INTERN BOOT CAMP:Altered Mental Status

Caroline Soyka

PGY3

Objectives

Provide an overview of the definition of “altered mental status”

Develop reasonable differential diagnosis for acute mental status changes

Explain first steps in diagnosis and management of common causes of mental status changes

Definition

No clear definition Mental status is composed of two parts:

– Arousal: wakefulness, responsiveness– Awareness: perception of environment

Delirium (which we see a lot)

– Transient, usually reversible– Decreased attention span and waning confusion

Delirium vs. Dementia

DELIRIUM DEMENTIA

Onset Acute/Subacute Insidious

Course Fluctuating Stable and progressive

Attention Fluctuates Steady

Sensorium Impaired Intact until late

Cognitive Globally impaired Poor short term memory

Perception Visual Hallucinations

Simple Delusions

Delirium

Extremely frequent– 14-56% of elderly hospitalized patients– 40% of ICU patients

In patients who are admitted with delirium, mortality rates as high as 10-26%

Development of delirium correlates with prolonged hospital stay, increased complications, increased cost, and long-term disability

McCusker J, Cole M, Abrahamowicz M, Primeau F, Belzile E. Delirium predicts 12-month mortality. Arch Intern Med. Feb 25 2002;162(4):457-63.

Alertness Awareness Perform Tasks

Attention Span

“Cloudy Consciousness”

decreased retain impaired decreased

Lethargy decreased retain impaired decreased

Obtundation decreased decreased Requires stimulus

decreased

Stupor decreased decreased Requires constant stimulus

decreased

Coma Decreased Decreased None None

Epidemiology

AMS is primary reason for ED visit in 4-10% patients

ED patients > 65– 25% with AMS– 26% with minimal cognitive impairment– 34% with moderate cognitive impairment

*prevalence of dementia 1% at age 60 and doubles every 5 years until age 85 (30-50%)

So you are called for MS Δ’s…

What are the vital signs? What was the time course? What is the patient’s baseline? What medications have they received? What is the patient’s past medical history? Was there any trauma? Is there any focality to the neuro exam?

First Steps

ABCDE:– Airway– Breathing– Circulation– Disability– Exposure

Workup

HISTORY!!!!– Ask family– New meds?– Any significant PMH?

PHYSICAL– Vitals– Detailed physical WITH neurologic exam– GCS

Etiology

A alcohol, alzheimer’s E endocrine, electrolyte, encephalopathy I infection, intoxication O opiates, overdose, oxygen U uremia T tumor, trauma I insulin P poisonings, psychosis S stroke, seizures, syncope, shock, SAH,

Case #1

73 YO WM with h/o HTN and gout admitted for suspected septic arthritis of left knee. Patient had arthrocentesis this afternoon, results pending. You are called at 9pm because patient has had an acute change in mental status.

Exam

VS: T 37.5, HR 64, RR 16, BP 124/74, 96%RA Lethargic, not conversant, moaning, withdraws all 4

extremities to pain, responds to sternal rub

AEIOUTIPS

Drugs

Medications implicated in 30% of cases of delirium Common causes of mental status changes include

opioids, benzos, any anticholinergics Clues in the exam

– Opioids: miosis, decreased respirations, and hypotension – Anticholinergics: bradycardia, salivation, lacrimation, and

diaphoresis

Reversal Agents

Opioids?– Narcan (naloxone) 0.04 mg to 0.4 mg every 2-3

minutes** may need to readminister doses at a later interval (ie,

20-60 minutes) depending on type/duration of opioid

– If reversal does not occur quickly or after 0.8 mg, diagnosis should be questioned

– Note: you need higher doses (0.4-2 mg) for known/suspected opioid overdose

Reversal Agents

Benzodiazepines?– Flumazenil 0.2mg IVP, repeat every 30 seconds

up to total dose of 2mg– If reversal does not occur quickly,

diagnosis should be questioned– Beware of black box warning:

– BZP reversal may seizures especially in patients on long term BZPs or following TCA overdose. Be prepared for seizures!

A Daily J.J. Diatribe… Polypharmacy in the Elderly:

Remember to check GFR and appropriately dose medications Check for drug-drug interactions and ask about OTC’s &

herbals Avoid anything with anticholinergic properties JUST STOP UNNECCSSARY MEDS

Case #2

61 YO AAM with ESRD 2/2 poorly controlled DM2 on HD admitted to Eckel for lack of HD access due to clotted fistula. You are called at 7am with mental status changes.

VS: T 35.6, HR 88, RR 20, BP 152/86, SAT 96% RA

Exam: Moaning, incoherent, diaphoretic, drooling

Accu-check Glucose: 28 mg/dL

AEIOUTIPS

Causes of Hypoglycemia

Overly aggressive insulin regimen Renal failure Liver failure Infection/Sepsis Excessive EtOH consumption Rare Stuff

– Adrenal insufficiency– Insulinoma

Hypoglycemia Management

Is patient awake enough to drink some juice, take glucose tabs?

– Three glucose tabs will raise blood sugar by 50. If unable to take PO and has IV access, then give

use IV dextrose– 1 amp D50 = 50 grams of glucose

If patient does not have IV access and unresponsive, give Glucagon 1mg IM/SC.

Always recheck glucose 15-20 minutes later to document return to euglycemia.

Case #3

64 YO obese WF with GOLD class III COPD on 2L home O2 admitted to Wearn team with COPD exacerbation. You are called for mental status changes at 10:55 PM.

VS: T 36.4, HR 88, RR 18, BP 134/66, SAT 99% on 8L O2 via NC

Exam: Lethargic, arouses only to sternal rub, lungs with poor air exchange

ABG: 7.18 / 103 / 95 / 98% on 8L Via NC

AEIOUTIPS

Hypercapnea because of supplemental Oxygen:

1) V/Q mismatch: if a part of the lung is underventilated it should be underperfused (hypoxic pulmonary vasoconstriction)adding O2 increases perfusion but NOT ventilation

2) Haldane effect: Deoxygenated hemoglobin is able to carry more carbon dioxide than oxygenated hemoglobin

3) Respiratory homeostasis: Chronic elevation of CO2 leads to CO2 being less of a stimulant for respiratory drive and PaO2 provides stimulus, therefore supplemental O2 decreases respiratory drive leading to CO2 retention

Five Causes of Hypoxia*

1. Hypoventilation

2. Shunt

3. Increased Diffusion Gradient

4. Decreased FiO2

5. V-Q Mismatch

* A favorite Schilz PIMP question.

Key Points to Remember

Whenever patients are requiring more FiO2, check an ABG to ensure they are not retaining CO2

Look at baseline HCO3 to have an idea of whether patient is a CO2 retainer

Elevated PaCO2 with mental status changes buys a ticket to the MICU

Case #4

62 YO WM with ischemic cardiomyopathy and HFrEF (last EF 10-15%) admitted to Hellerstein for volume overload and mental status changes

VS: T 36.4, HR 98, RR 20, BP 74/40, SAT 93% 3L

AEIOUTIPS

Hypoperfusion

Anything that decreases cerebral perfusion can alter mental status– CHF exacerbation with worsening cardiac output– Severe Sepsis– Hypovolemia– Myocardial Infarct– “Shock”

Indication for ICU transfer

A word on sepsis…

SIRS: >1 of the following manifestations: – Temperature > 38°C or < 36°C (> 100.4°F or < 96.8°F) – Heart rate > 90 beats/min – Tachypnea, as manifested by a respiratory rate > 20

breaths/min (or PaCO2 < 32 mm Hg)– White blood cell count > 12,000 cells/mm3, < 4,000

cells/mm3, or the presence of > 10% immature neutrophils Sepsis: At least two SIRS criteria caused by known

or suspected infection Severe Sepsis: Sepsis with acute organ dysfunction Septic Shock: Sepsis with persistent or refractory

hypotension or tissue hypoperfusion despite adequate fluid resuscitation

Case #5

93 YO WM with Alzheimer’s Dementia admitted for aspiration pneumonia. Patient had a PEG placed and is getting tube feeds via PEG while his pneumonia is being treated with Zosyn. Patient develops mental status changes on hospital day #4.

VS: T 36.4, HR 100, RR 22, BP 134/66, 94% on RA RFP: 158 118 27

4.8 32 1.5

AEIOUTIPS

Electrolyte Abnormalities

Hypernatremia Hyponatremia Hypercalcemia

Hypernatremia:

Signs and Symptoms: Mental status changes, hyperreflexia, seizures, and coma

Causes:-Hypovolemic: diarrhea, inadequate intake, renal losses-Euvolemic: DI (central and nephrogenic)-Hypervolemic: Hypertonic saline use, mineralcorticoid excess

Treatment: -Hypovolemic: Calculate Free H2O deficit: Replete with free H20 or D5W -Euvolemic: DI: Central: dDVAP, Nephrogenic: Treat underlying cause

-Hypervolemic: D5W and Loop Diuretic

                                                Serum [Na] Water deficit  =  Current TBW  x  (———————   -  1)                                                        140

Hyponatremia

Signs and Symptoms: Lethargy, seizures, mental status changes, cramps, anorexia

Diagnosis/Causes of Hyponatremia:- Hypovolemic: Diuretic use/Poor PO intake- Euvolemic: SIADH/Severe Trauma - Hypervolemic: CHF/Liver Failure/Nephrotic syndrome

Treatment:*** Only use hypertonic saline if actively seizing ***- Hypovolemic: NS- Euvolemic/Hypervolemic: water restriction

Note: SIADH which does not respond to water restriction, use a vaptan

(Vasopressin antagonist)

Hypercalcemia

Signs and symptoms– Bonesosteopenia– Stoneskidney stones and polyuria– Groansabdominal pain, anorexia, constipation, ileus, N/V– Psychiatric overtonesdepression, psychosis,

delirium/confusion

Causes of Hypercalcemia– MCC in outpatients is hyperparathyroidism– MCC in inpatients is malignancy– Other causes include vitamin A or D intoxication, sarcoid,

thiazide diuretics, immobilization, multiple myeloma

Hypercalcemia

Treatment– Hydrate the patient with NS– Calcium diuresis with furosemide– For severe hypercalcemia, calcitonin

rapidly/transiently lowers calcium in few hours– IV bisphosphonates lower further and last longer

but take for effect to kick in

Case #6

48 YO WM with h/o hepatitis C/Cirrhosis admitted for progressively worsening jaundice, weight loss, and AMS. RUQ u/s in ED, revealed a mass in liver. Pt admitted for work-up of mass and AMS. Upon arrival to room you find patient difficult to arouse.

Vitals: T 38.0 HR 66 RR 16 BP 96/60 SAT 98% RA

Exam

Gen: Stuporous, arousable but not coherentABD: Good bowel sounds, distended with moderate ascites,

diffusely tender to palpation with rebound tenderness NEURO: Diffuse hyperreflexia, + Asterixis

CT head: No hemorrhage or mass effect

Labs:- HCT 10/30 (Baseline 10.5/31)

- WBC: 18K (with left shift)

•AEIOUTIPS

Hepatic Encephalopathy

Stage Consciousness Intellect and Behavior Neurological Findings

0 Normal Normal Normal examination; impaired psychomotor testing

1 Mild lack of awareness

Shortened attention span; impaired addition or subtraction

Mild asterixis or tremor

2 Lethargic Disoriented; inappropriate behavior

Obvious asterixis;slurred speech

3 Somnolent but arousable

Gross disorientation; bizarre behavior

Muscular rigidity and clonus; Hyperreflexia

4 Coma Coma Decerebrate posturing

HE Precipitants

Infection: Infection may predispose to impaired renal function and to increased tissue catabolism, both of which increase blood ammonia levels.

Bleeding: The presence of blood in the upper gastrointestinal tract results in increased ammonia and nitrogen absorption from the gut. Bleeding may predispose to kidney hypoperfusion and impaired renal function. Blood transfusions may result in mild hemolysis, with resulting elevated blood ammonia levels.

Electrolytes: Decreased serum potassium levels and alkalosis may facilitate the conversion of NH4+ to NH3.

Med non-compliance: Ask family about lactulose use Renal failure: Renal failure leads to decreased clearance of urea,

ammonia, and other nitrogenous compounds. Medications: Drugs that act upon the central nervous system, such as

opiates, benzodiazepines, antidepressants, and antipsychotic agents, may worsen hepatic encephalopathy. Or ETOH use

Dehydration: vomiting, diarrhea, large volume para, diuretics

Management of HE

Correct the underlying cause…

1st line: Lactulose– Oral: 20 gm PO Q1-2 hrs for 3-5 BM’s/day– Enema: 300 mL in 1 L of water Q4-6 hrs – Diarrhea, flatulence, cramps

Antibiotics:

- Rifaximin: 550 mg BID

helps prevent recurrent episodes of HE

Case #7

52 YO WM with h/o etoh abuse, HTN, DM2 admitted for right femoral neck fracture after falling, went to OR for pinning. Remained in house for physical therapy and placement.

You are called for headache, agitation, and visual hallucinations.

Vitals: T 38.6, HR 96, RR 20, BP 170/86, 96%RA

•AEIOUTIPS

EtOH Withdrawal

CIWA Scale

Nausea/Vomiting

Tremor

Sweats

Anxiety

Agitation

Tactile Disturbances

Auditory Disturbances

Visual Disturbances

Headache

Orientation

-symptoms treated with ativan and other prn’s

**CIWA’s > 20 consider MICU transfer**

Case #8

45 YO AAF with h/o polysubstance abuse and HTN admitted to Carpenter for fevers and HA. You are called to room by nurse soon after admission for mental status changes.

VS: T 38.6, HR 101, RR 26, BP 101/58, Sat 98%RA GEN: uncomfortable, AAO x 2 HEENT: + nuchal rigidity LUNGS: CTA b/l NEURO: no focal weakness

•AEIOUTIPS

CNS infections

Meningitis– Bacterial– Viral– Aseptic

Encephalitis Toxoplasmosis JC virus West Nile Virus

Lumbar Puncture

CT head or Ophthalmologic Exam done first to document no increase intracerebral pressure

Draw blood cultures from periphery

Do not delay giving antibiotics waiting for the CT and doing the LP

Send CSF for glucose, protein, gram stain and culture, cell count & differential, and suspected viral serologies

Treatment Antibiotic selection must be empiric

immediately after CSF is obtained

Age Common Pathogens

Antimicrobials

2-50 years N. meningitidis,

S. pneumoniae Vancomycin plus a third-generation cephalosporin

> 50 years S. pneumoniae,

N. meningitidis,

L. monocytogenes,

Vancomycin plus ampicillin plus a third-generation cephalosporin

> 50 years w/ suppression

Above + pseudomonas Vancomycin plus ampicillin plus meropenem/cefepime

****Add dexamethasone if suspected S. pneumo****

Seizures

Status epilepticus– Annual incidence exceeding 100,000 cases in the United

States alone, of which more than 20% result in death– Classically tonic-clonic jerking; loss of bowel/bladder;

tongue biting– Usually have post-ictal confusion

Non-convulsive status– Harder to diagnose, must always think about it– Need EEG to make diagnosis

Labs to send post-suspected seizure: CPK and Prolactin

Management of Seizures

Call Neurology Supportive care (Remember the ABC’s)

– Check fingerstick glucose/give amp D50 empirically Benzodiazepines

– Diazepam 5-10 mg per minute – Lorazepam 4-8 mg– Terminate ~75% of seizures

AED’s (Phenytoin, fosphenytoin)

} Be prepared for airway management and ICU transfer

Case #9

42 YO with DM2 and depression on SSRI’s admitted from ED for recurrent lower extremity cellulitis; patient known to be colonizer with MRSA and had severe flushing with Vancomycin last admission. Started on IV Linezolid. About 12 hours after antibiotics you are called for fevers and mental status changes.

Exam

VS: T 39.4, HR 98, RR 20, BP 104/60, SAT 98% RA GEN: Anxious, diaphoretic, A+Ox1 Neuro: Diffuse hyperreflexia with myoclonus

+ = ?

Serotonin Syndrome

Case #10

78 YO WM with h/o Stage IIB Colon Cancer admitted with SOB, found to have a PE. Patient is now on heparin drip, and he suffers a fall in his room trying to drag his IV pole to the bathroom. You are called to assess the patient.

Vitals: T 36.5, HR 52, RR 12, BP 170/88

Exam significant for new LLE weakness

•AEIOUTIPS

Intracranial Bleeding

Intraparenchymal Hemorrhage– Common after trauma or

after initiating anticoagulation in embolic stroke

– Call Neurosurgery

Intracranial Bleeding

Subdural– Subacute onset after

trauma– Crescent-shaped– Shearing of the

bridging veins– Call Neurosurgery

Intracranial Bleeding

Epidural hemorrhage– Most commonly

associated with skull fracture in area of middle cerebral artery

– Lentiform appearance– Call Neurosurgery

Intracranial Bleeding

Subarachnoid– Worst headache of on

e’s life– Usually in setting of

hypertensive emergency

– Call neurosurgery and control BP

Stroke

Embolic Stroke– Commonly in setting of

atrial fibrillation– Call Neurology and

activate the BAT pager

Case #11

93 YO AAM with HTN and vascular dementia admitted for UTI. Patient on ceftriaxone IV and awaiting placement in Brecksville. You are called at 3 AM because patient attempting to climb out of bed, very disoriented, and trying to pull out Foley.

T-37.7, HR-65, RR-16, BP-120/80

PE: unrerkable

•AEIOUTIPS

Sun-Downing: Definition

Sun-downing: a group of behaviors occurring in some older patients with or without dementia at the time of nightfall or sunset.

Common Behaviors:– Confusion– Anxiety, agitation, or aggressiveness – Psychomotor agitation (pacing, wandering)– Disruptive, resistant to redirection– Increased verbal activity

Sun-Downing: Prevention

Give diuretics, laxatives early in day Discontinue any unneeded lines, catheters Ensure patient has glasses, working hearing aid Monitor amount of sensory stimulation Consider late afternoon bright light exposure Turn off lights and television during evening hours Avoid restraints if possible Attempt to re-orient patient Establish regular dose of drug for disturbing behavior

(if needed)