1. Altered Mental Status/Confusion
J. Stephen Huff, MD
Emergency Medicine and Neurology University of Virginia Charlottesville, Virginia 1

2. Case
A 60-year-old man is noted by his family to have fluctuating periods of agitation and confusion. He had a mild URI 3 days prior but otherwise in good health. He has a past history of diet-controlled diabetes and hypertension treated with enalapril. Social history-active, industrial worker. 2

3. Case
In the ED his vital signs are 160/90, 110, 24, and a rectal temperature of (38.1). General physical examination is unremarkable as is the neurological examination. Specifically, neck was supple, cranial nerves were intact. 3

4. Case
The patient was diagnosed with a viral syndrome. Serum laboratory work was unremarkable. Instructions were given to return if his condition worsened, which he did 8 hours later…febrile and combative... 4

5. Questions 1. How would you assess confusion?
2. What tests are available to assess confusion?
3. When is a spinal tap indicated in delirium?
4. What other laboratory studies are useful in the working of delirium? 5

6. What is Consciousness? Arousal function Content functions
Alerting and wakefulness
Anatomically-reticular activating system
Content functions
Language, reasoning
Anatomically-cerebral cortex 6

7. Disorders of Consciousness
Arousal functions
and/or
Content functions disrupted 7

8. Altered Mental Status
What does it mean?
What to do about it? 8

9. Altered Mental Status
Examples…
Coma
Dementia
Delirium 9

10. Delirium-Synonyms Acute confusional state Acute cognitive impairment
Acute encephalopathy
Altered mental status 10

11. Delirium Arousal functions & content functions disrupted
Difficulty focusing or sustaining attention
Fluctuating confusion
Disturbed wake-sleep patterns
Caregivers/family best source 11

12. Delirium-Criteria DSM IV
Reduced ability to maintain attention and shift attention
Disorganized thinking, rambling, irreverent, incoherent speech 12

13. Delerium Criteria DSM IV
At least 2 of the following
Reduced level of consciousness
Perceptual disturbances: misinterpretations, illusions or hallucinations
Disturbance of wake-sleep cycle
Increased OR decreased psychomotor activity
Disorientation to time, place, or person
Memory impairment

14. Delerium Criteria DSM IV
Symptoms develop over short period of time, fluctuate quickly
Either (1) etiologic organic factor
OR (2) absence non-organic disorder (such as manic episode)

15. Delirium-Pathophysiology
Complex
Widespread neuronal or neurotransmitter dysfunction
Intracranial process
Systemic diseases
Exogenous toxins
Drug withdrawal 13

16. Delirium Causes Infection pneumonia, urinary tract infections
Metabolic/toxic alcohol ingestion, electrolyte abnormalities, vasculitis, thyroid disorders, hepatic failure
Cerebrovascular ischemic stroke. hemorrhagic stroke
Trauma head injury, subdural hematoma 14

17. Delerium Causes
Cardiopulmonary congestive heart failure, myocardial infarction, pulmonary embolus, hypoxia
Medications digitalis, anticholinergics effects, polypharmacy
Other seizure and post-ictal state, severe urinary retention

18. “SMASHED”-Mnemonic For Acute Mental Status Change
S Substrates hyperglycemia, hypoglycemia, thiamine
Sepsis
M Meningitis meningitis and other CNS infections
Mental illness functional psychoses
A Alcohol intoxication, withdrawal
S Seizures Seizure activity, post-ictal states
Stimulants anticholinergics, hallucinogens, cocaine
H Hyper hyperthyroidism, hyperthermia, hypercarbia
Hypo hypotension, hypothyroidism, hypoxia, hypothermia
E Electrolytes hypernatremia, hyponatremia, hypercalcemia
Encephalopathy hepatic, uremic, hypertensive
D Drugs of any sort
Roberts JM. Ann Emerg Med 1990. 15

19. Physician’s Role Primary survey Resuscitation Secondary assessment
Establish unresponsiveness
A,B,C’s
Resuscitation
glucose, thiamine
Secondary assessment
Definitive care 16

20. Delirium-History Tempo of onset Associated symptoms
Medical history/medications
Witnesses 17

21. Delirium-History-Confusion Assessment Method (CAM)
Acuity of change of behavior–
Fluctuating course
Inattention
Disorganized thinking
Altered level of consciousness 18

22. General Examination
Vital signs
General physical examination 19

23. Neurologic Examination
Observation
Movements
Cranial nerves
Sensory
Motor
Reflexes 20

24. How Would You Assess Confusion?
Emergency physicians assess mental status informally…
Know when it needs to be done but, rarely perform systematic test…
Rely on history, informal assessments... 21

25. Why Do a Mental Status Exam?
Informal testing used most often BUT, informal testing insensitive
If a formal screening examination performed, assessments, workup, and dispositions change
Dziedzic L, Brady WJ, Lindsay R, Huff JS. J Emerg Med 1998. 22

26. What Is a Mental Status Exam?
Informal
Formal mental status
Mini-mental status exam
Brief mental status exam
Others 23

27. What Is a Mental Status Exam?
Appearance, behavior, attitude
Thought disorders
Perception disorders
Mood and affect
Insight and judgment
Sensorium and intelligence 24

28. Six Elements of Mental Status Evaluation
Appearance, behavior, and attitude
Disorders of thought
Are the thoughts logical and realistic?
Are false beliefs or delusions present?
Are suicidal or homicidal thoughts present?
Disorders of perception
Are hallucinations present?
Mood and affect 25

29. Six Elements of Mental Status Evaluation
Insight and judgment
Does the patient understand the circumstances surrounding the visit?
Sensorium and intelligence
Is the level of consciousness normal?
Is cognition or intellectual functioning impaired?

30. What Tests Are Available to Assess Confusion?
Folstein mini-mental status
The Brief Mental Status Examination
Folstein MF et al. J Psych Res 1975.
Kaufman DM, Zun L. J Emerg Med 1995. 26

31. The Brief Mental Status Examination
ITEM (number of errors) X (weight) = (Total)
What year is it now? 0 or 1 x 4 = ____
What month is it? 0 or 1 x 3 = ____
Present memory phrase: “Repeat this phrase after me and remember it: John Brown, 42 Market Street, New York.”
About what time is it? 0 or 1 x 3 = ____ (Answer correct if within one hour)
Count backwards from 20 to 1. 0, 1, or 2 x 2 = ____
Say the months in reverse 0, 1, or 2 x 2 = ____
Repeat memory phrase 0,1,2,3,4,or 5 x 2 = ____
(each underlined portion is worth 1 point) 27

32. The Brief Mental Status Examination
Final Score is the sum of the totals
For each response, circle the number of errors and
multiply the circled number by the weight to determine the score.
______________________________________
Possible score range from 0 to 28. 28

33. The Brief Mental Status Examination
The lowest possible score (indicating the least impairment) is 0.
The highest possible score is 28.
Categories of scores-
normal mildly impaired severely impaired

34. Returning to Our Patient–
The patient was febrile and combative. He could not speak in an understandable manner.
Brief Mental Status Examination Score=28
What was the score at the first visit? 29

35. Our Patient Continued
Rapid sequence intubation was performed. Antibiotics were administered for a presumed bacterial meningitis. CT was performed that was unremarkable. Lumbar puncture was performed yielding slightly cloudy CSF with 2500 WBC’s/hpf. 30

36. Clinical Course CSF cultures yielded Group B streptococcus.
Patient responded to antibiotics and did well.
Atypical CNS infections
Meningitis-viral
Fungal
Protozoal
Unusual bacteria
Encephalitis 31

37. When Is a Spinal Tap Indicated in Delirium?
“The primary indication for an emergent spinal tap is the possibility of CNS infection. CSF should be examined in patients with a fever of unknown origin, especially if an alteration in consciousness is present….”
Kookier JC, from Roberts and Hedges. 32

38. Easy To Say, Hard To Practice….
“The primary indication for an emergent spinal tap is the possibility of CNS infection. CSF should be examined in patients with a fever of unknown origin, especially if an alteration in consciousness is present….” 33

39. Question
What other laboratory studies are useful in the working of delirium? confusion? 34

40. Altered Mental Status–Workup
Level I-History, physical examination, mental status examination
Level II-electrolytes, CBC, urinalysis, CXR, ABG, drug screen
Level III-LP, CT, EEG brain biopsy, etc.
Zun L, Howes DS. Am J Emerg Med 1988. 35

41. Delirium-Treatment Treatment of underlying cause
Environmental manipulation
Sedation
Restraints 36

42. Why Do a Mental Status Exam?
Informal testing used most often BUT, informal testing insensitive
If a formal screening examination performed, assessments, workup, and dispositions change
Dziedzic L, Brady WJ, Lindsay R, Huff JS. J Emerg Med 1998. 37