Altered Mental Status/Confusion

1
Altered Mental Status/Confusion

• J. Stephen Huff, MD
• Emergency Medicine and NeurologyUniversity of
  VirginiaCharlottesville, Virginia

2
Case

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

3
Case

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

4
Case

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

5
Questions
1. How would you assess confusion? 2. What tests
are available to assess confusion? 3. When is a
spinal tap indicated in delirium? 4. What other
laboratory studies are useful in the working of
delirium?
6
What is Consciousness?

• Arousal function
• Alerting and wakefulness
• Anatomically-reticular activating system
• Content functions
• Language, reasoning
• Anatomically-cerebral cortex

7
Disorders of Consciousness

• Arousal functions
• and/or
• Content functions disrupted

8
Altered Mental Status

• What does it mean?
• What to do about it?

9
Altered Mental Status

• Examples
• Coma
• Dementia
• Delirium

10
Delirium-Synonyms

• Acute confusional state
• Acute cognitive impairment
• Acute encephalopathy
• Altered mental status

11
Delirium

• Arousal functions content functions disrupted
• Difficulty focusing or sustaining attention
• Fluctuating confusion
• Disturbed wake-sleep patterns
• Caregivers/family best source

12
Delirium-Criteria DSM IV

• Reduced ability to maintain attention and shift
  attention
• Disorganized thinking, rambling, irreverent,
  incoherent speech

13
Delerium Criteria DSM IV

• At least 2 of the following
• Reduced level of consciousness
• Perceptual disturbances misinterpretations,
  illusions or hallucinations
• Disturbance of wake-sleep cycle
• Increased OR decreased psychomotor activity
• Disorientation to time, place, or person
• Memory impairment

14
Delerium Criteria DSM IV

• Symptoms develop over short period of time,
  fluctuate quickly
• Either (1) etiologic organic factor
• OR (2) absence non-organic disorder (such
  as manic episode)

15
Delirium-Pathophysiology

• Complex
• Widespread neuronal or neurotransmitter
  dysfunction
• Intracranial process
• Systemic diseases
• Exogenous toxins
• Drug withdrawal

16
Delirium Causes

• Infection pneumonia, urinary tract infections
• Metabolic/toxic alcohol ingestion, electrolyte
  abnormalities, vasculitis, thyroid disorders,
  hepatic failure
• Cerebrovascular ischemic stroke. hemorrhagic
  stroke
• Trauma head injury, subdural hematoma

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Delerium Causes

• Cardiopulmonary congestive heart failure,
  myocardial infarction, pulmonary
  embolus, hypoxia
• Medications digitalis, anticholinergics
  effects, polypharmacy
• Other seizure and post-ictal state, severe
  urinary retention

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SMASHED-Mnemonic For Acute Mental Status Change

• S Substrates hyperglycemia, hypoglycemia,
  thiamine
• Sepsis
• M Meningitis meningitis and other CNS infections
• Mental illness functional psychoses
• A Alcohol intoxication, withdrawal
• S Seizures Seizure activity, post-ictal states
• Stimulants anticholinergics, hallucinogens,
  cocaine
• H Hyper hyperthyroidism, hyperthermia,
  hypercarbia
• Hypo hypotension, hypothyroidism, hypoxia,
  hypothermia
• E Electrolytes hypernatremia, hyponatremia,
  hypercalcemia
• Encephalopathy hepatic, uremic, hypertensive
• D Drugs of any sort

Roberts JM. Ann Emerg Med 1990.
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Physicians Role

• Primary survey
• Establish unresponsiveness
• A,B,Cs
• Resuscitation
• glucose, thiamine
• Secondary assessment
• Definitive care

20
Delirium-History

• Tempo of onset
• Associated symptoms
• Medical history/medications
• Witnesses

21
Delirium-History-Confusion Assessment Method (CAM)

• Acuity of change of behavior
• Fluctuating course
• Inattention
• Disorganized thinking
• Altered level of consciousness

22
General Examination

• Vital signs
• General physical examination

23
Neurologic Examination

• Observation
• Movements
• Cranial nerves
• Sensory
• Motor
• Reflexes

24
How Would You Assess Confusion?

• Emergency physicians assess mental status
  informally
• Know when it needs to be done but, rarely perform
  systematic test
• Rely on history, informal assessments...

25
Why Do a Mental Status Exam?

• Informal testing used most often BUT, informal
  testing insensitive
• If a formal screening examination performed,
  assessments, workup, and dispositions change

Dziedzic L, Brady WJ, Lindsay R, Huff JS. J Emerg
Med 1998.
26
What Is a Mental Status Exam?

• Informal
• Formal mental status
• Mini-mental status exam
• Brief mental status exam
• Others

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What Is a Mental Status Exam?

• Appearance, behavior, attitude
• Thought disorders
• Perception disorders
• Mood and affect
• Insight and judgment
• Sensorium and intelligence

28
Six Elements of Mental Status Evaluation

• Appearance, behavior, and attitude
• Disorders of thought
• Are the thoughts logical and realistic?
• Are false beliefs or delusions present?
• Are suicidal or homicidal thoughts present?
• Disorders of perception
• Are hallucinations present?
• Mood and affect

29
Six Elements of Mental Status Evaluation

• Insight and judgment
• Does the patient understand the circumstances
  surrounding the visit?
• Sensorium and intelligence
• Is the level of consciousness normal?
• Is cognition or intellectual functioning impaired?

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What Tests Are Available to Assess Confusion?

• Folstein mini-mental status
• The Brief Mental Status Examination

Folstein MF et al. J Psych Res 1975. Kaufman DM,
Zun L. J Emerg Med 1995.
31
The Brief Mental Status Examination

• ITEM (number of errors) X (weight) (Total)

What year is it now? 0 or 1 x 4 ____ What month
is it? 0 or 1 x 3 ____ Present memory phrase
Repeat this phrase after me and remember it
John Brown, 42 Market Street, New York. About
what time is it? 0 or 1 x 3 ____(Answer
correct if within one hour) Count backwards from
20 to 1. 0, 1, or 2 x 2 ____ Say the months in
reverse 0, 1, or 2 x 2 ____ Repeat memory
phrase 0,1,2,3,4,or 5 x 2 ____ (each underlined
portion is worth 1 point)
32
The Brief Mental Status Examination

• Final Score is the sum of the totals
• For each response, circle the number of errors
  and
• multiply the circled number by the weight to
  determine the score.
• ______________________________________
• Possible score range from 0 to 28.

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The Brief Mental Status Examination

• The lowest possible score (indicating the least
  impairment) is 0.
• The highest possible score is 28.
• Categories of scores-
• 0- 8 normal 9-19 mildly impaired
  20-28 severely impaired

34
Returning to Our Patient

• The patient was febrile and combative. He could
  not speak in an understandable manner.
• Brief Mental Status Examination Score28
• What was the score at the first visit?

35
Our Patient Continued

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

36
Clinical Course

• CSF cultures yielded Group B streptococcus.
• Patient responded to antibiotics and did well.
• Atypical CNS infections
• Meningitis-viral
• Fungal
• Protozoal
• Unusual bacteria
• Encephalitis

37
When Is a Spinal Tap Indicated in Delirium?

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

Kookier JC, from Roberts and Hedges.
38
Easy To Say, Hard To Practice.

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

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Question

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

40
Altered Mental StatusWorkup

• Level I-History, physical examination, mental
  status examination
• Level II-electrolytes, CBC, urinalysis, CXR, ABG,
  drug screen
• Level III-LP, CT, EEG brain biopsy, etc.

Zun L, Howes DS. Am J Emerg Med 1988.
41
Delirium-Treatment

• Treatment of underlying cause
• Environmental manipulation
• Sedation
• Restraints

42
Why Do a Mental Status Exam?

• Informal testing used most often BUT, informal
  testing insensitive
• If a formal screening examination performed,
  assessments, workup, and dispositions change

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