1. Altered Mental Status

2. 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

3. 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.
Additional features that may accompany delirium and confusion:
Psychomotor behavioral disturbances such as hypoactivity, hyperactivity with increased sympathetic activity and impairment in sleep duration and architecture.
Variable emotional disturbances, including fear, depression, euphoria, or perplexity.

4. 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
Delirium my persist for 12mos or longer, particularly those with underlying dementia.
In a report of pooled results from several studies the ……..This is approx. 2x that of those without delirium. Findings likely due in part to concomitant dementia and severe phyisical illness. However, 2 prospective observational studies that adjusted for dementia and other potential confounding factors still found that delirium was an independent marker for mortality at 6 or 12 mos after hospitalization.

5. DDx: Mental Status Changes
Mnemonics

6. DOGMIST Mnemonic Drugs Oxygen Glucose Metabolic Ischemia Infection
electrolytes
endocrine
hepatic
renal
vitamins & minerals
Ischemia
Infection
Seizure
Sleep/wake cycle
Trauma
Toxins

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

8. I WATCH DEATH Mnemonic Infection Withdrawal Acute metabolic Trauma
CNS pathology
Hypoxia
Deficiencies
Endocrinopathies
Acute vascular
Toxins or drugs
Heavy metals

9. 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

10. “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)

11. “M” Medications Analgesics: Opiods (especially morphine), NSAIDS
Anticholinergics: atropine, benztropine, trihexyphenidyl, scopolamine
Anticonvulsants: Carbamazepine, phenytoin, valproate, vigabatrin
Antidepressants: SSRI’s, TCA’s

12. “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

13. “M” Medications
CV meds: amiodarone, b-blockers, digoxin, disopyramide, diuretics
Dopamine agonists: amantadine, romocriptine, levodopa, pergolide, pramipexole ropinirole
Sedatives/hypnotics: barbituates, benzodiazepines, clozapine, lithium, phenothiazines

14. “M” Medications
Miscellaneous: baclofen, disulfiram, donepezil, INFs, IL-2, nitrous oxide, oral hypoglycemics
NOTE: Digoxin, lithium, quinidine
Can cause delirium even at “therapeutic” levels

15. “ O” Oxygen Deficiency Hypoxemia Asthma Sleep Apnea Anemia
Decreased Cardiac Output
Carbon Monoxide
Carbon Dioxide
Obstipation

16. “V” Vascular Disorders
Stroke
Intracranial Bleeds
Hypertensive encephalopathy
TTP or DIC
Hyperviscocity syndrome
Vasculitis
Migraine

17. “E” Electrolyte/Fluid Disorders Hypo or Hypernatremia
Hypo or Hypercalcemia
Hypomagnesemia
Hypokalemia
Environment
Glasses/hearing aid (Sensory deprivation)
Sleep deprivation
EtOH

18. “S” Seizures Active seizure vs post-ictal state Shock Silent MI
Structural abnormalities
Hydrocephalus

19. “T” Toxins Trauma Temperature Hyperthermia Hypothermia
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

20. “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

21. “P” Psychiatric Causes
Psychogenic coma
Catatonia (schizophrenia)
Depression
ICU psychosis
Uncontrolled Pain

22. “I” Infection CNS Meningitis Encephalitis Tertiary Syphilis
Lyme disease
TB/Crypto
Sepsis
Infections in the Elderly (PNA, UTI)

23. “D” Drugs of Abuse Acute intoxication Withdrawal syndromes
Dementia/Degenerative Diseases
Alzheimer’s, Multi-infarct Dementia, EtOH, Parkinson’s
Dialysis

24. Approach to the patient
?Confusional State
?Delirium
?Dementia
?Comatose
Approach to the patient

25. 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

26. 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

27. 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?
Drug tox accounts for about 30% of all cases of delirium.

28. 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

29. Pupils Bilaterally small & minimally reactive
narcotics
metabolic encephalopathy
Bilaterally large & minimally reactive
anticholinergics

30. Pupils cont’d Bilaterally midposition & fixed
midbrain lesion
increased ICP
transtentorial (central) herniation
Unilaterally dilated and fixed
CN III palsy
uncal (lateral) herniation

31. 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”)
Dolls eyes-eyes move opposite head movement
Cold calorics-eyes move towards lavaged ear
Brainstem intact

32. 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

33. 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
1.“Is there evidence of an acute change in mental status from patient’s baseline?”
“Did the abnormal behavior fluctuate during the day?”
2.“Did the patient have difficulty focusing attention/being easily distractible or having difficulty keeping track of what was being said?”
3.“Was the patient’s thinking disorganized or incoherent?”
4.“Overall, how would your rate this patient’s level of consciousness?”

34. 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
Ask pt to listen carefully and repeat series of random numbers. Begin with string of 2 digits, then increase. Read each number in nml tone at rate of one digit/sec.
Read list of 60 letters among which the letter “a” appears with greater than random frequ. The subject is required to indicate by tapping on desk whenever the target letter is spoken by examiner.

35. Rule out easily reversible conditions
Thiamin (100mg IV)
Fingerstick – or empirically give Amp D50
Naloxone 1mg IV/SQ/IM
Oxygen
IVF

36. Approach to the patient
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

37. Lab/Rads Eval 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
Bold: Reasonable when cause not immediately obvious
Drug levels: Delirium can occur even at therapeutic levels (dig, lithium, quinidine)
Tox screen: Common drugs (risperidone) not assessed in routine lab screens
ABG: hyperventilating pt: resp alk.>early sepsis, hepatic failure, early salicylate intox, CPP Met acid> late phases of sepsis or salicylate intox, methanol, ethylene glycol
Slow decline: tfts, b12
Neuroimaging: if initial clinical eval discloses obvious, no trauma, no new focal neuo signs, pt arousable and able to follow commands
MRI more sens for acute stroke, post fossa lesions, WM lesions. Unknown cause of delirium and neg head ct-r/o acute/subacute stroke and multifocal inflammatory lesions (reversible post leukoencephalopathy and acute disseminated encephalomyelitis.
LP-older pt’s with bact. Men.more likely to present with delirium vs. fever/ha/meningismus
EEG-R/O seizure, esp nonconvulsive or subclinical and confirm dx of certain met. Encephalopathies or infectious encephaliteds that have charact. EEG findings

38. 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

39. 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

40. Non-pharmacologic approaches cont’d
Maintain competency
Correct sensory impairments
glasses & hearing aids
dentures
interpreter
Encourage self-care & participation in treatment
Maximize periods of uninterrupted sleep
Maintain activity levels
ambulate x 15 minutes TID, or
ROM exercises x 15 minutes TID

41. 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 ml PO q1h until diarrhea
Uremia
Hemodialysis

42. 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 mg IV

43. 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

44. Sample Q’s

45. A 70 Y/O WF had an emergency chole 2 days ago
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

46. 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

47. 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

48. 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

49. 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

50. 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

51. References Pocket Medicine, second edition. Lippincott Williams &
Wilkins. section 9-1:2004
Uptodate.com (delirium)
Thanks to Dr. Jenny Curry and Dr. Dylan Wessman for
parts of their previous presentations on delirium.