Altered Mental Status/ConfusionAltered Mental Status/Confusion

J. Stephen Huff, MDJ. Stephen Huff, MD

Emergency Medicine and Emergency Medicine and NeurologyNeurology

University of VirginiaUniversity of VirginiaCharlottesville, VirginiaCharlottesville, Virginia

J. Stephen Huff, MD

CaseCase

A 60-year-old man is noted by his A 60-year-old man is noted by his family to have fluctuating periods of family to have fluctuating periods of agitation and confusion. He had a mild agitation and confusion. He had a mild URI 3 days prior but otherwise in good URI 3 days prior but otherwise in good health. He has a past history of diet-health. He has a past history of diet-controlled diabetes and hypertension controlled diabetes and hypertension treated with enalapril. Social history-treated with enalapril. Social history-active, industrial worker.active, industrial worker.

J. Stephen Huff, MD

CaseCase

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

J. Stephen Huff, MD

CaseCase

The patient was diagnosed with a viral The patient was diagnosed with a viral syndrome. Serum laboratory work was syndrome. Serum laboratory work was unremarkable. Instructions were given unremarkable. Instructions were given to return if his condition worsened, to return if his condition worsened, which he did 8 hours later…febrile and which he did 8 hours later…febrile and combative...combative...

J. Stephen Huff, MD

QuestionsQuestions

1.1. How would you assess confusion?How would you assess confusion?

2.2. What tests are available to assess What tests are available to assess confusion?confusion?

3.3. When is a spinal tap indicated in delirium?When is a spinal tap indicated in delirium?

4.4. What other laboratory studies are What other laboratory studies are useful in the working of delirium?useful in the working of delirium?

J. Stephen Huff, MD

What is Consciousness?What is Consciousness?

• Arousal functionArousal function

– Alerting and wakefulnessAlerting and wakefulness

– Anatomically-reticular activating systemAnatomically-reticular activating system

• Content functionsContent functions

– Language, reasoningLanguage, reasoning

– Anatomically-cerebral cortexAnatomically-cerebral cortex

J. Stephen Huff, MD

Disorders of ConsciousnessDisorders of Consciousness

• Arousal functions Arousal functions

and/orand/or

• Content functions disruptedContent functions disrupted

J. Stephen Huff, MD

Altered Mental StatusAltered Mental Status

• What does it mean?What does it mean?

• What to do about it?What to do about it?

J. Stephen Huff, MD

Altered Mental StatusAltered Mental Status

• Examples…Examples…

– ComaComa

– DementiaDementia

– DeliriumDelirium

J. Stephen Huff, MD

Delirium-SynonymsDelirium-Synonyms

• Acute confusional stateAcute confusional state

• Acute cognitive impairmentAcute cognitive impairment

• Acute encephalopathyAcute encephalopathy

• Altered mental statusAltered mental status

J. Stephen Huff, MD

DeliriumDelirium• Arousal functions & content functions disruptedArousal functions & content functions disrupted

• Difficulty focusing or sustaining attentionDifficulty focusing or sustaining attention

• Fluctuating confusionFluctuating confusion

• Disturbed wake-sleep patternsDisturbed wake-sleep patterns

• Caregivers/family best sourceCaregivers/family best source

J. Stephen Huff, MD

Delirium-Criteria DSM IVDelirium-Criteria DSM IV

• Reduced ability to maintain attention and Reduced ability to maintain attention and shift attentionshift attention

• Disorganized thinking, rambling, irreverent, Disorganized thinking, rambling, irreverent, incoherent speechincoherent speech

J. Stephen Huff, MD

Delerium Criteria DSM IVDelerium Criteria DSM IV

• At least 2 of the followingAt least 2 of the following

– Reduced level of consciousnessReduced level of consciousness

– Perceptual disturbances: misinterpretations, Perceptual disturbances: misinterpretations, illusions or hallucinationsillusions or hallucinations

– Disturbance of wake-sleep cycleDisturbance of wake-sleep cycle

– Increased OR decreased psychomotor activityIncreased OR decreased psychomotor activity

– Disorientation to time, place, or personDisorientation to time, place, or person

– Memory impairmentMemory impairment

J. Stephen Huff, MD

Delerium Criteria DSM IVDelerium Criteria DSM IV

• Symptoms develop over short period of Symptoms develop over short period of time, fluctuate quicklytime, fluctuate quickly

• EitherEither (1) etiologic organic factor (1) etiologic organic factor

OROR (2) absence non-organic disorder (2) absence non-organic disorder (such as manic episode) (such as manic episode)

J. Stephen Huff, MD

Delirium-PathophysiologyDelirium-Pathophysiology

• ComplexComplex

• Widespread neuronal or neurotransmitter Widespread neuronal or neurotransmitter dysfunctiondysfunction

– Intracranial processIntracranial process

– Systemic diseasesSystemic diseases

– Exogenous toxinsExogenous toxins

– Drug withdrawalDrug withdrawal

J. Stephen Huff, MD

Delirium CausesDelirium Causes

InfectionInfection pneumonia, urinary tract infectionspneumonia, urinary tract infections

Metabolic/toxicMetabolic/toxic alcohol ingestion, electrolyte alcohol ingestion, electrolyte abnormalities, vasculitis, thyroid disorders, abnormalities, vasculitis, thyroid disorders, hepatic failurehepatic failure

CerebrovascularCerebrovascular ischemic stroke. hemorrhagic strokeischemic stroke. hemorrhagic stroke

TraumaTrauma head injury, subdural hematomahead injury, subdural hematoma

J. Stephen Huff, MD

Delerium CausesDelerium Causes

CardiopulmonaryCardiopulmonary congestive heart failure, congestive heart failure, myocardial infarction, myocardial infarction, pulmonary embolus, pulmonary embolus, hypoxiahypoxia

Medications Medications digitalis, anticholinergics digitalis, anticholinergics effects, polypharmacyeffects, polypharmacy

OtherOther seizure and post-ictal state, seizure and post-ictal state, severe urinary retentionsevere urinary retention

J. Stephen Huff, MD

““SMASHED”-Mnemonic For Acute SMASHED”-Mnemonic For Acute Mental Status ChangeMental Status Change

SS SubstratesSubstrates hyperglycemia, hypoglycemia, hyperglycemia, hypoglycemia, thiaminethiamineSepsisSepsis

MM MeningitisMeningitis meningitis and other CNS infectionsmeningitis and other CNS infectionsMental illnessMental illness functional psychosesfunctional psychoses

AA AlcoholAlcohol intoxication, withdrawalintoxication, withdrawal

SS SeizuresSeizures Seizure activity, post-ictal statesSeizure activity, post-ictal statesStimulantsStimulants anticholinergics, hallucinogens, anticholinergics, hallucinogens, cocainecocaine

HH HyperHyper hyperthyroidism, hyperthermia, hyperthyroidism, hyperthermia, hypercarbiahypercarbiaHypoHypo hypotension, hypothyroidism, hypotension, hypothyroidism, hypoxia, hypothermiahypoxia, hypothermia

EE ElectrolytesElectrolytes hypernatremia, hyponatremia, hypernatremia, hyponatremia, hypercalcemiahypercalcemiaEncephalopathy Encephalopathy hepatic, uremic, hypertensivehepatic, uremic, hypertensive

DD Drugs of any sortDrugs of any sort

Roberts JM. Ann Emerg Med 1990.

J. Stephen Huff, MD

Physician’s RolePhysician’s Role

• Primary surveyPrimary survey

– Establish unresponsivenessEstablish unresponsiveness

– A,B,C’sA,B,C’s

• ResuscitationResuscitation

– glucose, thiamineglucose, thiamine

• Secondary assessmentSecondary assessment

• Definitive careDefinitive care

J. Stephen Huff, MD

Delirium-HistoryDelirium-History

• Tempo of onsetTempo of onset

• Associated symptomsAssociated symptoms

• Medical history/medicationsMedical history/medications

• WitnessesWitnesses

J. Stephen Huff, MD

Delirium-History-Confusion Delirium-History-Confusion Assessment Method (CAM)Assessment Method (CAM)

• Acuity of change of behavior–Acuity of change of behavior–

• Fluctuating courseFluctuating course

• InattentionInattention

• Disorganized thinkingDisorganized thinking

• Altered level of consciousnessAltered level of consciousness

J. Stephen Huff, MD

General ExaminationGeneral Examination

• Vital signsVital signs

• General physical examinationGeneral physical examination

J. Stephen Huff, MD

Neurologic ExaminationNeurologic Examination

• ObservationObservation

– MovementsMovements

• Cranial nervesCranial nerves

• Sensory Sensory

• MotorMotor

• ReflexesReflexes

J. Stephen Huff, MD

How Would You Assess Confusion?How Would You Assess Confusion?

• Emergency physicians assess mental Emergency physicians assess mental status informally…status informally…

• Know when it needs to be done but, rarely Know when it needs to be done but, rarely perform systematic test…perform systematic test…

• Rely on history, informal assessments...Rely on history, informal assessments...

J. Stephen Huff, MD

Why Do a Mental Status Exam?Why Do a Mental Status Exam?

• Informal testing used most often Informal testing used most often BUT, informal testing insensitiveBUT, informal testing insensitive

• If a formal screening examination If a formal screening examination performed, assessments, workup, performed, assessments, workup, and dispositions changeand dispositions change

Dziedzic L, Brady WJ, Lindsay R, Huff JS. J Emerg Med 1998.

J. Stephen Huff, MD

What Is a Mental Status Exam?What Is a Mental Status Exam?

• InformalInformal

• Formal mental statusFormal mental status

– Mini-mental status examMini-mental status exam

– Brief mental status examBrief mental status exam

– OthersOthers

J. Stephen Huff, MD

What Is a Mental Status Exam?What Is a Mental Status Exam?

• Appearance, behavior, attitudeAppearance, behavior, attitude

• Thought disordersThought disorders

• Perception disordersPerception disorders

• Mood and affectMood and affect

• Insight and judgmentInsight and judgment

• Sensorium and intelligenceSensorium and intelligence

J. Stephen Huff, MD

Six Elements of Mental Six Elements of Mental Status EvaluationStatus Evaluation

• Appearance, behavior, and attitudeAppearance, behavior, and attitude

• Disorders of thoughtDisorders of thought– Are the thoughts logical and realistic?Are the thoughts logical and realistic?

– Are false beliefs or delusions present?Are false beliefs or delusions present?

– Are suicidal or homicidal thoughts present?Are suicidal or homicidal thoughts present?

• Disorders of perceptionDisorders of perception– Are hallucinations present?Are hallucinations present?

• Mood and affectMood and affect

J. Stephen Huff, MD

Six Elements of Mental Status EvaluationSix Elements of Mental Status Evaluation

• Insight and judgmentInsight and judgment

– Does the patient understand the Does the patient understand the circumstances surrounding the visit?circumstances surrounding the visit?

• Sensorium and intelligenceSensorium and intelligence

– Is the level of consciousness normal?Is the level of consciousness normal?

– Is cognition or intellectual functioning Is cognition or intellectual functioning impaired?impaired?

J. Stephen Huff, MD

What Tests Are Available to What Tests Are Available to Assess Confusion?Assess Confusion?

• Folstein mini-mental statusFolstein mini-mental status

• The Brief Mental Status ExaminationThe Brief Mental Status Examination

Folstein MF et al. J Psych Res 1975.Kaufman DM, Zun L. J Emerg Med 1995.

J. Stephen Huff, MD

The Brief Mental The Brief Mental Status ExaminationStatus Examination

ITEMITEM (number of errors)(number of errors) X (weight) = X (weight) = (Total)(Total)

What year is it now?What year is it now? 0 or 10 or 1 x 4 =x 4 = ________

What month is it?What month is it? 0 or 10 or 1 x 3 =x 3 = ________

Present memory phrase: “Repeat this phrase after me and Present memory phrase: “Repeat this phrase after me and remember it: remember it: John Brown, 42 Market Street, New York.John Brown, 42 Market Street, New York.””

About what time is it?About what time is it? 0 or 10 or 1 x 3 =x 3 = ________(Answer correct if within one hour)(Answer correct if within one hour)

Count backwards from 20 to 1.Count backwards from 20 to 1. 0, 1, or 20, 1, or 2 x 2 =x 2 = ________

Say the months in reverseSay the months in reverse 0, 1, or 20, 1, or 2 x 2 =x 2 = ________

Repeat memory phraseRepeat memory phrase 0,1,2,3,4,or 50,1,2,3,4,or 5 x 2 =x 2 = ________

(each underlined portion is worth 1 point)(each underlined portion is worth 1 point)

J. Stephen Huff, MD

The Brief Mental Status ExaminationThe Brief Mental Status Examination

• Final Score is the sum of the totalsFinal Score is the sum of the totals

– For each response, circle the number of For each response, circle the number of errors anderrors and

– multiply the circled number by the weight to multiply the circled number by the weight to determine the score.determine the score.

– ____________________________________________________________________________

• Possible score range from 0 to 28.Possible score range from 0 to 28.

J. Stephen Huff, MD

The Brief Mental Status ExaminationThe Brief Mental Status Examination

• The lowest possible score (indicating the The lowest possible score (indicating the least impairment) least impairment) is 0.is 0.

• The highest possible score is 28. The highest possible score is 28.

• Categories of scores- Categories of scores-

– 0- 8 0- 8 normalnormal 9-19 9-19 mildly impairedmildly impaired 20-28 severely impaired 20-28 severely impaired

J. Stephen Huff, MD

Returning to Our Patient–Returning to Our Patient–

• The patient was febrile and combative. The patient was febrile and combative. He could not speak in an understandable He could not speak in an understandable manner.manner.

• Brief Mental Status Examination Score=28Brief Mental Status Examination Score=28

• What was the score at the first visit?What was the score at the first visit?

J. Stephen Huff, MD

Our Patient ContinuedOur Patient Continued

Rapid sequence intubation was Rapid sequence intubation was performed. Antibiotics were performed. Antibiotics were administered for a presumed bacterial administered for a presumed bacterial meningitis. CT was performed that was meningitis. CT was performed that was unremarkable. Lumbar puncture was unremarkable. Lumbar puncture was performed yielding slightly cloudy CSF performed yielding slightly cloudy CSF with 2500 WBC’s/hpf.with 2500 WBC’s/hpf.

J. Stephen Huff, MD

Clinical CourseClinical Course

• CSF cultures yielded Group B streptococcus. CSF cultures yielded Group B streptococcus.

• Patient responded to antibiotics and did well.Patient responded to antibiotics and did well.

• Atypical CNS infectionsAtypical CNS infections

– Meningitis-viralMeningitis-viral

– Fungal Fungal

– Protozoal Protozoal

– Unusual bacteriaUnusual bacteria

– EncephalitisEncephalitis

J. Stephen Huff, MD

Kookier JC, from Roberts and Hedges.

When Is a Spinal Tap Indicated When Is a Spinal Tap Indicated in Delirium?in Delirium?

““The primary indication for an The primary indication for an emergent spinal tap is the possibility of emergent spinal tap is the possibility of CNS infection. CSF should be CNS infection. CSF should be examined in patients with a fever of examined in patients with a fever of unknown origin, especially if an unknown origin, especially if an alteration in consciousness is alteration in consciousness is present….”present….”

J. Stephen Huff, MD

Easy To Say, Hard To Practice….Easy To Say, Hard To Practice….

““The primary indication for an The primary indication for an emergent spinal tap is the possibility of emergent spinal tap is the possibility of CNS infection. CSF should be CNS infection. CSF should be examined in patients with a fever of examined in patients with a fever of unknown origin, especially if an unknown origin, especially if an alteration in consciousness is alteration in consciousness is present….”present….”

J. Stephen Huff, MD

QuestionQuestion

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

J. Stephen Huff, MD

Altered Mental Status–WorkupAltered Mental Status–Workup

• Level I-History, physical examination, Level I-History, physical examination, mental status examination mental status examination

• Level II-electrolytes, CBC, urinalysis, Level II-electrolytes, CBC, urinalysis, CXR, ABG, drug screenCXR, ABG, drug screen

• Level III-LP, CT, EEG brain biopsy, Level III-LP, CT, EEG brain biopsy, etc.etc.

Zun L, Howes DS. Am J Emerg Med 1988.

J. Stephen Huff, MD

Delirium-TreatmentDelirium-Treatment

• Treatment of underlying causeTreatment of underlying cause

• Environmental manipulationEnvironmental manipulation

• SedationSedation

• RestraintsRestraints

J. Stephen Huff, MD

Why Do a Mental Status Exam?Why Do a Mental Status Exam?

• Informal testing used most often BUT, Informal testing used most often BUT, informal testing insensitiveinformal testing insensitive

• If a formal screening examination If a formal screening examination performed, assessments, workup, and performed, assessments, workup, and dispositions changedispositions change

Dziedzic L, Brady WJ, Lindsay R, Huff JS. J Emerg Med 1998.