Delirium

GANGGUAN JIWA

Psikotik

Neurotik(Non Psikotik)

Organik

Non Organik

Gangguan jiwa non psikotik yang kronis dan rekuren, yang ditandai terutama oleh KECEMASAN

Dipersepsikan secara langsung

• Cemas• Psikoseksual•Somatoform,dll

Psikotik

GMO

GMNOAtau

Fungsional

Gangguan dimana terdapat suatu patologi yang dapat diidentifikasi

•Demensia•Delirium•Sindrom otak organik ok rudapaksa kepala•Sindrom otak organik ok epilepsi.•Sindrom otak organik ok defisiensi vitamin,ggn.metabolisme , intoksikasi.Sindrom otak organik ok tumor intra kranial, CVD

Gangguan otak dimana tidak ada dasar organik yang dapat diterima secara umum

Skizofrenia. Depresi, Ggn.Mood

DELIRIUM

Delirium is defined by the acute onset of fluctuating cognitive

impairment and a disturbance of consciousness. Delirium is a

syndrome, not a disease, and it has many causes, all of which

result in a similar pattern of signs and symptoms relating to the

patient's level of consciousness and cognitive impairment

Factors that Predispose Patients to Delirium

• Vision impairment• Hypertension • Use of bladder

catheter• Medical illnesses

(severity and quantity) • Chronic obstructive

pulmonary disease • Preoperative cognitive

impairment • Cognitive impairment • Alcohol abuse • Functional limitations

• Older than 70 years • Smoking history • History of delirium • Any iatrogenic event • Abnormal sodium level • Abnormal potassium,

sodium, or glucose test Use of physical restraints

• Abnormal glucose level

• Preoperative use of benzodiazepines

Central nervous system disorder

•Seizure (postictal, nonconvulsive status, status)•Migraine•Head trauma, brain tumor, subarachnoid hemorrhage, subdural, epidural hematoma, abscess, intracerebral hemorrhage, cerebellar hemorrhage, nonhemorrhagic stroke, transient ischemia

Metabolic disorder

•Electrolyte abnormalities•Diabetes, hypoglycemia, hyperglycemia, or insulin resistance

Systemic illness

•Infection (e.g., sepsis, malaria, erysipelas, viral, plague, Lyme disease, syphilis, or abscess)•Trauma•Change in fluid status (dehydration or volume overload)•Nutritional deficiency•Burns•Uncontrolled pain•Heat stroke•High altitude (usually >5,000 m)

Table 10.2-4 Common Causes of Delirium

Medications Pain medications (e.g., postoperative meperidine [Demerol] or morphine [Duramorph])Antibiotics, antivirals, and antifungalsSteroidsAnesthesiaCardiac medicationsAntihypertensivesAntineoplastic agentsAnticholinergic agentsNeuroleptic malignant syndromeSerotonin syndrome

Over-the-counter preparations

Herbals, teas, and nutritional supplements

Botanicals Jimsonweed, oleander, foxglove, hemlock, dieffenbachia, and Amanita phalloides

Cardiac Cardiac failure, arrhythmia, myocardial infarction, cardiac assist device, cardiac surgery

Pulmonary Chronic obstructive pulmonary disease, hypoxia, SIADH, acid base disturbance

Endocrine Adrenal crisis or adrenal failure, thyroid abnormality, parathyroid abnormality

Hematological

Anemia, leukemia, blood dyscrasia, stem cell transplant

Renal Renal failure, uremia, SIADH

Hepatic Hepatitis, cirrhosis, hepatic failure

Neoplasm Neoplasm (primary brain, metastases, paraneoplastic syndrome)

Drugs of abuse

Intoxication and withdrawal

Toxins Intoxication and withdrawalHeavy metals and aluminum

SIADH, syndrome of inappropriate secretion of antidiuretic hormone.

PATHOPHYSIOLOGY

• Two main neuronal networks underlie attention, the first being diffuse, involving thalamic and bihemispheric pathways, and the second being focal, involving frontal and parietal cortex in the right hemisphere

• There is widespread disruption of higher cortical function in delirium, with evidence of dysfunction in several brain areas: subcortical structures, brain stem and thalamus, non dominant parietal lobe, fusiform, and pre-frontal cortices,as well as the primary motor cortex

• Right sided lesions have been suggested as important in the final common pathway for delirium45–47 and right cerebral artery and middle cerebral artery infarctions are associated with an agitated delirium

• There is evidence for a cholinergic deficiency in delirium

Symptoms• The core features of delirium include altered

consciousness, such as decreased level of consciousness; altered attention, which can include diminished ability to focus, sustain, or shift attention

• Impairment in other realms of cognitive function, which can manifest as disorientation (especially to time and space) and decreased memory; relatively rapid onset (usually hours to days); brief duration (usually days to weeks); and often marked, unpredictable fluctuations in severity and other clinical manifestations during the course of the day, sometimes worse at night (sundowning), which may range from periods of lucidity to severe cognitive impairment and disorganization

Diagnosis The DSM-IV-TR DSM-IV-TR Diagnostic Criteria for Delirium Due to General Medical Condition

A. Disturbance of consciousness (i.e., reduced clarity of awareness of the environment) with reduced ability to focus, sustain, or shift attention.

B. Change in cognition (such as memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted for by a preexisting, established, or evolving dementia

C. The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day

D. There is evidence from the history, physical examination, or laboratory findings that the disturbance is caused by the direct physiological consequences of a general medical condition

Table 10.2-6 DSM-IV-TR Diagnostic Criteria for Substance Intoxication Delirium

A. Disturbance of consciousness (i.e., reduced clarity of awareness of the environment) with reduced ability to focus, sustain, or shift attention

B. A change in cognition (such as memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted for by a preexisting, established, or evolving dementia

C. The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day

D. There is evidence from the history, physical examination, or laboratory findings of either (1) or (2)

DSM-IV-TR Diagnostic Criteria for Substance Withdrawal Delirium

A. Disturbance of consciousness (i.e., reduced clarity of awareness of the environment) with reduced ability to focus, sustain, or shift attention

B. A change in cognition (such as memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted for by a preexisting, established, or evolving dementia

C. The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day

D. There is evidence from the history, physical examination, or laboratory findings that the symptoms in Criteria A and B developed during, or shortly after, a withdrawal syndrome

DSM-IV-TR Diagnostic Criteria for Delirium Due to Multiple Etiologies

A. Disturbance of consciousness (i.e., reduced clarity of awareness of the environment) with reduced ability to focus, sustain, or shift attention.

B. A change in cognition (such as memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted for by a preexisting, established, or evolving dementia.

C. The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day

D. There is evidence from the history, physical examination, or laboratory findings that the delirium has more than one etiology (e.g., more than one etiological general medical condition, a general medical condition plus substance intoxication or medication side effect).

DSM-IV-TR Diagnostic Criteria for Delirium Not Otherwise Specified

This category should be used to diagnose a delirium that does not meet criteria for any of the specific types of delirium described in this section.Examples include

A. A clinical presentation of delirium that is suspected to be due to a general medical condition or substance use but for which there is insufficient evidence to establish a specific etiology

B. Delirium due to causes not listed in this section (e.g., sensory deprivation)

Physical and Laboratory Examinations

Physical Examination of the Delirious Patient

Parameter Finding Clinical ImplicationPulse Bradycardia Hypothyroidism

Stokes-Adams syndromeIncreased intracranial pressure

  Tachycardia HyperthyroidismInfectionHeart failure

Temperature Fever SepsisThyroid stormVasculitis

Blood pressure Hypotension ShockHypothyroidismAddison's disease

  Hypertension EncephalopathyIntracranial mass

Respiration Tachypnea DiabetesPneumoniaCardiac failureFeverAcidosis (metabolic)

  Shallow Alcohol or other substance intoxication

Heart Arrhythmia Inadequate cardiac output, possibility of emboli

  Cardiomegaly Heart failureHypertensive disease

Laboratory Workup of the Patient with Delirium

Standard studies   Blood chemistries (including electrolytes, renal and hepatic indexes, and glucose)   Complete blood count with white cell differential   Thyroid function tests   Serologic tests for syphilis   Human immunodeficiency virus (HIV) antibody test   Urinalysis   Electrocardiogram   Electroencephalogram   Chest radiograph   Blood and urine drug screens

Additional tests when indicated   Blood, urine, and cerebrospinal fluid (CSF) cultures

   B12, folic acid concentrations

   Computed tomography or magnetic resonance imaging brain scan   Lumbar puncture and CSF examination

Pharmacotherapy• The two major symptoms of delirium that may require

pharmacological treatment are psychosis and insomnia

– A commonly used drug for psychosis is haloperidol (Haldol), a butyrophenone antipsychotic drug

– Depending on a patient's age, weight, and physical condition, the initial dose may range from 2 to 6 mg intramuscularly, repeated in an hour if the patient remains agitated

– The effective total daily dose of haloperidol may range from 5 to 40 mg for most patients with delirium. Droperidol (Inapsine) is a butyrophenone available as an alternative intravenous formulation, although careful monitoring of the electrocardiogram may be prudent with this treatment

• Phenothiazines should be avoided in delirious patients because these drugs are associated with significant anticholinergic activity

• Use of second-generation antipsychotics, such as risperidone (Risperdal), clozapine, olanzapine (Zyprexa), quetiapine (Seroquel), ziprasidone (Geodon), and aripiprazole (Abilify), may be considered for delirium management, but clinical trial experience with these agents for delirium is limited