重症监护病房患者认知功能评定工具的研究进展

吴野环，张一，姚秋近，陈超，王涯，张瑜

重症监护病房患者认知功能评定工具的研究进展

吴野环，张一，姚秋近，陈超，王涯，张瑜

[摘要]谵妄和认知障碍在重症监护病房(ICU)中经常出现。对于谵妄，美国重症医学临床实践指南推荐5个筛查用量表：ICU精神错乱评定法(CAM-ICU)、重症监护谵妄筛查表(ICDSC)、谵妄认知测试(CTD)、护士用谵妄量表(Nu-DESC)和谵妄分级量表(DRS)。其中，CAM-ICU和ICDSC信度、效度、敏感性及特异性等最好，CTD和Nu-DESC次之，DRS最差。认知障碍的筛选和评定工具包括简易精神状态检查(MMSE)、简短精神状态检查(AMSE)、约翰-霍普斯金认知评定量表。约翰-霍普斯金认知评定量表是比较适合重症监护病房的量表之一，操作简单，内容全面，有较高的信度与效度。

[关键词]重症监护病房；认知功能；评定；综述

[本文著录格式]吴野环，张一，姚秋近，等.重症监护病房患者认知功能评定工具的研究进展[J].中国康复理论与实践, 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.

许多重症监护病房(intensivecareunits, ICU)幸存患者在出院后常常遭受认知损害，进而导致肢体障碍、睡眠障碍以及心理压力[1-2]。这些患者需要长期被照顾或需要使用一些辅助设备，从而导致生活质量下降，并给家人或亲属带来很大的心理压力[3]。在ICU，谵妄非常常见，可达80%以上[4]，它能导致更严重的认知损害，使老年患者一半以上发展为痴呆[2,5-6]。床边精神状态评估是每个患者评估的重要组成部分。目前关于谵妄的评估和量表研究比较多，下面就谵妄和认知障碍在ICU中常用的量表进行阐述。

1　谵妄

谵妄(delirium)在ICU中是一个非常严重的问题，它与患者的住院时间及死亡率息息相关[7-8]。谵妄筛查对临床至关重要。2013年，美国重症医学临床实践指南推荐5个筛查工具。

ICU精神错乱评定法(Confusion Assessment Method Intensive Care Unit, CAM-ICU)基于精神疾病统计诊断手册(The Diagnostic and Statistical Manual of Mental Disorders, DSM)Ⅲ版谵妄定义开发，主要评估其4个特点：急性发作、注意力不集中、意识水平的变化、思维紊乱[9-10]。其敏感性0.86，特异性0.93，测试时间<5min。Brummel等应用CAM-ICU量表评定谵妄[11]，敏感性和特异性较好。

重症监护谵妄筛查表(Intensive Care Delirium Screening Checklist, ICDSC)是基于DSM-Ⅳ版谵妄定义修订，纳入8个特点：意识水平的变化、注意力不集中、定向障碍、幻觉妄想精神障碍、精神运动多动缺陷障碍、言语增多和情绪障碍、睡眠-觉醒周期紊乱、症状变化[12]。其敏感性0.99，特异性0.64，每个项目评分分0、1分两个结果，总分8分，≥4分即可诊断，测试时间不定。

谵妄认知测试(Cognitive Test for Delirium, CTD)是基于DSM-Ⅲ谵妄定义开发，包括定向、注意力、记忆力、理解力和反应性5个方面[12-13]。敏感性0.947，特异性0.988，每个项目评分0～6分，总分30分，≤11分即可诊断，测试时间10～15 min。

护士用谵妄量表(Nursing Delirium Scale, Nu-DESC)是基于DSM-Ⅳ谵妄定义开发，包括定向障碍、异常行为、交流、幻觉及精神运动缺陷[14]。其敏感性0.83，特异性0.81，每个项目评分为0～2分，≥2分即可诊断谵妄，测试时间1 min。测试时间短，敏感性及特异性相对较高，适合护理人员使用。

谵妄分级量表(Delirium Rating Scale, DRS)包含13个关于患者谵妄严重性的项目和3个诊断项目，敏感性0.92，特异性0.93，每个项目评分0～3分，总分46分，≥15分即可诊断，测试时间不定。

在这5个量表中，信度、效度、敏感性及特异性等指标检测，CAM-ICU和ICDSC表现最好，CTD和Nu-DESC次之，DRS最差。

2013年美国重症医学临床实践指南推荐在ICU中使用CAM-ICU和ICDSC筛查谵妄[4]，两个量表具有A级证据[15]。Meta分析提示，CAM-ICU具有很高的特异性，适合诊断谵妄，而ICDSC具有很强的敏感性，更能排除谵妄[16-17]。

2　简易精神状态检查

简易精神状态检查(Mini-Mental State Examination, MMSE) 是1975年由Folstein编制，适用于老年认知障碍的一种筛查工具[18]。它是目前最具影响的认知障碍筛选工具之一。MMSE共19项，包括时间定向、地点定向、语言即刻记忆、注意、计算、短程记忆、物体命名、语言复述、阅读理解、语言理解、言语表达、图形描画[19-20]。MMSE的敏感性76%～81%[21-23]，特异性82%[24]。因其不能排除年龄、学历及疾病时间等因素的影响，敏感性不可能很高。

其优点为：①对病情恶化有很高敏感性；②大部分项目对认知障碍敏感；③能区分痴呆的两种类型[21]。Jackson等用MMSE观察53例重症患者3～8 d，发现MMSE可以对谵妄进行筛查，但建议联合其他量表一起使用[25]。Radtke等在ICU术后认知障碍的研究中使用MMSE评价患者认知功能，提示其对ICU患者认知障碍的筛查有一定意义[26]。目前该量表主要适用于老年患者，痴呆、脑卒中、多发性硬化等神经系统疾病患者，很少应用于ICU患者[27]。

3　简短精神状态检查

简短精神状态检查(Abbreviated Mental Status Examination, AMSE) 1988年由Merigian等根据Dick编写的应用于急诊科患者30项检查精神状态发展而来[28]。AMSE主要包括10个项目，分为时间定向、地点定向、计算力，记忆力以及执行功能5方面内容，每个项目0～1分，总分10分，8分以上为正常者。此量表为认知障碍筛查量表，使用比较方便，一般在5 min左右完成，非常适合在急诊科和ICU中使用。目前国内无汉译版本[29]。

Merigian等的研究表明，此量表与格拉斯哥昏迷量表(Glasgow Coma Scale, GCS)相关性极高，对认知障碍的筛查比GCS敏感，是用于ICU的很好筛查工具[28]。

4　约翰-霍普斯金认知评定量表

约翰-霍普斯金认知评定量表(the Johns Hopkins Adapted Cognitive Exam)由Lewin和他的团队以MMSE和Addenbrooke认知检查(Addenbrooke'sCognitiveExam,ACE)两个量表为基础开发的[30]，特别适用于ICU患者认知障碍的筛查，国外研究，其信度为0.99，效度为0.83[1,3,31]，比MMSE高出许多。内容主要包括定向力、言语、模仿能力、注意力与计算力以及记忆力5方面，总分100分，包括定向力30分，言语21分，模仿能力6分，注意力与计算力22分，记忆力21分[32]。目前国外已经广泛应用于临床ICU[33]，国内尚无中文译本。

5　结语

目前临床上越来越多的医生开始关注认知障碍，但往往关注病情相对稳定时患者的认知障碍，临床应用的大部分认知功能评价量表也针对于此。适用于ICU或急诊科患者认知功能的评价量表极少，约翰-霍普斯金认知评定量表是其中之一，它能应用于ICU或急诊科对认知障碍的筛查或评估，国外研究显示有很好的信度和效度，值得进一步研究。

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·综述·

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)

作者简介：作者单位：常州市第一人民医院神经外科，江苏常州市213003。吴野环(1986-)，男，汉族，黑龙江明水县人，硕士，医师，主要研究方向：颅脑创伤及脑血管病的康复评定与治疗。通讯作者：张一。E-mail: zhangyizhe1975@aliyun.com。

DOI:10.3969/j.issn.1006-9771.2015.11.011

[中图分类号]R749

[文献标识码]A

[文章编号]1006-9771(2015)11-1287-03