せん妄(delirium)
せん妄とは「因子の存在が急性の脳機能障害を引き起こし意識障害を認める」という状態を指す症候群である。せん妄では夕方～夜間に好発するという日内変動を認めることが多く、夜間に起こるせん妄を夜間せん妄と呼ぶ。
せん妄を引き起こす因子
せん妄を引き起こす因子は準備因子と誘発因子と直接因子に分けられる。
準備因子として高齢者・認知症などが挙げられる。
誘発因子としてICU・疼痛・人工物の体内留置・睡眠覚醒リズムの障害・環境の変化(病室の移動)などが挙げられる。
直接因子として感染症・電解質異常・手術・アルコール離脱症状・抗Parkinson病薬・ベンゾジアゼピン系薬などが挙げられる。
せん妄の予防
せん妄が発症すると患者の生命予後が悪化するので、できる限りせん妄を予防することが求められる。
誘発因子を取り除くとともになるべく患者に日常生活を送ってもらうようにする。家族との面会は予防として有効である。早期離床・早期退院を目指す。
早期離床とは手術や疾患の罹患によって寝たきり状態となってから、できる限り早くベッドから離れることができるようにするという一連のプロセスを指す。
ICUは閉鎖的な特殊空間であり、窓や時計がないので見当識が失われやすかったりモニターの音が大きく睡眠が妨げられやすかったりするのでせん妄を誘発しやすい。
ICUから一般病棟に移動させたり、部屋に時計・カレンダーを置くことで見当識を失わせないように予防する。疼痛管理も重要である。
せん妄の種類
せん妄というと「患者が夜に暴れる」というような過活動型せん妄を想像する人が多いが、実はせん妄にはうつ病と似たような症状を日中に呈するという低活動型せん妄もある。過活動型せん妄と低活動型せん妄が交互に出現する混合型せん妄では見過ごされることが少ないが、低活動型せん妄のみを呈する場合には見過ごされやすくうつ病と間違われることが多いとされ注意が必要である。
因子の存在によって脳内神経系のうち「GABA系の低下＋アセチルコリン系の抑制＋ドパミン系の亢進」が生じると主に夜間に問題となる過活動型せん妄となり、「GABA系の亢進」が生じると主に日中に問題となる低活動型せん妄となる。
過活動型せん妄では意識障害(見当識障害を含む)・興奮状態・幻覚(感覚器に刺激がないのに知覚が生じる)・錯覚(対象を誤って知覚する)などが起こる。追想は不可能であり、患者はせん妄状態を覚えていない。
せん妄の薬物治療
ドパミン抑制作用を持つ抗精神病薬が過活動型せん妄に対して有効である。
ただし、Lewy小体型認知症では抗精神病薬に対して感受性の亢進を認めるので使用できない。
また、通常ベンゾジアゼピン系薬はせん妄のリスク因子となるが、振戦せん妄に対してはベンゾジアゼピン系薬を治療に用いる。
振戦せん妄
大量飲酒者が急激に飲酒をやめた場合、アルコール離脱症状として振戦せん妄が起こることがある。
振戦せん妄は発汗・粗大な手指振戦・幻視(小動物幻視が多い)・精神運動の興奮(不安を伴い「ものすごく不安である」と訴える)などの症状が出る。
治療はビタミンを含む輸液で脱水とビタミンB1欠乏を解消して、ベンゾジアゼピン系薬(ジアゼパムなど)を用いる。
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