INTERN BOOT CAMP: Altered Mental Status

1. INTERN BOOT CAMP:Altered Mental Status Caroline Soyka PGY3

2. 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

3. 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

4. Delirium vs. Dementia

5. 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 2002;162(4):457-63.

7. Epidemiology • AMS is primary reason for ED visit in 4-10% patients • ED patients > 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%)

8. So you are called for MS Δ’s… • What are the vital signs? • What was the time course? • What is the patient’s baseline? • What medications have they received? • What is the patient’s past medical history? • Was there any trauma? • Is there any focality to the neuro exam?

9. First Steps • ABCDE: • Airway • Breathing • Circulation • Disability • Exposure

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

11. Etiology • A alcohol, alzheimer’s • 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,

13. 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.

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

15. 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

16. 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

17. 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!

18. 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 OTC’s & herbals • Avoid anything with anticholinergic properties • JUST STOP UNNECCSSARY MEDS

20. 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

21. Causes of Hypoglycemia • Overly aggressive insulin regimen • Renal failure • Liver failure • Infection/Sepsis • Excessive EtOH consumption • Rare Stuff • Adrenal insufficiency • Insulinoma

22. 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.

23. 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 10:55 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

24. 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

25. Five Causes of Hypoxia* • Hypoventilation • Shunt • Increased Diffusion Gradient • Decreased FiO2 • V-Q Mismatch * A favorite Schilz PIMP question.

26. 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

27. 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

28. 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

29. A word on sepsis… • SIRS: >1 of the following manifestations: • Temperature > 38°C or < 36°C (> 100.4°F or < 96.8°F) • Heart rate > 90 beats/min • Tachypnea, as manifested by a respiratory rate > 20 breaths/min (or PaCO2 < 32 mm Hg) • White blood cell count > 12,000 cells/mm3, < 4,000 cells/mm3, or the presence of > 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

30. Case #5 93 YO WM with Alzheimer’s 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

31. Electrolyte Abnormalities • Hypernatremia • Hyponatremia • Hypercalcemia

32. 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

33. 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)

34. 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

35. 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

36. 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

37. AEIOUTIPS Exam 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)

38. Hepatic Encephalopathy

41. 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

42. Management of HE Correct the underlying cause… 1st line: Lactulose • Oral: 20 gm PO Q1-2 hrs for 3-5 BM’s/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

43. AEIOUTIPS Case #7 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, 96%RA

44. EtOH Withdrawal

45. CIWA Scale Nausea/Vomiting Tremor Sweats Anxiety Agitation Tactile Disturbances Auditory Disturbances Visual Disturbances Headache Orientation -symptoms treated with ativan and other prn’s **CIWA’s > 20 consider MICU transfer**

46. AEIOUTIPS Case #8 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 98%RA • GEN: uncomfortable, AAO x 2 • HEENT: + nuchal rigidity • LUNGS: CTA b/l • NEURO: no focal weakness

47. CNS infections • Meningitis • Bacterial • Viral • Aseptic • Encephalitis • Toxoplasmosis • JC virus • West Nile Virus

48. 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

49. Treatment • Antibiotic selection must be empiric immediately after CSF is obtained ****Add dexamethasone if suspected S. pneumo****

50. 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