Copy-of-Approach-To-A-Patient-With-Acute - APPROACH TO A PATIENT

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Copy-of-Approach-To-A-Patient-With-Acute - APPROACH TO A PATIENT Powered By Docstoc
					                     Seminar # 13
                     15th June, 2005



The approach to a patient who is confused. requires
knowledge, skill, and experience, but can improve the
chances of a correct diagnosis and appropriate
management by careful history taking, examination,
and observation. This is one area in which expensive
investigations are difficult to perform and frequently
unhelpful. The challenges are:
Is this patient confused and what does that mean?
If so, what is the cause?
Can the cause be corrected so that the confusion
Confusion is defined as a loss of one's capacity to
think clearly and coherently, and it is a non-specific
symptom of many different mental disorders (e.g.
dementia, delirium, manic psychosis) or organic
pathology (eg.encephalitis or metabolic
Both delirium and dementia are characterized by a
global impairment in cognitive functioning and
meticulous history-taking is sometimes required to
differentiate between these two entities
Delirium, acute confusional state, acute cognitive
impairment, acute encephalopathy, and other
synonyms refer to a transient disorder where attention
and cognition are impaired.
Alerting functions are working.
 The patient may have difficulty in focusing, shifting,
or sustaining attention. It also includes disturbed
wake-sleep cycles and a fluctuating course of
confusion. The functions of intellect as well as
arousal are disordered in the central nervous system
in delirium.                                          4
Sepsis                                 Hypothyroidism
Cerebral abscess                       Hyperthyroidism
Meningitis                             Hyperparathyroidism
Encephalitis                           Hyperparathyroidism
HIV CNS infection                      Glucocorticoid excess
Neurosyphilis                          Adrenal insufficiency
  Pharmacologic                          Environmental
Medication reaction/interaction        Hypothermia
Polypharmacy                           Hyperthermia
Lithium toxicity
Salicylate toxicity
                                         Primary Neurological Disorder
Anticholinergic toxicity               CVA
Serotonin syndrome                     Space-occupying lesion
Alcohol or illicit drugs               Subdural hematoma
Carbon monoxide poisoning              Subarachnoid hemorrhage
                                       Complex partial epilepsy
                                       Complex migraine
                                       Temporal Artritis
     Common Causes of Delirium
  Metabolic                Cardiovascular disease
Hypoglycemia              Cardiac ischemia
Hyperglycemia             Arrhythmias
Hepatic failure           Hypertensive encephalopathy
Renal failure
Hypocalcaemia               Substance abuse
Hypocalcaemia             Alcohol
Hypernatremia             Cocaine
Hyponatremia              Amphetamines
Hypomagnesaemia            Paraneoplastic syndrome
Vitamin B 12 deficiency
Hypoxia                                                 6
Delirium is mainly characterized by a clouding of
consciousness, reduced ability to focus, sustain or shift
Difficulty perceiving and interpreting environmental
data, and he may misisinterpret information and not be
able to think clearly
Cannot solve problems logically, anticipate reactions
and grasp abstract meanings
Evolves rapidly over hours-days and is characterized by
a marked fluctuation in symptoms during the course
of the day with periods of hypo activity and/or
 Perceptual disturbances (illusions, delusions and
hallucinations), disturbances of the sleep-awake cycle
with night-time agitation and daytime somnolence, and   7

disorganized thinking.
A disturbance in short term memory
They are highly distractible & appear to be absent
minded and they readily lose the thread of their
Associated psychomotor features may be present: -
restlessness with 'plucking and picking' gestures,
slowness, slurred speech, abnormal motor movements
such as asterixis and multifocal myoclonus and
Associated autonomic features may be present: -
dilated pupils, tachycardia, fever, flushing, sweating,
excessive pilomotor responses, diarrhea or
Associated affective changes may be present: -
irritability, apprehension, fear, docility, jocularity,
perplexity, lethargy                                  8
Dementia is a chronic loss of intellectual function
+ clear state of consciousness
Memory impairment, (short-term memory), (long-
term memory)
Following cognitive disturbances, which may cause
a decline in social and occupational functioning
Aphasia (language disturbance)
Apraxia (impaired ability to perform complex motor
Agnosia (impaired ability to recognise objects)
Disturbances in executive function (planning,
organizing, sequencing and abstracting)
      Clinical Differentiation
       Between Delirium and
Clinical feature Delirium                    Dementia
Nature of onset      Abrupt onset            Gradual, ill-defined
Rapidity of          Rapid - hours           Slow - months
Duration of condition Temporary - days       Long lasting - years

Variability of       Fluctuating from        Stable from day-to-
symptoms             hour-to-hour            day
                     Lucid intervals         No lucid intervals
Attention span        Very short, variable   Unaffected in early
                     from moment-to-         disease, stable in
                     moment                  chronic disease        10
Clinical feature            Delirium            Dementia
Memory changes              Short-term memory Long-term memory
                            markedly affected poor
Disturbed sleep-wake        Common, varies      Rare, stable from
cycle                       from hour-to-hour   day-to-day
Clouding of                 Common (defining    Absent
consciousness               feature)
Marked psychomotor          Common              Absent
(motor restlessness,
multifocal myoclonus,
asterixis, hyperreflexia)

Marked autonomic            Common              Absent
      Distinguishing Delirium
           from Dementia
Delirium                                   Dementia
Abrupt, precise onset with an              Gradual onset that cannot be dated
identifiable date
Acute illness, generally lasting days to   Chronic illness that characteristically
weeks but rarely more than one month       progresses over years

Disorientation early                       Disorientation later in the illness, often
                                           after months or years
Usually reversible, often completely       Generally irreversible and often
                                           chronically progressive
Variability from moment to moment,         Generally stable from day to day (unless
hour to hour, throughout the day           delirium develops)

Prominent physiologic changes              Prominent physiologic changeless
                                           prominent physiologic changes
    Distinguishing Delirium
         from Dementia
Delirium                               Dementia

Clouded, altered and changing level of Consciousness not clouded until
consciousness                          terminal stage

Strikingly short attention span        Attention span not characteristically

Disturbed sleep-wake cycle with hour- Disturbed sleep-wake cycle with
to-hour variation                     day-night reversal, not variation
Marked psychomotor changes             Psychomotor changes
(hyperactive or hypoactive)            characteristically occurring late in
                                       the illness (unless depression
           Differential Diagnosis
                 of Delirium
Observation        Delirium      Dementia Depression Psychosis
Onset              Acute         Insidious   Variable   Variable

Orientation        Impaired      Impaired    Intact     Intact
Short-term         Impaired      Impaired    Intact     Intact
Sensorium          Fluctuating   Variable    Intact     Intact
Attentiveness      Impaired      Variable    Usually    Variable
Delusions (e.g.,   Common        Sometimes   Rare       Common

Hallucinations     Visual,       Uncommon Rare          Auditory
                   tactile, or
Duration           Short         Chronic     Variable   Variable
Differential Diagnosis
      of Delirium
The presence of lucid intervals with normal/near-normal
cognitive functioning strongly suggests delirium and excludes
the likelihood of dementia
A rational approach to delirious patients mandates a rigorous
search for multiple precipitating causes of delirium, which
means that an emergency physician must perform a thorough
clinical evaluation and an extensive diagnostic workup in all
delirious patients
The commonest causes of delirium in the elderly patient are:-
  use of psychotropic drugs
  underlying infections
  metabolic derangements
  an acute physical illness superimposed on an underlying
    dementing illness
History of the Present Illness
First determine the time of onset of the change in mental
status and determine whether the change has been
constant or fluctuating in course
Determine whether there is a diurnal pattern with
increasing confusion towards the end of the day ("sun
downing") and whether there are any lucid intervals
Changes in the patient's degree of attentiveness
The ability to sustain a conversation or a task; the ability
to concentrate and not be easily distracted
Inquire about changes in the patient's short-term memory
and degree of orientation
Inquire about changes in the patient's functional status
(ability to dress and groom oneself , ability to feed on self
and ability to perform social tasks such as shopping and
house-keeping)                                              16
History of the Present Illness
Inquire about changes in the patient's emotional status
Inquire about associated hallucinations, delusions or
Inquire about the patient's baseline mental status and
determine whether the patient is normally fully oriented,
cognitively intact, attentive and capable of normal social
If the patient has an abnormal baseline mental status
=> (when he last drove a car, balanced a checkbook, fed
himself, dressed himself , had a coherent conversation
and so on)
Inquire about any recent changes in the patient's state of
physical health and whether any apparent physical
illness precipitated the change in mental status
Inquire about constitutional symptoms
Fever (infectious process)
Weight loss (malignancy)                                     17

Night sweats (infections, TB)
History of the Present Illness
Inquire about specific disease symptoms suggestive of
acute organ dysfunction (AMI, CHF, pneumonia, UTI,
Inquire about headaches and focal neurological
symptoms (suggestive of a SAH, subdural hematoma,
CVA or tumor) or recent falls/head trauma (subdural
hematoma) or incontinence or gait difficulties
(hydrocephalus, frontal strokes) or psychomotor
automatisms (complex partial seizures)
Inquire about the use of psychotropic drugs (including
over-the-counter medications with anti-cholinergic
properties e.g. decongestants and cough preparations)
Review the patients list of medications and inquire about
any new medications or recent changes in drug doses
History of the Present Illness
Inquire about possible intentional or accidental
exposure to pesticides or plant toxins or heavy metals
or carbon monoxide or illicit drugs or volatile agents
Inquire about habitual (or occult) alcohol
Determine sudden withdrawal from alcohol or
sedative/hypnotic drugs
Inquire about the patient's nutritional habits
(thiamine deficiency, Vit B12 and folate deficiency)
Inquire about recent hospitalisations or cancer
treatments (paraneoplastic syndrome)
Inquire about chronic illnesses (hepatic or renal
failure or endocrinopathies or COPD or DM or CHF)
Determine whether has been any significant life-
altering events and review the home environmental    19
conditions and the social support system
Baseline mental and behavioral status
Baseline social functioning
Baseline occupational status
Home environment and social support systems
Change in mental status
Time of onset
Course and liability
Presence of lucid intervals
Changes in sleep-awake cycle
“Sun Downing" phenomenon
Degree of attentiveness and distractibility
Short term memory changes
Perceptual disturbances -illusions, hallucinations, delusions
Emotional liability and poor capacity to modulate emotional
Psychomotor disturbances - asterixis, myoclonus, motor
 Overt/occult alcohol or illicit drug abuse
 Any sudden withdrawal from alcohol or sedative drugs
 Any new psychotropic drugs
 Any new drugs or drug dose changes
 Any salicylate abuse
 Use of nutritional supplements or alternative medicines
Intentional/accidental exposure to pesticides, heavy metals,
plant toxins
 Intentional/accidental exposure to extreme environmental

Baseline nutritional status
Baseline physical status
Chronic illnesses or immunosuppressant
Previous history of alcoholism or Wernicke's
Physical, emotional, mental disabilities
 any recent life-altering social or emotional events
Recent hospitalizations
   Recent surgery
   Recent cancer treatment
   Recent outpatient therapy or dialysis
   Recent depression or suicide attempt
               Abnormal vital signs
Hypothermia (myxedema, exposure-induced, sepsis)
Hyperthermia (infections, heat stroke, thyroid storm, neuroleptic
malignant syndrome, drug intoxications e.g. anticholinergics)
Hypotension (volume/blood loss, sepsis, cardiogenic shock, Addisonian
Hypertension (hypertensive encephalopathy, hyper adrenergic crises)
               Poor nutritional status (thiamine or B12 or
folate deficiency, malignancy)
               Signs of neglect or physical abuse (elder abuse)
               Abnormal neurological examination
Cranial nerves (CVA, CNS tumor etc)
Muscle strength, tone, reflexes, abnormal movements (CVA, space-
occupying lesions, NMS or serotonin syndrome)
Pathologic primitive reflexes (frontal lobe tumor, strokes or subdural)
Gait apraxia (hydrocephalus, chronic subdural)

Peripheral neuropathy (alcoholic, porphyria,
paraneoplastic, vitamin B12 deficiency)
Nystagmus (Wernicke's encephalopathy, PCP
intoxication, alcohol (s) intoxication)
Circumoral and distal limb paresthesias and tetany
Abnormal mental status examination
  Level of orientation
  Behavior and cooperation
  Speech and language ability
  Constructional and arithmetic ability
  Delusions, hallucinations, illusions
  Memory function
  Mood                                               24
Physical Examination
Cardiac ischemia/AMI (abnormal heart sounds, murmurs)
CHF (tachyon, abnormal heart sounds, murmurs, rales,
hepatomegealy, pedal edema)
Pneumonia (tachypnea, rales, bronchial breathing)
Other infection (UTI, cellulites)
Renal failure (uremic frost, anasarca, lung rales)
Liver failure (jaundice, spider nevi, caput medusae, ascites,
hepatomegaly or shrunken hard liver, genital atrophy,
gynecomastia, fetor hepaticus)
thyrotoxicosis (enlarged thyroid, autonomic hyperactivity,
exophthalmoses, pretibial myxedema)
Toxidromes e.g. anticholinergic toxicity (red flushed skin,
mydriasis, tachycardia, hypertension, urinary retention,
decreased bowel sounds)                                         25
      Mini Mental Status
 5 What is the (year) (season) (date) (day) (month)
 5 Where are we (city) (state) (country) (hospital)

 3 Name three objects => ask the patient for all
 three after you have said them

 5 Serial 7's back from 100 (stop after 5 answers)
 3 Ask for the three objects repeated above
      Mini mental status
    Language and praxis
2     Name two subjects: pen and watch
1     Ask the patient to say: no "ifs, ands, or buts“
3     Three stage verbal command: " take this paper in
       your right hand, fold it and place it on the bed“
1      Read and obey the following command: "close
  your eyes"
1      Write a sentence:
1      Copy a diagram of overlapping pentagrams
  A score of 30 is normal and changes of the score
  allows monitoring of progress
  Dysnomia (inability to name objects correctly) and
  dysgraphia (impaired writing ability) may be the
  most sensitive tests for detecting delirium         27
 Confusion Assessment
Acute onset + fluctuating course + inattention
  evidence of acute change from baseline
  increasing or decreasing severity of behavioral changes
  difficulty focusing attention
  easily distracted
  difficulty keeping track of what was said
Disorganized thinking
  rambling or irrelevant conversation
  unclear or illogical flow of ideas
  unpredictable switching of subjects
  hyper alertness or lethargy
      Diagnostic testing
Pulse oximetry
 low (pneumonia, CHF, PE, COPD)
 tachyarrhythmia or bradyarrythmia
 cardiac ischemia or AMI or PE
 ECG signs of electrolyte disorders (potassium, calcium)
Chest X-ray
 signs of pneumonia or CHF or PE
Blood testing
 a minimal screening battery would include serum glucose, serum
  electrolytes, serum calcium and magnesium, liver function tests,
  CPK and a CBC
Serum glucose
 hypoglycemia (diabetic with insulin/oral hypoglycemic drug
  overdose, liver failure)
 hyperglycemia (DKA, HNKC)
        Diagnostic Testing
Serum electrolytes, serum calcium, magnesium, and creatinine
 Hyponatremia or hypernatremia
 Hyper/hypocalcaemia, hyper/hypomagnesaemia
 Increased BUN/creatinine (dehydration, renal failure)
Serum liver function tests
 Abnormal (liver failure, heat stroke, plant poisoning)
 Elevated (AMI, rhabdomyolysis associated with heat stroke and other
  Hyperpyrexia syndromes)
 Anemia (B12 and folate deficiency, chronic illness, microangiopathic
  Hemolytic anemia - TTP)
 Elevated white cell count (infections, sepsis, leukemia)
 Abnormal platelet count (thrombotic thrombocytopenic purpura)
 Hypercarbia (COPD)
 Metabolic acidosis (DKA, sepsis, shock, salicylate or methanol or
 cyanide toxicity, uremia)                                            30
    Diagnostic testing
increased WBC and bacteriae (UTI)
increased myoglobin (heat stroke, NMS)
Blood cultures
indicate if the patient is febrile or e.g. bacterial
Thyroid function testing, serum ammonia, vitamin
B12 levels, VDRL, urinary porphobilinogens,
screens for heavy metals
Serum and urine drug screens
serum salicylate and other drug levels (digoxin,
 theophylline, lithium)
CT scan of the head
Lumbar puncture
       Approach to the
       confused elderly
     patient inphysical examination, including
1. Comprehensive history and
cognitive testing

2. Review medications: stop all psychoactive medications (or
substitute less toxic alternatives); check side effects of all
3. Blood tests: blood count, blood urea, electrolytes, calcium,
liver function tests
4. Search for occult infection: urinalysis, chest x ray, blood
5. When no obvious cause revealed by the above tests, consider
further investigations in selected patients:
  Laboratory tests: magnesium, thyroid function tests, B12,
drug screen, toxicology screen, ammonia
  Arterial blood gases: in patients with breathing
difficulties, chronic lung disease, suspected venous
thrombosis, etc
  Electrocardiogram: in patients with chest pain,
shortness of breath or cardiac history
  Cerebrospinal fluid examination: in febrile patients
where meningitis is suspected
  CT or MRI scan: in patients with new focal
neurological signs, or history or signs of head trauma
  Electroencephalogram: useful in diagnosing seizure
disorder and differentiating delirium from functional
psychiatric disorders
  CT, computed tomography; MRI, magnetic resonance
imaging                                              33
  Medical Decision-Making
Attention should first be directed at stabilization of the
vital signs, treatment of the precipitating causes, and
physical/chemical restraints
Stabilize the vital signs and give supplemental oxygen
Exclude hypoglycemia and treat any hypoglycemia
Give thiamine (Wernicke's encephalopathy)
Give naloxone (opiate toxicity)
Promptly treat any precipitating causes e.g. hypoxia,
hyperpyrexia, cerebral hypoperfusion, metabolic
derangements, poisonings, meningitis, cardiac or renal or
liver failure or acute endocrinopathies
Use physical restaints to minimize self-harm
Chemical sedation agitation is extreme longlasting
Haloperidol is often the drug-of-choice
     Medical decision-making
Haloperidol can be given IV and titrated to effect - initial dose
of 0.5-1.0 mg IV => double the dose every 20-30 minutes
Droperidol is faster acting, but may be more likely to cause
Small doses of lorazepam (0.5-1mg) titrated IV
A Benzodiazepine may be the drug-of-choice when the
delirium is secondary to withdrawal from alcohol or
sedative/hypnotic agents
Minimize sensory overload by limiting the number of care-
givers and ensuring a quiet environment; and allow family
members to remain in constant/frequent attendance
Do not leave patients unattended in the hallway and ensure
that the bed side-rails are up
    environmental and
social factors that can
help manage a delirious
 Provide frequent support and orientation
 Communicate clearly and concisely
 Give repeated verbal reminders of the day, time, location
 Give repeated reminders of the identity of key individuals,
 such as members of the treatment team and relatives
 Provide clear signposts to patient's location including a clock,
 calendar, chart with the day's schedule
 Have familiar objects from the patient's home in the room
 Ensure consistency in staff (for example, a key nurse)
 Use television or radio for relaxation and to help the patient
 maintain contact with the outside world
 Involve family and caregivers to encourage feelings of security
 and orientation
    environmental and
social factors that can
help manage a delirious
 Provide an unambiguous environment
 Simplify care area by removing unnecessary
 Consider using single rooms to aid rest and avoid extremes of sensory
 Avoid using medical jargon in patient's presence because it may
 encourage paranoia
 Ensure that lighting is adequate to reduce misperceptions
 Control sources of excess noise (such as staff, equipment, visitors)
 Identify and correct sensory impairments; ensure patients have their
 glasses, hearing aid, dentures
 Consider whether an interpreter is needed
 Encourage self care and participation in treatment
 Arrange treatments to allow maximum periods of uninterrupted
 sleepeck list and questions
 1.) All of the following define acute change in mental
  status and are synonymous except--
      a.   Delirium
      b.   Acute confusional state
      c.   Acute encephalopathy
      d.   Dementia
 Answer: d.Dementia denotes a chronic impairment in memory
  and cognitive abilities.
 2.) Which of the following are consistent with the
  diagnosis of delirium--
    a. Acute onset of mental status abnormality with fluctuating
    b. Inattention
    c. Disorganized thinking
    d. Altered level of consciousness
    e. All of the above
 2.) Answer: e.In fact items a-d comprises the algorithm of
  the Confusion Assessment Method (CAM).                            38
 3.) Which of the following items are measured in the
  mini-mental state examination?
      a.   Mood
      b.   Orientation
      c.   Conceptualization
      d.   Appearance
 3.) Answer: b.Orientation is part of Folstein=s mini-mental
  state examination
 4.) An abnormal mini-mental state examination suggests
  or may be consistent with--
      a.   Dementia
      b.   Personality disorder with suicidal ideation
      c.   Delirium secondary to a metabolic abnormality
      d.   a and c above
 4.) Answer: d.Cognitive impairment is present in delirium
  and dementia.                                                 39
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