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

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

Case In the ED his vital signs are 160/90, 110, 24, and a rectal temperature of 100.5 (38.1). General physical examination is unremarkable as is the neurological examination. Specifically, neck was supple, cranial nerves were intact. 3

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

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

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

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

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

Altered Mental Status Examples… Coma Dementia Delirium 9

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

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

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

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

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)

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

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

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

“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

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

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

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

General Examination Vital signs General physical examination 19

Neurologic Examination Observation Movements Cranial nerves Sensory Motor Reflexes 20

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

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

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

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

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

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?

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

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

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

The Brief Mental Status Examination The lowest possible score (indicating the least impairment) is 0. The highest possible score is 28. Categories of scores- 0- 8 normal 9-19 mildly impaired 20-28 severely impaired

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

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

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

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

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

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

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

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

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