Altered Mental Status

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Altered Mental Status

• Susan Budnick, MD

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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

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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
• Addisons disease
• Hypothyroidism
• CO2 narcosis
• Toxins
• Hypertensive encephalopathy
• Drug reactions like NMS
• Environmental causes
• Hypothermia

And this list is not complete
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A useful mnemonic.AEIOU TIPS

• A Alcohol, Alzheimers
• 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

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Lets talk about AMS

• Lets go through some cases (5) and create a
  differential of the most likely causes for AMS in
  each patient.
• Use a patients clinical history to guide your
  workup for AMS
• Even if they cant give you a history!
• Whats the most important thing to remember when
  assessing a patient with an acute change in
  mental status?
• ABCs! Dont forget the basics

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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 wasnt 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
• Top differential while walking to the room?
• Hypercapnic respiratory failure, acute on chronic
  respiratory acidosis
• hypoglycemia
• iatrogenic/medication
• Electrolyte abnormality since labs might still be
  pending

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Case 1 a 72 yo M contd

• Next move?
• Evaluate the patient
• Reasonable labs
• FSBG
• ABG if any signs of respiratory distress
• Renal panel (check electrolytes, calculate an AG)
  
• CBC
• The FSBG shows a glucose of 36
• Whats next?
• Ask the nurse to give an amp of D50
• See how much and what type of insulin he received

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Case 1 a 72 yo M contd

• What does an amp of d50 do to a pts BG?
• Its hard to say to since we arent a static
  system.
• 50cc of 50 D50 25g dextrose
• It should raise our BG for at least a short
  period of time

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Case 1 a 72 yo M contd

• 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.

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Case 2- 36 yo F with abdominal pain

• Its your first day on the Dworken service and
  you are just learning about your new night float
  admits. J.R. is a 36 yo F with a PMHx of Crohns
  s/p colectomy and a total of 9 intra-abdominal
  surgeries that was admitted yesterday with
  increased abdominal pain concerning for a Crohns
  flare. When you saw her while prerounding at 645
  am, she seemed tired and slow to answer questions
  but you had just woken her up and she was still
  appropriately answering you. 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.
• 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?

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Case 2- 36 yo F w abdominal pain contd

• First move?
• Get fresh vitals- 37.1, 78, 108/74, 7, 86 on
  room air
• Next?
• Start some oxygen by NC
• Look at current inpatient medication list
• IV steroids
• Lisinopril 10mg
• IV dilaudid 2mg Q4H
• IV morphine 4mg Q2H

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Case 2- 36 yo F w abdominal pain contd

• 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.

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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.
  He was kept over a long holiday weekend for PT/OT
  assessment on Monday for social concerns at home.
  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 when getting his evening meds but she
  thought he looked ok
• The nurse asks, what do you want me to do?
• Top differential diagnosis before answering her?
• Sepsis, UTI
• PE
• Medication related/iatrogenic
• Hypotension/decreased cerebral perfusion 2/2 to
  ACS?

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Case 3 84 yo M contd

• 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
• Whats next?
• Look at the 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
  hasnt received it in the last day

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Case 3 84 yo M contd

• He appears stable for now not hypoxic, good
  vitals, no focal exam findings.
• Renal panel
• Na 142
• K 4.3
• Cl 104
• HCO3 24
• BUN 9
• Creatinine 0.97
• CBC with 11.5gt13.5/38.2lt291
• The UA comes back with moderate LE, mild
  nitrite, trace ketones and 81 WBCs.
• Now what?
• Start antibiotics for CAUTI
• 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

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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.
• 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

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Case 4- 87 yo F contd

• Differential Diagnosis?
• Delirium
• Hypoglyemia
• UTI, sepsis
• DVT, PE
• Other cause of sepsis HCAP?
• Iatrogenic- medications
• First move?
• Get vitals 37.5, 86, 108/68, 97 on 2L O2 by NC
  (improved since admission with diuresis)
• Order some labs
• FSBG (ASAP), renal panel, CBC (morning labs
  pending), ABG, UA and culture

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Case 4- 87 yo F contd

• Whats next?
• 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.
• Labs show
• BG 92
• Renal panel 136/3.8/106/23/8/0.74lt86
• CBC 9.8gt13.1/36.0lt264
• 7.38/42/78
• UA with no nitrites, leuk esterase, no sugar,
  protein or RBCs

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Case 4- 87 yo F contd

• 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)
• Anything else you could consider?
• CXR

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Case 4- 87 yo F contd
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Case 4- 87 yo F contd

• 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.
• Diagnoses still in the differential?
• Most likely ? Delirium (a diagnosis of exclusion)
• PE. Why is this much less likely?
• How to treat
• Minimize sedating medications, family and
  frequent reorientation, remove lines if not
  necessary, sleep hygiene (consider adding
  melatonin if sundowning), etc.

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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 (never underwent treatment,
  active IVDU) that was admitted to UH 2 days ago
  for altered mental status. A diagnostic and
  therapeutic 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
  hasnt been awake enough to take any oral
  medications all day.

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Case 5 52 yo M, contd

• You talk to the nurse for a history
• No falls
• He isnt taking any opioids
• No fevers, BP is at baseline, not tachycardic
  (but on a beta blocker)
• CT on admission negative
• Differential diagnosis for AMS in this patient?
• Hepatic encephalopathy
• Sepsis- SBP vs. endocarditis vs. aspiration PNA
  vs. UTI
• DVT, PE- hypercoagulable state
• CVA- septic emboli (recent IVDU)
• Iatrogenic look at med list
• GI bleed

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Case 5 52 yo M contd

• 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

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Case 5 52 yo M contd

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

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Case 5 52 yo M contd

• Labs?
• FSBG 89
• ABG 7.35/43/92
• Renal panel 133/4.3/106/25/8/1.2lt90
• CBC 8.5gt11.5/32.1lt148
• 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.

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• 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?

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Case 5 52 yo M contd

• 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!

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Key points

• Think through your patients unique clinical
  history to narrow the ddx for AMS
• Always remember the basics when assessing an
  altered patient -gt 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 cant 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!