Acute Mental Status Changes in the Intensive Care Unit

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Acute Mental Status Changes in the Intensive
Care Unit

• Danagra Georgia Ikossi, MD
• Stanford General Surgery Resident
• 10/24/2006

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Just because youre nuts, it doesnt mean youre
not sick the ongoing search for organic causes

• Brief review of Delirium, Seizures and Stroke
• ICU Psychosis
• How do you know if theyre confused? (J. Am. Ger.
  Soc. 2005)
• Why do they become delirious? (Critical Care
  2001)
• Does delirium portend a poor outcome? (JAMA 2004)
• Geriatrics Delirium plus dementia, what to do?
  (J. Am. Ger. Soc. 2005)

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Disorders of Mentation

• Abnormalities of mental function
• Conciousness
• Arousal (awake?)
• Awareness (responsive?)
• Cognition
• Orientation (accurate perception of experiences)
• Judgment and Reasoning (ability to process data
  and generate meaningful information)
• Memory (ability to store and retrieve
  information)

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• Levels of Conciousness
• Awake aroused and aware
• Somnolent easily aroused and aware
• Stuporous aroused with difficulty, impaired
  awareness
• Comatose unarousable and unaware
• Vegetative state aroused but unaware

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• Etiology of depressed level of consciousness
• In non head injured patients
• SMASHED
• Substrate deficiencies (glucose, thiamine)
• Meningoencephalitis or Mental illness
  (malingering, psychogenic coma)
• Alcohol or Accident (CVA)
• Seizures
• Hyper-capnia, -glycemia, -thyroid, -thermia OR
  Hypo-xia, -tension, -thyroid, -thermia
• Electrolyte abnormalities (hyperNa, hypoNa,
  hyperCa) and Encephalopathies
• Drugs

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Glascow Coma Scale GCS Max 15 Min 3 T
denotes intubation
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• Predictive value of GCS
• at 1 hour GCS lt6, 70 will not regain
  satisfactory neurologic recovery
• At 3 days, GCSlt6, 100 negative outcome

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• Septic Encephalopahthy
• Can be caused by any infection aside from CNS
  infections
• Early sign of sepsis
• Advanced cases progress to multiple abscesses
  throughout brain matter
• Similar biochemical changes to hepatic
  encephalopathy
• Increased aromatic amino acids, decreased
  branched chain amino acids in plasma

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Delirium

• Most common mental disorder in the hospitalized
  geriatric patient
• Up to 87 of elderly pts
• As many as 75 are not recognized by the
  physician caring for the patient
• Characterized by acute mental status change and
  inattention and disorganized thought or altered
  level of consciousness -- Hallmark acute onset
  and fluctuating clinical course
• Most often drug related (40) - but all other
  organic causes must be ruled out

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DSM-IV Diagnosis of Delirium

• A. Reduced ability to maintain and shift
  attention to external stimuli
• B. Disorganized thinking, as indicated by
  rambling, irrelevant, or incoherent speech
• C. At least two of the following
• 1. Reduced level of consciousness
• 2. Perceptual disturbances misinterpretations,
  illusions, or hallucinations
• 3. Disturbance of sleepwake cycle with insomnia
  or daytime sleepiness
• 4. Increased or decreased psychomotor activity
• 5. Disorientation to time, place, or person
• 6. Memory impairment
• D. Abrupt onset of symptoms (hours to days), with
  daily fluctuation
• E. Either one of the following
• 1. Evidence from history, physical examination,
  or laboratory tests of specific organic etiologic
  factor(s)
• 2. Exclusion of non-organic mental disorders
  when no etiologic organic factor can be
  identified

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Delirium

• Hypoactive delirium
• Characterized by lethargy rather than agitation
• Most common form in the elderly
• Dementia and Delerium
• Both have attention deficits and disordered
  thought
• Dementia is not acute and is not fluctuating
• 75 of delirium in hospital is superimposed on
  dementia
• Hospitalization can cause transient or permanent
  decompensation in the functioning of a patient
  with preexisting dementia

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Delirium

• Management
• identify and eradicate the cause
• Sedatives for patient protection
• Post-op use haloperidol
• Recommends
• mild anxiety 0.5 to 2mg
• Moderate 5-10mg
• severe 10-20mg
• Double the dose if no response in 20 minutes and
  redose. Add ativan if partial response.)
• THIS IS MUCH MORE THAN WE USE

• Maldonado Protocol
• AKA H2A
• 4am, 10am, 4pm, 10pm
• increased dose at 10pm for
• sleep-wake cycle preservation
• typically start at 21mg

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Important to differentiate Delirium from DTs

• Delirium Tremens
• Alcohol withdrawal
• Do not use haldol (lowers seizure threshold)
• Benzodiazepines are primary treatment
• Clonidine (alpha-2-agonist) for associated
  hypertension (also eases withdrawal centrally) \
• Valium Onset 1-2 min, lasts as long as 12 hrs
  (active metabolite)
• 10/10/10 (q8 hrs x 3)
• Ativan Slow onset (5-15 min) and longest
  duration (10-20hrs)
• Versed Fast onset, short acting
• Lipid soluble, prolonged sedation if used long
  term

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Cocaine Related Delirium

• Treated like Delirium Tremens
• Benzos, not haldol

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Who becomes delirious?

• Prospective analysis of over 800 ICU patients in
  Turkish hospital
• 11 rate of DSM diagnosis of delirium
• Collected clinical data and performed stepwise
  conditional logistic regression to identify
  predictors of development of delirium (compared
  to controls)
• Infection, fever, hypotension, anemia, and
  respiratory diseases.
• Hypocalcemia, hyponatremia, uremia, increased
  hepatic enzymes, hyperamylasemia,
  hyperbilirubinemia, metabolic acidosis

Aldemir et al Critical Care 2001
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Delirium, Dementia or Both?

• Delirium is a risk factor for increased ICU and
  Hospital length of stay
• In the geriatric population, becomes difficult to
  differentiate between underlying dementia and
  delirium
• Group at Brown did a prospective study of 118
  patients in ICU
• Baseline dementia diagnosis given by family on
  Blessed Dementia Scale
• Delirium diagnosed by CAM and CAM-ICU scales

Ely et al JAGS, May 2003
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• Blessed-Dementia Scale
• ActivityOne point for each, unless otherwise
  indicated.
• CHANGES IN PERFORMANCE OF EVERYDAY ACTIVITIES
• Inability to perform household tasks
• Inability to cope with small sums of money
• Inability to remember shortlist of items for
  example, in shopping list
• Inability to find way about indoors
• Inability to find way about familiar streets
•  more
• CHANGES IN HABITS
• Eating
• Dressing
• Sphincter control
• CHANGES IN PERSONALITY, INTERESTS, DRIVE
• Increased rigidity

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• CAM ICU SCORE
• 1. Acute Onset or Fluctuating Course Absent
  Present
• acute change in mental status from
  baseline? OR did the abnormal behavior fluctuate
  during the past 24 hours?
• 2. Inattention Absent Present
• Did the patient have difficulty focusing
  attention as evidenced by scores less than 8 on
  either the auditory or visual component of the
  Attention Screening Examination (ASE)?
• 3. Disorganized Thinking Absent Present
• Does the patient have disorganized or
  incoherent thinking as evidenced by incorrect
  answers to 2 or more of the following 4 questions
  and/or demonstrate an inability to follow
  commands?
• Questions (Alternate Set A and Set B) 2
  sets of logic questions (does a stone float? Does
  a leaf float?)
• 4. Altered Level of Consciousness Absent
  Present
• Is the patients level of consciousness
  anything other than alert (e.g. vigilant,
  lethargic or stuporous), or is VAMASS lt or gt 3
  (and not decreased due to sedation)?
• Alert Looks around spontaneously, fully aware of
  environment, interacts appropriately.
• Vigilant Hyperalert.
• Lethargic Drowsy but easily aroused. Unaware of
  some elements in the environment, or no
  appropriate spontaneous interaction with
  interviewer. Becomes fully aware and appropriate
  with minimal noxious stimulation.
• Stupor Becomes incompletely aware with strong
  noxious stimulation. Can be aroused only by
  vigorous and repeated stimuli. As soon as
  stimulus removed, subject lapses back into
  unresponsive state.
• Overall CAM ICU Score

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• 30 of pts had baseline dementia
• 14 were depressed
• 31 had delirium on first interview
• 70 had delirium sometime during hospitalization
• Most ICU delirium persisted after leaving ICU
• Patients with dementia had 2.4x risk of
  developing delirium during hospital stay compared
  to matched pts without delirium

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Delirium and mortality

• 275 patients over 1 year, prospectively enrolled,
  CAM-ICU and Richmond Agitation-Sedation scale
  used
• 81 delirious at some point during ICU stay
• Compared to well matched controls
• Increased mortality (34 vs 15)
• Increased length of stay (by 10 days on average)
• Adjusted Hazard Ratios 3.4 for mortality and 2.0
  for LOS

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Perspective on ICU Psychosis

• Until the 1990s, ICU pts were sedated and
  paralyzed and the changes in mental status went
  unrecognized
• Once the deleterious effects of longterm
  paralysis and sedation were realized, there was a
  decrease in the use of paralytics and sedatives
• It was realized that patients had changes in
  mental status
• Risk factors include preexisting mental
  illness, severity of illness, advanced age,
  medical comorbidity, sleep deprivation and
  medications

Polderman Critical Care 2005
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• ICU psychosis was almost normalconsequence
  of prolonged ICU stay
• Diagnosis is challenging with hypoactive delirium
  (more common)
• Many intensivists use a wait and see approach
  to treatment
• Others use Haldol liberally beware the side
  effects, EPS

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• Authors suggest
• Basic prevention Avoid sleep deprivation,
  increase cognitive stimulation, talk to the
  patient, play music, early mobilization, avoid
  dehydration, electrolyte disturbances, and
  hypoxia
• High index of suspicion, frequent screening
• Treatment should be more prompt (prevent
  sequelae)
• Stop offending drugs (benzos and narcotics
  misused to treat confusion)
• Treat with antipsychotics drug of choice
  remains haloperidol
• Monitor for prolonged QT
• Interacts with multiple othe drugs common in ICU
• Neuroleptics not well studied in the ICU may be
  helpful in non-agtated delerium (risperdol,
  olanzapine, ziprasidone)

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AACM and SCCM GuidelinesCritical Care Medicine
2001

• Recommendation Grade B Routine use of CAM-ICU
  by nursing to diagnose delerium
• Drugs
• Haldol works by antagonizing dopamine effects in
  cerebrum and basal ganglia
• Half life is 18-58 hours
• Dose dependent QT prolongation, increases risk of
  ventricular arrhythmias, 3.6 Torsades de Pointes
• Doses of 20mg at a time have been associated with
  ventricular arrhythmias
• Pre-exisiting cardiac disease increases the risk
• EPS risk is higher with PO haldol and BZOs can
  mask EPS
• EPS symptoms can be seen days after stopping drug
• Can last for 2 weeks in self-limited cases
• Treat by d/c haldol, give diphenhydramine or
  benztropine mesylate.

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AACM and SCCM GuidelinesCritical Care Medicine
2001

• Haldol also associated with 50 of neuroleptic
  malignant cases
• Chlorpromazine more anticholinergic, hypotensive
  effects
• Droperidol gives frightening dreams and
  hypotension by direct vasodilation
• Recommendation Grade C Haldol for chemical
  treatment of delirium

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AACM and SCCM GuidelinesCritical Care Medicine
2001

• Recommendation Grade B non-pharmacologic
  methods to increase and improve sleep with
  sedative/hypnotics as adjuncts.
• Titrate the environmental stimuli
• Sleep environment should be assessed
• Ear plugs help
• Single bed rooms, quiet time
• Day/night lighting and noise levels
• Relaxation techniques
• deep breathing exercises
• music therapy
• massage for 5-10 minutes

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Seizures

• Second most common neurologic complication in ICU
  
• Movements
• Tonic contractions (sustained contractions)
• Atonic contraction (no movement)
• Clonic contraction (periodic contractions with
  regular frequency and amplitude)
• Myoclonus (periodic contractions with irregular
  amplitude and frequency)
• Automatisms (lipsmacking, chewing, etc)

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• Generalized Seizures
• Symetric and syncrhonous electrical discharge of
  the entire cerebral cortex
• May or may not be accompanied by muscular
  contraction (if none, absence or petit-mal)
• Partial Seizures
• Electrical discharges that are confined to a
  restricted part of cortex
• Simple partial (does not impair consciousness)
• Complex partial (does impair consciousness)
• Temporal lobe seizures motionless stare and
  automatisms
• Epilepsia partialis continua persistent
  tonic-clonic movements of facial and limb muscles
  unilaterally
• Status Epilepticus
• more than 30 minutes of continuous seizure
  activity
• 2 or more sequential seizures without intervening
  consciousness

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New Onset Seizures

• Drug intoxication
• (amphetamies, cocaine, phenocyclidine, cipro,
  imipenam, lidocaine, PCN, theophylline, TCA)
• Drug withdrawal (EtOH, BZO, Barbiturates,
  Opiates)
• Infection (Meningoencephalitis, abscess)
• Ischemia (focal or diffuse)
• Space occupying lesion (tumors or bleeds)
• Metabolic derrangement
• (hepatic encephalopathy, uremia,
  hypo-glycemia, -natremia, -calcemia)

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• Evaluation
• Examination looking for lateralizing signs
• Review of medications
• Imaging (CT)
• Procedural diagnostics (LP, labs, blood cultures)
• Management
• BZO
• Valium 0.2mg/kg IV stops 80 of seizures within
  5 min, effect lasts 30 min
• Ativan 0.1mg/kg is as effective and lasts
  12-24hrs
• Dilantin 20mg/kg following valium, aim for 20mg/l
  therapeutic serum level

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Stroke

• Acute neurologic disorder
• Nontraumatic brain injury, vascular origin
• Focal findings (not global)
• Persists for more than 24 hours
• 80 ischemic, 20 of which are embolic
• Most thrombi are mural, LA, LV, DVT with PFO
• TIA transient ischemic attack, focal deficits
  resolve in less than 24 hours (ischemia rather
  than infarction)
• Minor Stroke RIND (reversible ischemic
  neurologic deficit) resolves within 3 weeks of
  event
• Major Stroke deficits persist for more than 3
  weeks

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• Evaluation common things youll see at the
  bedside
• Full neuro exam, looking for focal deficits
• Seixures in 10 of cases, focal and within first
  24 hours
• Fever in 50 of strokes (not with TIA) look for
  other sources
• Coma and LOC are not common more likely
  hemorrhage, massive infarct with edema, brainstem
  infarction, seizure (absence) or postictal state
• Aphasia Left MCA distribution
• Weakness in contralateral limbs (can also have
  other metabolic causes)

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Diagnostic Studies

• Time is brain
• Coags, Chemistries hypoglycemia, hyponatremia,
  ARF
• ECG Afib?
• CT head 70 sensitivity for infarct, 90 for
  hemorrhage - critical to distinguish btwn these
• Better if after 24 hours for infarct
• MRI more sensitive esp for brainstem and
  cerebellar strokes

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Diagnostics and Treatment

• ICP monitoring not recommended routinely
• Elevate HOB 30 degrees
• Do not use measures that will decrease CBF
• minimize suctioning (? HTN)
• Do not hyperventilate (reduces CBF)
• Steroids not recommended
• Hyperosmolar therapy can be used if edema is
  severe (Mannitol, HTS)