1. Altered Mental Status Aaron Abramovitz, MD

2. Defining altered mental status Change in level of consciousness Describe exactly how the patient is behaving when presenting a case with ‘altered mental status’. Coma Lethargy Delirium Mania/Psychosis

3. Differential Diagnosis The differential is quite broad. PAST MEDICAL HISTORY is the best predictor of the cause of altered mental status. Triage severity of impairment based on Glasgow Coma Score, vital signs, and ability to protect airway.

5. Coma This necessitates ACLS protocol. Airway, breathing, circulation. (hypoventilation, hypoperfusion) Check vitals. (hypotension, hypoxemia) Always examine pupils. (stroke, narcotic overdose) Check point of care glucose. (hypoglycemia) Get arterial blood gas. (hypoxemia, hypercapnea) Check 12-lead EKG. (arrhythmia) Intubate the patient to protect the airway and make sure there is good IV access.

6. Coma Now that you control the breathing and hemodynamics, it’s time to THINK. Get a STAT head CT while you’re thinking. Most of the time, coma will result from one of the causes in the previous slides. If not, further studies to consider: lumbar puncture, EEG, toxin screen… use your clinical judgment.

7. Lethargy This may require ACLS protocol and management as above. If vital signs are stable and the patient is protecting the airway, THINK. Always examine pupils. (stroke, narcotic overdose) Check point of care glucose. (hypoglycemia) Get arterial blood gas. (hypoxemia, hypercapnea) PAST MEDICAL HISTORY is the best predictor of the cause of altered mental status.

8. Lethargy Some considerations: Recent medication administration. Respiratory failure (esp. hypercapnea). Metabolic cause (esp. liver disease). Illicit drug use and/or withdrawal. CNS infection or stroke. If you can’t figure it out, get a STAT head CT and THINK more. Once again, consider EEG, lumbar puncture, and toxin screen.

9. The Patient Must be Stable for CT

10. Delirium Core features: Disturbance in consciousness – inability to focus, sustain or shift attention. Disturbance in cognition – problem solving and/or memory impairment; perceptual disturbance. Slow onset (hours to days) and fluctuation. Often associated: Hallucinations and/or delusions. Disruption of sleep/wake cycle. Inappropriate emotional states.

11. Delirium Check vitals. (hypoxemia, hypotension) If the patient is hemodynamically stable, THINK. PAST MEDICAL HISTORY is the best predictor of the cause of altered mental status. You will usually know the cause of delirium because it is often the primary presenting illness.

12. Delirium Hyperactive Agitated, verbose, hallucinations/delusions. Hypoactive Flat affect, non-verbal, ‘depressed’. These will share the core features of delirium. To distinguish hypoactive delirium from depression, perform MMSE, Short Blessed, Trails A, etc.

13. Delirium Delirium represents neurotransmitter/synaptic dysregulation in the brain, brought on by metabolic stress. It is more likely in people with underlying brain disease (vascular, dementia, trauma). Delirium is associated with RR 3-11 for 6 month mortality in ICU patients.

14. Delirium Therapy: 1) Protect the patient from harm Place a sitter to redirect the patient. Avoid restraints. If agitated, use typical antipsychotics PRN to sedate. –AVOID BENZODIAZEPINES. Minimize lines, tubes, and frequently reorient. 2) Regulate sleep/wake cycle Lights on during the day and reorientation. Risperidal 1-2mg QHS to ensure sleep. The antipsychotic will speed recovery.

15. Mania/Psychosis Check vitals. (hypoxemia, hypotension) If the patient is hemodynamically stable, THINK. PAST MEDICAL HISTORY is the best predictor of the cause of altered mental status. This may initially be hard to separate from delirium, so pursue medical workup as appropriate.

16. Mania/Psychosis Psychiatric illness and drug intoxication are the major DDx for manic behavior. This can be distinguished from delirium because the patient will often have intact problem solving/memory and be able to focus attention appropriately.

17. Mania/Psychosis If the patient is violent or agitated, use a combination of benzodiazepine and antipsychotic. “10 and 4” for big men and “5 and 2” for little old ladies. IM administration is effective. Call psychiatry.

18. Rapid Fire Cases Coma (why?): fevers, stiff neck found down at party NPO diabetic INR 10.5 COPD exacerbation dilaudid PCA ran out of Keppra tracheostomy patient

19. Rapid Fire Cases Lethargy (why?): UTI, fevers inpatient insomniac end stage liver disease last drink two days ago missed dialysis x1 week football practice in the sun motor vehicle collision

20. Some Final Thoughts When you are unsure, be systematic. You cannot go wrong with A, B, C evaluation. You can get a lot of information from non- contrast head CT and ABGs. Use these tools frequently. If meningitis is on the differential, get an LP.

21. Some Final Thoughts Once delirium is identified, have a plan for treating it. You can regulate sleep/wake cycle and treat disorganized behavior effectively with scheduled risperidal 1-2mg QHS. Avoid polypharmacy in patients with delirium— this makes it more difficult to manage.