Altered Mental Status/Confusion by XMKlV0

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									Altered Mental Status/Confusion

      J. Stephen Huff, MD
    Emergency Medicine and
           Neurology
      University of Virginia
     Charlottesville, 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.
                        J. Stephen Huff, MD
                  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.


                         J. Stephen Huff, MD
                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...


                       J. Stephen Huff, MD
              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?
                         J. Stephen Huff, MD
          What is Consciousness?
•   Arousal function
    –   Alerting and wakefulness
    –   Anatomically-reticular activating system
•   Content functions
    –   Language, reasoning
    –   Anatomically-cerebral cortex

                                   J. Stephen Huff, MD
      Disorders of Consciousness

•   Arousal functions

      and/or

•   Content functions disrupted



                         J. Stephen Huff, MD
         Altered Mental Status

•   What does it mean?

•   What to do about it?




                           J. Stephen Huff, MD
           Altered Mental Status

•   Examples…

    –   Coma

    –   Dementia

    –   Delirium


                         J. Stephen Huff, MD
          Delirium-Synonyms

•   Acute confusional state

•   Acute cognitive impairment

•   Acute encephalopathy

•   Altered mental status

                            J. Stephen Huff, MD
                   Delirium
•   Arousal functions & content functions
    disrupted

•   Difficulty focusing or sustaining attention

•   Fluctuating confusion

•   Disturbed wake-sleep patterns

•   Caregivers/family best source
                              J. Stephen Huff, MD
         Delirium-Criteria DSM IV

•   Reduced ability to maintain attention and
    shift attention
•   Disorganized thinking, rambling, irreverent,
    incoherent speech




                             J. Stephen Huff, MD
             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

                                      J. Stephen Huff, MD
          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)



                              J. Stephen Huff, MD
         Delirium-Pathophysiology
•   Complex
•   Widespread neuronal or neurotransmitter
    dysfunction
    –   Intracranial process
    –   Systemic diseases
    –   Exogenous toxins
    –   Drug withdrawal

                               J. Stephen Huff, MD
                  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



                                    J. Stephen Huff, MD
              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

                           J. Stephen Huff, MD
“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
                                           J. Stephen Huff, MD
D Drugs of any sort
                      Roberts JM. Ann Emerg Med 1990.
                  Physician’s Role
•   Primary survey
    –   Establish unresponsiveness
    –   A,B,C’s
•   Resuscitation
    –   glucose, thiamine
•   Secondary assessment
•   Definitive care
                               J. Stephen Huff, MD
            Delirium-History

•   Tempo of onset

•   Associated symptoms

•   Medical history/medications

•   Witnesses

                          J. Stephen Huff, MD
       Delirium-History-Confusion
       Assessment Method (CAM)
•   Acuity of change of behavior–

•   Fluctuating course

•   Inattention

•   Disorganized thinking

•   Altered level of consciousness
                            J. Stephen Huff, MD
          General Examination

•   Vital signs

•   General physical examination




                         J. Stephen Huff, MD
          Neurologic Examination
•   Observation
    –   Movements
•   Cranial nerves
•   Sensory
•   Motor
•   Reflexes

                        J. Stephen Huff, MD
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...


                             J. Stephen Huff, MD
       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.
                                                        J. Stephen Huff, MD
    What Is a Mental Status Exam?

•   Informal
•   Formal mental status
    –   Mini-mental status exam
    –   Brief mental status exam
    –   Others

                             J. Stephen Huff, MD
    What Is a Mental Status Exam?
•   Appearance, behavior, attitude
•   Thought disorders
•   Perception disorders
•   Mood and affect
•   Insight and judgment
•   Sensorium and intelligence

                            J. Stephen Huff, MD
            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

                                      J. Stephen Huff, MD
    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?

                                  J. Stephen Huff, MD
             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.
                                       J. Stephen Huff, MD
                 The Brief Mental
               Status Examination
ITEM                        (number of errors)          X (weight) = (Total)
What year is it now?              0 or 1                x4=            ____
What month is it?                 0 or 1                x3=            ____
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                  x3=            ____
(Answer correct if within one hour)
Count backwards from 20 to 1. 0, 1, or 2                x2=            ____
Say the months in reverse       0, 1, or 2              x2=            ____
Repeat memory phrase          0,1,2,3,4,or 5            x2=            ____
(each underlined portion is worth 1 point)
                                             J. Stephen Huff, MD
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.

                                 J. Stephen Huff, MD
    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

                              J. Stephen Huff, MD
        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?


                              J. Stephen Huff, MD
       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.
                       J. Stephen Huff, MD
                    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
                               J. Stephen Huff, MD
       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.
                                       J. Stephen Huff, MD
 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….”
                         J. Stephen Huff, MD
              Question

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




                        J. Stephen Huff, MD
      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.
                                        J. Stephen Huff, MD
           Delirium-Treatment

•   Treatment of underlying cause

•   Environmental manipulation

•   Sedation

•   Restraints
                         J. Stephen Huff, MD
       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.

                                                        J. Stephen Huff, MD

								
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