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.

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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

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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

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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.

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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).

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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).

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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

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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;

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• 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

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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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