Altered Mental Status

Definitions

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

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

Impairment in LEVEL of consciousness 30% of older medical patients will have delirium while

hospitalized Generally considered reversible

– 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

Drugs Oxygen Glucose Metabolic

– electrolytes– endocrine– hepatic– renal– vitamins & minerals

Ischemia Infection Seizure Sleep/wake cycle Trauma Toxins

SMASHED Mnemonic

Substrate deficiencies Meningoencephalitis or mental illness Alcohol or accident Seizures Hypers and hypos Electrolyte abnormalities or encephalopathies Drugs

I WATCH DEATH Mnemonic

Infection Withdrawal Acute metabolic Trauma CNS pathology Hypoxia

Deficiencies Endocrinopathies Acute vascular Toxins or drugs Heavy metals

MOVE STUPID Mnemonic

Metabolic derangements/Meds

O2 def./Obstipation Vascular disorders Electrolyte

derangements/EtOH/ Environment/Eye/Ear

Sz/Shock/Structural disorders

Tumors/Trauma/Temp Uremic or hepatic

encephalopathy Psychiatric Infections Drugs/Degenerative

dz/Depression

“M” Metabolic Derangements 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

Analgesics: Opiods (especially morphine), NSAIDS

Anticholinergics: atropine, benztropine, trihexyphenidyl, scopolamine

Anticonvulsants: Carbamazepine, phenytoin, valproate, vigabatrin

Antidepressants: SSRI’s, TCA’s

“M” Medications

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

CV meds: amiodarone, -blockers, digoxin, disopyramide, diuretics

Dopamine agonists: amantadine, romocriptine, levodopa, pergolide, pramipexole ropinirole

Sedatives/hypnotics: barbituates, benzodiazepines, clozapine, lithium, phenothiazines

“M” Medications

Miscellaneous: baclofen, disulfiram, donepezil, INFs, IL-2, nitrous oxide, oral hypoglycemics

NOTE: Digoxin, lithium, quinidine– Can cause delirium even at “therapeutic” levels

“ O”

Oxygen Deficiency– Hypoxemia– Asthma– Sleep Apnea– Anemia– Decreased Cardiac Output– Carbon Monoxide– Carbon Dioxide

Obstipation

“V” Vascular Disorders

Stroke Intracranial Bleeds Hypertensive encephalopathy TTP or DIC Hyperviscocity syndrome Vasculitis Migraine

“E”

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

ShockSilent MIStructural abnormalities

– Hydrocephalus

“T”

Toxins– Lead, Arsenic, Cyanide, Mercury, Thallium– Insecticides, Solvents, Ethylene Glycol

Trauma– Subdural/epidural hematoma– Frontal contusion

Temperature – Hyperthermia

Neuroleptic malignant syndrome or thyroid storm

– Hypothermia 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

“P” Psychiatric Causes

Psychogenic comaCatatonia (schizophrenia)Depression ICU psychosisUncontrolled Pain

“I” Infection

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

Approach to the patient

?Confusional State

?Delirium

?Dementia

?Comatose

The 3am Page

Things to ask when the nurse calls….– 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….

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)

What meds is the patient taking?– New meds? Increased dose? Altered clearance?– Remove/change contributory medications

History of trauma? Evidence of CNS pathology such as

headache/hemiparesis/ataxia/vomiting? Past medical history?

– DM, liver/renal disease, thyroid, CAD, COPD, Seizure d/o History of psychiatric illness? Peri-operative? Sundowning history?

Focused Examination

– 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

Bilaterally small & minimally reactive– narcotics– metabolic encephalopathy

Bilaterally large & minimally reactive– anticholinergics

Pupils cont’d

Bilaterally midposition & fixed– midbrain lesion– increased ICP– transtentorial (central) herniation

Unilaterally dilated and fixed– CN III palsy– uncal (lateral) herniation

Neurologic examination

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

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

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

Digit span– Inability to repeat a string of at least five digits

indicates probable impairment

Vigilance “A” test– Count errors of omission and commission. More

than two errors is considered abnormal

Rule out easily reversible conditions

Thiamin (100mg IV) Fingerstick – or empirically give Amp D50 Naloxone 1mg IV/SQ/IM Oxygen IVF

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

Approach to the patient

CBC, P2, LFT’s, Coags Urinalysis Tox screen ABG Cultures as appropriate Cortisol Ammonia TFT’s Drug Levels

CT MRI LP with opening

pressure EEG EKG or Tele CXR AAS

Lab/Rads Eval

Non-pharmacologic approaches

Provide support and orientation– 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 cont’d

Provide an unambiguous environment– 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 cont’d

Maintain competency– Correct sensory impairments

glasses & hearing aidsdenturesinterpreter

– Encourage self-care & participation in treatment– Maximize periods of uninterrupted sleep– Maintain activity levels

ambulate x 15 minutes TID, orROM exercises x 15 minutes TID

Pharmacologic approaches

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?

Low dose neuroleptic (haloperidol, risperidone, etc) and/or low dose short acting benzodiazepine– Mild: Haldol 0.5-2mg IV/IM– Moderate: Haldol 2-5mg IV/IM– Severe: Haldol 5-10mg IV/IM

Allow 30 min for response:– If none, then double Haldol dose– If partial, then add Ativan 0.5-2.0 mg IV

Strategies to help out your crossover..

ALWAYS document a MMSE Document Functional Status

– 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?

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

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

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?

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?

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 9-1:20041. Uptodate.com (delirium)2. Thanks to Dr. Jenny Curry and Dr. Dylan Wessman forparts of their previous presentations on delirium.