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1
deliriumi
klinikuri praqtikis erovnuli rekomendacia
(gaidlaini)
2
klinikuri praqtikis erovnuli rekomendacia (gaidlaini)
`deliriumi~ miRebulia klinikuri praqtikis erovnuli
rekomendaciebis (gaidlainebi) da daavadebaTa marTvis
saxelmwifo standartebis (protokolebi) SemuSavebis,
Sefasebis da danergvis erovnuli sabWos 2008 wlis 5
noembris #1 sxdomaze da damtkicebulia saqarTvelos
Sromis, janmrTelobisa da socialuri dacvis ministris
2008 wlis 18 dekembris # 274/o brZanebiT.
3
deliriumi
1. daavadebis definicia, sinonimebi, klasifikacia da terminologia
deliriumi - tvinis mwvave sindromi, cnobierebis mwvave aSlis
mdgomareoba (confusional state), mwvave organuli fsiqozi, mwvave fsiqo-
organuli sindromi, toqsikuri/metaboluri encefalopaTia (1).
C. Libermeister (1866) aRwera somaturi daavadebebis dros ganviTarebuli
cnobierebis paTologia, romelic xasiaTdeba mdgomareobis TandaTanobiTi
gauaresebiTa da gamoxatuli fsiqopaTologiuri simptomebiT
(mxedvelobiTi halucinaciebiT, iluziebiT, xatovani bodviT, cvalebadi
afeqtiTa da fsiqomotoruli agznebiT). literaturaSi termini
„deliriumi” sxvadasxva mniSvnelobiT ixmareba, zogjer mis qveS
gulisxmoben yvela saxis mwvave organul reaqcias, an cnobierebis
paTologiis konkretul saxes, rodesac verbaluri pasuxis unaris
SenarCunebis fonze gamoxatulia fsiqomotoruli agzneba, afeqturi
labiloba da aRqmis paTologia (2).
ICD 10-Si deliriumi ganmartebulia, rogorc etiologiurad
araspecifikuri organuli fsiqosindromi, romlisTvisac
damaxasiaTebelia cnobierebis aSla, yuradRebis, aRqmis, azrovnebis,
mexsierebis, emociuri da motoruli sferos darRvevebi da Zilis
ritmis moSla. am klasifikaciaSi DSM IV-sagan gansxvavebiT
gamoiricxeba alkoholiT (TeTri cxeleba, F10.4) da/an sxva
fsiqoaqtiuri nivTierebebiT ganpirobebuli deliriumi da
dauzustebeli deliriumi. deliriumis xangrZlivobac da
intensivobac sagrZnoblad meryeobs. avadmyofis mdgomareoba
SeiZleba iyos Zalian msubuqi an ukiduresad mZime. mdgomareobis
Tanmxlebi niSnebi, rogoricaa depresia, SfoTva, SiSi,
gamRizianebloba, eiforia, apaTia, dabneuloba, aRqmis paTologia
(iluziebi, halucinaciebi), tranzitoruli bodviTi ideebi, tipiuria
am aSlilobisTvis, magram specifikuri ar aris, amdenad, diagnozis
dasmisas maT gansakuTrebuli mniSvneloba ar eniWeba (3, 4).
DSM IV klasifikaciaSi „deliriumi” gamoiyeneba „mwvave organuli
sindromis” sinonimad da moicavs am ukanasknelis mTel speqtrs. am
klasifikaciaSi gamoyofilia:
• deliriumi, ganpirobebuli zogadi somaturi
mdgomareobebiT;
• wamlismieri deliriumi;
• mravaletiologiuri faqtorebiT ganpirobebuli deliriumi;
• sxvagvarad dauzustebeli deliriumi.
yvela am mdgomareobisaTvis wamyvania cnobierebis paTologia, rasac
Tan axlavs yuradRebisa da koncentraciis daqveiTeba, aRqmis,
mexsierebis, azrovnebisa da Zilis darRvevebi. mdgomareoba
viTardeba swrafad da axasiaTebs dReRamuri meryeoba (5).
orive klasifikaciis mixedviT aucilebelia cerebruli an
sistemuri daavadebis arsebobis damadasturebeli anamnezuri
4
cnobebi, fizikuri, nevrologiuri da/an laboratoriuli
gamokvlevebis monacemebi, romliTac aixsneba deliriuli
simptomatika.
2. epidemiologia
deliriumi gvxvdeba stacionirebul somatur pacientTa 10-30%-Si;
mogvianebuli asakis hospitalizebuli pacientebis 10-40%-Si,
onkologiuri avadmyofebis 25%-sa da SidsiT daavadebulTa 30-40% -
Si (6). postoperaciul periodSi deliriumis ganviTarebis riski
TiTqmis 51%-ia (7), xolo terminaluri mdgomareobebisas - 80%-ze
meti (8). momatebuli riskis jgufebs miekuTvnebian axalnaoperaciebi,
(gansakuTrebiT kardiotomiisa da organoTa transplantaciis
Semdeg), dializze myofi da pacientebi centraluri nervuli
sistemis dazianebiT.
deliriumis ganviTarebamde ramdenime dRiT adre SesaZloa
ganviTardes subklinikuri deliriumi, an prodromuli simptomebi,
rogoricaa SfoTva, gamRizianebloba, Zilis darRvevebi. Cveulebriv,
deliriumi amoiwureba 10-12 dReSi, Tumca SemTxvevaTa 15%-Si
grZeldeba 30 da meti dRe (9-14). gaxangrZlivebuli deliriumis
SemTxvevebi ufro xSiria asakovan pacientebSi (11, 12).
deliriumi, umetes SemTxvevaSi, mTavrdeba sruli gamojanmrTelebiT,
iSviaTad gadadis soporsa da komaSi, an viTardeba krunCxvebi.
SesaZloa letaluri gamosavalic (aranamkurnalev SemTxvevebSi).
deliriumi ufro mZimed mimdinareobs xandazmul pacientebSi, maT
Soris gamojanmrTelebis ricxvi 4-40%-ia (15). mdgomareobis
amowurvis Semdegac gamoxatuli rCeba kognituri daqveiTeba. aseTive
suraTi gvaqvs Sidsis drosac, pacientTa mxolod 27%-s aReniSneba
sruli gamojanmrTeleba (16).
somaturad damZimebul pacientebSi deliriuli mdgomareobis
ganviTareba mniSvnelovnadaa asocirebuli letalobasTan (17,18).
stacionirebul xandazmul pacientTa sikvdilianoba, romelTac
uviTardebaT deliriumi, aris 22-76% (19).
3. etiopaTogenezi
deliriumis etiopaTogenezis dadgena xSir SemTxvevaSi sakmaod
rTulia. deliriumi, SesaZloa, iyos pirveli da erTaderTi
gamovlineba seriozuli somaturi daavadebisa, an ukve arsebuli
avadmyofobis garTuleba. mizezis dadgena xdeba srulyofili
anamnezis, fsiqikuri, da fizikuri statusis Seswavlisa da
laboratoriul-instrumentuli kvlevebis monacemebis safuZvelze.
unda gvaxsovdes, rom umniSvnelo cvlilebebi (umniSvnelo anemias
damatebuli umniSvnelo hiponatriemia, damatebuli umniSvnelo
kalciemia) erTianobaSi SeiZleba mniSvnelovnad uwyobdes xels
deliriumis ganviTarebas, miuxedavad imisa, rom calcalke isini
araviTar saSiSroebas ar warmoadgenen.
deliriumis paTofiziologiis codna dResdReobiT Zalian
SezRudulia. varaudoben retikuluri sistemis disfunqcias, rasac
gansakuTrebuli roli eniWeba naTeli cnobierebis
5
mdgomareobisaTvis. arsebobs monacemebi qolinerguli sistemis
hipofunqciisa winatvinsa da ReroSi. sxvadasxva kvlevebi miuTiTebs
noradrenerguli, GABA (γ-aminoerbomJava)-erguli da
serotoninerguli sistemebis disfunqciaze. manamde arsebuli
monacemebi globaluri cerebruli metabolizmis moSlis Sesaxeb,
jerjerobiT, dadasturebuli ar aris (20).
deliriumis gamomwvevi mizezebi mocemulia cxrilSi (1)
cxrili 1
mwvave organuli reaqciis gamomwvevi mizezebi
simsivne, moculobiTi procesi cerebruli simsivne, subduruli
hematoma, cerebruli abscesi
infeqcia encefalitebi, meningiti, aiv
infeqcia, meningovaskuluri
sifilisi, streptokokuli
infeqcia, septicemia, pnevmonia,
virusuli infeqcia, tifi,
malaria da a.S.
sisxlZarRvovani mwvave cerebruli Trombozi an
embolia, gardamavali cerebruli
iSemiuri mdgomareoba,
subaraqnoiduli hemoragia,
wiTeli mglura
metaboluri uremia, RviZlis disfunqcia,
eleqtrolituri disbalansi,
alkalozi, acidozi, da sxv.
endokrinuli hiper- da hipoparaTireozi,
miqsedema, adisonis daavadeba,
diabeturi prekoma, hipoglikemia
epilefsia kompleqsuri parcialuri
krunCxvebi, mcire gulyrebi,
gulyris Semdgomi mdgomareoba.
vitaminebis nakleboba nikotinis mJavas, Tiaminis,
foliumis mJavasa da B12 vitaminis nakleboba
degeneraciuli demenciasTan TandarTuli
infeqcia, hipoqsia da sxv.
6
4. klinikuri simptomatika
deliriumis klinikuri niSnebia:
• mwvave dasawyisi;
• cnobierebis paTologia – avadmyofi dabneuli da
dezorientirebulia;
• gaZnelebulia gageba, gacnobiereba da gaazreba.
amas xSirad Tan axlavs:
• mexsierebis daqveiTeba;
• agzneba, aforiaqeba;
• gafantuli yuradReba;
• iluziebi da halucinaciebi (upiratesad mxedvelobiTi);
• Zilis ritmis darRveva;
• bodviTi ideebi.
avtonomiuri (somato-vegetatiuri) niSnebia:
• oflianoba, taqikardia;
• arteriuli wnevis meryeoba, mZime SemTxvevebSi vardna;
• mZime SemTxvevebSi viTardeba centraluri genezis hiperTermia.
nevrologiuri simptomebia:
• kunTebis hipotonia, hiperrefleqsia, tremori, ataqsia,
konvergenciis sisuste;
• mZime SemTxvevebSi aRiniSneba kisris kunTebis daWimuloba,
keringis simptomi, oraluri avtomatizmi, aTetozuri da
qoreaformuli hiperkinezebi, nistagmi, ftozi, strabizmi,
gayinuli mzera (21).
deliriuli mdgomareobis ganviTarebaSi gamoyofen Semdeg stadiebs:
I stadia – simptomebi Cveulebriv SesamCnevi xdeba saRamos saaTebSi.
viTardeba zogadi agzneba, mimika da metyveleba
gacxovelebuli da aCqarebulia. avadmyofebi bevrs da
daukavSireblad metyveleben. aRiniSnebaT xatovani
warmodgenebisa da mogonebebis mozRvaveba. moZraobebi
gamoirCeva gadaWarbebuli gamomsaxvelobiT. gaRizianebis
zRurbli daweulia. avadmyofebs aRizianebT umniSvnelo
sinaTle da xmauric ki. guneb-ganwyoba cvalebadia. Zili
zedapirulia, Tan axlavs koSmaruli sizrmebi. diliT pacienti
moTenTili da modunebulia.
II stadia – aRniSnuli aSlilobebis fonze avadmyofs aqvs
mxedvelobiTi pareidoluri iluziebi, gardamavali, epizoduri
xasiaTis orientaciis darRvevebi drosa da adgilSi.
CaZinebisas (daxuWuli TvalebiT) avadmyofs aqvs
kaleidoskopurad cvalebadi halucinaciebi. sizmrebis
intensivoba Zlierdeba, xanmokle gaRviZebebis periodSi
avadmyofs uWirs realobisa da sizmris gamijvna
(kriptomnezia).
7
III stadia – am dros viTardeba erTeuli an mravlobiTi WeSmariti
halucinaciebi. etiologiuri faqtoridan gamomdinare
halucinaciebi gansxvavdeba erTmaneTisgan (magaliTad,
zooptikuri – alkoholizmisa da kokainuri intoqsikaciis
dros). am stadiaze mxedvelobiT halucinaciebTan erTad
vlindeba smeniTi, taqtiluri, ynosviTi halucinaciebic.
avadmyofebs darRveuli aqvT garemoSi orientaciis unari,
amasTan yuradRebis miqcevis SemTxvevaSi pacientebi pasuxoben
SekiTxvebs da orientirebulni arian sakuTar TavSi.
darRveulia Zili. mdgomareobas axasiaTebs gardamavali
xasiaTi da periodulad dgeba luciduri (naTeli) periodebi
ramdenime wuTidan ramdenime saaTamde (2).
cnobierebis paTologiis gaRrmaveba miuTiTebs ZiriTadi daavadebis
damZimebaze. SeiZleba ganviTardes profesiuli, an musitirebadi
deliriumi:
profesiuli (saqmiani) deliriumis dros avadmyofebi asruleben
stereotipul, maTTvis Cveul moqmedebebs, magaliTad, sakvebis
miReba, dagva, dasufTaveba, an profesiasTan dakavSirebul
moZraobebs, magaliTad, kerva, beWdva da sxv. am dros avadmyofebi
rCebian erT adgilze, TiTqmis ar saubroben, SeiZleba gamoTqvamdnen
calkeul sityvebs. halucinacia da bodviTi ideebi sustadaa
gamoxatuli. naTeli periodebi praqtikulad ar aris.
musitirebadi (Cumi deliriumi, an deliriumi butbutiT) aris
deliriuli mdgomareoba, rodesac avdmyofi imyofeba sawolis
farglebSi, TavisTvis butbutebs da masTan kontaqtis damyareba
SeuZlebelia. gamoxatulia arakoordinirebuli, motoruli agzneba,
avadmyofebi TiTqos raRacas “taceben” (karfologiis simptomi).
profesiuli da mobutbute deliriumis dros avadmyofi ukontaqtoa.
dRis saaTebSi SesaZloa ganviTardes gabrueba, rac mdgomareobis
gauaresebaze miuTiTebs.
deliriumidan gamosvla, Cveulebriv kritikulad (ucbad) xdeba. II da
III stadiidan gamosvlis Semdeg avadmyofebs aReniSnebaT
nawilobrivi amnezia.
somaturad dauZlurebul da, gansakuTrebiT, xandazmul pacientebSi
mdgomareoba SeiZleba gagZeldes ramdenime kvira, am dros saubroben
prolongirebul, an qronikul delirze.
ZiriTadad, deliriumis Semdgom viTardeba asTenia, ufro iSviaTad,
afeqturi – subdepresiuli da depresiuli mdgomareoba. mdgomarebis
ara kritikulad (swrafad), aramed lizisurad (TandaTanobiT)
akrefis SemTxvevaSi SeiZleba darCes rezidualuri bodva.
mZime deliriuli mdgomareoba xSirad gadadis sxva fsiqoorganul
sindromebSi (22).
8
5. diagnostika
deliriumis diagnostikuri kriteriumebi ICD 10 mixedviT:
a. gamoxatulia cnobierebis aSla, e.i. gaZnelebulia garemos
gacnobierebis unari, daqveiTebulia yuradReba da
koncentracia;
b. kognituri aSliloba vlindeba erTdroulad Semdegi ori
niSniT:
1. darRveulia axlo warsulSi momxdari movlenebis
gaxsenebis unari, xolo, metnaklebad, SenarCuneulia
Soreuli ambebis gaxseneba;
2. gamoxatulia dezorientacia droSi, adgilSi, sakuTar
TavSi.
g. saxezea, sul cota, erTi romelime fsiqomotoruli aSliloba:
1. swrafi, araprognozirebadi gadasvla hipoaqtivobidan
hiperaqtivobaSi;
2. Senelebuli motoruli reaqciebi;
3. Senelebuli an aCqarebuli metyveleba.
d. darRveulia Zilisa da sifxizlis ritmi, razedac miuTiTebs
Semdegi erTi niSani mainc:
1. Zilis darRvevebi (sifxizlisa da Zilis fazebi
Senacvlebulia);
2. simptomatika mwvavdeba Ramis saaTebSi;
3. aRiniSneba mousvenari Zili, Ramis koSmarebi, romlebic
gamofxizlebis Semdeg grZeldeba iluziebisa da
halucinaciebis saxiT.
e. damaxasiaTebelia simptomebis swrafi ganviTareba da dRe-Ramuri
meryeoba;
v. arsebobs anamnezuri cnobebi, somaturi, nevrologiuri, an
laboratoriuli gamokvlevebis monacemebi, romlebic
adastureben cerebruli an sistemuri daavadebis arsebobas,
riTac aixsneba A-E punqtebSi aRwerili klinikuri simptomatika.
meaTe gadasinjvaSi calke ganixileba fsiqoaqtiuri nivTierebebiTa
da alkoholiT gamowveuli deliriumi (TeTri cxeleba F 10.4)
TeTri cxeleba (delirium tremens) – yvelaze gavrcelebuli
alkoholuri fsiqozia, romelsac axasiaTebs cnobierebis aSla,
WeSmariti mxedvelobiTi, taqtiluri da smeniTi halucinaciebi,
iluziebi da bodviTi aSlilobebi. am dros Senaxuli
autofsiqikuri cnobierebis fonze aRiniSneba labiluri afeqti,
SiSi, motoruli agzneba. ganasxvaveben TeTri cxelebis ramdenime
variants: klasikurs, reducirebuls, atipursa da Sereuls.
klasikuri deliriumi iseve viTardeba da gadis imave stadiebs, rac
sxva faqtorebiT ganpirobebuli deliriumi. mdgomareoba grZeldeba
2-8 dRe, iSviaTad - 10-12 dRe. mdgomareobidan gamosvlisas
mamakacebSi xSiria rezidualuri bodva, xolo qalebSi depresiuli
an subdepresiuli mdgomareoba. deliriums yovelTvis axlavs
9
nevrologiuri da somaturi niSnebi: kanis hiperemia, tremori,
ataqsia, kunTebis hipotonia, hiperrefleqsia, taqikardia, qoSini,
arteriuli wnevis meryeoba, sklerebis gayviTleba, subfebriluri
temperatura, SesaZloa gulyrebis ganviTarebac (aReniSneba
pacientTa 5%-s).
reducirebuli deliriumi klasikurisagan gansxvavdeba fsiqozuri
simptomatikis qvemwvave da xanmokle xasiaTiT. gamoxatuli araa
aRqmis paTologia, nawilobriv SenarCunebulia orientacia da
grZeldeba ramdenime saaTi.
atipuri deliriumis dros ufro damaxasiaTebelia endogenuri
fsiqozebis msgavsi simptomatika. suraTis gaSlis SemTxvevaSi
viTardeba ideatoruli da motoruli avtomatizmebi, senestopaTiuri
aSlilobebi da ipoqondriuli bodviTi ideebi. mdgomareobis
ganviTarebis sawyis stadiaze ukve vlindeba sxeulis sqemis moSla,
cnobierebis darRvevebi, “ukve nanaxis” fenomeni da xatovani bodva.
atipuri deliriumisTvis damaxasiaTebelia verbaluri da taqtiluri
halucinaciebi, senestopaTiuri aSlilobebi. xdeba garemo
movlenebis bodviTi interpretacia, zemoqmedebis gancda (avadmyofze
moqmedeben lazeriT, eleqtrobiT da sxv.) (24).
arakeTilsaimedo prognozze miuTiTebs temperaturis mateba (380-390),
tremoris gaZliereba, mioklonuri krunCxvebi, Zlieri fsiqo-
motoruli agzneba. deliriuli mdgomareobis damZimebis SemTxvevaSi
musitirebadi da profesiuli deliriumis ganviTarebis dros
gamoxatulia somato-vegetatiuri darRvevebi. aRiniSneba taqikardia
an bradikardia, arteriuli wnevis meryeoba, kolaptoiduri
mdgomareoba. sunTqva araTanabari da zedapirulia, xdeba organizmis
dehidratacia. sikvdilis mizezTa Soris yvelaze xSiria
TandarTuli interkurentuli daavadebebi da gul-sisxlZarRvTa
mwvave ukmarisoba (23).
1. deliriuli mdgomareobis diagnostirebisaTvis aucilebelia:
• guldasmiT Sefasdes deliriuli simptomatika ICD 10
klasifikaciaSi mocemuli kriteriumebis mixedviT.
• gatardes diferenciuli diagnozi sxva mdgomareobebTan;
yvelaze xSirad saWiro xdeba deliriumisa da demenciis
diferencireba (SesaZlebelia deliriumisa da demenciis
Tanaarsebobac).
• SeZlebisdagvarad maqsimaluri informaciis moZieba:
samedicino Canawerebidan (avadmyofobis istoria, fsiqiatrisa
da eqTnis Canawerebi), ojaxis wevrebisagan da yvela SesaZlo
wyarodan.
2. klinikuri statusis kvleva moicavs:
I. pacientis fsiqikuri statusis dadgenas:
• pacientis TviT- an sxvaTa dazianebis riskis Sefasebas;
• dazianebis riskis gaanalizebas misi simZimisa da letalobis
gaTvaliwinebiT;
10
• fsiqozuri simptomatikis - bodviTi ideebisa da
halucinaciebis gamovlenas.
II. fizikuri mdgomareobis Sefasebas:
gadatanili somaturi daavadebebisa da amJamindeli fizikuri
statusis gaTvaliswinebiT
• deliriumis dros aucilebelia, guldasmiT iqnas Seswavlili
pacientis warsuli da amJamindeli somaturi mdgomareoba da
daniSnuleba (yvela medikamentis gaTvaliswinebiT).
gansakuTrebuli yuradReba eqceva im mdgomareobebs, romlebic
warmoadgenen deliriumis gamomwvev potenciur mizezs;
• fsiqiatrTan erTad, pacientis mdgomareobis Sefasebas, xSir
SemTxvevaSi, axorcielebs Terapevti, nevrologi da sxva
specialobis eqimi.
3. aucileblad unda iqnas gaTvaliswinebuli alkoholisa da sxva
wamalmoxmareba
4. srulfasovnad unda Sefasdes sxva arsebuli fsiqikuri
aSliloba
5. srulad unda iqnas Seswavlili pacientis warsuli fsiqiatriuli
istoria:
• deliriumis epizodi warsulSi;
• TviT- an sxvaTa dazianebis tendenciebi;
• warsulSi gadatanili daavadebebis mkurnalobis efeqturoba;
• warsulSi alkoholisa an sxva wamalmoxmareba.
6. mniSvnelovania pacientis fsiqosocialuri mdgomareobis
Sefaseba, romelic moicavs:
• ojaxur da interpersonalur urTierTobebs;
• premorbidul fsiqosocialur, samuSao, sacxovrebel da
kulturalur garemos;
• gadawyvetilebis miRebas; unarSezRduli pacientis SemTxvevaSi
misi ojaxis wevris an sxva pasuxismgebeli piris gamovlenas,
vinc SesZlebs gadawyvetilebis miRebas (24).
diferenciuli diagnozi:
deliriuli mdgomareobis diferenciuli diagnozi unda gatardes
sxva organul sindromebTan, gansakuTrebiT demenciasTan (F00-F03), mwvave da tranzitorul fsiqikuri aSlilobebTan (F23.-), SizofreniasTan (F20.-), da afeqtur aSlilobebTan (25).
demenciisagan gansxvavebiT, deliriumi viTardeba mwvaved da ufro
mcire xangrZlivobisaa. demenciisaTvis ar aris damaxasiaTebeli
simptomTa fluqtuacia (simptomTa dReRamuri meryeoba). demenciis
11
sawyis stadiaze orientacia, yuradReba, aRqma, asakisTvis
damaxasiaTebeli Zil-RviZilis ritmi Senaxulia. naklebadaa
gamoxatuli fsiqo-motoruli agzneba. deliriumis dros aRiniSneba
dezorganizaciuli azrovneba, xolo demenciisas azrovnebis
gaRaribeba. deliriumis dros darRveulia xanmokle mexsiereba,
xolo demenciisas - xanmokle da xangrZlivi mexsierebac. deliriumi
SeiZleba ganviTardes demenciis fonzec (F05.1) (26,27).
mwvave da tranzitoruli fsiqikuri aSlilobebis dros, romelTac
axasiaTebs halucinaciuri da bodviTi simptomatikis mwvave
ganviTareba, afeqturi abneva da simptomTa polimorfizmi,
deliriumisagan gansxvavebiT orientacia droSi, adgilSi da
garemoSi Senaxulia.
SozofreniasTan diferenciuli diagnozis gatarebisas unda
gaviTvaliswinoT, rom deliriumis dros umetesad adgili aqvs
mxedvelobiT halucinaciebsa da xatovan bodvas, xolo Sizofreniis
dros ganviTarebuli fsiqozuri simptomatika ufro myaria, Warbobs
makomentirebeli Sinaarsis smeniTi halucinaciebi, zemoqmedebis
bodviTi ideebi da fsiqikuri avtomatizmebi. avadmyofis orientacia
droSi, adgilsa da sivrceSi Senaxulia, xolo kognituri
funqciebis darRvevebi ar atarebs globalur xasiaTs (28).
deliriumis diferenciuli diagnozi
!! deliriumi demencia depresia fsiqozebi
dasawyisi mwvave Semparavi sxvadasxva sxvadasxva
orienta
cia darRveuli darRveuli intaqturi intaqturi
xanmokle
mexsiereba darRveuli darRveuli intaqturi intaqturi
yuradRe
ba darRveuli darRveuli daqveiTebuli sxvadasxva
bodviTi
ideebi
xSiria
xatovani,
arasistemati
zebuli
bodva
zogjer
aRiniSneba
Raribi
Sinaarsis
bodviTi
ideebi
iSviaTia,
upiratesad
aRiniSneba
TviTbralde
bis da
TviTdamcire
bis azrebi
xasiaTdeba mdgradobiT,
sistematizaciisaken
tendenciiT.
xSiria zemoqmedebis
bodviTi ideebi
halucinacie
bi
Warbobs
vizualuri,
taqtiluri,
ynosviTi
iSviaTia iSviaTia upiratesad smeniTi
halucinaciebi
aSlilo
bebi
klinik
uri
niSnebi
12
mimdinareoba mwvave qronikuli sxvadasxva sxvadasxva
6. gamokvlevebis sqema
(cxrili 2)
fizikuri statusi
• istoria
• zogadi fizikuri da nevrologiuri gamokvleva
• sacicocxlo funqciebis Sefaseba
• zogadi fizikuri da fsiqikuri statusis Canawerebis
wakiTxva
• mkurnalobisa da daniSnulebis naxva da qceviT
darRvevebTan korelaciis dadgena
fsiqikuri statusi
• interviu
• mini-mentaluri statusis kvleva (MMSE)
bazisuri laboratoriuli gamokvlevebi (yvela deliriuli
pacientisTvis)
• sisxlis saerTo analizi
• sisxlis bioqimiuri analizi (eleqtrolitebi, Saqari,
kalciumi, albumini, kreatinini, bilirubini)
• Sardis saerTo analizi
• eleqtrokardiogrfia
• gulmkerdis rentgenografia
damatebiTi laboratoriuli gamokvlevebi
(klinikuri mdgomareobis mixedviT)
• sisxlis serologiuri analizi
• Tav-zurgtvinis siTxis punqcia
• kompiuteruli tomografia, birTvul-magnituri
rezonansuli tomografia
• eleqtroencefalografia (29)
13
7. mkurnalobis sqema
SemTxvevis marTva
mkurnalobis gegmis SemuSavebisas da Semdgom, misi
ganxorcielebisas, aucilebelia Semdegi ZiriTadi principebis
gaTvaliswineba:
1. sxva specialobis eqimebTan koordinireba
deliriumis mqone pacientis mkurnaloba xSirad
saWiroebs fsiqiatrisa da sxva specialobis eqimebis
mier erToblivi da koordinirebuli RonisZiebebis
gatarebas
2. etiologiuri faqtorebis gamovlena da maTze zemoqmedeba
unda moviZioT informacia pacientis avadmyofobis
istoriebidan, misi naTesavebisagan da axloblebisagan
unda Catardes laboratoriuli da radiologiuri
gamokvlevebi, raTa dadgindes deliriumis gamomwvevi
savaraudo mizezi. specifikuri gamokvlevebi iniSneba
klinikuri Sefasebis safuZvelze
3. gadaudebeli daxmarebis aRmoCena
• deliriumSi myofi pacientis mZime somaturi
mdgomareoba SeiZleba saWiroebdes saswrafo
samedicino Carevas, mizezebis aRmoCenamdec
• mudmivad unda xdebodes pacientis sacicoxlo
funqciebis monitoringi
14
4. sxva daavadebebis specifikuri mkurnalobis Catareba
deliriumis mizezebis dadgenis Semdeg aucilebelia
Sesabisi mkurnalobis Catareba
5. usafrTxoebis Sefaseba da uzrunvelyofa
• TviT- da sxvebis dazianebis riskis Sefaseba. sarisko
qceva xSirad unebliea da ganpirobebulia
halucinaciebiT an bodviTi simptomatikiT
• unda vizrunoT riskis Semcirebaze. SesaZleblobis
mixedviT unda gatardes efeqturi, magram
minimalurad SemzRudavi RonisZiebebi
o fsiquri statusis Sefaseba
• simptomebis, maT Soris, qceviTi aSlilobebis mudmivi
monitoringi, vinaidan deliriumis dros
damaxasiTebelia simptomTa fluqtuacia
• unda daisaxos Sesabamisi mkurnalobis strategia
6. pacientTan da misi ojaxis wevrebTan TanamSromluri
urTierTobis damyareba
• pacientTan Terapiuli aliansis damyareba
• pacientis axloblebTan, sxva samedicino
personalTan da momvlelebTan mWidro
TanamSromloba
7. daavadebis Sesaxeb informaciis miwodeba
• pacients (misi mdgomareobis gaTvaliswinebiT)
gasagebad da martivad unda mivawodoT informacia
deliriumis gamomwvevi mizezis Sesaxeb
• aseve mniSvnelovania deliriumis Sesaxeb Sesabamisi
informacis miwodeba sxva samedicino
personalisTvis, ojaxis wevrebisTvis, an
15
momvlelebisTvis
o postdeliriuli periodis marTva
• gamojanmTelebis Semdeg pacients da mis axloblebs
kidev erTxel unda ganemartos deliriumis
etiologia, misi mimdinareoba da klinikuri niSnebi,
raTa Tavidan aviciloT recidivi
• yuradReba unda mieqces deliriumis gamomwvev mizezs
yovel konkretul SemTxvevaSi
• deliriumis Semdgomi disstresuli simptomebis
dasaZlevad pacienti saWiroebs Tanadgomasa da
fsiqologiur daxmarebas
intervenciis saxeebi
I. garemo faqtorebis Sesusteba, romlebic xels uwyoben
deliriuli mdgomareobis ganviTarebas
• ganaTebis uzrunvelyofa imdagvarad, rom
SesaZlebeli iyos dRisa da Ramis garCeva
• monotonuri, hiper- an hipostimulebis mocileba
• pacientis garemo SeZlebisdagvarad gavxadoT misTvis
nacnobi (axlobeli adamianebis yofna, nacnobi
adgili, nivTebi, an ojaxuri fotoebi) (30-33)
II. pacientis mxardaWera
• pacientis reorientacia droSi, adgilsa da garemoSi
– reorientacia unda ganaxorcielos nebismierma
pirma, romelic daamyarebs pacientTan kontaqts (34,C)
• saWiroa pacientis gamxneveba da imis Tqma, rom es
mdgomareoba droebiTi da gardamavalia
III. ojaxis mxardaWera da ganaTleba
• pacientis ojaxis wevrebs da axloblebs unda
ganemartos deliriuli mdgomareobis mizezi da
miewodos informacia deliriumis Sesaxeb
• axloblebis da ojaxis wevrebis monawileoba
mniSvnelovania, raTa uzrunvelyon pacientisTvis
nacnobi garemos Seqmna da daexmaron mas
reorientaciaSi (35,C)
16
IV. medikamenturi intervencia antifsiqozuri preparatebi
deliriumis mkurnalobisas antifsiqozuri preparatebis gamoyenebis
efeqturoba mravaljeradi kvlevebiTaa Seswavlili (36,A., 37,A).
antifsiqozuri mkurnaloba efeqturia agreTve aJitaciisa da
fsiqozuri simptomatikis samkurnalod somaturad mZime da
xandazmul pacientebSi (38,A., 39,A).
kvlevebiT dadasturda deliriuli mdgomareobis mkurnalobaSi
antifsiqozuri preparatebis wamyvani roli benzodiazepinebTan
SedarebiT (40,A., 41,A).
antifsiqozuri mkurnalobis dros xSiria nevrologiuri
garTulebebis, gansakuTrebiT eqstrapiramiduli darRvevebis
ganviTareba. Tumca arsebobs mosazreba, rom gverdiTi movlenebi
ufro iSviaTia wamlis intravenuri Seyvanis SemTxvevaSi (42,B).
haloperidoli – Zlieri antifsiqozuri moqmedebis preparati aris
pirveli arCevis farmakologiuri saSualeba deliriumis
mkurnalobisTvis
• haloperidoli miiReba oralurad, intramuskulurad, an
intravenurad;
• haloperidolis sawyisi dozebia 1-2 mg yovel 2, an 4 sT-Si.
xandazmul pacientebSi 0,25 – 0,5 mg yovel 4 sT-Si;
• intravenuri infuzia mizanSewonilia mwvave, refraqtoruli
simptomebis mqone avadmyofebisaTvis, romlebic saWiroeben
mravaljerad mzard dozebs. aucilebelia ekg monitoringi.
haloperidolis Seyvana SeiZleba daiwyos intravenurad dozis
10 mg-mde TandaTanobiTi gazrdiT da Semdgom gagrZeldes 5-10
mg/sT intravenuri infuziiT (43,B);
• rodesac viyenebT haloperidols deliriumis samkurnalod,
aucilebelia ekg monitoringi. SesaZloa ganviTardes
ventrikuluri taqikardia, ventrikuluri fibrilacia da
dasruldes uecari sikvdiliT. aseTi garTuleba ufro xSiria
im SemTxvevaSi, Tu haloperidolis intravenurad Seyvanili
doza >35mg/dRe (44,C., 45,A).
axali Taobis antifsiqozuri preparatebi
• atipiuri neiroleptikebi (risperidoni, olanzapini da
qvetiapini), maTi naklebad gamoxatuli gverdiTi movlenebis
gamo, sul ufro xSirad gamoiyeneba deliriumis samkurnalod
• deliriumis dros am wamlebis gamoyenebis randomizibuli,
ormagi-brma, placebo-kontrolirebadi kvleva jerjerobiT ar
arsebobs (46,C., 47,C)
antifsiqozuri mkurnalobis iSviaTi garTulebebia: galaqtorea,
RviZlis enzimebis donis mateba, leikopoezis inhibicia, avTvisebiani
17
neirolefsiuri sindromi, krunCxviTi mzaoba, moZraoba-moqmedebebis
darRvevebi.
antifsiqozuri preparatebis miReba xdeba oralurad, inravenurad
da intramuskulurad, amasTan, intravenurad Seyvana yvelaze
efeqturia. haloperidolisTvis optimaluri sawyisi dozaa 1-2mg 2-4
sT-Si, agznebuli pacienti saWiroebs SedarebiT maRal dozas.
haloperidolisa da droperidolis intravenuri infuzia (uwyvetad
Seyvana, gadasxma) ufro efeqturia, vidre mzardi dozebiT
erTjeradi ineqciebis saxiT intravenuri Seyvana. amiT Tavidan
avicilebT erTjerad ineqciasTan dakavSirebul garTulebebs
(magaliTad, hipotenzias). Tu pacients esaWiroeba 8-10 mg-ze meti
haloperidoli 24 sT-is ganmavlobaSi, an 10mg/sT 5 an meti
Tanmimdevruli intervalebiT, maSin rekomendebulia intravenuri
infuzia (49,B).
benzodiazepinebi
• benzodiazepinebi monoTerapiis saxiT gamoiyeneba alkoholuri/
sedaciur-hipnozuri/benzodiazepinuri abstinenciiT, an
krunCxviT ganpirobebuli deliriumis SemTxvevebSi;
• benzodiazepinebidan upiratesoba eniWeba lorazepams, vinaidan
mas aqvs mokle naxevardaSlis periodi da araaqtiuri
metabolitebi;
• benzodiazepinebisa da antifsiqozuri preparatebis kombinacia
mizanSewonilia im pacientebisTvis, romlebic ver itanen
antifsiqotikebis maRal dozebs, an aReniSnebaT agznebisa da
SfoTvis maRali done;
• kombinirebuli mkurnaloba SeiZleba daiwyos 3 mg
haloperidoliT, ris Semdegac dauyonebliv eZleva 0,5 -1 mg
lorazepami (50,B).
benzodiazepinebis gamoyeneba gamarTlebulia garkveuli tipis
deliriumis dros, kerZod alkoholuri da benzodiazepinuri
abstinenciisas (51,C). aseve iseT SemTxvevebSi, sadac momatebulia
krunCxviTi mzaoba, an gamoxatulia antifsiqozuri mkurnalobiT
gamowveuli antiqolinerguli efeqti, rac amZimebs pacientis saerTo
mdgomareobas. sxvadasxva kvlevebiT dadasturebulia, rom
kombinirebuli mkurnaloba benzodiazepinebiTa da antifsiqotikebiT
amcirebs gverdiT movlenebs da zrdis klinikur efeqturobas
garkveul SemTxvevebSi, magaliTad simsivnis, an Sidsis dros.
haloperidolisa da lorazepamis erTdroulad intravenurad
Seyvana ufro swrafad moqmedebs deliriul simptomatikaze da
nakleb iwvevs eqstrapiramidul garTulebebs (50,B).
garTulebebi
gansakuTrebul yuradRebas saWiroebs benzodiazepinebis gverdiTi
movlenebi. naCvenebia kavSiri benzodiazepinebis gamoyenebasa da
postoperaciuli deliriumis ganviTarebas Soris. metad saSiSia
18
xangrZlivi moqmedebis benzodiazepinebi (magaliTad, diazepami.
garTulebebidan aRsaniSnavia sedacia, qceviTi ganmuxruWeba, amnezia,
ataqsia, respiraciuli depresia, fizikuri damokidebuleba, insomnia,
abstinencia da deliriumi. geriatriul pacientebSi gverdiTi
movlenebis ganviTarebis riski gansakuTrebiT maRalia. bavSTa da
mozardTa mkurnalobisas sayuradReboa qceviTi ganmuxruWebis,
emociuri labilobis, gazrdili SfoTvis, halucinaciebis, agresiis,
Zilis darRvevebis, eiforiisa da koordinaciis darRvevebis
ganviTarebis saSiSroeba (52,B., 53,C).
benzodiazepinebis gamoyeneba ukunaCvenebia hepaturi encefalopaTiis
dros glutaminis akumulaciis gamo, rac qimiurad dakavSirebulia
aminoerbomJavasTan. mizanSewonili ar aris benzodiazepinebis
gamoyeneba sunTqvis gaZnelebis drosac.
RviZlis ukmarisobis dros, an roca pacienti iRebs preparatebs,
romelTa metabolizmSi monawileobs citoqrom P450 sistema, iniSneba
iseTi benzodiazepinebi, romlebic metabolizdeba glukuronidaciiT
(magaliTad, lorazepami, oqsazepami, temazepami) (54,C).
benzodiazepinebis daniSvnisas upiratesoba eniWeba xanmokle
naxevardaSlis periodisa da araaqtiuri metabolitebis mqone
preparatebs, magaliTad, lorazepams (55,B)
ramdenime kvleviT gamovlinda, rom aucilebelia dozebis
yuradRebiT SerCeva, vinaidan benzodiazepinebi Tavad iwveven
deliriums. alkoholuri, an sedaciur/hipnozuri preparatebis
abstinenciisas ganviTarebuli deliriumis SemTxvevaSi iniSneba
xangrZlivi naxevardaSlis periodis mqone benzodiazepinebi
SedarebiT didi doziT (55,B)
onkologiur pacientebSi deliriumis mkurnalobis Seswavlam aCvena,
rom maqsimaluri efeqtis misaRwevad mkurnaloba unda daiwyos 3 mg
haloperidoliT, rasac dauyonebliv moyveba 0,5-1,0 mg lorazepami.
wamlis Semdgomi dozireba da miRebis sixSire damokidebulia
pacientis mdgomareobaze. Adams et al aCvenes, rom, Tu gaumjobeseba ar
dgeba 20 wuTis ganmavlobaSi, maSin damatebiT Segvyavs 5 mg
haloperidoli da 0,5-2,0 mg lorazepami (56,C). Zlier agznebul
pacientebSi haloperidolis saboloo dRiurma dozam SesaZloa
miaRwios 100-150 mg-s, xolo lorazepamis 20-30 mg (57,B).
qolinerguli preparatebi
antiqolenerguli meqanizmi safuZvlad udevs bevr wamliT
ganpirobebul deliriul mdgomareobas. garda amisa,
antiqolenerguli meqanizmi SeiZleba mniSvnelovani iyos hipoqsiiT,
hipoglikemiiT, Tiaminis deficitiT, qala-tvinis travmiTa da
insultiT ganpirobebuli deliriumis ganviTarebis drosac (58,C). miuxedavad amisa, qolinerguli preparatebis gamoyeneba Zalian
SezRudulia. qolinerguli preparatebis xmareba naCvenebia mxolod
aSkarad antiqolenerguli preparatebiT gamowveuli deliriumis
SemTxvevaSi. ufro xSirad gamoiyeneba qolinesTerazas inhibitori
fizostigmini, ufro iSviaTad - takrini da donezepili. sxvadasxva
19
kvlevebiT gamovlinda, rom fizostigminiT mkurnaloba efeqturi
aRmoCnda atropiniTa da skopolaminiT (59,A), ranitidiniT (60,B),
homatropiniT (61,B), benztropiniTa (62,A) da meperidiniT (63,B)
gamowveuli deliriuli mdgomareobis samkurnalod.
antiqolinerguli preparatebiT ganpirobebuli deliriumis takriniT
mkurnalobis Sesaxeb arsebuli monacemebi umniSvneloa.
axali qolinesTeraza inhibitorebis efeqturoba, romelTac
takrinze naklebi gverdiTi movlenebi axasiaTebs, jerjerobiT ar
aris Seswavlili.
qolinerguli preparatebis gverdiTi movlenebi
gverdiTi efeqtebidan SesaZloa gamovlindes bradikardia,
gulisreva, pirRebineba, hipersalivacia, kuWnawlavis mJavianobis
momateba. fizostigminma SesaZloa gamoiwvios krunCxva,
gansakuTrebiT intravenurad, swrafad Seyvanis SemTxvevaSi (64, B).
takrini iwvevs RviZlis enzimebis usimptomo matebas, TiTqmis samjer
gazrda dafiqsirda daaxloebiT 30% pacientSi. es mdgomareoba
Seqcevadia preparatis dozis Semcirebasa da SewyvetasTan erTad.
SemTxvevaTa 5-10%-Si adgili aqvs RviZlis fermentebis ufro
gamoxatul, magram zogadad Seqcevad zrdas. am dros aucilebelia
takriniT mkurnalobis dauyonebliv Sewyveta (65, A).
fizostigmini Cveulebriv oralurad miiReba, Tumca deliriumis
samkurnalod, agreTve, gamoyeneba intavenuri da intramuskuluri
ineqciebi 0,16-2 mg doziT, an intravenuri gadasxma 3 mg/sT (59-65). takrinis gamoyeneba deliriumis samkurnalod praqtikulad ar aris
Seswavlili. antiqolinerguli mkurnalobiT ganpirobebuli
deliriumis dros calkeul SemTxvevebSi gamoiyenebuli iyo 30 mg
takrini (65, A).
eleqtro-krunCxviTi Terapia
ekT ar aris miCneuli efeqtur Terapiad deliriumis SemTxvevaSi.
kvlevebSi, romlebic am mimarTulebiTaa Catarebuli, mTeli rigi
xarvezebia daSvebuli; mdgomareobis sadiagnostikod ar aris
gamoyenebuli standartizebuli kriteriumebi da mgomareobis
Sefasebis skalebi. Sizofreniis, maniis, fsiqozuri depresiis mqone
pacientebs daesvaT deliriumis diagnozi imis gamo, rom
aReniSnebodaT dezorganizebuli azrovneba da kognituri
gauareseba; aseve mwiria monacemebi Tavad proceduris Catarebis
Sesaxeb (66-72).
vinaidan ar arsebobs myari mtkicebuleba ekT-iT deliriuli
mdgomareobis mkurnalobis efeqturobis Sesaxeb, amdenad, misi
gamoyeneba mxolod iSviaT SemTxvevebSia mizanSewonili. garda amisa,
ekT garkveul risks warmoadgens arastabiluri somaturi
mdgomareobis pacientebisTvis. ekT SeiZleba dainiSnos
neirolefsiuri avTvisebiani sindromis SemTxvevaSi, magram ara,
rogorc ZiriTadi, inicialuri mkurnaloba. ekT-s gamoyeneba
safrTxiloa parkinsonis (gansakuTrebiT, Tu pacienti iRebs
20
karbidopas), Huntington daavadebebisa, an insultis dros
ganviTarebuli deliriumis SemTxvevaSi (73, B).
metaboluri darRvevebi
arasrulfasovani kveba da vitaminebis nakleboba iwvevs deliriuli
mdgomareobis ganviTarebas, amitom aseT SemTxvevebSi efeqturia
deficituri nivTierebis Seyvana. magaliTad, hemodializze myof
pacientebs, romlebsac aReniSneba nikotinamiduri ukmarisoba,
uviTardebaT deliriumi bodviTi simptomebiT, romlis
samkurnalodac gamoiyeneba 500 mg/dRe nikotinamidis
parenteralurad Seyvana (74, B). arasrulfasovani kvebisa da
vitaminebis deficitis mqone qronikuli alkoholizmiT daavadebul
pacientebSi B jgufis vitaminebis intravenurad Seiyvana iwvevs
swraf gaumjobesebas (75, B). B jgufis vitaminebi gamoiyeneba Tiaminis
deficitis drosac (76, B). operaciis win da Semdgom B da C vitaminebis intravenuri Seyvana xandazmul pacientebSi amcirebs
postoperaciuli deliriumis ganviTarebis risks (77, A).
detoqsikacia (78, D)
intoqsikaciiT ganpirobebuli deliriumis dros ZiriTad
mkurnalobasTan erTad tardeba detoqsikacia, romlis drosac:
• intravenurad wveTovnad SehyavT glukoza, an Nacl-is izotonuri xsnari; pacients eZleva didi raodenobiT siTxe;
• tvinis SeSupebis Tavidan acilebis mizniT gamoiyeneba
dehidrataciuli saSualebebi – furosemidi, manitoli,
magniumis sulfati da a.S.
• karg Sedegs iZleva nootropebisa da antioqsidantebis
gamoyeneba
detoqsikaciis Catareba mizanSewonilia im SemTxvevaSi, rodesac
toqsikuri nivTiereba bolomde ar aris gamosuli organizmidan. Tu
toqsikuri nivTiereba cnobilia, maSin naCvenebia maTi
makoreqtirebeli nivTierebebis gamoyeneba, magaliTad atropinis
gamoyeneba fosfororganuli naerTebiT mowamlvisas, an natriumis
marilebis gamoyeneba liTiumis marilebiT intoqsikaciisas da a.S.
sxva danarCen SemTxvevaSi gamoiyeneba zogadgamajansaRebeli Terapia,
maT Soris, vitaminoTerapia. mdgomareobidan gamomdinare, gamoiyeneba
simptomuri saSualebebic: sedaciuri – agznebisas, analefsiuri,
bemegridi – komuri mdgomareobebis dros, gul-sisxlZarRvTa
saSualebebi – sisxlis mimoqcevis moSlis SemTxvevaSi,
antiparoqsizmuli – krunCxviTi gantvirTvebis dros.
mwvave alkoholuri intoqsikaciis SemTxvevaSi gamoiyeneba 20 ml 40%
glukozis, 15 erT insulinis, 10 ml 5% askorbinis mJavisa da 1 ml
1% nikotinmJavas intravenuri Seyvana. aseve intravenurad wveTovnad
SehyavT 250 ml hemodezi 250 ml natriumis qloridis izotonur
xsnarTan erTad, 10 ml pananginis, 3 ml 5%-iani B6 vitaminis, 3ml 5% B1 da 5ml 5% C vitaminis damatebiT.
21
8. gaidlainis gadasinjvisa da ganaxlebis vada – 3 weli
9. gaidlainis miRebis xerxi/wyaro
1. The Maudsley Prescribing Guideline 2005 –2006 8-th edition; 2. Practice Guideline for the Treatment of Patients with Delirium., APA., 2007
. SemuSavda arsebuli rekomendaciebis adaptirebuli varianti,
romelic erTis mxriv pasuxobs saerTaSoriso moTxovnebs, xolo
meore mxriv iTvaliswinebs saqarTvelos samedicino
dawesebulebaTa rogorc adamianur, ise teqnikur resursebs.
10. alternatiuli gaidlaini ar arsebobs
11. gamoyenebuli literatura
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eqspertebi:
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socialuri dacvis saministros janmrTelobis dacvis
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