Transcript Altered Mental Status

Altered Mental Status
Susan Budnick, MD
Goals of this lecture…

To provide a framework for assessing patients when called for acute altered
mental status in hospitalized patients

To learn how to begin diagnostic workup for patients that are acutely altered

How to manage basic issues that can cause patients to be altered in an acute
setting
There are many causes of altered
mental status…

Encephalopathies

Hypertensive encephalopathy 

Hypoxic encephalopathy

Drug reactions like NMS

Metabolic encephalopathy:

Environmental causes

Infarction


Hemispheric, brainstem
CNS infections/inflammation

Hypoglycemia

Hypothermia

Encephalitis

Hyperosmolar states
(hyperglycemia)

Hyperthermia

Anti-NMDA receptor
encephalitis

Hyponatremia

Hypernatremia

Hypercalcemia

Sepsis

Uremia

Primary CNS disease or trauma

Hepatic encephalopathy

Direct CNS trauma

Organ failure

Addison’s disease

Hypothyroidism

CO2 narcosis

Deficiency state




Neoplasms

Seizures

Diffuse axonal injury

Subdural/epidural hematoma 
Vascular disease

Toxins
Wernicke encephalopathy
Intraparenchymal hemorrhage
Subarachnoid hemorrhage
And this list is not complete…



Nonconvulsive status
epilepticus

Postictal state
Psychiatric
Acute psychosis
Malingering
A useful mnemonic….AEIOU TIPS

A – Alcohol, Alzheimer’s

E – Endocrine, electrolytes

I – Infections, intoxications

O – Opiates, oxygen (hypoxia)

U - Uremia

T – Tumor, treatments

I – Insulin

P – Poisoning, psychosis (delirium)

S – Seizure, shock, stroke, SAH
Let’s talk about AMS…

Let’s go through some cases (5) and create a differential of the most likely
causes for AMS in each patient.

Use a patient’s clinical history to guide your workup for AMS


Even if they cant give you a history!
What’s the most important thing to remember when assessing a patient with
an acute change in mental status?

ABCs! Don’t forget the basics
Case 1: a 72 yo M admitted for COPD
exacerbation

You are on NF at UH and you get a call about a patient that was just admitted
earlier this evening. According to your signout, the patient is a 72 yo M with a
PMHx of COPD, HTN, and poorly controlled DM that was admitted for a presumed
COPD exacerbation. The nurse calls and states that during the 9pm vital checks,
the patient seemed lethargic and wasn’t answering questions appropriately.

What do you want before you hang up the phone?


Vitals: 95, 135/84, 37.2, 20, 92% on 4L O2 by NC
Top differential while walking to the room?

Hypercapnic respiratory failure, acute on chronic respiratory acidosis

hypoglycemia

iatrogenic/medication

Electrolyte abnormality since labs might still be pending
Case 1: a 72 yo M cont’d…

Next move?

Evaluate the patient

Reasonable labs

FSBG

ABG if any signs of respiratory distress

Renal panel (check electrolytes, calculate an AG)

CBC

The FSBG shows a glucose of 36

What’s next?

Ask the nurse to give an amp of D50

See how much and what type of insulin he received
Case 1: a 72 yo M cont’d…

What does an amp of d50 do to a pt’s BG?

It’s hard to say to since we aren’t a static system.

50cc of 50% D50 = 25g dextrose

It should raise our BG for at least a short period of time
Case 1: a 72 yo M cont’d…

Follow through… What else will you have to do before this issue is solved?


Look to see how much insulin the patient got and is scheduled to get
What if the repeat BG after 30 minutes is 50?

Repeat the hypoglycemia protocol!

If the patient got a large bolus of insulin, they could need a D5 drip or another amp
D50 before this issue is resolved.
Case 2- 36 yo F with abdominal pain

It’s your first day on the Dworken service and you are just learning about your new
night float admits. J.R. is a 36 yo F with a PMHx of Crohn’s s/p colectomy and a
total of 9 intra-abdominal surgeries that was admitted yesterday with increased
abdominal pain concerning for a Crohn’s flare. When you saw her while prerounding
at 6:45 am, she seemed tired and slow to answer questions but you had just woken
her up and she was still appropriately answering you. At that time, her vitals were
stable and her physical exam was unremarkable other than a tender, but nonsurgical appearing abdomen. Morning labs were still pending.

You get called during rounds by the nurse at 9am who is concerned that the patient
seems “out of it” and would like a doctor to come assess her.

Top differential on the way to the room?

Sepsis 2/2 intra-abdominal process

Iatrogenic – medication related

Less likely things- PE? Syncope?
Case 2- 36 yo F w abdominal pain cont’d…

First move?


Get fresh vitals- 37.1, 78, 108/74, 7, 86% on room air
Next?

Start some oxygen by NC

Look at current inpatient medication list

IV steroids

Lisinopril 10mg

IV dilaudid 2mg Q4H

IV morphine 4mg Q2H
Case 2- 36 yo F w abdominal pain cont’d…


Decision time… more data or a plan?

Naloxone 0.4mg IV push

The patient wakes up and is no longer lethargic and is complaining of pain
Follow through…

Patient may need more naloxone – it is short acting and may need to be redosed in
30 minutes or so

Decrease the amount of pain medications she is getting!

Communicate with the team including the nurses about how to proceed.
Case 3 – 84 yo M admitted for chest pain

Your patient M.R. is an 84 yo M with a PMHx of CAD s/p PCI and stent
placement in 2014, BPH, and HTN that was admitted 1 day ago for chest pain
rule out. In the ED, a foley catheter as placed for urinary retention thought to
be secondary to BPH. All of his cardiac workup has been negative. He was
kept over a long holiday weekend for PT/OT assessment on Monday for social
concerns at home. On the morning of his planned discharge to SNF, you find
him during prerounds more confused than usual. He is answering questions
appropriately but only oriented to his own name. According to the overnight
nurse, he was a little confused last night when getting his evening meds but
she thought he looked “ok”

The nurse asks, “what do you want me to do?”

Top differential diagnosis before answering her?

Sepsis, UTI

PE

Medication related/iatrogenic

Hypotension/decreased cerebral perfusion 2/2 to ACS?
Case 3 – 84 yo M cont’d…


First move? More data…
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Get vitals – 37.3, 68, 114/86, 14, 96% on RA

Exam: In NAD, Oriented to name only, RRR, good pulses, clear lungs and no focal neuro
findings…

Labs- morning renal panel, FSBG, CBC are already pending. Ask RN to get UA and culture
What’s next?

Look at the medication list:

Aspirin 81mg

Clopidogrel 75mg

Metoprolol 25mg BID

Lisinopril 20mg

Melatonin 3mg

Finasteride 5mg

Tamsulosin 0.4mg

Morphine 4mg IV Q6H PRN chest pain – but he hasn’t received it in the last day
Case 3 – 84 yo M cont’d…


He appears stable for now – not
hypoxic, good vitals, no focal exam
findings.

Renal panel:

Na 142

K 4.3

Cl 104

HCO3 24

BUN 9

Creatinine 0.97

CBC with 11.5>13.5/38.2<291

The UA comes back with + moderate
LE, + mild nitrite, trace ketones and
81 WBCs.

Now what?

Start antibiotics for CAUTI

Remove foley with voiding trial but
may need to be replaced with a new
one
Follow through…

Check back with your patient to
make sure he is still stable and is
improving with treatment
Case 4- 87 yo F admitted for HFrEF and
severe AS

You admit an 87 yo F with a PMHx of severe aortic stenosis and valvular HFrEF (EF
25%, 3 recent hospitalizations for ADHF) that was admitted for TAVR workup.
Other PMHx includes recurrent UTIs, HLD, and type 2 DM (last HbA1c 7.2%). The
patient completed TAVR workup including her coronary angiogram and LHC
negative for any ischemic disease. She is now awaiting TAVR scheduled 4 days
from now.

When you see her this morning, she is less animated than usual. Although she
awakens when you touch her arm, she is not oriented to time or place and
quickly falls back asleep. You talk to the evening nurse that says she was awake
all night and agitated. She was calling out and trying to get out of bed without
assistance.

Later on rounds, she is more alert but only oriented to her name. While
presenting to the attending, you list Altered Mental Status on her problem list.
She asks for your differential diagnosis…
Case 4- 87 yo F cont’d…


Differential Diagnosis?

Delirium

Hypoglyemia

UTI, sepsis

DVT, PE

Other cause of sepsis – HCAP?

Iatrogenic- medications
First move?

Get vitals – 37.5, 86, 108/68, 97% on 2L O2 by NC (improved since
admission with diuresis)

Order some labs

FSBG (ASAP), renal panel, CBC (morning labs pending), ABG, UA and
culture
Case 4- 87 yo F cont’d…

What’s next?


Exam: Alert, oriented to name only, No focal neurologic findings,
RRR, AS murmur unchanged, good distal pulses, crackles to mid lung
fields, 1+ pitting edema, JVP at 10cm.
Labs show:

BG: 92

Renal panel: 136/3.8/106/23/8/0.74<86

CBC: 9.8>13.1/36.0<264

7.38/42/78
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UA with no nitrites, leuk esterase, no sugar, protein or RBCs
Case 4- 87 yo F cont’d…
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Medications:
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Metoprolol 25mg BID

Simvastatin 20mg
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Lisinopril 5mg daily

Lasix 40mg PO BID
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Mild sliding scale insulin

Heparin SQ 5000 units TID (you made sure she has been getting
this since admission)
Anything else you could consider?

CXR
Case 4- 87 yo F cont’d…
Case 4- 87 yo F cont’d…
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Decision time.

Patient sounds volume overloaded – needs diuresis

For the AMS?



No clear etiology at this time but patient is HDS and dangerous etiologies are ruled out or
much less likely.
Diagnoses still in the differential?

Most likely ? Delirium (a diagnosis of exclusion)

PE. Why is this much less likely?
How to treat…

Minimize sedating medications, family and frequent reorientation, remove lines if not
necessary, sleep hygiene (consider adding melatonin if sundowning), etc.
Case 5: 52 yo M admitted for AMS

M.K. is a 52 yo M with a PMHx of COPD, HTN and cirrhosis 2/2 hep C (never
underwent treatment, active IVDU) that was admitted to UH 2 days ago for
altered mental status. A diagnostic and therapeutic paracentesis showed no
evidence of SBP. The patient was not compliant with his home medications
and became progressively more altered until family brought him back to the
hospital.

Now the nurse is calling you saying that he seems more altered than he did
yesterday when she took care of him. He only wakes up to sternal rub and
hasn’t been awake enough to take any oral medications all day.
Case 5: 52 yo M, cont’d…
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
You talk to the nurse for a history…
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No falls

He isn’t taking any opioids

No fevers, BP is at baseline, not tachycardic (but on a beta blocker)

CT on admission negative
Differential diagnosis for AMS in this patient?

Hepatic encephalopathy

Sepsis- SBP vs. endocarditis vs. aspiration PNA vs. UTI

DVT, PE- hypercoagulable state

CVA- septic emboli (recent IVDU)

Iatrogenic – look at med list

GI bleed
Case 5: 52 yo M cont’d…

First move?

Get vitals: 37.3, 67, 97/62, 95% on RA

Examine patient:

Neuro: Alert to sternal rub, can say name, DOB but confused when asked
questions, quickly falls back asleep, moving all extremities, no obvious CN
deficits (but exam difficult), + asterixis

Cardiac: RRR, no MRGs

Pulm: CTAB but not following commands and taking deep breaths

Abdomen: Distended, dull to percussion, non-tender, no guarding, rigidity

Extremities: +2 peripheral edema to the knee, good distal pulses
Case 5: 52 yo M cont’d…

Medications:

Nadolol 40mg

Spironolactone 100mg

Lasix PO 40mg BID

Lactulose 30mg BID

Daily MTV

Duonebs Q6H prn

Fluticasone + Salmeterol (Advair)
Case 5: 52 yo M cont’d…

Labs?

FSBG: 89

ABG: 7.35/43/92

Renal panel: 133/4.3/106/25/8/1.2<90

CBC: 8.5>11.5/32.1<148

UA: Negative for nitrites, LE, RBCs, trace proteins

Blood cultures from admission (2 days ago) are negative

Ammonia?

Not something we clinically follow. Used for diagnosis rather than following
improvements, deterioration of clinical status.

Returning to the differential diagnosis?

Hepatic encephalopathy

Sepsis- SBP vs. endocarditis vs. aspiration PNA vs. UTI

DVT, PE- hypercoagulable state

CVA- septic emboli (recent IVDU)

Iatrogenic

GI bleed

Most likely Dx?

What about the other diagnoses?
Case 5: 52 yo M cont’d…

Decision time…


Place an NG and lactulose Q2H until patient wakes up
Follow through…

Liver patients are often critically ill, even if they are on the floor

Check back early and often!

If not improving, consider a paracentesis to rule out SBP, etc.

Reconsider your differential!
Key points…

Think through your patient’s unique clinical history to narrow the ddx for AMS

Always remember the basics when assessing an altered patient -> ABCs

Code whites and BATs exist for a reason

Many etiologies that are life threatening can be ruled out quickly if needed


FSBG, vitals, ABG, UA, stat head CT if warranted
Clinical history is still important – even if the patient can’t provide it

Look at medications the pt is getting (!!), talk to nurses/techs that might know the
pts baseline

Call family if needed. They are often very helpful!