dr.

Hadi Widjaja, MBiomed, SpS

Neurologist - Siloam Hospital Kupang
Pendahuluan
 Delirium = acute confusional state
 merupakan gejala klinis bkn diagnosis akhir

 Perubahan alur pikir global, akut, disertai gangguan

persepsi, atensi & perubahan kesadaran

 Umum dijumpai pada rawat inap, khususnya usia

lanjut
 Secara umum dibedakan
menjadi jenis:
 Hiperaktif: Agitasi
 Hipoaktif: Confusion 
dementia / depresi
 Berlangsung sesaat: hari –
minggu
 Mortalitas 25% pada kasus
rawat inap
 Merupakan gejala klinis,
bukan diagnosis akhir
DEFINITION
The American Psychiatric Association's Diagnostic and Statistical
Manual, 5th edition (DSM-V):
1. Disturbance in attention (reduced ability to direct, focus, sustain,
and shift attention) and awareness.
2. The disturbance develops over a short period of time (usually
hours to days), represents a change from baseline, and tends to
fluctuate during the course of the day.
3. An additional disturbance in cognition (memory deficit,
disorientation, language, visuospatial ability, or perception –
illusions & hallucinations)
4. There is evidence from the history, physical examination, or
laboratory findings that the disturbance is caused by a medical
condition, substance intoxication or withdrawal, or medication side
effect.
5. The disturbances are not better explained by another preexisting,
evolving or established neurocognitive disorder, and do not occur in
the context of a severely reduced level of arousal, such as coma
Diagnostic and Statistical
Manual, 5th ed
Additional features
 Psychomotor behavioral disturbances such as
hypoactivity, hyperactivity with increased sympathetic
activity, and impairment in sleep duration &
architecture (reversal of the sleep-wake cycle).
 Variable emotional, including fear, depression,
euphoria.

Diagnostic and Statistical

Manual, 5th ed
EPIDEMIOLOGY
 Nearly 30 percent of older medical patients experience
delirium
 surgical patients
 complex procedures: cardiac surgery
 hip fracture
 intensive care units (70 %)
 hospice units (42 %)
PATHOGENESIS
 poorly understood

 Attention is a universal feature of confusional states:

 Arousal & attention may be disrupted by brain lesions
involving the ascending reticular activating system (ARAS):
mid-pontine tegmentum rostrally to the anterior cingulate
regions.
 attention is governed by the "nondominant" parietal and
frontal lobes.

 Acetylcholine plays a key role in the pathogenesis of

delirium
Precipitating Factors Risk Factors
 Polypharmacy  most commonly identified
 Infection risk factors are underlying
 Dehydration
brain diseases
 dementia, stroke, parkinson
 Immobility
ds.
 Malnutrition
 elderly patients with femoral
 The use of bladder catheters neck fractures
 EVALUATION
Recognizing the disorder Uncovering underlying ds
 Criteria DSM-V  V (Vascular): Stroke dng afasia sensorik,
SAH, Hypertensive Encephalopathy
 General exam
 I (Infection): primary CNS infection,
 Neurologic exam secondary (sistemic) infection
 T (Trauma): open / closed head trauma,
acute / chronic SDH
 A (Autoimun): SLE, MS
 M (Metabolik): hyper / hypo-glicemia,
hyponatremia, uremic / hepatic
encephalopathy, intoxication /
withdrawal drug / alcohol
 I (Idiopatik): deficiency folat / B 12
 N (Neoplasma): primary / secondary
brain tumor, paraneoplastic syndrome
 S (Seizure): post ictal state, status
epileptic non convulsive
 Other (Psychiatric)
General Examination
1. Pernafasan: 3. Cardiopulmonary
 Bau nafas  Takipneau
2. Kepala leher  Bunyi paru
 Laserasi SCALP  Aritmia
 Cephal-hematom 4. Abdomen
 Battle sign  Hepatomegali
 Racoon eye 5. Extremity
 Meningeal sign:  Edema: cardiac / renal
kaku kuduk failure
 Neurological Examination
1. Mental status: MMSE 3. Motor
 Alertness: GCS  Power
 Attentiveness: digit span  Tremor
 Language: paraphasia,  Asterixis
comprehension  Myoclonic
 Thought content 4. Sensory
2. Cranial nerve 5. Gait
 Pupil:  Ataxia ~ intoxication
 pinpoint ~ opiate OD
 Dilated ~ cholinergic OD
6. Reflexes
 Anisokor ~ herniation  Babinski sign
syndrome
 Facial asymmetry
Major Threat to Life
 SOL (Space Occupying Lession) with impanding
herniation
 Jarang terjadi, SOL dng impending herniasi tnp deficit
neurologis fokal
 Klinis: bingung / perubahan kesadaran
 Umumnya: Bilateral SDH / SAH dng edema difus
 Bacterial meningitis / encephalitis
 Major treatable illness
 Fatal to be missed diagnosed
 Delirium Tremens
 Occuring 48 hours after cessation of alcohol comsumption
 Autonomic instability: high fever, tachicardia, BP fluctuation
 Mortality rate 15%
ADDITIONAL DIAGNOSTIC TESTS
 Laboratory tests  Lumbar puncture
 FBC  EEG testing
 Electrolyte panel
 Glucose
 Liver function
 Arterial Blood Gases
 Urine & toxicology
 Imaging
 Routine imaging: chest
x-ray
 Neuroimaging
Managemen
1. Control of delirium
 Antipsikotik: haloperidol
 Benzodiazepine: diazepam
2. Treatment of life treatening disorder
 Meningitis: antibiotics
 Impending herniation: osmotic agent / steroid
 Delirium tremens: benzodiazepine, thiamin,
supportive agent
3. Treatment of underlying disease
EVALUATION
Two important aspects to the diagnostic evaluation:
1. Recognizing that the disorder is present
 Criteria DSM-V
 Mental status exam  sensitive indicator
 formal mental status testing: MMSE
 bedside tests of attention: serial 7, digit span, backward
spelling
 Neurologic exam:
 Level of consciousness
 Focal neurologic disease: deficit of cranial nerve & motoric
function
 Neuroimaging, lumbar puncture, & EEG as indicated
EVALUATION
2. Uncovering the underlying medical illness
 V (Vascular): Stroke dng afasia sensorik, SAH, Hypertensive
Encephalopathy
 I (Infection): primary CNS infection, secondary (sistemic)
infection
 T (Trauma): open / closed head trauma, acute / chronic SDH
 A (Autoimun): SLE, MS
 M (Metabolik): hyper / hypo-glicemia, hyponatremia, uremic /
hepatic encephalopathy, intoxication / withdrawal drug / alcohol
 I (Idiopatik): deficiency folat / B 12
 N (Neoplasma): primary / secondary brain tumor, paraneoplastic
syndrome
 S (Seizure): post ictal state, status epileptic non convulsive
 Other (Psychiatric)