Transcript Acute Mental Status Changes

A neurology primer
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Descriptions exist prior to Hippocrates
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Phrenitis
◦ Acute transient mental disorder seen in association
with medical illness, with psychomotor agitation,
insomnia and disturbances of mood/perception
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Lethargus
◦ Somnolence, inertia, reduced response to stimuli
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An acute disorder characterized by
disturbances in consciousness, disorganized
thinking, fluctuating course with reduced
ability to focus, sustain, or shift attention
Develops over a short time
Disturbances in cognition (memory,
disorientation, perceptual/spatial
disturbance)
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Acute confusional state
Toxic/metabolic encephalopathy
ICU psychosis
Organic brain syndrome
Hepatic encephalopathy
Beclouded dementia
“Sundowning”
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20% of hospitalized elders
50% of hip fracture patients
Annual costs ~ $8 billion dollars
Results in longer hospital stays, morbidity,
mortality, & nursing home placement
32-67% of cases never detected
“The physician who is greatly
concerned to protect the
integrity of the heart, liver,
kidneys of his patient has not
yet learned to have the similar
regard for the functional
integrity of his patient’s brain”
Romano & Engel 1959 J Chron Dis
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A syndrome with cognitive, psychiatric, and
neurological manifestations
Understanding the key elements of the
syndrome is the most critical skill
Remembering “laundry lists” of potential
causes is not useful
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Read the nursing and therapy staff notes
◦ Often the consult is literally done before ever
having to see the patient
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Listen to families & don’t tell them their loved
one is “back to baseline” if they state
otherwise
Educate families & other medical staff
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Hypervigilant
◦ Frequently associated with drug
intoxication/withdrawal (delirium tremens) with
increased arousal and autonomic lability
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Hypovigilant or “quiet delirium”
◦ Somnolent, sluggish, and apathetic
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Mixed forms
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A disorder of attention (ability to maintain a
coherent stream of thought, free of
interference from external or internal
stimuli)
◦ Sustained attention
◦ Divided attention
◦ Ability to inhibit irrelevant stimuli
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Disorientation, poor memory, visuospatial
disturbances & language changes are in
large part due to disordered attention
(unless they pre-existed due to underlying
dementia)
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Mood changes (depression, apathy,
irritability, anxiety, & mania)
Psychosis is common!
◦ Suspiciousness, paranoid delusions
◦ Visual hallucinations
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Delirium is the most common cause of new
onset psychosis in the elderly
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Asterixis
Action or postural tremor
Impaired postural control (balance)
Bowel and bladder incontinence
Motor tone abnormalities (gegenhalten type
rigidity)
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The neuroanatomy of attention/arousal is
diffuse & vulnerable at many points
Often the first to “fall apart” when elderly
patients get ill for whatever reason
Precipitating cause is seldom “in the brain
itself”, such as a new stroke, brain tumor,
bleed, or CNS infection
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CT scans, MRI scans, lumbar punctures are
seldom useful and often red herrings
If you got one, look at it (brain size,
vasculopathy, hippocampal atrophy,
ventricolomegaly)
If you are completely unsure, then EEG is
helpful but rarely needed
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Delirious patients have decompensation of
other processes that rely on widely
distributed neural networks (maintaining the
upright posture and continence)
Not surprisingly these recover together
A person’s gait/balance may be just as good
an indicator of recovery from delirium!
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Attention and arousal are dependent upon
widely distributed neural circuitry and
therefore vulnerable to a variety of insults
The neurotransmitters acetylcholine (ACh)
and dopamine seem particularly important
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Anticholinergic drugs cause delirium
Cholinergic agonists reverse drug-induced
delirium
Lewy body dementia mimics delirium
Hypoxia, hyperglycemia, thiamine
deficiency cause decreased ACh release
Alzheimer’s and other dementia at
increased risk
Serum anticholinergic activity correlates
with delirium severity and incidence
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Dopamine agonists can cause delirium
Dopamine blockade treats delirium
Dopamine release increases in hypoxia
Dopamine is important in prefrontal areas
Dopamine density in prefrontal cortex
decreases with aging and correlates with
attentional measures
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Distractibility
Poor persistence
Tangentiality and rambling incoherence
Intrusions of irrelevant information
◦ Results in inability to learn new information, solve
problems or engage in goal-directed behavior
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“Patient is pleasantly confused”
“He kept speaking of going to the circus,
& had difficulty following directions”
Patient stated “I want off this train. I am
choking”
“Patient is very sleepy, and difficult to
arouse”
Patient had a “rough night, was up all
night and agitated”
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Digit span forwards and backwards
◦ Normal forwards is 7 +/- 2
◦ Backwards usually 2 less than forward
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Reciting overlearned tasks
◦ Alphabet
◦ Months forward, days of week forward/backwards
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Counting 1-20 forwards, backwards
Continuous performance task such as the
“A” test
◦ Raise and lower hand in response
to letter A
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Writing is extremely sensitive to delirium
◦ Draws on many complex skills and
falls apart early
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Document the mental status examination
including description of cognitive/affective
features
◦ Record some test of attention (digit span,
counting span, months forward, alphabet etc.)
◦ Describe mood/behavior (irritability,
hallucinations, paranoia, apathy, mood lability,
sadness, etc.)
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Document some neurologic exam (asterixis,
action tremor, poor balance/instability)
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Studies
CBC, CMP, urinalysis, pulse ox/ABG, EKG
Physical examination
Chest XRAY, other body imaging
Sometimes drug screen, tsh, b12/folate, thiamine,
lumbar puncture, neuroimaging
◦ EEG can be useful in unclear cases looking for
diffuse slowing
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Medications! (perform a detailed review)
Common geriatric infections (pneumonia,
urinary tract infections, abdominal
infections, cutaneous)
Hip fracture
Metabolic disturbances (glucose, sodium,
calcium, acid-base)
Hypoxemia
CHF, myocardial ischemia
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Furosemide 0.22
Digoxin 0.25
Warfarin 0.12
Nifedipine 0.22
Isosorbide 0.15
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Ranitidine 0.22
Theophylline 0.44
Prednisone 0.55
Codeine 0.11
Cimetidine 0.86
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Correct/remove all contributing factors
Provide meticulous supportive care (feeding,
mobility, continence, pressure wounds)
Engage patient/family provide reassurance
Correct sensory deficits (glasses, hearing
aids, avoid complete darkness)
Falls alarm, sitter, family member
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Avoid too much or too little stimulation
Try to improve sleep/wake cycle
Avoid iatrogenesis (physical restraints)
Plan for discharge, follow-up and next level
of care
Document your examination findings
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Antipsychotics are first line
Benzodiazepines only for alcohol or drug
withdrawal states
Occasionally cholinesterase inhibitors may be
useful and are likely to play an important role
as new research evolves
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Avoid benzodiazepines except for
alcohol/drug withdrawal
◦ Haloperidol recommended first line for most
 0.5 mg q 3
◦ Avoid older sedating antipsychotics
(anticholinergic)
◦ Atypical antipsychotics
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Put on standing dose if requirement is
frequent and supplement with prn
Goal is to treat cognition/psychiatric
dysfunction, not sedation!
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Haldol generally favored
◦ Can be given IM, SQ, IV, PR, PO
◦ Low doses in elderly frail patients 0.5 mg initially
and then every 4 hrs
◦ Avoid in parkinsonian patients (need to recognize
EPS)
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Increasing use of “atypical antipsychotics”
◦ Olanzapine, quetiapine, risperidone, ziprasidone
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Ensure not only medical but cognitive follow
up as well
Document your exam for others
Anticipate it will recur in the future and try to
optimize conditions so it will not
Educate families about medications, and the
syndrome of delirium
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Delirium is a common, costly and morbid
condition
Delirium is fundamentally a disorder of
attention
Delirium is poorly recognized
Many patients have unrecognized preexisting dementia
Many patients will ultimately develop
dementia