DELIRIUM

Pembimbing
dr. Iwan Sys, Sp.KJ
Oleh
Teddy Prawiro, S.Ked
(201320401011106)

Definition
Delirium according to Diagnostic Statistical
Manual of Mental Disorders is syndrome that
has many causes and is associated with the
degree of consciousness and cognitive
disorders.
Distinctive sign is loss offf consciousness
and cognitive disorders. Mood disorder,
perception and behavior is a symptom of
psychiatric deficit

Clinical Characteristics
Because delirium remains a
bedside diagnosis, understanding
its clinical features is crucial to
the diagnosis of delirium.
Delirium has hypoactive and
hyperactive forms. The
hypoactive form of delirium is
more common among older
persons and often goes
unrecognized

Predisposing risk factors

>60 years of age

Male sex
Visual impairment
Underlying brain
pathology such as
stroke, tumor,
vasculitis, trauma,
dementia
Major medical illness
Recent major surgery

Depression
Functional dependence
Dehydration
Substance
abuse/dependence
Hip fx
Metabolic
abnormalities
Polypharmacy

Precipitating risk factors

Meds (see list)

Severe acute illness
UTI
Hyponatremia
Hypoxemia
Shock
Anemia
Pain

Orthopedic surgery
Cardiac surgery
ICU admission
High number of
hospital procedures

Pathogenesis
The
pathophysiology
of
delirium
remains
poorly
understood.
Electroencephalographic
studies
have
demonstrated diffuse slowing of cortical background
activity, which does not correlate with underlying causes.
Neuropsychological and neuroimaging studies reveal
generalized disruption in higher cortical function, with
dysfunction in the prefrontal cortex, subcortical structures,
thalamus, basal ganglia, frontal and temporoparietal
cortex, fusiform cortex, and lingual gyri, particularly on the
nondominant side. The leading hypotheses for the
pathogenesis of delirium focus on the roles of
neurotransmission, inflammation, and chronic stress.

 Dopaminergic excess also appears to contribute to delirium,

possibly owing to its regulatory influence on the release of
acetylcholine. Dopaminergic drugs (e.g., levodopa and
bupropion) are recognized precipitants of delirium, and
dopamine
antagonists
(e.g.,
antipsychotic
agents)
effectively treat delirium symptoms. Perturbations of other
neurotransmitters, such as norepinephrine, serotonin, aminobutyric acid, glutamate, and melatonin, may also have
a role in the pathophysiology of delirium, but the evidence
is less well developed. These neurotransmitters may exert
their influence through interactions with the cholinergic and
dopaminergic pathways.

Dementia vs Delirium
Dementia has an insidious onset, chronic
memory and executive function disturbance,
tends not to fluctuate. In delirium cognitive
changes develop acutely and fluctuate.
Dementia has intact alertness and attention
but impoverished speech and thinking. In
delirium speech can be confused or
disorganized. Alertness and attention wax
and wane.

Schizophrenia vs Delirium
Onset of schizophrenia is rarely after 50.
Auditory hallucinations are much more
common than visual hallucinations
Memory is grossly intact and disorientation is
rare
Speech is not dysarthric
No wide fluctuations over the course of a day

Mood disorders vs
Delirium
Mood disorders manifest persistent rather
than labile mood with more gradual onset
In mania the patient can be very agitated
however cognitive performance is not usually
as impaired
Flight of ideas usually have some thread of
coherence unlike simple distractibility
Disorientation is unusual in mania

Treatment
First and foremost treat the underlying cause
Environmental interventions: cues for
orientation (calendar, clock, family pictures,
windows), frequently reorient the patient,
have family or friends visit frequently making
sure they introduce themselves, minimize
staff switching.
Minimize psychoactive medications

Course and Prognosis

Prodromal symptoms may occur a few days
prior to full development of symptoms
The symptoms will continue to
progress/fluctuate until underlying cause
treated
Most of the symptoms of delirium will resolve
within a week of correction/improvement of
the underlying etiology HOWEVER symptoms
may wax and wane. In some patients it can
take weeks for the symptoms to resolve.
Some patients, particularly older patients,
may never return to baseline

EDUCATION
Let the family know what is going on
including that delirium waxes and wanes and
can last for several weeks
Once the patient starts to improve explain to
them what delirium is, how common it is and
the usual course. It is very frightening for
them and may fear they have a psychiatric
illness.