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Altered Mental Status in Older ED Patients Anita Chopra MD FACP Director, NJ Institute for Successful Aging UMDNJ-SOM.

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Presentation on theme: "Altered Mental Status in Older ED Patients Anita Chopra MD FACP Director, NJ Institute for Successful Aging UMDNJ-SOM."— Presentation transcript:

1 Altered Mental Status in Older ED Patients Anita Chopra MD FACP Director, NJ Institute for Successful Aging UMDNJ-SOM

2 Altered Mental Status in Older ED Patients This Care of the Aging Medical Patient in the Emergency Room (CAMP ER ) presentation is offered by the Department of Emergency Medicine in coordination with the New Jersey Institute for Successful Aging. This lecture series is supported by an educational grant from the Donald W. Reynolds Foundation Aging and Quality of Life program.

3 A.Opiate overdose due to excessive use of oxycodone B.Subdural hematoma C.Medication-induced delirium D.Alcohol intoxication E.Dementia-related sundown phenomenon An 80 year old woman is brought to the ER by her daughter because the patient was noted to be confused when the daughter was visiting her after work. Patient lives alone and has a past medical history of spinal stenosis, osteoporosis, falls, and mild cognitive impairment. She has fallen multiple times in the past 6 months, but has had no fractures. She visited her PCP two days ago, complaining about severe back pain and difficulty sleeping at night. She was prescribed cyclobenzaprine, low-dose amitriptyline, and prn oxycodone. Physical examination, including a neurological exam, is unrevealing. Which of the following is the most likely diagnosis?

4 A.Acute onset, altered level of consciousness, and memory impairment. B.Acute onset, disorganized thinking, and inattention. C.Acute onset, altered level of consciousness, and executive dysfunction. D.Acute onset, inattention, and hallucinations. E.Acute onset, hypervigilant, and disorganized thinking. An 82 year old patient is brought to the ER with acute change in mental status. You utilize Confusion Assessment Method (CAM) to screen for the presence of delirium. Which of the following meets the CAM criteria for delirium?

5 A.CBC. B.Electrolytes. C.Blood sugar. D.Urine analysis. E.CT of the head. A 78 year old patient is brought to the ER with altered mental status and is diagnosed with delirium. Which of the following diagnostic tests is not appropriate for initial evaluation of the patient?

6 Learning Objectives Describe a systematic approach to assessing an older patient presenting with altered mental status Recognize negative consequences of missed diagnosis of delirium Describe distinguishing features of delirium and dementia Identify risk factors of delirium Discuss the diagnosis and management of delirium in the ED setting.

7 Altered Mental Status/Cognitive Impairment Common in ED, and more than 25% of older ED patients are cognitively impaired Frequently missed and recognized only 28-38% of the time Broadly categorized as delirium or cognitive impairment without delirium Approx. 10% of older ED patients suffer from delirium and identification is really poor (16- 36% of cases)

8 Mental Status: Main Components Level of consciousness or arousal Cognition: content of consciousness

9 Level Of Consciousness Consciousness is the ability of a person to be able to receive information, process that information, and then act upon it. A normal level of consciousness consists of a patient who is alert and attentive –Hyperalert/vigilant- Stupor –Normal- Coma –Lethargic/somnolent Tools: AVPU, GCS, RASS( Richmond agitation assessment scale)

10 Cognition: Domains Orientation: place, time, person Attention: Attention refers to the person’s ability to focus on a given task,such as naming the months backwards or spelling ‘‘world’’ backwards or digit span test Memory: New and old memory Executive function: Ability to judge a situation, shift parameters, plan, and appropriately take action Tools: Mini Cog, MMSE, Six Item Screener

11 Quality indicators for Cognitive Assessment SAEM Geriatric Task Force 1.IF an older adult presents to an ED, THEN the ED provider should carry out and document a cognitive assessment (such as an indication of level of alertness and orientation or an indication of abnormal or intact cognitive status) or document why a cognitive assessment did not occur 2.IF an older adult is found to have cognitive impairment, THEN an ED care provider should document whether there has been an acute change in mental status from baseline (or document an attempt to do so). Terrell KM, Hustey FM, Hwang U, et al. Acad Emerg Med 2009;16(5):

12 Delirium versus Dementia DeliriumDementia OnsetAcute Insidious DurationHours to daysMonths to years CourseFluctuatingSlowly progressive AttentionPoorUsually unaffected ConsciousnessImpairedClear until late in the course of illness Both may be associated with memory impairment, orientation difficulties, hallucinations and delusions. It is common for delirium to be superimposed on dementia.

13 Dementia with Lewy Bodies (DLB) DLB is the second most common subtype of dementia (after Alzheimer’s disease) and affects 15% to 25% of elderly patients with dementia Characterized by a rapid decline and fluctuation in cognition, attention, and level of consciousness Perceptual disturbances are frequently observed in patients with DLB Patients with DLB have parkinsonian motor symptoms, such as cog wheeling, shuffling gait, stiff movements, and reduced arm swing during walking.

14 Delirium “Acute confusional state” “Acute brain failure” “Sundowning” “Encephalopathy” “ICU psychosis”

15 Negative Consequences of Delirium Powerful prognostic marker associated with in- hospital and long term mortality Increased mortality risk in patients who are discharged home from ED with delirium Poses a significant threat to the quality of life –Accelerated functional and cognitive decline –Longer length of stay Costs more that $100 billion in direct and indirect charges

16 Diagnostic Criteria of Delirium DSM-IV-TR –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 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 the direct physiological consequences of a general medical condition. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association, 2000.

17 Clinical Features Of Delirium Acute onset Fluctuating course Inattention Disorganized thinking Altered level of consciousness Cognitive deficits Perceptual disturbances Altered sleep wake cycle Emotional disturbances

18 Psychomotor Variants Of Delirium Hyperactive –Agitation, combativeness, restlessness, hallucinations –Easiest to recognize (loud, disruptive patients) Hypoactive –Depressed, sedated, somnolent and even lethargic –More likely to go unrecognized (“good patients”) Mixed –Features of both hypo and hyperactive delirium Han JH, Zimmerman EE, Cutler N, et al. Acad Emerg Med 2009;16(3):193–200. Hypoactive delirium and mixed-type delirium seem to be the predominant subtypes in older patients

19 Risk Factors Can be split into two categories –Predisposing factors “Pre-hospitalization” Can alert the physician/staff to risk but are often non modifiable in the acute setting For at risk patients, efforts can focus on prevention –Precipitating factors “Post-hospitalization” Often iatrogenic Often modifiable Often preventable

20 Threshold for Delirium Interrelationship between patient vulnerability and precipitating factors Predisposing Factors/ Vulnerability Precipitating Factors/ Insults Low Vulnerability High Vulnerability Less Noxious Insult Noxious Insult Inouye SK, Charpentier PA. JAMA 1996;275(1):

21 Predisposing Factors Demographics –Advancing Age –Male gender Co-Morbidity –Dementia –No./severity of co- morbid conditions –Functional impairment Sensory impairment –Hearing –Visual Medications and drugs –Polypharmacy –Psychoactive med(s) use –Alcohol abuse Decreased oral intake –Dehydration –Malnutrition Psychiatric –Depression

22 Precipitating Factors Systemic –Infection –Inadequate pain control –Trauma Metabolic –Electrolyte disturbance –Hepatic or renal failure –Hypoglycemia Medications and drugs –Meds and meds changes –Drugs or drug withdrawal Central Nervous System –CVA –Hemorrhage –Seizures and post ictal state Cardiopulmonary –Acute MI –CHF –Respiratory failure Iatrogenic event –Indwelling bladder catheter –Physical restraints –Procedures/surgery

23 High Risk Medications Sedatives-hypnotics –Benzodiazepines –Antihistamines Narcotics H 2 blocking agents Antiparkinsonian meds Anticonvulsants Drugs with anticholinergic effects –Oxybutynin, tolterodine –Anti-nauseants –Tricyclic antidepressants –Antipsychotics, e.g., low potency neuroleptics such as chlorpromazine –Promotility agents

24 Diagnosing Delirium In ER Several Assessment Tools Confusion Assessment Method (CAM) CAM- ICU Delirium Symptom Interview (DSI) Delirium rating scale Memorial Delirium Assessment Scale (MDAS) Nursing Delirium Screening Scale (NuDESc)

25 Confusion Assessment Method (CAM) 1. History of acute onset of change in patient’s normal mental status & fluctuating course AND 2.Lack of attention AND EITHER 3. Disorganized thinking 4.Altered Level of Consciousness; Alert, hyper alert, lethargic or drowsy, stupor, coma Inouye SK, van Dyck CH, Alessi CA, et al. Ann Intern Med 1990;113(12): Pompei P, Foreman M, Cassel CK, et al. Arch Intern Med 1995;155(3): Sensitivity: % Specificity: 90-95%

26 CAM-ICU Scale based on degree of consciousness Visual recognition to test attention and short-term memory Head nodding and hand movements as responses Sensitivity and specificity comparable to the basic CAM Ely EW, Margolin R, Francis J, et al. Crit Care Med 2001;29(7):

27 CAM-ICU Video Source: icudelirium.org. Copyright © 2002, E. Wesley Ely, MD, MPH and Vanderbilt University, all rights reserved

28 Richmond Agitation-Sedation Scale Step 1 Level of Consciousness (RASS) Sessler CN, Gosnell MS, Grap MJ, et al. Am J Respir Crit Care Med 2002;166(10): Ely EW, Truman B, Shintani A, et al. JAMA 2003;289(22): Image Source: icudelirium.org. Copyright © 2002, E. Wesley Ely, MD, MPH and Vanderbilt University, all rights reserved

29 CAM-ICU Flow Sheet “Copyright © 2002, E. Wesley Ely, MD, MPH and Vanderbilt University, all rights reserved”

30 What Causes Delirium? Widespread imbalance of neurotransmitters & disruption of synaptic communication resulting from –Drugs –Hypoxemia, metabolic derangements → global impairment of cerebral metabolism → decreased synthesis and release of neurotransmitters –Systemic inflammation → activation of microglia→ increased cytokine levels Some studies support the notion that CNS blood flow may be disrupted during delirium Gunther ML, Morandi A, Ely EW. Crit Care Clin 2008;24(1): Fong TG, Tulebaev SR, Inouye SK. Nat Rev Neurol 2009;5(4):

31 Evaluation Of ED Patient With Delirium History: –Time course of mental status changes –Baseline mental status and cognition –History of trauma, fall –Medication review, any recent changes –Alcohol abuse Physical exam: –Vital signs –Emphasis on neurologic including mental status, cardiovascular, pulmonary exam –Signs of infection, volume status Diagnostic tests – Oxygen saturation – Rapid glucose determination – CBC, electrolytes, renal and liver function tests – urine analysis – Chest X-ray – EKG: myocardial ischemia, arrhythmia, and to assess for QTc prolongation –Dependent upon the clinical scenario consider: Head CT, lumbar puncture, blood cultures, toxicology screening, thyroid

32 ED Patient With Acute Change In Mental Status: Differential Diagnosis Delirium Structural CNS process Non-convulsive status epilepticus Psychiatric illness

33 Pharmacologic Management Of Delirium Search and treat the underlying cause Create a safe environment for the patient and staff Psychotropic meds reserved for patients in distress due to severe agitation or psychotic symptoms Aim for monotherapy, lowest effective dose, and tapering as soon as possible Antipsychotics are the treatment of choice Use of Benzodiazepines should be avoided –Reserved for delirium caused by withdrawal from alcohol/sedatives hypnotics

34 Antipsychotics Haloperidol is suggested as the antipsychotic of choice based on the best available evidence to date –Haloperidol, mg IM/PO: evaluate effect in 30 minutes to 1 hour. Administer additional doses until agitation is controlled (max 3-5mg/24 hours) –Clinical endpoint should be an awake but manageable patient –A subsequent maintenance dose consisting of ½ loading dose over 24 hours in divided doses - taper 2-3 days –Baseline EKG is recommended prior to initiation of IV Haldol to measure baseline QT interval Atypical antipsychotics may be considered as alternative agents, lower rates of extra pyramidal signs –Risperidone: mg PO or oral dissolvable, q8-12 hrs –Olanzapine: mg IM q1h prn, mg PO QD –Quetiapine: mg PO q8-12 hrs prn, mg PO BID

35 Nonpharmacologic Management Of Delirium Discontinue or decrease drugs Supportive care and reorientation Glasses/hearing aids Attention to patient concerns & fears Remove immobilizing lines and devices Avoid restraints

36 Disposition Low threshold for admission Delirious patients discharged from ED more likely to return and be hospitalized When admitted to the hospital, admission to a specialized geriatric unit preferable Regardless of patient disposition, delirium detected in ED should be communicated to the physician at next stage of care

37 Quality Indicators For Cognitive Assessment SAEM Geriatric Task Force 3. IF an older adult presenting to an ED is found to have cognitive impairment that is a change from baseline and is discharged home, THEN the ED provider should document the following: –Support in the home environment to manage the patient’s care –A plan for medical follow-up

38 Conclusion In any patient with a change in mental status consider delirium as possible diagnosis Consider altered mental state to be acute until proven otherwise Delirium is very common in the ED and is often missed Missing delirium can result in loss of a window of opportunity to diagnosis and treat reversible medical and surgical conditions that can present as delirium

39 References 1.Terrell KM, Hustey FM, Hwang U, et al. Quality indicators for geriatric emergency care. Acad Emerg Med 2009;16(5): American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association, Han JH, Zimmerman EE, Cutler N, et al. Delirium in older emergency department patients: recognition, risk factors, and psychomotor subtypes. Acad Emerg Med 2009;16(3):193– Inouye SK, Charpentier PA. Precipitating factors for delirium in hospitalized elderly persons: Predictive model and interrelationship with baseline vulnerability. JAMA 1996;275(1): Inouye SK, van Dyck CH, Alessi CA, et al. Clarifying confusion: The Confusion Assessment Method: A new method for detection of delirium. Ann Intern Med 1990;113(12):

40 References 6.Pompei P, Foreman M, Cassel CK, et al. Detecting delirium among hospitalized older patients. Arch Intern Med 1995;155(3): Ely EW, Margolin R, Francis J, et al. Evaluation of delirium in critically ill patients: Validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Crit Care Med 2001;29(7): Sessler CN, Gosnell MS, Grap MJ, et al. The Richmond Agitation-Sedation Scale: Validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med 2002;166(10): Ely EW, Truman B, Shintani A, et al. Monitoring sedation status over time in ICU patients: Reliability and validity of the Richmond Agitation-Sedation Scale (RASS). JAMA 2003;289(22): Gunther ML, Morandi A, Ely EW. Pathophysiology of delirium in the intensive care unit. Crit Care Clin 2008;24(1): Fong TG, Tulebaev SR, Inouye SK. Delirium in elderly adults: Diagnosis, prevention and treatment. Nat Rev Neurol 2009;5(4):


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