Altered Mental Status

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

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.

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.

DDx: Mental Status Changes Mnemonics

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

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

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

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

“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)

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

“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

“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

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

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

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

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

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

“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

“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

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

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

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

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

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

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

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.

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

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

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

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

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

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?”

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.

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

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

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

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

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

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

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 30-60 ml PO q1h until diarrhea Uremia Hemodialysis

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 0.5-2.0 mg IV

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

Sample Q’s

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

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

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

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

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

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

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.