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

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Presentation on theme: "Altered Mental Status/Confusion J. Stephen Huff, MD Emergency Medicine and Neurology University of Virginia Charlottesville, Virginia."— Presentation transcript:

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

2 J. Stephen Huff, MD 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.

3 J. Stephen Huff, MD 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.

4 J. Stephen Huff, MD 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...

5 J. Stephen Huff, MD 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?

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

7 J. Stephen Huff, MD Disorders of Consciousness Arousal functions Arousal functionsand/or Content functions disrupted Content functions disrupted

8 J. Stephen Huff, MD Altered Mental Status What does it mean? What does it mean? What to do about it? What to do about it?

9 J. Stephen Huff, MD Altered Mental Status Examples… Examples… – Coma – Dementia – Delirium

10 J. Stephen Huff, MD Delirium-Synonyms Acute confusional state Acute confusional state Acute cognitive impairment Acute cognitive impairment Acute encephalopathy Acute encephalopathy Altered mental status Altered mental status

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

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

13 J. Stephen Huff, MD Delerium Criteria DSM IV At least 2 of the following 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 J. Stephen Huff, MD Delerium Criteria DSM IV Symptoms develop over short period of time, fluctuate quickly Symptoms develop over short period of time, fluctuate quickly Either(1) etiologic organic factor Either(1) etiologic organic factor OR(2) absence non-organic disorder (such as manic episode)

15 J. Stephen Huff, MD Delirium-Pathophysiology Complex Complex Widespread neuronal or neurotransmitter dysfunction Widespread neuronal or neurotransmitter dysfunction – Intracranial process – Systemic diseases – Exogenous toxins – Drug withdrawal

16 J. Stephen Huff, MD Delirium Causes Infectionpneumonia, urinary tract infections Metabolic/toxicalcohol ingestion, electrolyte abnormalities, vasculitis, thyroid disorders, hepatic failure Cerebrovascularischemic stroke. hemorrhagic stroke Traumahead injury, subdural hematoma

17 J. Stephen Huff, MD Delerium Causes Cardiopulmonarycongestive heart failure, myocardial infarction, pulmonary embolus, hypoxia Medications digitalis, anticholinergics effects, polypharmacy Otherseizure and post-ictal state, severe urinary retention

18 J. Stephen Huff, MD “SMASHED”-Mnemonic For Acute Mental Status Change SSubstrateshyperglycemia, hypoglycemia, thiamine Sepsis MMeningitismeningitis and other CNS infections Mental illnessfunctional psychoses AAlcoholintoxication, withdrawal SSeizuresSeizure activity, post-ictal states Stimulantsanticholinergics, hallucinogens, cocaine HHyperhyperthyroidism, hyperthermia, hypercarbia Hypohypotension, hypothyroidism, hypoxia, hypothermia EElectrolyteshypernatremia, hyponatremia, hypercalcemia Encephalopathy hepatic, uremic, hypertensive DDrugs of any sort Roberts JM. Ann Emerg Med 1990.

19 J. Stephen Huff, MD Physician’s Role Primary survey Primary survey – Establish unresponsiveness – A,B,C’s Resuscitation Resuscitation – glucose, thiamine Secondary assessment Secondary assessment Definitive care Definitive care

20 J. Stephen Huff, MD Delirium-History Tempo of onset Tempo of onset Associated symptoms Associated symptoms Medical history/medications Medical history/medications Witnesses Witnesses

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

22 J. Stephen Huff, MD General Examination Vital signs Vital signs General physical examination General physical examination

23 J. Stephen Huff, MD Neurologic Examination Observation Observation – Movements Cranial nerves Cranial nerves Sensory Sensory Motor Motor Reflexes Reflexes

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

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

26 J. Stephen Huff, MD What Is a Mental Status Exam? Informal Informal Formal mental status Formal mental status – Mini-mental status exam – Brief mental status exam – Others

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

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

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

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

31 J. Stephen Huff, MD The Brief Mental Status Examination The Brief Mental Status Examination ITEM(number of errors)X (weight) = (Total) What year is it now?0 or 1x 4 =____ What month is it?0 or 1x 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 1x 3 =____ (Answer correct if within one hour) Count backwards from 20 to 1.0, 1, or 2x 2 =____ Say the months in reverse0, 1, or 2x 2 =____ Repeat memory phrase0,1,2,3,4,or 5x 2 =____ (each underlined portion is worth 1 point)

32 J. Stephen Huff, MD The Brief Mental Status Examination Final Score is the sum of the totals 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. Possible score range from 0 to 28.

33 J. Stephen Huff, MD The Brief Mental Status Examination The lowest possible score (indicating the least impairment) is 0. The lowest possible score (indicating the least impairment) is 0. The highest possible score is 28. The highest possible score is 28. Categories of scores- Categories of scores- – 0- 8 normal 9-19mildly impaired severely impaired

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

35 J. Stephen Huff, MD 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.

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

37 J. Stephen Huff, MD Kookier JC, from Roberts and Hedges. 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….”

38 J. Stephen Huff, MD 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….”

39 J. Stephen Huff, MD Question What other laboratory studies are useful in the working of delirium? confusion?

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

41 J. Stephen Huff, MD Delirium-Treatment Treatment of underlying cause Treatment of underlying cause Environmental manipulation Environmental manipulation Sedation Sedation Restraints Restraints

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


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