DELIRIUMAyu Putri Haryani201410401011044FAKULTAS KEDOKTERANUNIVERSITAS MUHAMMADIYAH MALANG*

DefinitionDelirium has been defined as a transient organic brain syndrome characterized by the acute onset of disordered attention and cognition, accompanied by disturbances of cognition, psychomotor behaviour and perceptionDelirium is a common cause of mortality and morbidity in older people in hospital, and indicates severe illness in younger patients. *

DSM IV Criteria of Delirium*

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EtiologyCauses of Delirium: usually multi-factorialNeoplasticPrimary tumour of brain.Metastases.Tumour burden or location.Infection/inflammatory pneumonia and urinary tract infection, other causes of sepsis.Metabolic hypercalcemia, uremia, hypoglycemia, hyperglycemia, or hyponatremia.Drug effect*

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PathophysiologyMany hypotheses exist including :Neuritransmitter abnormalitiesInflammatory response with increased cytokinesChanges in the blood- brain barrier permeabilityWidespread reduction of cerebral oxidative metabolismIncreased activity of hypothalamic-pituitary adrenal axis*

Predisposing Factors of Delirium*

Precipitating Factors of Delirium*

The Differential Diagnose of Delirium*

Delirium Vs Psychiatric disorderClouded conciousness or decreased level of allertnessDisorientation Acuity of onset and coursePresence of risk factors for delirium, recent medical illness or treatment.*

Delirium Vs DementiaDementia has an insisdious onset, chronic memory and executive function disturbance, tends not to fluctuate. In delirium cogntive changes develop ACUTELY and fluctuate.Deementia has intact alertness and attention but impoverished speech and thinking. In delirium speech can be confused or disorganized. Alertness and attention wav and wane.*

Schizophrenia Vs DeliriumOnset of schizophrenia is rarely after 50Auditory hallucinations are much more common than visual hallucinationsMemory is grossly intact and disorientation is rareNo wide fluctuations over the course of a day*

Treatment*

Non- PharmacologicalWatch for the sun downing effect (nocturnal confusion) as it is often the firstsymptom of early delirium.Provide a calm, quiet environment and help the patient reorient to time, place and person (visible clock, calendar, well known object).Presence of a well known family member is preferred.Provide a well lit, quiet environment. Provide night light.Keep visitors to a minimum to prevent over stimulation and minimal staff changesand room changes. Correct reversible factors dehydration nutrition alteration in visual or auditory acuity (provide aids)sleep deprivation.Avoid the use of physical restraints, catheterization or other impediments to ambulation.Encourage activity if patient is physically able.*

PharmacologicalAntipsychotics decrease psychotic symptomps. Ex : Confusion, agitationAntipsychotics IV Haldol is the first line. Antipsychotic drugs are the mainstay of treatment and are effective in all types of delirium. Except in cases of delirium caused by alcohol or sedative hypnotic withdrawal, neuroleptics are the treatment of choice, resulting in improvement before elucidation of the underlying cause.Haloperidol in doses of 0.5 to 10 mg a day (intramuscularly or intravenously) improves most symptoms of delirium and is especially effective in the control of more severely disturbed and aggressive patients.The adage in psychopharmacology in older people is start low, go slow and, if the patients clinical condition allows, starting doses of 0.5 mg a day of haloperidol and risperidone and 2.5 mg a day of olanzapine are appropriate. Atypical antipsychotics such as olanzapine and risperidone have been used with success.*

PharmacologicalThe adage in psychopharmacology in older people is start low, go slow and, if the patients clinical condition allows, starting doses of 0.5 mg a day of haloperidol and risperidone and 2.5 mg a day of olanzapine are appropriate. Atypical antipsychotics such as olanzapine and risperidone have been used with success.Benzodiazepines may be particularly helpful where the delirium is caused by withdrawal of alcohol or sedatives. Benzodiazepines with rapid onset and short duration of action, such as lorazepam, are preferred and may be given orally or intravenously, with a recommended upper limit of 2 mg intravenously every four hours.*

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

ConclusionDelirium is a common cause of mortality and morbidity in older people in hospital, and indicates severe illness in younger patients. Identification of risk factors, education of professional carers, and a systematic approach to management can improve the outcome of the syndrome. Physicians should be aware that delirium sufferers often have an awareness of their experience, which may be belied by their varying grasp of reality.*