Delirium dan Demensia

dr. N.K. Sri Diniari, Sp.KJ

FK UNUD/RSUP Sanglah

 DELIRIUM
• Sindrome
• =Acute confusional state, Sundowning,
Ensephalopaty, dan sindroma otak organik
akut
• Neurocognitive disorder (DSM-5)
• Acute onset fluctuating cognitive impairment
and disturbance of consiousness
• Epidemiology: 0,4 -1,1%
• 10-30% of medically ill patients
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 Diagnostic criteria Delirium (DSM-5)

A. A disturbance in attention (i.e., reduced ability to direct, focus, sustain, and
shift attention) and awareness (reduced orientation to the environment).
B. The disturbance develops over a short period of time (usually hours to a few
days), represents a change from baseline attention and awareness, and
tends to fluctuate in severity during the course of a day.
C. An additional disturbance in cognition (e.g., memory deficit, disorientation,
language, visuospatial ability, or perception).
D. The disturbances in Criteria A and C are not better explained by another
preexisting, established, or evolving neurocognitive disorder and do not
occur in the context of a severely reduced level of arousal, such as coma.
E. There is evidence from the history, physical examination, or laboratory
findings that the disturbance is a direct physiological consequence of
another medical condition, substance intoxication or withdrawal (i.e., due to
a drug of abuse or to a medication), or exposure to a toxin, or is due to
multiple etiologies.

Delirium (PPDGJ-III)
• Gangguan kesadaran dan perhatian.
• Gangguan kognitif
– Halusinasi, ilusi, distorsi persepsi
– Disorientasi, ggn daya ingat, berpikir abstrak
• Gangguan psikomotor
• Gangguan siklus tidur-bangun
• Gangguan emosional
• Onset cepat (akut), hilang timbul sepanjang
hari (berfluktuatif), < 6 bulan
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Karakteristik
• Terjadi akut (jam-hari)
• Kondisi kesadaran fluktuatif , disorientasi
• Berkurangnya kemampuan memusatkan
perhatian
• Agitasi atau somnolen berlebihan
• Emosi labil yang ekstrim
• Dapat terjadi defisit kognitif

Tipe delirium
• Hiperaktif
• Hipoaktif
• Mixed

Gejala Klinis Delirium

1. Delirium Hipoaktif (29%):
Setidaknya 4 (empat) dari perilaku : penurunan orientasi, penurunan
kesiagaan, bicara yang jarang-jarang atau lambat, letargi, pergerakan
yang melambat, melotot, atau apati.

2. Delirium Hiperaktif (21%):

Setidaknya 3 (tiga) dari karakteristik : kesiagaan berlebihan, tidak bisa
diam, bicara cepat atau keras, iritabilitas, sikap bermusuhan,
ketidaksabaran, menyumpah, bernyanyi, tertawa, tidak mau bekerja
sama, euforia, marah, berjalan mondar-mandir, mudah terkejut,
respons motorik yang cepat, perhatian yang mudah teralih, bicara yang
tidak nyambung, mimpi buruk, atau pikiran yang persisten.

3. Subtipe Campuran (43%):

Datang dengan karakteristik delirium hipoaktif dan hiperaktif, dan
merupakan subtipe yang paling sering didiagnosis.
Saxena dan
Lawley, 2010;7
Kalish et al.,

 Etiology
Multifaktorial:
– Penyakit sistemik
– Terapi psikoaktif
– Adanya faktor risiko

 mnemonic
Dementia
Electrolytes
Lungs, liver, heart, kidney, brain
Infection
Rx (especially medications)
Injury, pain, stress
Unfamiliar environment
Metabolic
Inouye SK. Conn Med1993;57:309-15
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 Penyakit sistemik

• Infeksi
• Ketidakseimbangan elektrolit
• Disfungsi endokrin
• Kegagalan hati- ensefalopati hepatikum
• Gagal ginjal- ensefalopati uremikum
• Penyakit paru dengan hipoksemia
• Penyakit jantung : CHF, aritmia, infark
• Patologis SSP: tumor, stroke , kejang
• Defisiensi nutrisi: tiamin, asam folat, B12

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 Obat
– Antikholinergics (difenhidramin), TCAs
( amitriptilin, imipramin), antipsikotik
(chlorpromazine, thioridazine)
– Antiinflamasi , steroid
– Benzodiazepin atau alkohol — toksik akut atau
withdrawal
– Kardiovascular (digitalis, antihipertensif)
– diuretics
– Anti Histamin (cimetidine, ranitidine)
– Lithium
– Opioid (terutama meperidine)
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 Faktor Predisposisi
• > 60 tahun • Depresi
• Laki-laki • Dependensi fungsional
• Gangguan visual • Dehidrasi
• Kelainan SSP stroke, • Ketergantungan/
tumor, vasculitis, ketagihan zat tertentu
trauma, demensia • Fraktur panggul
• Operasi besar yang baru • Abnormalitas metabolik
dijalani • Polifarmasi

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 Faktor Presipitasi
• Obat-obatan • Pembedahan ortopedi
• Penyakit akut berat • Pembedahan jantung
• UTI • ICU admission
• Hiponatremia • Prosedur rumah sakit
• Hipoksemia yang sering
• Syok
• Anemia
• Nyeri

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 Patofisiologi
Acetylcholine
- Preoperative plasma cholinesterase menurun !
postoperative delirium
- Teori : Terapi Anticholinergic! ACS, pasien dengan
gangguan transmisi ACH (contoh: Alzheimer), lebih rentan
Dopamine
- Pada delirium, aktivitas dopamin berlebihan! terapi
antidopamin
•

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 • Neurotransmiter lain:
- Serotonin: meningkat pada hepatic
encephalopathy dan septic
- Gamma-aminobutyric acid (GABA): hepatic
encephalopathy, inhibitory GABA meningkat
GABA juga menurun pada benzodiazepine dan
alcohol withdrawal.

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• Cortisol dan beta-endorphins

• Inflamasi: sitokin! Il-1, Il-6
• Reaksi stres: psikososial dan kurang tidur
• Mekanisme struktural ! jalur spesifik tidak
diketahui.

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Inouye SK. Delirium in older persons. N Engl J Med. 2006;354:

1157-1165.

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 Penilaian Delirium
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● Identifikasi delirium memerlukan penilaian ulang secara

berkelanjutan selama pasien tinggal di rumah sakit, di rumah,
atau suatu fasilitas keperawatan.
● Confusion Assessment Method (CAM) adalah alat yang
paling efektif untuk identifikasi delirium, dan dapat
membantu untuk mengidentifikasi delirium pada pasien.
● 4 kriteria CAM :
○ 1. Acute onset and fluctuating course
○ 2. Inattentions
○ 3. Disorganizes thinking
○ 4. Altered consciousness.
● Diagnosis delirium membutuhkan penilaian untuk kriteria 1
dan 2, dan sebaiknya 3 atau 4. Sensitivitasnya memiliki
rentang dari 94% hingga 100%

Kalish et al.,
2014

 Differential Diagnosis
• Psychotic disorders
• Bipolar
• Depressive disorders with psychotic
features.
• Other neurocognitive disorders
(Dementia)
• Acute stress disorder
• Malingering and factitious disorder
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 Terapi non famakologis

• Yang terpenting atasi penyakit dasar
• Intervensi lingkungan: petunjuk yang
mempermudah orientasi (kalender, jam, foto
keluarga, jendela), mengorientasi pasien
berulang, keluarga dan teman yang berkunjung
memperkenalkan diri mereka, meminimalisir
pergantian shift paramedis yang bertugas
• Meminimalisir obat psikoaktif

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 Terapi Farmakologis
• Tidak ada obat spesifik yang diindikasikan untuk
mengatasi gejala perilaku
• Haloperidol ! paling banyak diteliti, efektif untuk
agitasi
• Low dose
– Dosis: 2-3 x 0,5 -1,5 mg i.o
– Injeksi 2,5 – 5 mg IM /IV @ 12-24 jam
• Efek samping antikolinergik minimal
• Efek samping kardiovaskuler yang minimal
• prolonged QT intervaL
• Waspada EPS (ektrapyramidal symptom)
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 Atypical Antipsychotic
• Penelitian! sama efektifnya dengan haloperidol

• EPS kurang jika dibandingkan dengan haloperidol

• Tidak ada preparat IV

• Pilihan IM:
• Olanzapine 2.5 - 5mg IM q 4-6 hours prn maksimal 20mg/
hari
• Ziprasidone IM 10mg IM q 6-8 hours prn maksimal 30mg/
hari

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 • Mulai dengan prn namun jika sering digunakan, dapat

diberikan rutin:
o Haloperidol 0.5-1 mg i.o - @8-12 jam sampai 10 mg/
hari
o Quetiapine 12.5-25 mg i.o - @12jam sampai 150 mg/hari
(pilihan utama untuk Parkinson’s atau Lewy Body)
o Risperidone 0.25-0.5 mg i.o- @8-12 jam sampai 2 mg/
hari
o Olanzapine 2.5-5 mg i.o - @12-24 jam sampai 10 mg/
hari

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 DEMENTIA
• (DSM-5)
= Major Neurocognitive Disorders
• Progressive impairment of cognitive functions occurring
in clear consciousness.
• Global impairment of intellect is the essential feature,
manifested as difficulty with memory, attention,
thinking, and comprehension.
• Other mental functions can often be affected, including
mood, personality, judgment, and social behavior.

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Epidemiology
• General population ≥ 65 y.o: 5%
• General population ≥ 85 y.o: 20-40%
• Outpatient general medical practices: 15-20%
• In chronic care facilities: 50%
• Type:
– Alzheimer
– Vascular
– Others (trauma; alkohol; Huntington ds;Parkinson
ds; etc)

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Cause of Dementia

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Screening

• MMSE (Mini Mental State Examination)

• Clock Drawing Test
• ADAS-Cog
• CDR (The Clinical Dementia Rating Scale)
• FAST (Functional Assessment Staging)
• Etc .

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Clock drawing test

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 Diagnostic Criteria DSM-5
Major Neurocognitive disorders (Dementia)
A. Evidence of significant cognitive decline from a previous level of
performance in one or more cognitive domains (complex attention,
executive function, learning and memory, language, perceptual-motor,
or social cognition) based on:
1. Concern of the individual, a knowledgeable informant, or the clinician
that there has been a significant decline in cognitive function; and
2. A substantial impairment in cognitive performance, preferably
documented by standardized neuropsychological testing or, in its
absence, another quantified clinical assessment.
B The cognitive deficits interfere with independence in everyday
activities (i.e., at a minimum, requiring assistance with complex
instrumental activities of daily living such as paying bills or managing
medications).
C. The cognitive deficits do not occur exclusively in the context of a
delirium.
D. The cognitive deficits are not better explained by another mental
disorder (e.g., major depressive disorder, schizophrenia).
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 Major Neurocognitive Disorders

(=Dementia)
Specify:
Without behavioral disturbance: If the cognitive disturbance is not
accompanied by any clinically significant behavioral disturbance.

With behavioral disturbance (specify disturbance): If the cognitive

disturbance is accompanied by a clinically significant behavioral
disturbance (e.g., psychotic symptoms, mood disturbance, agitation,
apathy, or other behavioral symptoms).
(BPSD= Behavioral and Psychological symptom of Dementia)

Specify current severity:

Mild: Difficulties with instrumental activities of daily living (e.g.,
housework, managing money).
Moderate: Difficulties with basic activities of daily living (e.g., feeding,
dressing).
Severe: Fully dependent.

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Demensia (PPDGJ-III)
• Penurunan kemampuan daya ingat dan daya pikir,
yang sampai mengganggu kegiatan harian
seseorang (personal activities of daily living)
seperti mandi, berpakaian, makan, kebersihan
diri, buang aor besar dan kecil.
• Clear consciousness (tidak ada ggn kesadaran)
• Gejala dan disabilitas sdh nyata ± 6 bulan

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CLINICAL FEATURE

Dementia Wandering, Etc

symptoms

Cognitive Non Cognitive

(= BPSD)

Decline cognitive Verbal & physical Anxiety Psychotic symptom Sleep disturbances Depression
functions agression, agitation

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 Differential Diagnosis
• Mild Cognitive Impairment
• Delirium
• Depression
• Specific learning disorder and other
neurodevelopmental disorders
• Factitious Disorders

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DEMENTIA Vs DEPRESSION

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Comorbidity
• Dementia + delirium
• Dementia + neurodevelopmental disorders

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 Treatment

1. Terapi Non Farmakologi

2. Terapi Farmakologi

Prinsip penatalaksanaan:
✓ Non-farmakologi lini pertama
✓ Farmakologi!derajat sedang-berat, atau tidak
memberikan respon terhadap terapi non-farmakologi
✓ Risks and benefits
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 Non-pharmacological Therapy
• Activity and recreation.
• Aromatherapy, Massage.
• Reminiscence therapy.
• Music therapy.
• Muscle relaxation training.
• Pets.
• Carer education (communication, environmental
modifications, etc)
• Physical restraint
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Simfoni Kehidupan Manusia

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Pharmacological Therapy
• No proven alternative psychotropic
• Antipsychotic atypical/typical, for psychotic
symptoms, agitation, aggression.
• Antidepressants
• Cognitive Enhancers
• Other Medications
– Anticonvulsants
– Benzodiasepines
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Treatment Demensia
1.Kognitif
1. 1st class: Cholinesterase inhibitors
Donepezil HCl, galantamine, rivastigmine
2. 2nd class: NMDA Receptor Antagonist
Memantine
3. Others
Ginkgo biloba, NSAID, estrogen ! efficacy unclear

2.Non Kognitif (BPSD)

1. Antipsikotik (Haloperidol, Olanzapine, Risperidone, etc)
2. Anti depresant
3. Anti anxietas Waldemar G et al. Eur J Neurol. 2007 Jan;14(1):e1-26.
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Pharmacological Therapy
• Gejala psikotik/agresi/agitasi:
– Anti psikotik (haloperidol, risperidon, olanzapine, etc)
– Mood stabilizer
• Gejala Depresi
– Anti depresi ( Sertraline, Fluoxetine, etc)
• Gejala cemas
– Anti anxietas kombinasi dgn antidepres
• Gejala insomnia
– anti insomnia (Zolpidem, Ramelteon, benzodiazepine
short half life) prn /kalau perlu saja.

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 Course and Prognosis

• Variable depending on the etiology
• Insidious except when it is caused by a
cerebrovascular event
• Progressive cognitive decline and progressive
functional impairment

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THANK YOU 47