1. Altered Mental Status PI Project 2011

2. Mnemonic: AEIOU TIPS Alcohol intoxication/withdrawal, elevated ammonia (hepatic encephalopathy) Electrolyte abnormalities, especially hypoglycemia and severe hypoNa, hyperCa. Endocrine – severe hyper/hypothyroidism, Addisonian crisis, DKA/HHNS Iatrogenic – i.e. steroid psychosis, anticholinergics in elderly, opiates, benzos O – HypOxemia – pneumonia, PE, carbon monoxide etc. CO 2 narcosis

3. Mnemonic: AEIOU TIPS Uremic encephalopathy Trauma (concussion, subdural or epidural hematoma), TIA/CVA Infection – sepsis, encephalitis, meningitis, UTI, pneumonia (elderly are especially prone to AMS with infection) Poisons/toxins – including intoxication or withdrawal from drugs of abuse Seizures – ictal (including nonconvulsive) or post-ictal

4. Other causes of AMS not mentioned in mnemonic Constipation. Common in elderly!! Hydrocephalus complicated migraine CNS vasculitis Hypertensive encephalopathy Wilson’s disease

5. Delerium is common! Affects 10-20% of all hospitalized adults, 30-40% of elderly hospitalized patients, 60% to 80% of mechanically ventilated medical and surgical ICU patients and 50% to 70% of non- ventilated medical ICU patients

6. Delerium vs Dementia Delerium: Disturbance of consciousness (reduced clarity of awareness of the environment, with reduced ability to focus, sustain, or shift attention) Change in cognition (e.g., problem-solving impairment or memory impairment) or a perceptual disturbance Onset of hours to days, and tendency to fluctuate (as opposed to dementia)

7. Pointers on Treatment ABCs and vitals first! Remember to get head CT before LP if there is possibility of increased ICP If pt is alcoholic, remember to give thiamine 100mg IV PRIOR to any dextrose to prevent exacerbation of Wernicke’s encephalopathy Indication for Narcan: acute narcotic overdose and respiratory rate <8. Do not give simply for drowsiness! Discuss with your senior resident. Indication for Flumazenil: acute benzo overdose and respiratory rate <8. Be extremely cautious when giving to patients with long-standing benzo use, as giving flumazenil may induce seizure.

8. Pointers on Treatment Make sure pain is adequately treated, lytes are repleted, no constipation, nutrition is optimized Talk to patient, frequent re-orientation (i.e. tell them where they are, what time/day it is etc), family at bedside (familiar faces) are helpful. Consider placing clock in patient’s room. Minimize intrusive procedures or exams to the extent possible Medication of choice is Haldol check baseline EKG for prolonged QT if giving frequently/regularly, monitor periodic EKG or tele

9. Pointers on Treatment Do NOT give IV haldol to patient’s on a ward (non-ICU) bed. Can only give IM. Watch for extrapyramidal side effects, especially with prolonged use Neuroleptic malignant syndrome is a rare complication Typical dosing: Initial: 2-10 mg depending on degree of agitation; may repeat bolus dose (with sequential doubling of initial bolus dose) every 15-30 minutes until calm achieved, then administer 25% of the last bolus dose every 6 hours. After the patient is controlled, haldol should be tapered over several days. Note: QTc prolongation may occur with cumulative doses ≥35 mg and torsade de pointes has been reported with single doses of ≥20 mg

10. Pointers for Neuro Exam pupil size and reactivity: pinpoint: suspect opiates midposition and fixed: midbrain lesion fixed and dilated: severe anoxic injury or herniation signs of increased ICP: papilledema, pronator drift, unilateral dilated pupil. Cushing’s response causes HTN and bradycardia Brainstem reflex testing: Oculocephalics (“Doll’s eye”): moving head  eyes should move in opposite direction Oculovestibular (“cold calorics”)  inject cold water into ear  eyes should move toward lavaged ear. Mnemonic: COWS (COld Water Same side)

11. Diagnostic Testing to Consider In addition to the routine tests (use the mnemonic to help you): ammonia, LFTs Lytes EtOH level, urine toxicology, salicylates Infectious workup, including u/a, CXR, pancultures KUB (for constipation/ileus) TSH ABG CT of head EEG Lumbar puncture