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INTERN BOOT CAMP: Altered Mental Status Caroline Soyka PGY3 Objectives Provide an overview of 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 No clear 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 Attention Fluctuates Stable and progressive Steady Sensorium Impaired Intact until late Cognitive Globally impaired Poor short term memory Visual Simple Delusions Hallucinations Perception 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, alzheimer’s E endocrine, electrolyte, encephalopathy I infection, intoxication O opiates, overdose, oxygen U uremia T tumor, trauma I insulin 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, decreased respirations, and hypotension Anticholinergics: bradycardia, salivation, lacrimation, and diaphoresis Reversal Agents Opioids? – Narcan (naloxone) 0.04 mg to 0.4 mg every 2-3 minutes ** 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 Note: you need higher doses (0.4-2 mg) for known/suspected opioid overdose Reversal Agents Benzodiazepines? – – – Flumazenil 0.2mg IVP, repeat every 30 seconds up to total dose of 2mg 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! A Daily J.J. Diatribe… 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 to Eckel 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 Stuff – Adrenal insufficiency – Insulinoma Hypoglycemia Management Is patient awake enough to drink some juice, take glucose tabs? – If unable to take PO and has IV access, then give use IV dextrose – Three glucose tabs will raise blood sugar by 50. 1 amp D50 = 50 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 to Wearn team with 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 hemoglobin is able to carry more carbon dioxide than oxygenated hemoglobin 3) Respiratory homeostasis: Chronic elevation of CO2 leads to CO2 being less of a stimulant for respiratory drive and PaO2 provides stimulus, therefore supplemental O2 decreases respiratory drive leading to CO2 retention Five Causes of Hypoxia* 1. 2. 3. 4. 5. Hypoventilation Shunt Increased Diffusion Gradient Decreased FiO2 V-Q Mismatch * A favorite Schilz PIMP question. Key Points to Remember Whenever patients are requiring more FiO2, check an ABG to ensure they are not retaining CO2 Look at baseline HCO3 to have an idea of whether patient is a CO2 retainer Elevated PaCO2 with mental status changes buys a ticket to the MICU Case #4 62 YO WM with ischemic cardiomyopathy and HFrEF (last EF 10-15%) admitted to Hellerstein 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 A word on sepsis… SIRS: >1 of the following manifestations: – – – – Temperature > 38°C or < 36°C (> 100.4°F or < 96.8°F) Heart rate > 90 beats/min Tachypnea, as manifested by a respiratory rate > 20 breaths/min (or PaCO2 < 32 mm Hg) White blood cell count > 12,000 cells/mm3, < 4,000 cells/mm3, or the presence of > 10% immature neutrophils Sepsis: At least two 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’s Dementia admitted for aspiration pneumonia. Patient had a PEG placed and is getting tube feeds via PEG 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 RFP: 158 118 27 4.8 32 1.5 AEIOUTIPS Electrolyte Abnormalities 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 RA HR 66 RR 16 BP 96/60 SAT 98% •AEIOUTIPS Exam Gen: Stuporous, arousable but not coherent ABD: Good bowel sounds, distended with moderate ascites, diffusely tender to palpation with rebound tenderness NEURO: Diffuse hyperreflexia, + Asterixis CT head: No hemorrhage or mass effect Labs: - HCT 10/30 (Baseline 10.5/31) - WBC: 18K (with left shift) 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: Infection may predispose to impaired renal function and to increased tissue catabolism, both of which increase blood ammonia levels. Bleeding: The presence of blood in the upper gastrointestinal tract results in increased ammonia and nitrogen absorption from the gut. Bleeding may 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 3-5 BM’s/day – Enema: 300 mL in 1 L of water Q4-6 hrs – Diarrhea, flatulence, cramps Antibiotics: - Rifaximin: 550 mg BID helps prevent recurrent episodes of HE •AEIOUTIPS 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. Vitals: T 38.6, HR 96, RR 20, BP 170/86, 96%RA EtOH Withdrawal CIWA Scale Nausea/Vomiting Tremor Sweats Anxiety Agitation Tactile Disturbances Auditory Disturbances Visual Disturbances Headache Orientation -symptoms treated with ativan and other prn’s **CIWA’s > 20 consider MICU transfer** •AEIOUTIPS Case #8 45 YO AAF with h/o polysubstance abuse and HTN admitted to Carpenter for fevers and HA. You are called to room 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 CNS infections Meningitis – Bacterial – Viral – Aseptic Encephalitis Toxoplasmosis JC virus West Nile Virus Lumbar Puncture CT head or Ophthalmologic Exam done first to document no increase intracerebral pressure Draw blood cultures from periphery Do not delay giving antibiotics waiting for the CT and doing the LP Send CSF for glucose, protein, gram stain and culture, cell count & differential, and suspected viral serologies Treatment Antibiotic selection must be empiric immediately after CSF is obtained Age Common Pathogens Antimicrobials 2-50 years N. meningitidis, S. pneumoniae Vancomycin plus a thirdgeneration 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 – – – Non-convulsive status – – Annual incidence exceeding 100,000 cases in the United States alone, of which more than 20% result in death Classically tonic-clonic jerking; loss of bowel/bladder; tongue biting Usually have post-ictal confusion 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 Call Neurology Supportive care (Remember the ABC’s) – Benzodiazepines – – – Check fingerstick glucose/give amp D50 empirically Diazepam 5-10 mg per minute Lorazepam 4-8 mg Terminate ~75% of seizures } Be prepared for airway management and ICU transfer AED’s (Phenytoin, fosphenytoin) Case #9 42 YO with DM2 and depression on SSRI’s admitted from ED for recurrent lower extremity cellulitis; patient known to be colonizer with MRSA and had severe flushing 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 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 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 one’s life Usually in setting of hypertensive emergency Call neurosurgery and control BP Stroke Embolic Stroke – – Commonly in setting of atrial fibrillation Call Neurology and activate the BAT pager •AEIOUTIPS Case #11 93 YO AAM with HTN and vascular dementia admitted for UTI. Patient on ceftriaxone IV and awaiting placement in Brecksville. You are called at 3 AM 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: unrerkable 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 Give diuretics, laxatives early in day 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 Avoid restraints if possible Attempt to re-orient patient Establish regular dose of drug for disturbing behavior (if needed)
