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Altered Mental Status/Confusion. J. Stephen Huff, MD Emergency Medicine and Neurology University of Virginia Charlottesville, Virginia. Case.

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Altered mental status confusion

Altered Mental Status/Confusion

J. Stephen Huff, MD

Emergency Medicine and NeurologyUniversity of VirginiaCharlottesville, Virginia


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.


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.


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 later…febrile and combative...


Questions
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?


What is consciousness
What is Consciousness?

  • Arousal function

    • Alerting and wakefulness

    • Anatomically-reticular activating system

  • Content functions

    • Language, reasoning

    • Anatomically-cerebral cortex


Disorders of consciousness
Disorders of Consciousness

  • Arousal functions

    and/or

  • Content functions disrupted


Altered mental status
Altered Mental Status

  • What does it mean?

  • What to do about it?


Altered mental status1
Altered Mental Status

  • Examples…

    • Coma

    • Dementia

    • Delirium


Delirium synonyms
Delirium-Synonyms

  • Acute confusional state

  • Acute cognitive impairment

  • Acute encephalopathy

  • Altered mental status


Delirium
Delirium

  • Arousal functions & content functions disrupted

  • Difficulty focusing or sustaining attention

  • Fluctuating confusion

  • Disturbed wake-sleep patterns

  • Caregivers/family best source


Delirium criteria dsm iv
Delirium-Criteria DSM IV

  • Reduced ability to maintain attention and shift attention

  • Disorganized thinking, rambling, irreverent, incoherent speech


Delerium criteria dsm iv
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


Delerium criteria dsm iv1
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)


Delirium pathophysiology
Delirium-Pathophysiology

  • Complex

  • Widespread neuronal or neurotransmitter dysfunction

    • Intracranial process

    • Systemic diseases

    • Exogenous toxins

    • Drug withdrawal


Delirium causes
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


Delerium causes
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


Smashed mnemonic for acute mental status change
“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.


Physician s role
Physician’s Role

  • Primary survey

    • Establish unresponsiveness

    • A,B,C’s

  • Resuscitation

    • glucose, thiamine

  • Secondary assessment

  • Definitive care


Delirium history
Delirium-History

  • Tempo of onset

  • Associated symptoms

  • Medical history/medications

  • Witnesses


Delirium history confusion assessment method cam
Delirium-History-Confusion Assessment Method (CAM)

  • Acuity of change of behavior–

  • Fluctuating course

  • Inattention

  • Disorganized thinking

  • Altered level of consciousness


General examination
General Examination

  • Vital signs

  • General physical examination


Neurologic examination
Neurologic Examination

  • Observation

    • Movements

  • Cranial nerves

  • Sensory

  • Motor

  • Reflexes


How would you assess confusion
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...


Why do a mental status exam
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.


What is a mental status exam
What Is a Mental Status Exam?

  • Informal

  • Formal mental status

    • Mini-mental status exam

    • Brief mental status exam

    • Others


What is a mental status exam1
What Is a Mental Status Exam?

  • Appearance, behavior, attitude

  • Thought disorders

  • Perception disorders

  • Mood and affect

  • Insight and judgment

  • Sensorium and intelligence


Six elements of mental status evaluation
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


Six elements of mental status evaluation1
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?


What tests are available to assess confusion
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.


The brief mental status examination
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)


The brief mental status examination1
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.


The brief mental status examination2
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


Returning to our patient
Returning to Our Patient–

  • The patient was febrile and combative. He could not speak in an understandable manner.

  • Brief Mental Status Examination Score=28

  • What was the score at the first visit?


Our patient continued
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 WBC’s/hpf.


Clinical course
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


When is a spinal tap indicated in delirium
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.


Easy to say hard to practice
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….”


Question
Question

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


Altered mental status workup
Altered Mental Status–Workup

  • 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.


Delirium treatment
Delirium-Treatment

  • Treatment of underlying cause

  • Environmental manipulation

  • Sedation

  • Restraints


Why do a mental status exam1
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.


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