Altered Mental Status Aaron Abramovitz, MD

1. Altered Mental StatusAaron Abramovitz, MD

2. Defining altered mental status • Change in level of consciousness • Describe exactly how the patient is behaving when presenting a case with ‘altered mental status’. • Coma • Lethargy • Delirium • Mania/Psychosis

3. Differential Diagnosis • The differential is quite broad. • PAST MEDICAL HISTORY is the best predictor of the cause of altered mental status. • Triage severity of impairment based on Glasgow Coma Score, vital signs, and ability to protect airway.

5. Coma • This necessitates ACLS protocol. Airway, breathing, circulation. (hypoventilation, hypoperfusion) • Check vitals. (hypotension, hypoxemia) • Always examine pupils. (stroke, narcotic overdose) • Check point of care glucose. (hypoglycemia) • Get arterial blood gas. (hypoxemia, hypercapnea) • Check 12-lead EKG. (arrhythmia) • Intubate the patient to protect the airway and make sure there is good IV access.

6. Coma • Now that you control the breathing and hemodynamics, it’s time to THINK. • Get a STAT head CT while you’re thinking. • Most of the time, coma will result from one of the causes in the previous slides. • If not, further studies to consider: lumbar puncture, EEG, toxin screen… use your clinical judgment.

7. Lethargy • This may require ACLS protocol and management as above. If vital signs are stable and the patient is protecting the airway, THINK. • Always examine pupils. (stroke, narcotic overdose) • Check point of care glucose. (hypoglycemia) • Get arterial blood gas. (hypoxemia, hypercapnea) • PAST MEDICAL HISTORY is the best predictor of the cause of altered mental status.

8. Lethargy • Some considerations: • Recent medication administration. • Respiratory failure (esp. hypercapnea). • Metabolic cause (esp. liver disease). • Illicit drug use and/or withdrawal. • CNS infection or stroke. • If you can’t figure it out, get a STAT head CT and THINK more. • Once again, consider EEG, lumbar puncture, and toxin screen.

9. The Patient Must be Stable for CT

10. Delirium • Core features: • Disturbance in consciousness – inability to focus, sustain or shift attention. • Disturbance in cognition – problem solving and/or memory impairment; perceptual disturbance. • Slow onset (hours to days) and fluctuation. • Often associated: • Hallucinations and/or delusions. • Disruption of sleep/wake cycle. • Inappropriate emotional states.

11. Delirium • Check vitals. (hypoxemia, hypotension) • If the patient is hemodynamically stable, THINK. • PAST MEDICAL HISTORY is the best predictor of the cause of altered mental status. • You will usually know the cause of delirium because it is often the primary presenting illness.

12. Delirium • Hyperactive • Agitated, verbose, hallucinations/delusions. • Hypoactive • Flat affect, non-verbal, ‘depressed’. • These will share the core features of delirium. To distinguish hypoactive delirium from depression, perform MMSE, Short Blessed, Trails A, etc.

13. Delirium • Delirium represents neurotransmitter/synaptic dysregulation in the brain, brought on by metabolic stress. • It is more likely in people with underlying brain disease (vascular, dementia, trauma). • Delirium is associated with RR 3-11 for 6 month mortality in ICU patients.

14. Delirium • Therapy: • 1) Protect the patient from harm • Place a sitter to redirect the patient. Avoid restraints. • If agitated, use typical antipsychotics PRN to sedate. • AVOID BENZODIAZEPINES. • Minimize lines, tubes, and frequently reorient. • 2) Regulate sleep/wake cycle • Lights on during the day and reorientation. • Risperidal 1-2mg QHS to ensure sleep. The antipsychotic will speed recovery.

15. Mania/Psychosis • Check vitals. (hypoxemia, hypotension) • If the patient is hemodynamically stable, THINK. • PAST MEDICAL HISTORY is the best predictor of the cause of altered mental status. • This may initially be hard to separate from delirium, so pursue medical workup as appropriate.

16. Mania/Psychosis • Psychiatric illness and drug intoxication are the major DDx for manic behavior. • This can be distinguished from delirium because the patient will often have intact problem solving/memory and be able to focus attention appropriately.

17. Mania/Psychosis • If the patient is violent or agitated, use a combination of benzodiazepine and antipsychotic. • “10 and 4” for big men and “5 and 2” for little old ladies. IM administration is effective. • Call psychiatry.

18. Rapid Fire Cases • Coma (why?): • fevers, stiff neck • found down at party • NPO diabetic • INR 10.5 • COPD exacerbation • dilaudid PCA • ran out of Keppra • tracheostomy patient

19. Rapid Fire Cases • Lethargy (why?): • UTI, fevers • inpatient insomniac • end stage liver disease • last drink two days ago • missed dialysis x1 week • football practice in the sun • motor vehicle collision

20. Some Final Thoughts • When you are unsure, be systematic. You cannot go wrong with A, B, C evaluation. • You can get a lot of information from non-contrast head CT and ABGs. Use these tools frequently. • If meningitis is on the differential, get an LP.

21. Some Final Thoughts • Once delirium is identified, have a plan for treating it. You can regulate sleep/wake cycle and treat disorganized behavior effectively with scheduled risperidal 1-2mg QHS. • Avoid polypharmacy in patients with delirium—this makes it more difficult to manage.