Transcript A Confused Old Man

HKCEM College Tutorial
A Confused
Old Man
AUTHOR
DR. E. YUEN
REVISED BY
DR. WONG CHEUNG LUN WILLIAM
OCT, 2013
Triage note
▪ 76 years old man
▪ ‘Decrease GC?’
▪ BP 170/50
▪ HR 120
▪ RR 20, SaO2 97% on 2L O2
▪ GCS 14 (E4 V4 M6)
▪ Temp 38°C
History
▪ Brought in by Home helper
▪ Notice ‘Not quite himself’
▪ Home helper left before attended by MO
▪ No relative/ informant available
▪ Pt talking nonsense & not answering questions
Where else can you find more information about him?
History from CMS
▪ COAD, DM & HT
▪ Last admitted one month ago for pneumonia
▪ Exercise Tolerance: 5 min level ground
▪ Home Oxygen 1L/min
▪ Drug History:
▪ Adalat retard, Diamicron, Ventolin, Becloforte
▪ Living alone
▪ Meals-on-wheels from home help
What are the 3Ds for
confusion in elders?
DELIRIUM (TOXINS)
DEMENTIA (DEGENERATED BRAIN)
DEPRESSION (PSYCHIATRIC PROBLEMS)
How do you evaluate the mental status ?
▪ Appearance and
behavior
▪ Self caring ability
▪ Mood and affect
▪ Speech
▪ Thought process
▪ Delusion
▪ Perception
▪ Hallucination
▪ Cognitive function
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Orientation
Memory
Attention
Concentration
▪ Insight
What is the Mini-Mental State Exam?
Mini-mental state examination (MMSE)
▪ Level of consciousness ▪ Attention span and
calculation
▪ Alert, Drowsy, Stupor,
Coma, Fluctuating
▪ Orientation
▪ Serial 7
▪ Language ability
▪ Time, Place, Person,
Purpose
▪ Dysnomia (name object)
▪ Dysgraphia (writing)
Most sensitive
indicator of delirium
▪ Memory
▪ Short and Long term
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In US & many western countries
9+ education: MMSE≤23 :
Cognitive impairment
In Hong Kong (Chiu et al, 1994,1998)
- Cut off 19/20
- illiterate: 18 or below
- 1-2 years schooling: 20 or below
- > 2 years schooling: 22 or below
Cognitive impairment ≠ Dementia
Abbreviated Mental Test (AMT)
▪ Consists of 10 simple questions
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Age (±5 years)
Time (Nearest to hour, AM/noon/PM)
Address for recall at the end of test
Year (±1 year)
Place name
Recognition of two persons
Date of birth (day and month)
Date of mid-Autumn festival
Name of present Governor or Chinese leader
Count 20 -1 backwards
▪ Cut off: 6, below 6 = cognitive impairment
Examination
▪ Drowsy, Dehydrated, Urinary incontinence
▪ NO sign of Head Injury or trauma
▪ Temp: 38 oC
▪ BP 170/50, HR 120, Normal Heart sound
▪ Wheezy chest
▪ Abdomen soft
▪ No meningism
▪ Unable to perform CNS exam
What are your
Differential Diagnosis?
Cause of acute confusion – I WATCH DEATH
Potential cause
Differential Diagnosis
Potential cause
Differential Diagnosis
Infection
Sepsis, encephalitis, meningitis,
syphilis, CNS abscess, UTI
Deficiencies
Vit B12, thiamine,
Withdrawal
Alcohol, sedative hyponotics,
Environmental
Hypo/hyperthermia,
endocrinopathies,
diabetes, adrenal,
thyroid
Acute
Acidosis, electrolyte disturbances,
hepatic/renal failure, other
metabolic disturbances
Acute vascular
Hypertensive
emergency, SAH,
Sagittal vein
thrombosis
Toxin/drugs
Medications, alcohols,
Heavy metal
Lead, mercury
metabolic
barbiturates
Trauma
Head, burns
CNS
Hemorrhage, CVA, seizures, tumor,
vasculitis
hypovitaminosis, nicacin,
street drugs, CO, CN, Solvent
disease
Hypoxia
Acute hypoxia, chronic lung disease, hypotension
Smith J, Seirafi J. Delirium and dementia. In: Marx JA III, Hockberger RS, Walls RM, eds. Rosen’s Emergency
Medicine Concepts and Clinical Practices. 7th ed. Philadelphia, PA: Elsevier; 2010:1367–73.
Commonly prescribed drugs associated with delirium
Drug
Examples
Drug
Examples
Sedative
Hypnotics
Benzodiazepines
Barbiturates
Sleeping medications
Nacrotics
All
Anticholingerics
Antihistamines
Antispasmodics
TCA
Neuroleptics
Incontinence
Oxybutynin
Hyoscyamine
Atropine
Cardiac
Digitalis glycosides
Antiarrhythmics
Antihypertensive
(beta-blocker, aldomet)
GI
H2 blocker
PPI
Metoclopramide
Herbs
Agostini JV, Inouye SK. Delirium. In: Hazzard WR, Blass JP, Halter JB, et al, eds.
Principles of Geriatric Medicine & Gerontology. 5th ed. New York, NY:
McGraw-Hill; 2003:1503–15.
What tests would you
perform?
Investigation
▪ Hb 10.2, H’stix 16
▪ ECG:
▪ Sinus Rhythm with RBBB
▪ No ST segment change or new T wave abnormality
▪ Urine multistix:
▪ RBC 1+, WBC 4+, Protein -ve, Ketone 1+
▪ CXR:
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Hyperinflated chest
No pneumothorax
No consolidation
Apical fibrosis
The likely diagnosis?
▪ Delirium
▪ Underlying urinary tract infection
▪ Confused patient
▪ Missed dose of DM/ HT drug
▪ Not eating or drinking for 2 days
What is the immediate management?
▪ Rehydration – Fluid resuscitation
▪ Management of sepsis – Blood/Urine C/ST, Antibiotics
▪ Relief bronchospasm – Inhale Ventolin
▪ Admission for further stabilization
Acute Confusion in Elderly
▪ Delirium (Toxic confusion)
▪ Dementia (Organic confusion)
▪ Depression (Psychiatric confusion)
Delirium
“A disturbance of consciousness and a change in
cognition that develops over a short period of time”
American Psychiatric Association
Acute onset or fluctuating course
Transient cerebral dysfunction
Reversible decline in
attention and cognition
▪
Inattention
▪
Altered level of consciousness
▪
Disorganised thinking
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Aggression, restless behaviour and
hallucinations
▪
Often worse at night
3 Forms of Delirium
Hyperactive
Mixed
Hypoactive
Delirium
▪ Hyperactive form
▪ Agitation, increased vigilance, hallucination
▪ Hypoactive form
▪ Lethargy and reduce psychomotor functioning
▪ More common, underdiagnosed, poorer prognosis
Confusion Assessment Method (CAM)
Features
Assessment
1. Acute onset and
fluctuating course
“Is there evidence of an acute change in mental status from the
patient’s baseline?”
“ Did the abnormal behavior fluctuate during the day, that is tend
to come and go, or increased and decrease in severity?”
2. Inattention
“Did the patient difficulty focusing attention, for example, being
easily distractible or having difficulty keeping tack of what was
being said?”
3. Disorganized thinking “Was the patient thinking disorganized or incoherent, such as
rambling or irrelevant conversation, unclear or illogical flow of
ideas, or unpredictable switching from subject to subject?”
4. Altered level of
consciousness
(Positive if any answer
other than “Alert”)
“Overall, how would you rate this patient’s level of
consciousness?”
Normal = Alert
Drowsy, easily aroused = Lethargic
Unarousble = Coma
Hyperalert = Vigilant
Difficult to arouse = Stupor
Diagnosis of delirium: 1 AND 2 plus either 3 OR 4
Management of Delirium
▪ Admission usually required
▪ Unless the cause is easily reversible
▪ or the delirium abates in ED
▪ Identify and treat the precipitating cause(s)
▪ Simple measures (frequently overlook)
▪ Adequate lighting
▪ Close monitoring with one-to-one support
▪ ideally a family member or caregiver
▪ A quiet environment to decrease sensory overload
▪ Use of hearing aids/glassess
Management of Delirium
▪ Elderly with hyperactive delirium
▪ Chemical restrain may be required to complete the examination
▪ Haloperiodol (0.5-1mg intramuscular) may be effective
▪ Beware of QTc prolongation, elderly with ACS, decompensated CHF
▪ Acute dystonic reaction
▪ Lorazepam (1mg intramuscular/intravenously)
▪ A prospective study revealed combination of both lorazepam and haloperidol
appeared to be more effective during 1st hour of treatment
▪ Beware of respiratory suppression (Flumazenil may be needed)
▪ May cause further confusion, reduce attentiveness and
impair orientation
▪ Minimize the use of sedative medications
▪ Risperidone (0.25 – 0.5mg oral)
▪ Effective, with fewer extrapyramidal side effect
Dementia
“A decline in intellectual function affecting memory and other
cognitive functions which occurs in clear consciousness”
▪ Prevalence
▪ 5-10% above 65 years old, 20% above 80 years old
▪ Increases with age, very rare below 55
▪ Mini-mental examination helpful
▪ Disorder of cognitive function
▪ Memory loss – Salient feature
▪ Memory loss for recent events more severe than remote events
▪ Confabulation may be present
▪ Loss of intellect and Loss of insight but clear consciousness
▪ Judgment and general knowledge impaired
▪ Disorientation in time, place and person
Dementia
▪ Language Problem
▪ Word finding difficulties initially
▪ May talk nonsense or incoherent, mute at late stage
▪ Delusion and hallucination
▪ May have paranoid ideas, delusion of theft
▪ Behavior changes
▪ Inappropriate behavior, distractibility, restlessness
▪ Change in personality
▪ Mood changes
▪ Sleep and appetite disturbance
▪ Impaired function
▪ Physical and functional ADL
Dementia Causes
▪ Alzheimer’s disease
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The most commonest cause
Senile plaques and neurofibrillary tangles in the cortex
Subcortical reduction in neurotransmitters
Insidious in onset, with slow deterioration
Mean survival of 5 - 7 years
• Multi-infarct dementia
• 25% of cases
• Multiple small strokes, sudden onset with stepwise deterioration
Dementia Causes
▪ Other causes
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Dementia with Lewy bodies
Chronic alcohol abuse
Jakob-Creutzfeldt disease
HIV infection
▪ Anoxia - CO poisoning, post-cardiac arrest
▪ Potentially reversible cause (10-15%)
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Hypothyroidism
Syphilis
Deficiencies of thiamine, B12 and folate
Subdural Haematoma (SDH)
Normal pressure hydrocephalus
Management of Dementia
▪ Admission for sudden deterioration in known demented patient
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Inability to report somatic symptoms
Manifestation of disease may be atypical
Often suffered from multiple co-morbidity
Prevention of complications
(infection/malnutrition/incontinence/delirium)
▪ Definite new diagnosis of dementia
▪ Seldom made in A&E
▪ Frequently required admission for workup
▪ Need to rule out reversible causes
Depression
▪ May presented up to one third of older ED patients
▪ Interfere the clinical presentation of acute medical
disorders
▪ May manifest with demanding & withdrawn behavior;
hypochondria, difficulty to sleep and a loss of self interest.
▪ Consider admission for those living alone, physically
incapacitated, previous suicidal attempts
3 Item Emergency Department Depression Screening Instrument
(ED-DSI)
In general… History
▪ Need reliable source of history e.g. family member
▪ Baseline functional and cognitive
▪ Temporal course of symptoms and signs
▪ History of fall and head injury
▪ New-onset of incontinence is a common presentation
of delirium
▪ Drug history
▪ Medication is the single most commonest reversible
cause of delirium
▪ Past medical history
Examination
▪ Evidence of trauma, dehydration
▪ Autonomic instability
▪ e.g. diaphoresis, tachycardia, fever …etc
▪ Focal neurological signs
▪ Mental status examination
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Level of consciousness (AVPU, GCS, Fluctuating conscious level)
Orientation in time, place, person
Attention span
Memory, Speech
Thought content and process
Investigations
▪ Blood glucose
▪ CXR (for Pneumonia)
▪ ECG (for ACS)
▪ SpO2
▪ Renal function test
▪ Dehydration and electrolyte disturbance
▪ CT scan for focal CNS pathologies
Discharge an elderly only if
▪ Go home safely
▪ Cope with their daily living
▪ e.g. cooking, shopping and dressing up
▪ Medication
▪ Understand existing and new medications
▪ Caring issue
▪ Their relatives and friends can cope with looking after them
If Not
▪ Discharge is risky
▪ Seek help from medical social workers
▪ ‘Meals on wheels’, Emergency accommodations
▪ Community nurses (CNS)
▪ Services such as change of dressings and urinary catheters
Learning points
▪ Remember the three categories of Confusion
▪ Screening tools for Delirium, Dementia, Depression
▪ History is especially important to ascertain the previous
mental state
▪ Rapidly identifiable causes include infection, drug
effect and, metabolic causes
▪ Must rule out Head Injury
▪ Consider home & social condition before discharging
The end