Altered Mental Status

CMR Lecture

Objectives

Overview the definition of “altered mental status”

Develop reasonable differential diagnosis for acute

mental status changes

Explain first steps in diagnosis and management of

common causes of mental status changes

Definition

Mental status is composed of two parts:

– Arousal: wakefulness, responsiveness

– Awareness: perception of environment

Delirium (which we see a lot)

– Transient, usually reversible

– Decreased attention span and waning confusion

Delirium vs. Dementia

DELIRIUM DEMENTIA

Onset Acute/Subacute Insidious

Course Fluctuating Stable and

progressive

Attention Fluctuates Steady

Sensorium Impaired Intact until late

Cognitive Globally impaired Poor short term

memory

Perception Visual

Hallucinations

Simple Delusions

Delirium

Extremely frequent

– 14-56% of elderly hospitalized patients

– 40% of ICU patients

In patients who are admitted with delirium, mortality

rates as high as 10-26%

Development of delirium correlates with prolonged

hospital stay, increased complications, increased

cost, and long-term disability

McCusker J, Cole M, Abrahamowicz M, Primeau F, Belzile E. Delirium

predicts 12-month mortality. Arch Intern Med. Feb 25 2002;162(4):457-63.

Alertness Awareness Perform

Tasks

Attention

Span

“Cloudy

Consciousness”

Decreased Retain Impaired Decreased

Lethargy Decreased Retain Impaired Decreased

Obtundation Decreased Decreased Requires

stimulus

Decreased

Stupor Decreased Decreased Requires

constant

stimulus

Decreased

Coma Decreased Decreased None None

Epidemiology

AMS is primary reason for ED visit in 4-10%

patients

ED patients > 65

– 25% with AMS

– 26% with minimal cognitive impairment

– 34% with moderate cognitive impairment

*prevalence of dementia 1% at age 60 and doubles

every 5 years until age 85 (30-50%)

So you are called for MS Δ’s…

What are the vital signs?

What was the time course?

What is the patient’s baseline?

What medications have they received?

What is the patient’s past medical history?

Was there any trauma?

Is there any focality to the neuro exam?

First Steps

ABCDE:

– Airway

– Breathing

– Circulation

– Disability

– Exposure

Workup

HISTORY!!!!

– Ask family

– New meds?

– Any significant PMH?

PHYSICAL

– Vitals

– Detailed physical WITH neurologic exam

– GCS

Etiology

A alcohol, ammonia, alzheimer

E endocrine, electrolyte, encephalopathy

I infection, intoxication

O opiates, overdose, oxygen, CO2

U uremia

T tumor, trauma

I insulin (hypoglycemia)

P poisonings, psychosis

S stroke, seizures, syncope, shock, SAH,

Case #1

73 YO WM with h/o HTN and gout admitted for

suspected septic arthritis of left knee. Patient had

arthrocentesis this afternoon, results pending. You

are called at 9pm because patient has had an acute

change in mental status.

Exam

VS: T 37.5, HR 64, RR 16, BP 124/74, 96%RA

Lethargic, not conversant, moaning, withdraws all 4

extremities to pain, responds to sternal rub

AEIOUTIPS

Drugs

Medications implicated in 30% of cases of delirium

Common causes of mental status changes include

opioids, benzos, any anticholinergics

Clues in the exam

– Opioids: miosis (pinpoint pupils), decreased respirations,

and hypotension

– Anticholinergics: mydriasis, bradycardia, salivation,

lacrimation, and diaphoresis

Reversal Agents

Opioids?

– Narcan (naloxone) 0.04 mg to 0.4 mg q 2-3 min

** may need to readminister doses at a later interval (ie,

20-60 minutes) depending on type/duration of opioid

– If reversal does not occur quickly or after 0.8 mg,

diagnosis should be questioned

Reversal Agents

Benzodiazepines?

– Flumazenil 0.2 mg IVP, repeat q30 sec up to total

dose of 2 mg

– If reversal does not occur quickly,

diagnosis should be questioned

– Beware of black box warning:

– BZP reversal may seizures especially in

patients on long term BZPs or following TCA

overdose. Be prepared for seizures!

Polypharmacy in the Elderly:

Remember to check GFR and appropriately dose medications

Check for drug-drug interactions and ask about OTC’s & herbals

Avoid anything with anticholinergic properties

JUST STOP UNNECCSSARY MEDS

Case #2

61 YO AAM with ESRD 2/2 poorly controlled DM2 on HD admitted for lack of HD access due to clotted fistula. You are called at 7am with mental status changes.

VS: T 35.6, HR 88, RR 20, BP 152/86, SAT 96% RA

Exam: Moaning, incoherent, diaphoretic, drooling

Accu-check Glucose: 28 mg/dL

AEIOUTIPS

Causes of Hypoglycemia

Overly aggressive insulin regimen

Renal failure

Liver failure

Infection/Sepsis

Excessive EtOH consumption

Rare Causes

– Adrenal insufficiency

– Insulinoma

Hypoglycemia Management

Is patient awake enough to drink some juice, take glucose tabs?

– Three glucose tabs will raise blood sugar by 50 g/dL.

If unable to take PO and has IV access, then give use IV dextrose

– 1 amp D50 = 25 grams of glucose

If patient does not have IV access and unresponsive, give Glucagon 1mg IM/SC.

Always recheck glucose 15-20 minutes later to document return to euglycemia.

Case #3

64 YO obese WF with GOLD class III COPD (on 2L

home O2) admitted for COPD exacerbation. You are

called for mental status changes at 10:55 PM.

VS: T 36.4, HR 88, RR 18, BP 134/66, SAT 99% on

8L O2 via NC

Exam: Lethargic, arouses only to sternal rub, lungs

with poor air exchange

ABG: 7.18 / 103 / 95 / 98% on 8L Via NC

AEIOUTIPS

Hypercapnea because of supplemental Oxygen:

1) V/Q mismatch: if a part of the lung is underventilated it should be underperfused (hypoxic pulmonary vasoconstriction) adding O2 increases perfusion but NOT ventilation

2) Haldane effect: Deoxygenated Hg is able to carry more carbon dioxide than oxygenated Hg

3) Respiratory homeostasis: Chronic elevation of CO2 leads to CO2 being less of a stimulant for respiratory drive, and instead O2 provides stimulus. Hence, supplemental O2 can decrease respiratory drive leading to CO2 retention.

Five Causes of Hypoxia

1. Hypoventilation

2. Shunt

3. Increased Diffusion Gradient

4. Decreased FiO2

5. V-Q Mismatch

Key Points to Remember

Look at baseline HCO3 to have an idea of

whether patient is a CO2 retainer

Whenever patients are requiring more FiO2,

check ABG to ensure not retaining CO2

Elevated PaCO2 with mental status changes

buys a ticket to the MICU (need BPAP vs intubation)

Case #4

62 yo WM with ischemic cardiomyopathy and systolic

CHF (last EF 10-15%) admitted for volume overload

and mental status changes.

VS: T 36.4, HR 98, RR 20, BP 74/40, SAT 93% 3L

AEIOUTIPS

Hypoperfusion

Anything that decreases cerebral perfusion

can alter mental status

– CHF exacerbation with worsening cardiac output

– Severe Sepsis

– Hypovolemia

– Myocardial Infarct

– “Shock”

Indication for ICU transfer

Review of sepsis…

SIRS Criteria – Temperature > 38C or < 36C (> 100.4F or < 96.8F)

– Heart rate > 90 beats/min

– Respiratory rate > 20 breaths/min (or PaCO2 < 32 mm Hg)

– White blood cell count > 12,000 or < 4,000 cells/mm3 (or presence of > 10% immature neutrophils “bands”)

Sepsis: At least 2 SIRS criteria caused by known or suspected infection

Severe Sepsis: Sepsis with acute organ dysfunction

Septic Shock: Sepsis with persistent or refractory hypotension or tissue hypoperfusion despite adequate fluid resuscitation

Case #5

93 yo WM with Alzheimer Dementia admitted for

aspiration pneumonia. Patient had a PEG placed

and is getting tube feeds while his pneumonia is

being treated with Zosyn. Patient develops mental

status changes on hospital day #4.

VS: T 36.4, HR 100, RR 22, BP 134/66, 94% on RA

BMP: 158 118 27

4.8 32 1.5

AEIOUTIPS

Electrolyte Abnormalities -> AMS

Hypernatremia

Hyponatremia

Hypercalcemia

Hypernatremia:

Signs and Symptoms: Mental status changes, hyperreflexia, seizures, and coma

Causes:

-Hypovolemic: diarrhea, inadequate intake, renal losses

-Euvolemic: DI (central and nephrogenic)

-Hypervolemic: Hypertonic saline use, mineralcorticoid excess

Treatment:

-Hypovolemic: Calculate Free H2O deficit: Replete with free H20 or D5W

-Euvolemic: DI: Central: dDVAP, Nephrogenic: Treat underlying cause

-Hypervolemic: D5W and Loop Diuretic

Serum [Na] Water deficit = Current TBW x (——————— - 1) 140

Hyponatremia

Signs and Symptoms: Lethargy, seizures, mental status changes, cramps, anorexia

Diagnosis/Causes of Hyponatremia:

- Hypovolemic: Diuretic use/Poor PO intake

- Euvolemic: SIADH/Severe Trauma

- Hypervolemic: CHF/Liver Failure/Nephrotic syndrome

Treatment:

*** Only use hypertonic saline if actively seizing***

- Hypovolemic: NS

- Euvolemic/Hypervolemic: water restriction

Note: SIADH which does not respond to water restriction, use a vaptan

(Vasopressin antagonist)

Hypercalcemia

Signs and symptoms

– Bonesosteopenia

– Stoneskidney stones and polyuria

– Groansabdominal pain, anorexia, constipation, ileus, N/V

– Psychiatric overtonesdepression, psychosis,

delirium/confusion

Causes of Hypercalcemia

– MCC in outpatients is hyperparathyroidism

– MCC in inpatients is malignancy

– Other causes include vitamin A or D intoxication, sarcoid,

thiazide diuretics, immobilization, multiple myeloma

Hypercalcemia

Treatment

– Hydrate the patient with NS

– Calcium diuresis with furosemide

– For severe hypercalcemia, calcitonin

rapidly/transiently lowers calcium in few hours

– IV bisphosphonates lower further and last longer

but take for effect to kick in

Case #6

48 yo WM with h/o hepatitis C/Cirrhosis admitted for progressively worsening jaundice, weight loss, and AMS. RUQ u/s in ED, revealed a mass in liver. Pt admitted for work-up of mass and AMS. Upon arrival to room you find patient difficult to arouse.

Vitals: T 38.0 HR 66 BP 96/60 RR 16 98% RA

Exam

Gen: Stuporous, arousable but not coherent

ABD: Good bowel sounds, distended with moderate ascites, diffusely tender with rebound tenderness

NEURO: Diffuse hyperreflexia, + Asterixis

CT head: No hemorrhage or mass effect

Labs:

- Hg/Hct 10/30 (Baseline 10.5/31)

- WBC: 18K (with left shift)

•AEIOUTIPS

Hepatic Encephalopathy

Stage Consciousness Intellect and Behavior Neurological Findings

0 Normal Normal Normal examination;

impaired

psychomotor testing

1 Mild lack of

awareness

Shortened attention

span; impaired

addition or subtraction

Mild asterixis or

tremor

2 Lethargic Disoriented;

inappropriate behavior

Obvious asterixis;

slurred speech

3 Somnolent but

arousable

Gross disorientation;

bizarre behavior

Muscular rigidity and

clonus; Hyperreflexia

4 Coma Coma Decerebrate

posturing

HE Precipitants

Infection: May predispose to impaired renal function and to increased tissue catabolism, both of which increase blood ammonia levels.

Bleeding: Blood in the upper GI tract results in increased ammonia and nitrogen absorption from the gut. Bleeding may also predispose to kidney hypoperfusion and impaired renal function. Blood transfusions may result in mild hemolysis, with resulting elevated blood ammonia levels.

Electrolytes: Decreased serum potassium levels and alkalosis may facilitate the conversion of NH4+ to NH3.

Med non-compliance: Ask family about lactulose use

Renal failure: Renal failure leads to decreased clearance of urea, ammonia, and other nitrogenous compounds.

Medications: Drugs that act upon the central nervous system, such as opiates, benzodiazepines, antidepressants, and antipsychotic agents, may worsen hepatic encephalopathy. Or ETOH use.

Dehydration: vomiting, diarrhea, large volume para, diuretics

Management of HE

Correct the underlying cause…

1st line: Lactulose

– Oral: 20 gm PO Q1-2 hrs for goal 3-4 BM’s/day

– Enema: 300 mL in 1 L of water Q4-6 hrs

– Side effects: Diarrhea, flatulence, cramps

Antibiotics:

- Rifaximin: 550 mg BID

helps prevent recurrent episodes of HE

Case #7

52 yo WM with h/o etoh abuse, HTN, DM2 admitted for

right femoral neck fracture after falling, went to OR

for pinning. Remained in house for physical therapy

and placement.

You are called for headache, agitation, and visual

hallucinations on hospital D#3.

Vitals: T 38.6, HR 96, RR 20, BP 170/86, 96%RA

•AEIOUTIPS

EtOH Withdrawal

CIWA Scale

Nausea/Vomiting

Tremor

Sweats

Anxiety

Agitation

Tactile Disturbances

Auditory Disturbances

Visual Disturbances

Headache

Orientation

Sx treated with ativan

**CIWA > 20 consider MICU**

http://www.aafp.org/afp/2004/0315/p1443.html

Case #8

45 yo AAF with h/o polysubstance abuse and HTN admitted for fever and HA. You are called by nurse soon after admission for mental status changes.

VS: T 38.6, HR 101, RR 26, BP 101/58, Sat 98%RA

GEN: uncomfortable, AAO x 2

HEENT: + nuchal rigidity

LUNGS: CTA b/l

NEURO: no focal weakness

•AEIOUTIPS

CNS infections

Meningitis

– Bacterial

– Viral

– Aseptic

Encephalitis

Toxoplasmosis

JC virus

West Nile Virus

Lumbar Puncture

CT head or Fundoscopic Exam done first to document no increased intracerebral pressure

Draw blood cultures from periphery

Do not delay giving antibiotics waiting for CT and doing the LP

Send CSF for glucose, protein, gram stain + culture, cell count w/ diff, and suspected viral serologies

Treatment

Age Common

Pathogens

Antimicrobials

2-50 years N. meningitidis

S. pneumoniae

Vancomycin plus a third-

generation cephalosporin

> 50 years S. pneumoniae

N. meningitidis

L. monocytogenes

Vancomycin plus ampicillin plus a

third-generation cephalosporin

> 50 years w/

suppression

Above + pseudomonas Vancomycin plus ampicillin plus

meropenem/cefepime

****Add dexamethasone if suspected S. pneumo****

Seizures

Status epilepticus – Annual incidence >100,000 cases in the US, of which more

than 20% result in death

– Classically sx include tonic-clonic jerking; loss of bowel/bladder; tongue biting

– Usually have post-ictal confusion

Non-convulsive status – Harder to diagnose, must always think about it

– Need EEG to make diagnosis

Labs to send post-suspected seizure: CPK and Prolactin

Management of Seizures

Supportive care (Remember the ABC’s) – Check fingerstick glucose/give amp D50 empirically

Benzodiazepines – Diazepam 5-10 mg per minute

– Lorazepam 4-8 mg

– Terminate ~75% of seizures

AED’s (Phenytoin, fosphenytoin)

Call Neurology

} Be prepared for airway management and ICU transfer

Case #9

42 yo with DMT2 and depression (on SSRI) admitted

for recurrent lower extremity cellulitis. Patient known

to be colonized with MRSA and has had severe

flushing rxn with Vancomycin last admission.

Started on IV Linezolid. About 12 hours after

antibiotics you are called for fevers and mental

status changes.

Exam

VS: T 39.4, HR 98, RR 20, BP 104/60, SAT 98% RA

GEN: Anxious, diaphoretic, A+Ox1

Neuro: Diffuse hyperreflexia with myoclonus

+ = ?

Serotonin Syndrome

•AEIOUTIPS

Serotonin Syndrome

Treatment

– Discontinuation of all serotonergic agents

– Supportive care aimed at vital signs

– Sedation with benzodiazepines (Ativan 1-2 mg IV)

– If benzos and supportive care fail to improve

agitation and abnormal vital signs, give

cyproheptadine (12 mg orally or by OG/NG)

– Temperature >41.1C (105F) -> immediate

sedation, paralysis, and endotracheal intubation;

avoid antipyretics such as acetaminophen

Case #10

78 yo WM with h/o Stage IIB Colon Cancer admitted

with SOB, found to have a PE. Patient is now on

heparin drip, and he suffers a fall in his room trying

to drag his IV pole to the bathroom. You are called to

assess the patient.

Vitals: T 36.5, HR 52, RR 12, BP 170/88

Exam significant for new LLE weakness

•AEIOUTIPS

Intracranial Bleeding

Intraparenchymal

Hemorrhage

– Common after trauma or

after initiating

anticoagulation in

embolic stroke

– Call Neurosurgery

Intracranial Bleeding

Subdural

– Subacute onset after

trauma

– Crescent-shaped

– Shearing of the

bridging veins

– Call Neurosurgery

Intracranial Bleeding

Epidural hemorrhage

– Most commonly

associated with skull

fracture in area of

middle cerebral artery

– Lentiform appearance

– Call Neurosurgery

Intracranial Bleeding

Subarachnoid – Worst headache of my life

– Usually in setting of hypertensive emergency

– Control BP and call neurosurgery

Stroke

Embolic Stroke

– Commonly in setting of

atrial fibrillation

– Call Neurology and

activate code stroke

Case #11

93 yo AAM with HTN and vascular dementia admitted

for UTI. Patient on ceftriaxone IV and awaiting

placement. You are called at 3AM because patient

attempting to climb out of bed, very disoriented, and

trying to pull out Foley.

T-37.7, HR-65, RR-16, BP-120/80

PE: unremarkable

•AEIOUTIPS

Sun-Downing: Definition

Sun-downing: a group of behaviors occurring in some older patients with or without dementia at the time of nightfall or sunset.

Common Behaviors: – Confusion

– Anxiety, agitation, or aggressiveness

– Psychomotor agitation (pacing, wandering)

– Disruptive, resistant to redirection

– Increased verbal activity

Sun-Downing: Prevention

Discontinue any unneeded lines, catheters

Ensure patient has glasses, working hearing aid

Monitor amount of sensory stimulation

Consider late afternoon bright light exposure

Turn off lights and television during evening hours

Give diuretics/laxatives/steroids early in day

Avoid restraints

Attempt to re-orient patient

Establish regular dose of drug for disturbing behavior (haldol if needed)

Thank you for your attention

Any questions?