処方を増量。

・日中の不穏が強い場合は、日中も抗精神病薬を定期で使用。

・治療中は錐体外路症状の出現に注意。

・クエチアピンやオランザピンはケトアシドーシスの危険性があるため、糖尿病患者には禁忌。

・原因への対応、抗精神病薬の増量にても精神興奮の緩和が困難な場合は、ベンゾジアゼピン系薬 ✚ の併用を慎重に考慮。その際、抗精神病薬に加え、眠前定期投与として以下を開始。投与量は年齢や腎機能等により適宜調節。

・flunitrazepam(2 mg/A) 0.25A 点滴

・bromazepam座薬(3 mg) 1個 挿肛

・diazepam座薬(6 mg) 1個 挿肛

2.非薬物療法[84]

・静かな落ちついた環境の調整。

・睡眠・覚醒のバランスをつける(日中はカーテンを開ける、夜間は薄明かりに)。

・日付・時間の手がかり(カレンダー、時計を置く)。

・眼鏡、補聴器の使用。

・親しみやすい環境を整える(家族の面会、自宅で親しんできた物を置く)。

・オリエンテーションを繰り返しつける(部屋・スタッフの変更は最小限に)。

・訪室の時間を調整する。

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2. 日本緩和医療学会緩和医療ガイドライン作成委員会編. がん患者の呼吸器症状の緩和に関するガイドライン2011年版. 金原出版. 2011.

3. 日本緩和医療学会・日本サイコオンコロジー学会PEACE(Palliative care Emphasis program on symptom management and Assessment for Continuous medical Education)プロジェクト. 第16回緩和ケアの基本教育に関する指導者研修会参加者ハンドブック.

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