INTERN BOOT CAMP: Altered Mental Status

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INTERN BOOT CAMPAltered Mental Status

• Caroline Soyka
• PGY3

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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

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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

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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
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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 2002162(4)457-63.
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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
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Epidemiology

• AMS is primary reason for ED visit in 4-10
  patients
• ED patients gt 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)

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So you are called for MS ?s

• What are the vital signs?
• What was the time course?
• What is the patients baseline?
• What medications have they received?
• What is the patients past medical history?
• Was there any trauma?
• Is there any focality to the neuro exam?

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First Steps

• ABCDE
• Airway
• Breathing
• Circulation
• Disability
• Exposure

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Workup

• HISTORY!!!!
• Ask family
• New meds?
• Any significant PMH?
• PHYSICAL
• Vitals
• Detailed physical WITH neurologic exam
• GCS

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Etiology

• A alcohol, alzheimers
• 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,

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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.

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Exam

• VS T 37.5, HR 64, RR 16, BP 124/74, 96RA
• Lethargic, not conversant, moaning, withdraws all
  4 extremities to pain, responds to sternal rub

AEIOUTIPS
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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

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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

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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!

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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
  OTCs herbals
• Avoid anything with anticholinergic properties
• JUST STOP UNNECCSSARY MEDS

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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
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Causes of Hypoglycemia

• Overly aggressive insulin regimen
• Renal failure
• Liver failure
• Infection/Sepsis
• Excessive EtOH consumption
• Rare Stuff
• Adrenal insufficiency
• Insulinoma

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Hypoglycemia Management

• Is patient awake enough to drink some juice, take
  glucose tabs?
• Three glucose tabs will raise blood sugar by 50.
• If unable to take PO and has IV access, then give
  use IV dextrose
• 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.

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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 1055 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
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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

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Five Causes of Hypoxia

1. Hypoventilation
2. Shunt
3. Increased Diffusion Gradient
4. Decreased FiO2
5. V-Q Mismatch

A favorite Schilz PIMP question.
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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

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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
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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

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A word on sepsis

• SIRS gt1 of the following manifestations
• Temperature gt 38C or lt 36C (gt 100.4F or lt
  96.8F)
• Heart rate gt 90 beats/min
• Tachypnea, as manifested by a respiratory rate gt
  20 breaths/min (or PaCO2 lt 32 mm Hg)
• White blood cell count gt 12,000 cells/mm3, lt
  4,000 cells/mm3, or the presence of gt 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

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Case 5

• 93 YO WM with Alzheimers 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
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Electrolyte Abnormalities

• Hypernatremia
• Hyponatremia
• Hypercalcemia

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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

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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)

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Hypercalcemia

• Signs and symptoms
• Bones?osteopenia
• Stones?kidney stones and polyuria
• Groans?abdominal pain, anorexia, constipation,
  ileus, N/V
• Psychiatric overtones?depression, 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

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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

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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 RR 16 BP 96/60
  SAT 98 RA

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Exam

• AEIOUTIPS

• 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)

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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 asterixisslurred speech
3 Somnolent but arousable Gross disorientation bizarre behavior Muscular rigidity and clonus Hyperreflexia
4 Coma Coma Decerebrate posturing
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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

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Management of HE

• Correct the underlying cause
• 1st line Lactulose
• Oral 20 gm PO Q1-2 hrs for 3-5 BMs/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

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Case 7

• AEIOUTIPS

• 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, 96RA

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EtOH Withdrawal
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CIWA Scale
Nausea/Vomiting Tremor Sweats Anxiety Agitation Ta
ctile Disturbances Auditory Disturbances Visual
Disturbances Headache Orientation -symptoms
treated with ativan and other prns CIWAs gt 20
consider MICU transfer
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Case 8

• AEIOUTIPS

• 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 98RA
• GEN uncomfortable, AAO x 2
• HEENT nuchal rigidity
• LUNGS CTA b/l
• NEURO no focal weakness

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CNS infections

• Meningitis
• Bacterial
• Viral
• Aseptic
• Encephalitis
• Toxoplasmosis
• JC virus
• West Nile Virus

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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

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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 third-generation cephalosporin
gt 50 years S. pneumoniae, N. meningitidis, L. monocytogenes, Vancomycin plus ampicillin plus a third-generation cephalosporin
gt 50 years w/ suppression Above pseudomonas Vancomycin plus ampicillin plus meropenem/cefepime
Add dexamethasone if suspected S. pneumo
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Seizures

• Status epilepticus
• 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
• 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

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Management of Seizures

• Call Neurology
• Supportive care (Remember the ABCs)
• Check fingerstick glucose/give amp D50
  empirically
• Benzodiazepines
• Diazepam 5-10 mg per minute
• Lorazepam 4-8 mg
• Terminate 75 of seizures
• AEDs (Phenytoin, fosphenytoin)

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Case 9

• 42 YO with DM2 and depression on SSRIs 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.

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Exam

• VS T 39.4, HR 98, RR 20, BP 104/60, SAT 98 RA
• GEN Anxious, diaphoretic, AOx1
• Neuro Diffuse hyperreflexia with myoclonus

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Serotonin Syndrome
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Case 10

• AEIOUTIPS

• 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

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Intracranial Bleeding

• Intraparenchymal Hemorrhage
• Common after trauma or after initiating
  anticoagulation in embolic stroke
• Call Neurosurgery

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Intracranial Bleeding

• Subdural
• Subacute onset after trauma
• Crescent-shaped
• Shearing of the bridging veins
• Call Neurosurgery

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Intracranial Bleeding

• Epidural hemorrhage
• Most commonly associated with skull fracture in
  area of middle cerebral artery
• Lentiform appearance
• Call Neurosurgery

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Intracranial Bleeding

• Subarachnoid
• Worst headache of ones life
• Usually in setting of hypertensive emergency
• Call neurosurgery and control BP

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Stroke

• Embolic Stroke
• Commonly in setting of atrial fibrillation
• Call Neurology and activate the BAT pager

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Case 11

• AEIOUTIPS

• 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

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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

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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)