2007.10.19. EM R3 김현진

Introduction Mental status abnormalities are common reason for older patients to visit the ED require extensive work-up There is still diagnostic uncertainty, further testing is required to make definitive diagnosis

Objectives This article reviews Significance of altered mental status in older ED patients Specific diagnoses are discussed, including delirium, stupor and coma, and dementia with focus on delirium. Approach to all older patients is suggested that should result Increased clinician comfort with older patients Improved ability to communicate with other physicians lncreased quality of care Improved patient and family satisfaction

Background Two main components of altered mental status Level of the consciousness (arousal) Content of the consciousness (cognition) May help lead physician to appropriate diagnosis

Background Normal level of consciousness Patient who is awake and attentive. This level of arousal depends on intact reticular activating system, cerebral cortex, and communication between the two. Hyperalert or vigilant patients Lethargic patients Stupor patients Comatose patients

Delirium Acute, fluctuating change in cognition, impaired attention and consciousness The most serious cause of altered mental status seen in older ED patients 10% of ED patients over age 65 years present Most often, not diagnosed by the emergency physician Higher mortality

Epidemiology The mortality associated with delirium depending on whether or not the diagnosis is made in the ED (or in hospital) Kakuma found statistically significant association between delirium and mortality(3-month mortality ) delirium was undetected in the ED (31%), which was significantly higher than that of those whose delirium was detected (12%), and non-delirious subjects(14%)

Epidemiology The mortality rate for elders who develop delirium during hospitalization 22% to 76%, 3-month mortality rate of delirium is 14 times Although many patients recover fully, Prone to prolonged recovery period Increased likelihood of persistent cognitive deficits

Diagnosis of delirium Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV First deficit to appear is generally impairment of short-term memory (three-item recall) Disorientation to time or place Perceptual disturbances (delusions, illusions, misperceptions, or hallucinations) Lethargy (not reach level of stupor or coma) Inattention, or Psychomotor stimulation (hyperalert)

The Confusion Assessment Method (CAM) The Confusion Assessment Method Instrument: 1. [Acute Onset] Is there evidence of an acute change in mental status from the patient’s baseline? 2A. [Inattention] Did the patient have difficulty focusing attention, for example, being easily distractible, or having difficulty keeping track of what was being said? 2B. (If present or abnormal) Did this behavior fluctuate during the interview, that is, tend to come and go or increase and decrease in severity? 3. [Disorganized thinking] Was the patient’s thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject? 4. [Altered level of consciousness] . Overall, how would you rate this patient’s level of consciousness? (Alert [normal]; Vigilant [hyperalert, overly sensitive to environmental stimuli, startled very easily], Lethargic [drowsy, easily aroused]; Stupor [difficult to arouse]; Coma; [unarousable]; Uncertain) 5. [Disorientation] Was the patient disoriented at any time during the interview, such as thinking that he or she was somewhere other than the hospital, using the wrong bed, or misjudging the time of day? 6. [Memory impairment] Did the patient demonstrate any memory problems during the interview, such as inability to remember events in the hospital or difficulty remembering instructions? 7. [Perceptual disturbances] Did the patient have any evidence of perceptual disturbances, for example, hallucinations, illusions or misinterpretations (such as thinking something was moving when it was not)? 8A. [Psychomotor agitation] At any time during the interview did the patient have an unusually increased level of Motor activity such as restlessness, picking at bedclothes, tapping fingers or making frequent sudden changes of position? 8B. [Psychomotor retardation]. At any time during the interview did the patient have an unusually decreased level of motor activity such as sluggishness, staring into space, staying in one position for a long time or moving very slowly? 9. [Altered sleep-wake cycle]. Did the patient have evidence of disturbance of the sleep-wake cycle, such as excessive daytime sleepiness with insomnia at night? First described by Inouye in 1990 Operationalized the DSM-III criteria Sensitivity of 96% and a specificity of 93%. The CAM requires the presence of acute onset and fluctuating course and inattention, and either disorganized thinking or altered level of consciousness Memory impairment and disorientation are not incorporated into the CAM

Differential diagnosis Dementia because both may cause impaired cognition Onset of the symptoms; in delirium : the symptoms are acute in dementia : the onset is longer and more subtle Additionally, dementia Generally do not have impairment in level of consciousness

Differential diagnosis Primary psychiatric disorders, such as acute psychosis ‘‘pseudodelirium” Should be made only in patients without prior history of psychiatric disease after extensive evaluation, rather than in the ED

Other symptoms of delirium Altered sleep–wake patterns (60 ~70%) Emotional disturbances may occur and fluctuate Nonfocal neurologic deficits such as speech and language deficits (dysarthria, dysnomia, dysgraphia, or aphasia)

Other symptoms of delirium Many of physical signs and symptoms associated with specific etiologies Asterixis : hepatic and renal disease Nystagmus and cerebellar abnormalities : alcohol or drug Pupillary abnormalities : drug intoxication (eg, miosis with narcotics) Alcohol or sedative–hypnotic withdrawal : coarse tremors, tachycardia, and low-grade fever Frequency of anticholinergic medications “anticholinergic toxidrome” (dry mouth, urinary retention, tachycardia, fever)

Etiology 25% 43% 18%

Etiology Meperidine Fentanyl pathch 12%

Diagnostic testing Directed at discovering the etiology Careful clinical assessment Tailored diagnostic tests rather than shotgun approach CBC, electrolytes, BUN, creatinine, glucose, EKG Chest radiograph and urinalysis (Common infections : pneumonia & UTI ) Lumbar puncture : if sign of meningitis are present Cardiac enzymes : EKG shows new abnormalities Hepatic function tests and serum ammonia Arterial blood gas study : chronic lung disease

Diagnostic testing Routine use of CT of brain is not recommended CT should be considered stupor, coma, or new focal neurologic findings If no plausible etiology of the delirium

Treatment Directed at the underlying cause of the delirium Some patients require environmetal interventions turning off the lights bringing families to the bedside providing with glasses or hearing aids Physical restraints should be avoided if possible

Treatment Pharmacologic treatment of the symptoms antipsychotic haloperidol recommended frequently limited anticholinergic effects 0.5 to 1.0 mg orally, IM, IV can be repeated every 30 minutes Droperidol also has been used more likely to cause hypotension, sedation, and extrapyramidal effects prolongation of the QT interval and arrhythmia

Treatment Pharmacologic treatment of the symptoms Benzodiazepines (lorazepam) used most commonly alcohol or sedative hypnotic withdrawal or seizures risk for paradoxic central nervous system reactions

Disposition Delirium has many causes (potentially serious) Mortality is high, especially if unrecognized Older ED patients should be admitted for evaluation unless there is single, clear, and reversible etiology of the delirium (such as intoxication from short-acting medication)

Tests for cognitive impairment The standard mental status screen since 1975 has been the Mini Mental Status Exam (MMSE) comprehensive, testing orientation, registration, recall, calculation, and ability to follow commands

MMSE Undesirable for routine ED use First, it is not memorized or scored easily, making use of instructions and scoring sheets It requires intact vision, hearing, and the ability to write Finally, it takes a median of 6 minutes and a maximum of 14 minutes to complete

Orientation Memory Concentration Test OMCT used in ED-based research studies Consisting of six questions temporal orientation, counting backward from 20, saying the months in reverse order, and short-term memory, the test takes 2 to 5 minutes to perform

Clock-Drawing Test Evaluates many different cognitive functions, a complete circle numbers correctly placed (3) one hand larger than the other (4) hands read the correct time Evaluates many different cognitive functions, including long-term memory, concentration, and abstract thinking Although scoring is somewhat subjective, emergency physicians with only brief training in scoring on whether CDT is normal or abnormal Similar to MMSE, requires intact vision and ability to write

Mini-Cog Developed as brief screen for use in primary care settings Incorporates a clock-drawing test with three- item recall (such as ‘‘pencil, car, boat’’)

Six-Item Screener Rapid, easily remembered, and easily scored Taking a median of 1 minute to administer Can be incorporated into physical examination Unlikely to substantially increase the time to evaluate an older patient Simplicity makes it easy to remember and score without scoring sheets or pocket cards Two core components of cognition : short-term memory and orientation

Stupor and coma Most cases of coma (85%) are caused by systemic disease rather than by primary CNS abnormalities the etiologies are similar to those of delirium Substantial overlap between discussion of delirium and that of stupor or coma Require more rapid evaluation, evaluation is similar to that of delirious patients AVPU, the Glasgow Coma Scale (GCS)

Dementia gradual and progressive development of multiple cognitive deficits, especially memory Can be referred for evaluation as an outpatient Chronic cognitive impairment, from limiting reliability of the medical history to reducing understanding of and compliance with discharge instructions

General approach Mental status abnormalities are common in older emergency department patients may be present in up to 40% of ED patients This approach should be used to evaluate mental status in all older ED patients, because recognition of delirium is difficult and consequences of missed delirium are serious

General approach The 1ST item to assess : Level of consciousness Disturbance of consciousness (ie, reduced clarity of awareness of the environment) with reduced ability to focus, sustain, or shift attention. The 1ST item to assess : Level of consciousness (which corresponds to item A of the DSM-IV-R criteria) Normal is alert and attentive Abnormal include alert and inattentive, hyperalert, lethargic, stuporous, or comatose In stupor or coma, it is important to document response to verbal and painful stimuli by AVPU scale or the GCS

General approach The 2ND item assessed is cognition Short-term memory should be tested to improve the recognition of cognitive impairment Six-item screener(SIS) MMSE OMCT If uncertainty exists about cognitive status, the clock drawing test can be added

General approach If impaired consciousness or impaired cognition, evaluation of the acuity of onset of the symptoms must be investigated Onset of symptoms is acute (hours to days), delirium should be the working diagnosis and further testing is warranted If the symptoms are chronic and progressive, however, dementia is more likely

Summary Making the diagnosis of delirium in the ED is challenging and requires systematic approach to identify those geriatric patients who have acute changes Mortality who have delirium that is not diagnosed in the ED or in the hospital is significantly high the recognition of delirium is essential for provision of quality ED care

Summary Approach to older ED patients that focuses on appropriately categorizing mental status impairment without substantially increasing time to evaluate patient has been presented in article It is hoped that adoption of this approach should result in improvement in the care of older ED patients