INTERN BOOT CAMP:

Altered Mental Status

Caroline Soyka
PGY3
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
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
 Delirium vs. Dementia
DELIRIUM DEMENTIA
Onset Acute/Subacute Insidious
Course Fluctuating Stable and
progressive
Attention Fluctuates Steady
Sensorium Impaired Intact until late
Cognitive Globally impaired Poor short term
memory
Perception Visual Simple Delusions
Hallucinations
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.
 Alertness Awareness Perform Attention
Tasks Span

“Cloudy decreased retain impaired decreased

Consciousness”

Lethargy decreased retain impaired decreased

Obtundation decreased decreased Requires decreased

stimulus

Stupor decreased decreased Requires decreased

constant
stimulus

Coma Decreased Decreased None None

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%)
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?
First Steps

 ABCDE:
– Airway
– Breathing
– Circulation
– Disability
– Exposure
Workup

 HISTORY!!!!
– Ask family
– New meds?
– Any significant PMH?
 PHYSICAL
– Vitals
– Detailed physical WITH neurologic exam
– GCS
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,
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.
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
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
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
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!
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
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
Causes of Hypoglycemia

 Overly aggressive insulin regimen

 Renal failure
 Liver failure
 Infection/Sepsis
 Excessive EtOH consumption
 Rare Stuff
– Adrenal insufficiency
– Insulinoma
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.
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
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
Five Causes of Hypoxia*

1. Hypoventilation
2. Shunt
3. Increased Diffusion Gradient
4. Decreased FiO2
5. V-Q Mismatch

* A favorite Schilz PIMP question.

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
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
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
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
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
Electrolyte Abnormalities

 Hypernatremia
 Hyponatremia
 Hypercalcemia
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
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)
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
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
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
 •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)
Hepatic Encephalopathy

Stage Consciousness Intellect and Behavior Neurological Findings

0 Normal Normal Normal examination;

impaired
psychomotor testing
1 Mild lack of Shortened attention Mild asterixis or
awareness span; impaired tremor
addition or subtraction
2 Lethargic Disoriented; Obvious asterixis;
inappropriate behavior slurred speech
3 Somnolent but Gross disorientation; Muscular rigidity and
arousable bizarre behavior clonus; Hyperreflexia
4 Coma Coma Decerebrate
posturing
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
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
 •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
EtOH Withdrawal
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**
 •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
CNS infections

 Meningitis
– Bacterial
– Viral
– Aseptic
 Encephalitis
 Toxoplasmosis
 JC virus
 West Nile Virus
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
 Treatment
 Antibiotic selection must be empiric
immediately after CSF is obtained

Age Common Antimicrobials

Pathogens

2-50 years N. meningitidis, Vancomycin plus a third-

S. pneumoniae generation cephalosporin

> 50 years S. pneumoniae, Vancomycin plus ampicillin plus a

N. meningitidis, third-generation cephalosporin
L. monocytogenes,

> 50 years w/ Above + pseudomonas Vancomycin plus ampicillin plus

meropenem/cefepime
suppression
****Add dexamethasone if suspected S. pneumo****
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
Management of Seizures

 Call Neurology
 Supportive care (Remember the ABC’s)
– Check fingerstick glucose/give amp D50 empirically
 Benzodiazepines
Diazepam 5-10 mg per minute

}
– Be prepared for
airway management
– Lorazepam 4-8 mg and ICU transfer
– Terminate ~75% of seizures
 AED’s (Phenytoin, fosphenytoin)
Case #9

42 YO with DM2 and depression on SSRI’s admitted

from ED for recurrent lower extremity cellulitis;
patient known to be colonizer with MRSA and had
severe flushing with Vancomycin last admission.
Started on IV Linezolid. About 12 hours after
antibiotics you are called for fevers and mental
status changes.
Exam

 VS: T 39.4, HR 98, RR 20, BP 104/60, SAT 98% RA

 GEN: Anxious, diaphoretic, A+Ox1
 Neuro: Diffuse hyperreflexia with myoclonus

+ = ?
Serotonin Syndrome
 •AEIOUTIPS

Case #10

78 YO WM with h/o Stage IIB Colon Cancer admitted

with SOB, found to have a PE. Patient is now on
heparin drip, and he suffers a fall in his room trying
to drag his IV pole to the bathroom. You are called to
assess the patient.
Vitals: T 36.5, HR 52, RR 12, BP 170/88
Exam significant for new LLE weakness
Intracranial Bleeding

 Intraparenchymal
Hemorrhage
– Common after trauma or
after initiating
anticoagulation in
embolic stroke
– Call Neurosurgery
Intracranial Bleeding

 Subdural
– Subacute onset after
trauma
– Crescent-shaped
– Shearing of the
bridging veins
– Call Neurosurgery
Intracranial Bleeding

 Epidural hemorrhage
– Most commonly
associated with skull
fracture in area of
middle cerebral artery
– Lentiform appearance
– Call Neurosurgery
Intracranial Bleeding

 Subarachnoid
– Worst headache of
one’s life
– Usually in setting of
hypertensive
emergency
– Call neurosurgery and
control BP
Stroke

 Embolic Stroke
– Commonly in setting of
atrial fibrillation
– Call Neurology and
activate the BAT pager
 •AEIOUTIPS

Case #11

93 YO AAM with HTN and vascular dementia admitted

for UTI. Patient on ceftriaxone IV and awaiting
placement in Brecksville. You are called at 3 AM
because patient attempting to climb out of bed, very
disoriented, and trying to pull out Foley.
T-37.7, HR-65, RR-16, BP-120/80
PE: unrerkable
Sun-Downing: Definition

 Sun-downing: a group of behaviors occurring

in some older patients with or without
dementia at the time of nightfall or sunset.
 Common Behaviors:
– Confusion
– Anxiety, agitation, or aggressiveness
– Psychomotor agitation (pacing, wandering)
– Disruptive, resistant to redirection
– Increased verbal activity
Sun-Downing: Prevention

 Give diuretics, laxatives early in day

 Discontinue any unneeded lines, catheters
 Ensure patient has glasses, working hearing aid
 Monitor amount of sensory stimulation
 Consider late afternoon bright light exposure
 Turn off lights and television during evening hours
 Avoid restraints if possible
 Attempt to re-orient patient
 Establish regular dose of drug for disturbing behavior
(if needed)