DELIRIUM

Delirium didefinisikan sebagai gangguan kognitif dan kesadaran fluktuatif yang terjadi secara
akut. Delirium merupakan sindrom bukan penyakit.
Epidemiologi : 0,4% terjadi pada usia 18 tahun dan 1,1% usia 55tahun.
10-30% pasien yang dirawat dirumah sakit mengalami delirium. 30% pasien di
surgical intensive care unit dan cardiac intensive care unit mengalami delirium.
40% pasien post op fraktur panggul mengalami delirium.
Etiologi
:
CNS disorder : Seizure (postictal, nonconvulsive status, status)
Migraine
Trauma kepala, Tumor otak, SAH, subdural,epidural hematoma, abscess, ICH,
Cerebellar hemorrhage, nonhemorrhagic stroke, transient ischemia
Metabolic disorder
: gangguan elektrolit
Diabetes, hipoglikemi, hiperglikemi, resistensi insulin
Systemic illness
: Infeksi (sepsis, malaria, erysipelas, viral, plague, lyme disease,
syphilis, abscess)
Trauma
Perubahan cairan (dehidrasi, volume overload)
Defisiensi nutrisi
Luka bakar
Uncontrolled pain
Heat stroke
High altitude ( >5000m)
Medication
: Pain medication ( postoperative meperidine, morphine)
Antibiotic, antiviral, anti fungal
Steroid
Anesthesia
Cardiac medication
Antihipertensi
Antineoplastic agent
Anticholinergic agentome
Neuroleptic malignant syndrome
Serotonin syndrome
Over the counter preparation ( herbal, the, suplemen)
Botanical
(Jimsonweed, oleander)
Cardiac
(cardiac failure, aritmia, myocard infarct, cardiac assist device, cardiac surgery)
Pulmonary
( COPD, hypoxia, SIADH, acid base disorder)
Endocrine
( krisis adrenal, abnormalitas thyroid atau parathyroid)
Renal
(renal failure, uremia)
Hepar
(hepatitis, cirrhosis, hepatic failure)
Neoplasma

Kriteria diagnosis delirium

A. There is clouding of consciousness, i.e., reduced clarity of awareness of the
environment, with reduced ability to focus, sustain, or shift attention.
B. Disturbance of cognition is manifest by both:
1. impairment of immediate recall and recent memory, with relatively intact remote
memory;
2. disorientation in time, place, or person.
C. At least one of the following psychomotor disturbances is present:
1. rapid, unpredictable shifts from hypoactivity to hyperactivity;
2. increased reaction time;
3. increased or decreased flow of speech;
4. enhanced startle reaction.
D. There is disturbance of sleep or of the sleep-wake cycle, manifest by at least one of the
following:
1. insomnia, which in severe cases may involve total sleep loss, with or without
daytime drowsiness, or reversal of the sleep-wake cycle;
2. nocturnal worsening of symptoms;
3. disturbing dreams and nightmares, which may continue as hallucinations or
illusions after awakening.
E. Symptoms have rapid onset and show fluctuations over the course of the day.
F. There is objective evidence from history, physical and neurological examination, or
laboratory tests of an underlying cerebral or systemic disease (other than psychoactive
substance-related) that can be presumed to be responsible for the clinical manifestations
in Criteria A - D.
Pemeriksaan Tambahan
Pemeriksaan standar
Blood chemistries (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
Pemeriksaan tambahan jika ada indikasi
Blood, urine, and cerebrospinal fluid (CSF) cultures
B12, folic acid concentrations
Computed tomography or magnetic resonance imaging brain scan
Lumbar puncture and CSF examination

Differential Diagnosis
1. Demensia
Feature
Onset
Duration
Attention
Memory
Speech
Sleep wake cycle
Thoughts
Awareness
Alertness

Dementia
Slow
Months to years
Preserved
Impaired remote memory
Word-finding difficulty
Fragmented sleep
Impoverished
Unchanged
Usually normal

Delirium
Rapid
Hours to weeks
Fluctuates
Impaired recent and immediate memory
Incoherent (slow or rapid)
Frequent disruption (e.g., daynight reversal)
Disorganized
Reduced
Hypervigilant or reduced vigilance

2. Schizophrenia atau Depresi

Treatment
Atasi penyebabnya.
Kalau penyebabnya toksisitas antikolinergik Tx : physostigmine salicylate (Antilirium) 1-2 mg
IV/IM, dosis boleh diulang dalam 15-30 menit.
gejala delirium yang butuh farmakoterapi : psikosis & insomnia.
Tx Psikosis : Haloperidol dosis awal 2-6 mg IM diulang dalam 1 jam jika pasien masih agitasi.
Kalau pasien sudah tenang ganti Haloperidol oral 5-40 mg/hari. 2/3 dosis diberikan sebelum
tidur.
Haloperidol dapat menyebabkan reaksi extrapiramidal, sehingga perlu dimonitoring. Haloperidol
tidak boleh untuk wanita hamil.
Tx Insomnia : Lorazepam 1-2 mg sebelum tidur.
Benzodiazepam tidak boleh digunakan bersama depresan SSP seperti alcohol, pada penderita
PPOK