1

DELIRIUM
Ayu Putri Haryani
201410401011044
FAKULTAS KEDOKTERAN
UNIVERSITAS MUHAMMADIYAH MALANG

Definition
Delirium 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 perception
Delirium 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

Etiology
Causes of Delirium: usually multi-factorial
Neoplastic
Primary 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

Pathophysiology

Many hypotheses exist including :

Neuritransmitter abnormalities
Inflammatory response with increased cytokines
Changes in the blood- brain barrier permeability
Widespread reduction of cerebral oxidative metabolism
Increased activity of hypothalamic-pituitary adrenal axis

Predisposing Factors of Delirium

Precipitating Factors of Delirium

10

The Differential Diagnose of Delirium

Delirium Vs Psychiatric disorder

Clouded conciousness or decreased level of allertness
Disorientation
Acuity of onset and course
Presence of risk factors for delirium, recent medical illness or
treatment.

11

12

Delirium Vs Dementia
Dementia 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 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
No wide fluctuations over the course of a day

13

Treatment

14

15

Non- Pharmacological
Watch 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.

Pharmacological

16

Antipsychotics decrease psychotic symptomps. Ex : Confusion, agitation

Antipsychotics 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.

17

Pharmacological
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.
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.

18

Prognosis
Prodormal symptomps may occur a few days prior to full
development symptomps
The 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.

19

Conclusion
Delirium 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.