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

T – Tumor, treatments

E – Endocrine,
electrolytes

I – Insulin

P – Poisoning, psychosis
(delirium)

S – Seizure, shock, stroke,
SAH

I – Infections,
intoxications

O – Opiates, oxygen
(hypoxia)

U - Uremia
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
Case 1: a 72 yo M admitted for COPD
exacerbation

Top differential while walking to the room?

Hypercapnic respiratory failure, acute on chronic respiratory
acidosis

Hypoglycemia

iatrogenic/medication

Electrolyte abnormality, hyponatremia
Case 1: a 72 yo M cont’d…

Next move?
 Evaluate
the patient
 Reasonable
labs?
 FSBG
 ABG
if any signs of respiratory distress
 Renal
 CBC
panel (check electrolytes, calculate an AG)
Case 1: a 72 yo M cont’d…

The FSBG shows a glucose of 36

What’s next?

Ask the nurse to give an amp of D50
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
 It
of 50% D50 = 25g dextrose
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. Your new NF
admission is J.R., 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
pre-rounding at 6:45 am, she seemed tired but was
answering questions appropriately. At that time, her vitals
were stable and her physical exam was unremarkable other
than a tender, but non-surgical appearing abdomen.
Morning labs were still pending.
Case 2- 36 yo F with abdominal pain

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 medication list
Case 2- 36 yo F w abdominal pain cont’d…

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. Urology recommended dc with the catheter
until he can follow up in clinic. He was kept over a long
holiday weekend for PT/OT assessment.
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 but looked “OK”.
Case 3 – 84 yo M admitted for chest pain

Top differential diagnosis?

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…
 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
Case 3 – 84 yo M cont’d…

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.

Labs:

Renal panel:

142/ 4.3/ 104 /24 /9 /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.
Case 3 – 84 yo M cont’d…

Now what?



Start antibiotics for CAUTI

3rd gen cephalosporin or fluoroquinolone if they’re not sick

Cefepime or zosyn if you have reason to suspect a MDR organism
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.
Case 4- 87 yo F admitted for HFrEF and
severe AS

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
Case 4- 87 yo F cont’d…
 First
move?
 Get
vitals – 37.5, 86, 108/68, 97% on 2L O2 by NC
 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.
Case 4- 87 yo F cont’d…

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

UA with no nitrites, leuk esterase, no sugar, protein or RBCs
Case 4- 87 yo F cont’d…

Medications:

Metoprolol 25mg BID

Simvastatin 20mg

Lisinopril 5mg daily

Lasix 40mg PO BID

Mild sliding scale insulin

Heparin SQ 5000 units TID (you made sure she has been getting
this since admission)
Case 4- 87 yo F cont’d…
Case 4- 87 yo F cont’d…

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.
Current most likely diagnosis?

Most likely ? Delirium (a diagnosis of exclusion)

PE. Why is this much less likely?
Case 4- 87 yo F cont’d…

How to treat…

Minimize sedating medications

Glasses, hearing aids

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 (still an active IVDU) that was admitted to UH 2
days ago for altered mental status. A diagnostic
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…

Looking for more history, you talk to the RN and
look through the chart…
 No
falls
 He
isn’t taking any opioids
 No
fevers, BP is at his baseline, not tachycardic (but on
a BB)
 CT
head on admission negative
Case 5: 52 yo M, cont’d…

Differential diagnosis for AMS in this patient?
 Hepatic
 Sepsis-
encephalopathy
SBP vs. endocarditis vs. aspiration PNA
 DVT,
PE- hypercoagulable state (why?)
 CVA-
septic emboli (recent IVDU)
 Iatrogenic
 GI
bleed
– look at med list
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.
Case 5: 52 yo M cont’d…

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!