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ALTERED MENTAL STATUS Key Teaching Points for EM Faculty Delirium Risk Factors
1. Anticholinergic drugs: antihistamines, antiemetics, antipsychotics antiparkinsonian drugs, antidepressant
antispasmodic (GI) 2. Narcotics 3. Sedative hypnotics 4. Corticosteroids 5. H2 blockers 6. Antibiotics (e.g., fluoroquinolones) Addresses Cognitive and Behavioral Disorders Competencies Delirium is an acute, fluctuating change in cognition accompanied by impaired attention and consciousness. Approximately 10% of ED patients present with delirium. In over ½ of the cases, delirium is unrecognized. Delirium is a potentially life threatening medical emergency. Undetected in the ED, it has a 3 month mortality rate of 31%. Dementia is a primary risk factor for delirium. Clinical Pathway: Mental Status Assessment Evaluation Diagnosis: Confusion Assessment Method (CAM) 1+2+ (3 or 4)
1. Acute & fluctuating (history from family member, nursing home staff); 2. Inattention (ask patient days, months backwards; digit span test [normal can repeat 5 random numbers correctly]); 3. Disorganized thinking OR 4. Altered level of consciousness (hypoactive form more common & frequently missed) Etiology: Delirium is OFTEN multifactorial!* D E L I R I U M Dementia, drugs Electrolyte disturbance, thyroid abnormality Lack of drugs (withdrawal from ETOH, benzos, poorly controlled pain) Infection Reduced sensory input Intracranial infection, hemorrhage, stroke, tumor Urinary retention, fecal impaction Myocardial infarction, COPD, hypoxia Delirium Acute Fluctuating Disordered Disordered Often Present Often Present Dementia
Insidious
Constant
Generally Preserved
Generally Preserved
Generally Absent
Generally Absent
Patient‐related Risks for Developing Delirium: The Yale Hospital System's Experience Prediction of delirium at admission
1.  Vision (<20/70) 2. Severe Illness 3. Preexisting  Cognition 4. Dehydration (BUN/Cr > 18) 1‐2 = Intermediate Risk  RR 4.7 3‐4 = High Risk  RR 9.5 Management 1. Identify and treat underlying cause 2. Non‐pharmacologic c.
Reduce noise, have staff reorient patient a.
Use families or sitters as first line
b. Avoid physical restraint d. Provide eyeglasses, hearing aid 3. Pharmacologic management reserved for patients with severe agitation that causes interruption of therapy and/or poses safety hazard to patient or staff. Use low‐dose high potency antipsychotics. a. Haloperidol (Haldol): 0.25 mg – 0.5 mg PO or IM (IV short‐acting ↑risk of Torsades), 0.5 mg – 1 mg parenterally in severe cases. Repeat dose q 30 minutes until sedation achieved (max haloperidol dose=3‐5 mg/24 hours). Maintenance 50% loading dose in divided doses over next 24 hours. Taper dose over next few days. b. Benzodiazepines (e.g., Lorazepam) 0.5 to 2 mg q 4 to 6 hours if delirium secondary to alcohol or benzodiazepine withdrawal. Discharge Plan Delirium versus Dementia Based on DSM‐IV Criteria Feature Onset Course Attention Consciousness Hallucinations Involuntary Movement Search for underlying cause 1. Vital signs & physical exam, including neurologic exam 2. Review medication list, including O‐T‐C, herbal 3. Alcohol history 4. Targeted metabolic workup (CBC, lytes, BUN/Cr, Glucose, LFTs, Calcium, U/A, PO2, EKG, Chest x‐ray) 5. Search for occult infection (LP should be performed if sign of meningitis present) 6. Neuroimaging Criteria (Routine use of CT brain not recommended) a.
History of recent fall or head
d. Fever / acute mental status change / suspicion of encephalitis trauma e.
No identifiable etiology of acute b. Signs of head trauma mental status change c.
Focal neurologic changes Precipitating risk factors for delirium during hospitalization
1. Physical Restraints 2. Malnutrition 3. > 3 Medications added 4. Bladder Catheter 5. Any Iatrogenic Event Intermediate Risk = 1‐2  RR 7.1 High Risk = 3‐5  RR 17.5 1. Low threshold to admit 2. Admit elderly patient with delirium 3. If patient is discharged home: a.
Document support in the home environment to manage patient care b. Plan for medical follow‐up c.
Call primary care physician * Delirium mnemonic was based in part on a mnemonic developed by University of Texas Southwestern Medical Center (SAGE). References 1. Inouye SK, van Dyck H, Alessi CA, et al. Ann Intern Med 1990;113:941–948. 2. Inouye SK, Viscoli CM, Horwitz RI, et al. Ann Intern Med 1993;119:474‐481. 3. Inouye SK, Charpentier PA. JAMA 1996;275(11):852‐857. 4. Salen P, Heller M, Oller C, Reed J. J Emer Med 2009;37(1):8‐12. 5. Terrell KM, Hustey FM, Hwang U, et al. Acad Emer Med 2009;16(5):441–449. 6. Wilber ST, Lofgren SD, Mager TG, et al. Acad Emer Med 2005;12(7):612‐616. 7. Wilber ST. Emerg Med Clin N Am 2006;24(2):219‐316. Revised 11/1/11