Altered Mental StatusSusan Budnick, MD

Goals of this lecture…

To provide a framework for assessing patients when called for acute altered mental status in hospitalized patients

To learn how to begin diagnostic workup for patients that are acutely altered

How to manage basic issues that can cause patients to be altered in an acute setting

There are many causes of altered mental status… Encephalopathies

Hypoxic encephalopathy Metabolic encephalopathy:

Hypoglycemia Hyperosmolar states

(hyperglycemia) Hyponatremia Hypernatremia Hypercalcemia Uremia Hepatic encephalopathy Organ failure Addison’s disease Hypothyroidism CO2 narcosis

Toxins Hypertensive

encephalopathy

Drug reactions like NMS Environmental causes

Hypothermia Hyperthermia

Deficiency state Wernicke encephalopathy

Sepsis Primary CNS disease or

trauma Direct CNS trauma

Diffuse axonal injury Subdural/epidural hematoma

Vascular disease Intraparenchymal

hemorrhage Subarachnoid hemorrhage

Infarction Hemispheric, brainstem

CNS infections/inflammation Encephalitis Anti-NMDA receptor

encephalitis Neoplasms Seizures

Nonconvulsive status epilepticus

Postictal state Psychiatric Acute psychosis Malingering

And this list is not complete…

A useful mnemonic….AEIOU TIPS

A – Alcohol, Alzheimer’s

E – Endocrine, electrolytes

I – Infections, intoxications

O – Opiates, oxygen (hypoxia)

U - Uremia T – Tumor, treatments I – Insulin P – Poisoning,

psychosis (delirium) S – Seizure, shock,

stroke, SAH

Let’s talk about AMS…

Let’s go through some cases (5) and create a differential of the most likely causes for AMS in each patient.

Use a patient’s clinical history to guide your workup for AMS Even if they cant give you a history!

What’s the most important thing to remember when assessing a patient with an acute change in mental status? ABCs! Don’t forget the basics

Case 1: a 72 yo M admitted for COPD exacerbation You are on NF at UH and you get a call about a patient that

was just admitted earlier this evening. According to your signout, the patient is a 72 yo M with a PMHx of COPD, HTN, and poorly controlled DM that was admitted for a presumed COPD exacerbation. The nurse calls and states that during the 9pm vital checks, the patient seemed lethargic and wasn’t answering questions appropriately.

What do you want before you hang up the phone? Vitals: 95, 135/84, 37.2, 20, 92% on 4L O2 by NC

Case 1: a 72 yo M admitted for COPD exacerbation Top differential while walking to the room?

Hypercapnic respiratory failure, acute on chronic respiratory acidosis

Hypoglycemia iatrogenic/medication Electrolyte abnormality, hyponatremia

Case 1: a 72 yo M cont’d… Next move?

Evaluate the patient

Reasonable labs? FSBG ABG if any signs of respiratory distress Renal panel (check electrolytes, calculate an AG) CBC

Case 1: a 72 yo M cont’d… The FSBG shows a glucose of 36

What’s next? Ask the nurse to give an amp of D50

Case 1: a 72 yo M cont’d… What does an amp of d50 do to a pt’s BG?

It’s hard to say to since we aren’t a static system.

50cc of 50% D50 = 25g dextrose

It should raise our BG for at least a short period of time

Case 1: a 72 yo M cont’d… Follow through… What else will you have to do

before this issue is solved? Look to see how much insulin the patient got and is

scheduled to get

What if the repeat BG after 30 minutes is 50? Repeat the hypoglycemia protocol! If the patient got a large bolus of insulin, they could need a

D5 drip or another amp D50 before this issue is resolved.

Case 2- 36 yo F with abdominal pain It’s your first day on the Dworken service. Your new

NF admission is J.R., a 36 yo F with a PMHx of Crohn’s (s/p colectomy and a total of 9 intra-abdominal surgeries) that was admitted yesterday with increased abdominal pain concerning for a Crohn’s flare. When you saw her while pre-rounding at 6:45 am, she seemed tired but was answering questions appropriately. At that time, her vitals were stable and her physical exam was unremarkable other than a tender, but non-surgical appearing abdomen. Morning labs were still pending.

Case 2- 36 yo F with abdominal pain You get called during rounds by the nurse at 9am

who is concerned that the patient seems “out of it” and would like a doctor to come assess her.

Top differential on the way to the room? Sepsis 2/2 intra-abdominal process Iatrogenic – medication related Less likely things- PE? Syncope?

Case 2- 36 yo F w abdominal pain cont’d… First move?

Get fresh vitals- 37.1, 78, 108/74, 7, 86% on room air

Next? Start some oxygen by NC Look at current medication list

Case 2- 36 yo F w abdominal pain cont’d… Current inpatient medication list

IV steroids Lisinopril 10mg IV dilaudid 2mg Q4HIV morphine 4mg Q2H

Case 2- 36 yo F w abdominal pain cont’d… Decision time… more data or a plan?

Naloxone 0.4mg IV push The patient wakes up and is no longer lethargic and is

complaining of pain

Follow through… Patient may need more naloxone – it is short acting and may

need to be redosed in 30 minutes or so Decrease the amount of pain medications she is getting! Communicate with the team including the nurses about how to

proceed.

Case 3 – 84 yo M admitted for chest pain Your patient M.R. is an 84 yo M with a PMHx of CAD (s/p

PCI and stent placement in 2014), BPH, and HTN that was admitted 1 day ago for chest pain rule out. In the ED, a foley catheter as placed for urinary retention thought to be secondary to BPH. All of his cardiac workup has been negative. Urology recommended dc with the catheter until he can follow up in clinic. He was kept over a long holiday weekend for PT/OT assessment.

On the morning of his planned discharge to SNF, you find him during prerounds more confused than usual. He is answering questions appropriately but only oriented to his own name. According to the overnight nurse, he was a little confused last night but looked “OK”.

Case 3 – 84 yo M admitted for chest pain Top differential diagnosis?

Sepsis, UTI PE Medication related/iatrogenic Hypotension/decreased cerebral perfusion 2/2 to ACS?

Case 3 – 84 yo M cont’d… First move? More data…

Get vitals – 37.3, 68, 114/86, 14, 96% on RA

Exam: In NAD, Oriented to name only, RRR, good pulses, clear lungs and no focal neuro findings…

Labs- morning renal panel, FSBG, CBC are already pending.

Ask RN to get UA and culture

Case 3 – 84 yo M cont’d… Medication list:

Aspirin 81mg Clopidogrel 75mg Metoprolol 25mg BID Lisinopril 20mg Melatonin 3mg Finasteride 5mg Tamsulosin 0.4mg Morphine 4mg IV Q6H PRN chest pain – but he hasn’t received

it in the last day

Case 3 – 84 yo M cont’d… He appears stable for now – not hypoxic, good vitals, no focal

exam findings.

Labs: Renal panel:

142/ 4.3/ 104 /24 /9 /0.97 CBC with 11.5>13.5/38.2<291 The UA comes back with + moderate LE, + mild nitrite,

trace ketones and 81 WBCs.

Case 3 – 84 yo M cont’d… Now what?

Start antibiotics for CAUTI 3rd gen cephalosporin or fluoroquinolone if they’re not sick Cefepime or zosyn if you have reason to suspect a MDR

organism Remove foley with voiding trial but may need to be

replaced with a new one Follow through…

Check back with your patient to make sure he is still stable and is improving with treatment

Case 4- 87 yo F admitted for HFrEF and severe AS You admit an 87 yo F with a PMHx of severe

aortic stenosis and valvular HFrEF (EF 25%, 3 recent hospitalizations for ADHF) that was admitted for TAVR workup. Other PMHx includes recurrent UTIs, HLD, and type 2 DM (last HbA1c 7.2%). The patient completed TAVR workup including her coronary angiogram and LHC negative for any ischemic disease. She is now awaiting TAVR scheduled 4 days from now.

Case 4- 87 yo F admitted for HFrEF and severe AS When you see her this morning, she is less animated

than usual. Although she awakens when you touch her arm, she is not oriented to time or place and quickly falls back asleep. You talk to the evening nurse that says she was awake all night and agitated. She was calling out and trying to get out of bed without assistance.

Later on rounds, she is more alert but only oriented to her name. While presenting to the attending, you list Altered Mental Status on her problem list. She asks for your differential diagnosis…

Case 4- 87 yo F cont’d… Differential Diagnosis?

Delirium Hypoglyemia UTI, sepsis DVT, PE Other cause of sepsis – HCAP? Iatrogenic- medications

Case 4- 87 yo F cont’d…First move?

Get vitals – 37.5, 86, 108/68, 97% on 2L O2 by NC

Exam: Alert, oriented to name only, No focal neurologic findings, RRR, AS murmur unchanged, good distal pulses, crackles to mid lung fields, 1+ pitting edema, JVP at 10cm.

Case 4- 87 yo F cont’d… Labs show:

BG: 92 Renal panel: 136/3.8/106/23/8/0.74<86 CBC: 9.8>13.1/36.0<264 7.38/42/78 UA with no nitrites, leuk esterase, no sugar, protein or RBCs

Case 4- 87 yo F cont’d… Medications:

Metoprolol 25mg BID Simvastatin 20mg Lisinopril 5mg daily Lasix 40mg PO BID Mild sliding scale insulin Heparin SQ 5000 units TID (you made sure she has been

getting this since admission)

Case 4- 87 yo F cont’d…

Case 4- 87 yo F cont’d… Decision time.

Patient sounds volume overloaded – needs diuresis For the AMS?

No clear etiology at this time but patient is HDS and dangerous etiologies are ruled out or much less likely.

Current most likely diagnosis? Most likely ? Delirium (a diagnosis of exclusion) PE. Why is this much less likely?

Case 4- 87 yo F cont’d… How to treat…

Minimize sedating medications Glasses, hearing aids Family and frequent reorientation Remove lines if not necessary Sleep hygiene (consider adding melatonin if sundowning), etc.

Case 5: 52 yo M admitted for AMS M.K. is a 52 yo M with a PMHx of COPD, HTN and

cirrhosis 2/2 hep C (still an active IVDU) that was admitted to UH 2 days ago for altered mental status. A diagnostic paracentesis showed no evidence of SBP. The patient was not compliant with his home medications and became progressively more altered until family brought him back to the hospital.

Now the nurse is calling you saying that he seems more altered than he did yesterday when she took care of him. He only wakes up to sternal rub and hasn’t been awake enough to take any oral medications all day.

Case 5: 52 yo M, cont’d… Looking for more history, you talk to the RN

and look through the chart… No falls He isn’t taking any opioids No fevers, BP is at his baseline, not tachycardic

(but on a BB) CT head on admission negative

Case 5: 52 yo M, cont’d… Differential diagnosis for AMS in this patient?

Hepatic encephalopathy Sepsis- SBP vs. endocarditis vs. aspiration PNA DVT, PE- hypercoagulable state (why?) CVA- septic emboli (recent IVDU) Iatrogenic – look at med list GI bleed

Case 5: 52 yo M cont’d… First move?

Get vitals: 37.3, 67, 97/62, 95% on RA Examine patient:

Neuro: Alert to sternal rub, can say name, DOB but confused when asked questions, quickly falls back asleep, moving all extremities, no obvious CN deficits (but exam difficult), + asterixis

Cardiac: RRR, no MRGs Pulm: CTAB but not following commands and taking deep

breaths Abdomen: Distended, dull to percussion, non-tender, no

guarding, rigidity Extremities: +2 peripheral edema to the knee, good distal

pulses

Case 5: 52 yo M cont’d… Medications:

Nadolol 40mg Spironolactone 100mg Lasix PO 40mg BID Lactulose 30mg BID Daily MTV Duonebs Q6H prn Fluticasone + Salmeterol (Advair)

Case 5: 52 yo M cont’d… Labs?

FSBG: 89 ABG: 7.35/43/92 Renal panel: 133/4.3/106/25/8/1.2<90 CBC: 8.5>11.5/32.1<148 UA: Negative for nitrites, LE, RBCs, trace proteins Blood cultures from admission (2 days ago) are negative Ammonia?

Not something we clinically follow. Used for diagnosis rather than following improvements, deterioration of clinical status.

Case 5: 52 yo M cont’d… Returning to the differential diagnosis…

Hepatic encephalopathy Sepsis- SBP vs. endocarditis vs. aspiration PNA vs. UTI DVT, PE- hypercoagulable state CVA- septic emboli (recent IVDU) Iatrogenic GI bleed

Most likely Dx?

What about the other diagnoses?

Case 5: 52 yo M cont’d… Decision time…

Place an NG and lactulose Q2H until patient wakes up

Follow through… Liver patients are often critically ill, even if they are on the floor Check back early and often! If not improving, consider a paracentesis to rule out SBP, etc. Reconsider your differential!

Key points… Think through your patient’s unique clinical history to narrow the ddx

for AMS

Always remember the basics when assessing an altered patient -> ABCs

Code whites and BATs exist for a reason

Many etiologies that are life threatening can be ruled out quickly if needed FSBG, vitals, ABG, UA, stat head CT if warranted

Clinical history is still important – even if the patient can’t provide it Look at medications the pt is getting (!!), talk to nurses/techs that might

know the pts baseline Call family if needed. They are often very helpful!