Title: Acute Mental Status Changes in the Intensive Care Unit
1Acute Mental Status Changes in the Intensive
Care Unit
- Danagra Georgia Ikossi, MD
- Stanford General Surgery Resident
- 10/24/2006
2Just 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)
3Disorders 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)
4- 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
-
5- 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
6Glascow Coma Scale GCS Max 15 Min 3 T
denotes intubation
7- Predictive value of GCS
- at 1 hour GCS lt6, 70 will not regain
satisfactory neurologic recovery - At 3 days, GCSlt6, 100 negative outcome
8- 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
9Delirium
- 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
10DSM-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
11Delirium
- 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
12Delirium
- 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
13Important 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
14Cocaine Related Delirium
- Treated like Delirium Tremens
- Benzos, not haldol
15Who 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
16Delirium, 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
17- 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
18- 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
19- 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
20Delirium 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
21Perspective 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
22- 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
23- 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)
24AACM 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.
25AACM 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
26AACM 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
27Seizures
- 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)
28- 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
29New 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)
30- 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
31Stroke
- 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
32- 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)
33Diagnostic 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
34Diagnostics 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)