1.
EM R3 김현진

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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%)

8. 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

9. 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)

10. 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

11. 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

12. 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

13. 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)

14. 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)

15. Etiology
25%
43%
18%

16. Etiology
Meperidine
Fentanyl pathch
12%

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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)

23. 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

24. 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

25. 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

26. 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

27. 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’’)

28. 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

29. 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)

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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