Transcript Altered_Mental_Status

Altered Mental Status
Definitions
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Confusion: (encephalopathy): unable to maintain
coherent thought process
Delirium: confusional state with additional sympathetic
signs
Drowsiness: decreased level of consciousness, but
rapid arousal to verbal or noxious stimuli
Stupor: impaired arousal to noxious stimuli, but
preserved purposeful movements
Coma: sleep-like state of unresponsiveness, with no
purposeful response to stimuli
Delirium
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DSM-IV lists four key features:
Disturbance of consciousness with reduced ability to focus, sustain,
or shift attention.
A change in cognition or the development of a perceptual disturbance
that is not better accounted for by a preexisting, established, or evolving
dementia.
The disturbance develops over a short period of time (usually hours
to days) and tends to fluctuate during the course of the day.
There is evidence from the history, physical examination, or
laboratory findings that the disturbance is caused by a medical
condition, substance intoxication, or medication side effect.
Delirium
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Impairment in LEVEL of consciousness
30% of older medical patients will have delirium while
hospitalized
Generally considered reversible
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Symptoms after hospitalization may take months to resolve
Less than 40% of elderly still independent a year after a
hospitalization with mod-severe delirium
50% of those diagnosed with delirium on hospital
admission will have a diagnosis of dementia within
one year
Associated one and six mo. mortality: 14 and 22%,
respectively
DDx: Mental Status Changes
Mnemonics
DOGMIST Mnemonic
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Drugs
Oxygen
Glucose
Metabolic
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electrolytes
endocrine
hepatic
renal
vitamins & minerals
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Ischemia
Infection
Seizure
Sleep/wake cycle
Trauma
Toxins
SMASHED Mnemonic
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Substrate deficiencies
Meningoencephalitis or mental illness
Alcohol or accident
Seizures
Hypers and hypos
Electrolyte abnormalities or encephalopathies
Drugs
I WATCH DEATH Mnemonic
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Infection
Withdrawal
Acute metabolic
Trauma
CNS pathology
Hypoxia
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Deficiencies
Endocrinopathies
Acute vascular
Toxins or drugs
Heavy metals
MOVE STUPID Mnemonic
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Metabolic
derangements/Meds
O2 def./Obstipation
Vascular disorders
Electrolyte
derangements/EtOH/
Environment/Eye/Ear
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Sz/Shock/Structural
disorders
Tumors/Trauma/Temp
Uremic or hepatic
encephalopathy
Psychiatric
Infections
Drugs/Degenerative
dz/Depression
“M” Metabolic Derangements
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Wilson’s Disease
Thiamin deficiency (Wernicke-Korsakoff: ataxia,
encephalopathy, horizontal nystagmus,
confabulation)
Vit B12 deficiency (dementia, psychosis)
Niacin deficiency (Pellegra: fatigue, insomnia,
encephalopathy)
Thyrotoxicosis/Myxedema
Hyper/Hypoglycemia
Addisons (stupor/coma)
Cushing’s (irritability, emotional lability, confusion,
overt psychosis)
“M” Medications
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Analgesics: Opiods (especially morphine),
NSAIDS
Anticholinergics: atropine, benztropine,
trihexyphenidyl, scopolamine
Anticonvulsants: Carbamazepine, phenytoin,
valproate, vigabatrin
Antidepressants: SSRI’s, TCA’s
“M” Medications
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Antibiotics: acyclovir, amphotericin B,
cephalosporins, chloroquine, cycloserine,
isoniazid, mefloquine, nalidixic acid, penicillin,
piperazine, quinolones, rifampin, streptomycin,
sulfonamides, tobramycin
Corticosteroids
H2-blockers: cimetidine, famotidine, ranitidine
“M” Medications
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CV meds: amiodarone, b-blockers, digoxin,
disopyramide, diuretics
Dopamine agonists: amantadine, romocriptine,
levodopa, pergolide, pramipexole ropinirole
Sedatives/hypnotics: barbituates,
benzodiazepines, clozapine, lithium,
phenothiazines
“M” Medications
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Miscellaneous: baclofen, disulfiram, donepezil,
INFs, IL-2, nitrous oxide, oral hypoglycemics
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NOTE: Digoxin, lithium, quinidine
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Can cause delirium even at “therapeutic” levels
“ O”
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Oxygen Deficiency
– Hypoxemia
– Asthma
– Sleep Apnea
– Anemia
– Decreased Cardiac Output
– Carbon Monoxide
– Carbon Dioxide
Obstipation
“V” Vascular Disorders
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Stroke
Intracranial Bleeds
Hypertensive encephalopathy
TTP or DIC
Hyperviscocity syndrome
Vasculitis
Migraine
“E”
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Electrolyte/Fluid Disorders
– Hypo or Hypernatremia
– Hypo or Hypercalcemia
– Hypomagnesemia
– Hypokalemia
Environment
– Glasses/hearing aid (Sensory deprivation)
– Sleep deprivation
EtOH
“S”
Seizures
– Active seizure vs post-ictal state
 Shock
 Silent MI
 Structural abnormalities
– Hydrocephalus
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Toxins
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Trauma
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Lead, Arsenic, Cyanide, Mercury, Thallium
Insecticides, Solvents, Ethylene Glycol
Subdural/epidural hematoma
Frontal contusion
Temperature
– Hyperthermia
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Neuroleptic malignant syndrome or thyroid storm
Hypothermia
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Exposure, sepsis, adrenal insufficiency, myxedema
“U” Uremic or Hepatic Encephalopathy
End Stage Renal Failure (BUN >100)
 Fulminant Hepatitis or Cirrhosis
– Usually preceded by GIB, SBP,
azotemia
 Acute Intermittent porphyria
– Anxiety, depression, disorientation,
hallucinations
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“P” Psychiatric Causes
Psychogenic coma
 Catatonia (schizophrenia)
 Depression
 ICU psychosis
 Uncontrolled Pain
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“I” Infection
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CNS
– Meningitis
– Encephalitis
– Tertiary Syphilis
– Lyme disease
– TB/Crypto
Sepsis
Infections in the Elderly (PNA, UTI)
“D”
Drugs of Abuse
– Acute intoxication
– Withdrawal syndromes
 Dementia/Degenerative Diseases
– Alzheimer’s, Multi-infarct Dementia,
EtOH, Parkinson’s
 Dialysis
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?Confusional State
?Delirium
?Dementia
?Comatose
Approach to the patient
The 3am Page
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Things to ask when the nurse calls….
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ABC’s
Vital Signs
Time course of changes
Diabetic?
Any recent narcotics or sedatives given?
Any patient with decreased level of
consciousness should be seen immediately
Know the most likely etiologies….
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Infections (urinary tract, respiratory tract, skin and
soft-tissue)
Fluid and electrolyte disturbances (dehydration,
hypo/hypernatremia)
Drug toxicity (30% of cases) or alcohol
Metabolic disorders (hypoglycemia, hypercalcemia,
uremia, liver failure, thyrotoxicosis)
Low perfusion states (shock, heart failure)
Withdrawal from alcohol, barbiturates,
benzodiazepines, SSRI’s)
Post-op in the elderly
History (typically from others)
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What meds is the patient taking?
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History of trauma?
Evidence of CNS pathology such as
headache/hemiparesis/ataxia/vomiting?
Past medical history?
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New meds? Increased dose? Altered clearance?
Remove/change contributory medications
DM, liver/renal disease, thyroid, CAD, COPD, Seizure d/o
History of psychiatric illness?
Peri-operative?
Sundowning history?
Focused Examination
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ABC’s and Vital Signs
Gen: ?Toxic appearing, level of
responsiveness
HEENT: trauma, pupil size/reactivity (see
next slides) papilledema, nuchal rigidity
Respiratory pattern
Abdomen: ascites/jaundice/distention
Skin: signs of hydration level
Pupils
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Bilaterally small & minimally reactive
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narcotics
metabolic encephalopathy
Bilaterally large & minimally reactive
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anticholinergics
Pupils cont’d
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Bilaterally midposition & fixed
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midbrain lesion
increased ICP
transtentorial (central) herniation
Unilaterally dilated and fixed
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CN III palsy
uncal (lateral) herniation
Neurologic examination
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Observation for spontaneous movements,
response to stimuli, papilledema
Cranial Nerves: eye position at rest, response
to visual threat, corneal reflex, facial grimace to
nasal tickle, cough/gag (with ET tube
manipulation if necessary)
Intact oculocephalic (“doll’s eyes”) or
oculovestibular (“cold calorics”)
Neurologic examination
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Look for signs of increased ICP: H/A, vomiting,
HTN, bradycardia, papilledema, unilateral
dilated pupil
Motor response in extremities to noxious
stimuli-noting purposeful vs posturing
DTR’s, Babinski response
GCS or MMSE
Confusion Assessment Method
(CAM) for the dx of delirium
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1. Acute onset and fluctuating course
2. Inattention
3. Disorganized thinking
4. Altered level of consciousness
Dx requires presence of features 1 AND 2 plus
either 3 OR 4
Bedside Tests of Attention
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Digit span
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Inability to repeat a string of at least five digits
indicates probable impairment
Vigilance “A” test
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Count errors of omission and commission. More
than two errors is considered abnormal
Rule out easily reversible
conditions
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Thiamin (100mg IV)
Fingerstick – or empirically give Amp D50
Naloxone 1mg IV/SQ/IM
Oxygen
IVF
Approach to the patient
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Treat obvious causes
Determine the deviation from baseline
Get your resident involved if this represents a
marked change in pt status
“Hospital Psychosis” or dementia should be a
diagnosis of relative exclusion
Use caution with centrally active meds in the
elderly
Lab/Rads Eval
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CBC, P2, LFT’s, Coags
Urinalysis
Tox screen
ABG
Cultures as appropriate
Cortisol
Ammonia
TFT’s
Drug Levels
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CT
MRI
LP with opening
pressure
EEG
EKG or Tele
CXR
AAS
Non-pharmacologic approaches
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Provide support and orientation
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Remind patient of day, time, location, identity
Provide clock, calendar, daily schedule
Place familiar objects in room
Ensure consistency of nurses & corpsmen
Use radio or TV for relaxation & information
Involve patient’s family members
Non-pharmacologic approaches
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Provide an unambiguous environment
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Consider private room for the patient
Minimize clutter in the patient’s room
Avoid medical jargon; use layman’s terms
Ensure adequate lighting; provide night light
Control excess noise (staff, visitors, equipment)
Maintain room temperature 70-75° F
Non-pharmacologic approaches
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Maintain competency
– Correct sensory impairments
 glasses & hearing aids
 dentures
 interpreter
– Encourage self-care & participation in treatment
– Maximize periods of uninterrupted sleep
– Maintain activity levels
 ambulate x 15 minutes TID, or
 ROM exercises x 15 minutes TID
Pharmacologic approaches
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Alcohol withdrawal
– Ativan 1-2 mg IV q 5 min
– until patient is calm but awake
Narcotic OD
– Naloxone 0.4 mg IV q 2-3 min
Benzo OD
– Flumazenil 0.2 mg IV over 30 sec
Hepatic encephalopathy
– Lactulose 30-60 ml PO q1h until diarrhea
Uremia
– Hemodialysis
Does patient’s behavior interfere
with care or safety?
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Low dose neuroleptic (haloperidol, risperidone,
etc) and/or low dose short acting
benzodiazepine
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Mild: Haldol 0.5-2mg IV/IM
Moderate: Haldol 2-5mg IV/IM
Severe: Haldol 5-10mg IV/IM
Allow 30 min for response:
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If none, then double Haldol dose
If partial, then add Ativan 0.5-2.0 mg IV
Strategies to help out your crossover..
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ALWAYS document a MMSE
Document Functional Status
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ADL’s, Mobility
Tests of Attention (digit span, vigilance “A” test)
Include Contact Phone Numbers on chart
Specifically ask about sensitivities to common
medications
Ask family about prior episodes of delirium
Include drug of choice in sign-out
Sample Q’s
A 70 Y/O WF had an emergency chole 2 days ago. Today, she appears
to be confused. When you ask her how she is, she just stares at your
stethoscope, and then says, "That snake may bite you." When you
ask further questions she seems distracted and does not answer the
question asked. At times, she closes her eyes and seems to fall
asleep unless questioned. She does not know her daughter, who is
in the room when you are.
Which one of the following additional observations would help you
determine whether the patient has delirium or dementia?
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Her mental status was normal before surgery, and on successive
visits it fluctuates
Her neurologic examination is normal, except for the noted mental
status changes
She cannot remember today's date or the day of the month, interpret
proverbs, name the president, or even remember your name (her
beloved, long-time family doctor)
Her pulse, blood pressure, temperature, and respiratory rate are all
normal
A 53-year-old white male presents to the emergency
department with a temperature of 39.0° C (102.2° F)
and muscular rigidity associated with increasing
confusion. The patient has a history of paranoid
schizophrenia and has been maintained on
haloperidol (Haldol).
The most likely diagnosis is
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drug-induced parkinsonism
neuroleptic malignant syndrome
heatstroke
thyroid storm
A previously alert, otherwise healthy 74-year-old
African-American male has a history of slowly
developing progressive memory loss and dementia
associated with urinary incontinence and gait
disturbance resembling ataxia. The most likely
diagnosis is
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multiple sclerosis
subacute sclerosing panencephalitis
Alzheimer's disease
normal pressure hydrocephalus
Which one of the following is most accurate regarding
the management of a hospitalized elderly patient with
a new onset of confusion?
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A search for an underlying medical problem should
be undertaken
The patient is delirious; delirium tremens (DTs)
precautions should be instituted
The patient is having a normal response to a new
environment; a mild tranquilizer will help
The patient has dementia; a light should be left on
and a family member should be present constantly
A patient of yours brings his 84-year-old mother to you
for consultation. She is showing signs of mildly
decreased mental function and is having a great deal
of trouble eating and writing. She has mild stable
angina and had a myocardial infarction 2 years ago.
Physical examination discloses no significant
abnormalities other than a corrected visual acuity of
20/200. Funduscopic examination is difficult due to
bilateral lenticular opacities.
Which one of the following is most appropriate?
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Physostigmine (Tensilon) challenge
Re-evaluation by a cardiologist
Neuropsychiatric testing
Begin levodopa/carbidopa (Sinemet)
Cataract surgery
Metabolic derangements or Medications
Oxygen deficiency or Obstipation
Vascular disorders
Electrolyte derangements or Etoh
Environment/Eye/Ear
Seizures, Shock, or Structural disorders
Tumors, Trauma, Temperature Derangements
Uremic or hepatic encephalopathy
Psychiatric disorders
Infections
Drugs or Degenerative disease or Depression
References
1. Pocket Medicine, second edition. Lippincott Williams &
Wilkins. section 9-1:2004
1. Uptodate.com (delirium)
2. Thanks to Dr. Jenny Curry and Dr. Dylan Wessman for
parts of their previous presentations on delirium.