Altered Mental Status in
Older ED Patients
Anita Chopra MD FACP
Director, NJ Institute for Successful Aging
UMDNJ-SOM
Altered Mental Status in
Older ED Patients
This Care of the Aging Medical Patient in
the Emergency Room (CAMPER)
presentation is offered by the Department of
Emergency Medicine in coordination with the
New Jersey Institute for Successful Aging.
This lecture series is supported by an educational grant from the
Donald W. Reynolds Foundation Aging and Quality of Life
program.
An 80 year old woman is brought to the ER by her daughter because
the patient was noted to be confused when the daughter was visiting
her after work. Patient lives alone and has a past medical history of
spinal stenosis, osteoporosis, falls, and mild cognitive impairment. She
has fallen multiple times in the past 6 months, but has had no fractures.
She visited her PCP two days ago, complaining about severe back pain
and difficulty sleeping at night. She was prescribed cyclobenzaprine,
low-dose amitriptyline, and prn oxycodone. Physical examination,
including a neurological exam, is unrevealing. Which of the following
is the most likely diagnosis?
A.
B.
C.
D.
E.
Opiate overdose due to excessive use of oxycodone
Subdural hematoma
Medication-induced delirium
Alcohol intoxication
Dementia-related sundown phenomenon
An 82 year old patient is brought to the ER with acute
change in mental status. You utilize Confusion
Assessment Method (CAM) to screen for the presence of
delirium. Which of the following meets the CAM criteria
for delirium?
A. Acute onset, altered level of consciousness, and
memory impairment.
B. Acute onset, disorganized thinking, and inattention.
C. Acute onset, altered level of consciousness, and
executive dysfunction.
D. Acute onset, inattention, and hallucinations.
E. Acute onset, hypervigilant, and disorganized thinking.
A 78 year old patient is brought to the ER with altered
mental status and is diagnosed with delirium. Which of
the following diagnostic tests is not appropriate for initial
evaluation of the patient?
A.
B.
C.
D.
E.
CBC.
Electrolytes.
Blood sugar.
Urine analysis.
CT of the head.
Learning Objectives
• Describe a systematic approach to assessing an
older patient presenting with altered mental
status
• Recognize negative consequences of missed
diagnosis of delirium
• Describe distinguishing features of delirium and
dementia
• Identify risk factors of delirium
• Discuss the diagnosis and management of
delirium in the ED setting.
Altered Mental Status/Cognitive
Impairment
• Common in ED, and more than 25% of older
ED patients are cognitively impaired
• Frequently missed and recognized only 28-38%
of the time
• Broadly categorized as delirium or cognitive
impairment without delirium
• Approx. 10% of older ED patients suffer from
delirium and identification is really poor (1636% of cases)
Mental Status: Main Components
• Level of consciousness or arousal
• Cognition: content of consciousness
Level Of Consciousness
• Consciousness is the ability of a person to be
able to receive information, process that
information, and then act upon it. A normal
level of consciousness consists of a patient who
is alert and attentive
– Hyperalert/vigilant
– Normal
– Lethargic/somnolent
- Stupor
- Coma
• Tools: AVPU, GCS, RASS( Richmond agitation
assessment scale)
Cognition: Domains
• Orientation: place, time, person
• Attention: Attention refers to the person’s ability to focus on
a given task ,such as naming the months backwards or spelling
‘‘world’’ backwards or digit span test
• Memory: New and old memory
• Executive function: Ability to judge a situation, shift
parameters, plan, and appropriately take action
• Tools: Mini Cog, MMSE, Six Item Screener
Quality indicators for Cognitive Assessment
SAEM Geriatric Task Force
1. IF an older adult presents to an ED, THEN the ED
provider should carry out and document a cognitive
assessment (such as an indication of level of alertness
and orientation or an indication of abnormal or intact
cognitive status) or document why a cognitive
assessment did not occur
2. IF an older adult is found to have cognitive impairment,
THEN an ED care provider should document whether
there has been an acute change in mental status from
baseline (or document an attempt to do so).
Terrell KM, Hustey FM, Hwang U, et al. Acad Emerg Med 2009;16(5):441-449.
Delirium versus Dementia
Onset
Duration
Course
Attention
Consciousness
Delirium
Dementia
Acute
Insidious
Hours to days
Months to years
Fluctuating
Slowly progressive
Poor
Usually unaffected
Impaired
Clear until late in the course of
illness
Both may be associated with memory impairment, orientation
difficulties, hallucinations and delusions. It is common for delirium
to be superimposed on dementia.
Dementia with Lewy Bodies (DLB)
• DLB is the second most common subtype of dementia
(after Alzheimer’s disease) and affects 15% to 25% of
elderly patients with dementia
• Characterized by a rapid decline and fluctuation in
cognition, attention, and level of consciousness
• Perceptual disturbances are frequently observed in
patients with DLB
• Patients with DLB have parkinsonian motor symptoms,
such as cog wheeling, shuffling gait, stiff movements,
and reduced arm swing during walking.
Delirium
•
•
•
•
•
“Acute confusional state”
“Acute brain failure”
“Sundowning”
“Encephalopathy”
“ICU psychosis”
Negative Consequences of Delirium
• Powerful prognostic marker associated with inhospital and long term mortality
• Increased mortality risk in patients who are
discharged home from ED with delirium
• Poses a significant threat to the quality of life
– Accelerated functional and cognitive decline
– Longer length of stay
• Costs more that $100 billion in direct and indirect
charges
Diagnostic Criteria of Delirium
• DSM-IV-TR
– Disturbance of consciousness with reduced ability to focus,
sustain, or shift attention.
– A change in cognition or the development of a perceptual
disturbance that is not better accounted for by a preexisting,
established, or evolving dementia.
– The disturbance develops over a short period of time and
tends to fluctuate during the course of the day.
– There is evidence from the history, physical examination, or
laboratory findings that the disturbance is caused by the
direct physiological consequences of a general medical
condition.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association, 2000.
Clinical Features Of Delirium
•
•
•
•
Acute onset
Fluctuating course
Inattention
Disorganized
thinking
• Altered level of
consciousness
• Cognitive deficits
• Perceptual
disturbances
• Altered sleep wake
cycle
• Emotional
disturbances
Psychomotor Variants Of Delirium
• Hyperactive
– Agitation, combativeness, restlessness, hallucinations
– Easiest to recognize (loud, disruptive patients)
• Hypoactive
– Depressed, sedated, somnolent and even lethargic
– More likely to go unrecognized (“good patients”)
• Mixed
– Features of both hypo and hyperactive delirium
Hypoactive delirium and mixed-type delirium seem to be the predominant subtypes in older patients
Han JH, Zimmerman EE, Cutler N, et al. Acad Emerg Med 2009;16(3):193–200.
Risk Factors
• Can be split into two categories
– Predisposing factors
• “Pre-hospitalization”
• Can alert the physician/staff to risk but are often non
modifiable in the acute setting
• For at risk patients, efforts can focus on prevention
– Precipitating factors
•
•
•
•
“Post-hospitalization”
Often iatrogenic
Often modifiable
Often preventable
Threshold for Delirium
Interrelationship between patient vulnerability and precipitating factors
Predisposing Factors/
Vulnerability
Low Vulnerability
High Vulnerability
Precipitating Factors/
Insults
Less Noxious Insult
Noxious Insult
Inouye SK, Charpentier PA. JAMA 1996;275(1):852-857.
Predisposing Factors
• Demographics
– Advancing Age
– Male gender
• Co-Morbidity
– Dementia
– No./severity of comorbid conditions
– Functional impairment
• Sensory impairment
– Hearing
– Visual
• Medications and drugs
– Polypharmacy
– Psychoactive med(s) use
– Alcohol abuse
• Decreased oral intake
– Dehydration
– Malnutrition
• Psychiatric
– Depression
Precipitating Factors
• Systemic
– Infection
– Inadequate pain control
– Trauma
• Metabolic
– Electrolyte disturbance
– Hepatic or renal failure
– Hypoglycemia
• Medications and drugs
– Meds and meds changes
– Drugs or drug withdrawal
• Central Nervous System
– CVA
– Hemorrhage
– Seizures and post ictal state
• Cardiopulmonary
– Acute MI
– CHF
– Respiratory failure
• Iatrogenic event
– Indwelling bladder catheter
– Physical restraints
– Procedures/surgery
High Risk Medications
• Sedatives-hypnotics
– Benzodiazepines
– Antihistamines
•
•
•
•
Narcotics
H 2 blocking agents
Antiparkinsonian meds
Anticonvulsants
• Drugs with anticholinergic
effects
–
–
–
–
Oxybutynin, tolterodine
Anti-nauseants
Tricyclic antidepressants
Antipsychotics, e.g., low
potency neuroleptics such as
chlorpromazine
– Promotility agents
Diagnosing Delirium In ER
Several Assessment Tools
•
•
•
•
•
•
Confusion Assessment Method (CAM)
CAM- ICU
Delirium Symptom Interview (DSI)
Delirium rating scale
Memorial Delirium Assessment Scale (MDAS)
Nursing Delirium Screening Scale (NuDESc)
Confusion Assessment Method
(CAM)
1. History of acute onset of change in patient’s normal
mental status & fluctuating course
AND
2. Lack of attention
AND EITHER
Sensitivity: 94-100%
Specificity: 90-95%
3. Disorganized thinking
4. Altered Level of Consciousness; Alert, hyper alert,
lethargic or drowsy, stupor, coma
Inouye SK, van Dyck CH, Alessi CA, et al. Ann Intern Med 1990;113(12):941-948.
Pompei P, Foreman M, Cassel CK, et al. Arch Intern Med 1995;155(3):301-307.
CAM-ICU
• Scale based on degree of consciousness
• Visual recognition to test attention and short-term
memory
• Head nodding and hand movements as responses
• Sensitivity and specificity comparable to the basic
CAM
Ely EW, Margolin R, Francis J, et al. Crit Care Med 2001;29(7):1370-1379.
CAM-ICU
www.icudelirium.org
Video Source: icudelirium.org. Copyright © 2002, E. Wesley Ely, MD, MPH and
Vanderbilt University, all rights reserved
Richmond Agitation-Sedation Scale
Image Source: icudelirium.org. Copyright © 2002, E. Wesley Ely, MD,
MPH and Vanderbilt University, all rights reserved
Step 1 Level of Consciousness (RASS)
Sessler CN, Gosnell MS, Grap MJ, et al. Am J Respir Crit Care Med 2002;166(10):1338-1344.
Ely EW, Truman B, Shintani A, et al. JAMA 2003;289(22):2983-2991.
CAM-ICU Flow Sheet
“Copyright © 2002, E. Wesley Ely, MD, MPH and Vanderbilt University, all rights reserved”
What Causes Delirium?
• Widespread imbalance of neurotransmitters &
disruption of synaptic communication resulting from
– Drugs
– Hypoxemia, metabolic derangements → global impairment
of cerebral metabolism → decreased synthesis and release
of neurotransmitters
– Systemic inflammation → activation of microglia→
increased cytokine levels
• Some studies support the notion that CNS blood flow
may be disrupted during delirium
Fong TG, Tulebaev SR, Inouye SK. Nat Rev Neurol 2009;5(4):210-220
Gunther ML, Morandi A, Ely EW. Crit Care Clin 2008;24(1):45-65.
Evaluation Of ED Patient With
Delirium
•
History:
– Time course of mental status
changes
– Baseline mental status and
cognition
– History of trauma, fall
– Medication review, any recent
changes
– Alcohol abuse
• Physical exam:
– Vital signs
– Emphasis on neurologic
including mental status,
cardiovascular, pulmonary exam
– Signs of infection, volume status
• Diagnostic tests
Oxygen saturation
– Rapid glucose determination
– CBC, electrolytes, renal and
liver function tests
– urine analysis
– Chest X-ray
– EKG: myocardial ischemia,
arrhythmia, and to assess for
QTc prolongation
– Dependent upon the clinical
scenario consider: Head CT,
lumbar puncture, blood
cultures, toxicology screening,
thyroid
–
ED Patient With Acute Change In
Mental Status: Differential Diagnosis
•
•
•
•
Delirium
Structural CNS process
Non-convulsive status epilepticus
Psychiatric illness
Pharmacologic Management Of
Delirium
• Search and treat the underlying cause
• Create a safe environment for the patient and staff
• Psychotropic meds reserved for patients in distress due
to severe agitation or psychotic symptoms
• Aim for monotherapy, lowest effective dose, and
tapering as soon as possible
• Antipsychotics are the treatment of choice
• Use of Benzodiazepines should be avoided
– Reserved for delirium caused by withdrawal from
alcohol/sedatives hypnotics
Antipsychotics
• Haloperidol is suggested as the antipsychotic of choice
based on the best available evidence to date
– Haloperidol, 0.25-1.0 mg IM/PO: evaluate effect in 30 minutes to 1 hour.
Administer additional doses until agitation is controlled (max 3-5mg/24
hours)
– Clinical endpoint should be an awake but manageable patient
– A subsequent maintenance dose consisting of ½ loading dose over 24 hours
in divided doses - taper 2-3 days
– Baseline EKG is recommended prior to initiation of IV Haldol to measure
baseline QT interval
• Atypical antipsychotics may be considered as alternative
agents, lower rates of extra pyramidal signs
– Risperidone: 0.25 - 0.5 mg PO or oral dissolvable, q8-12 hrs
– Olanzapine: 2.5 - 5 mg IM q1h prn, 2.5 - 5 mg PO QD
– Quetiapine: 12.5 - 25 mg PO q8-12 hrs prn, 12.5 - 25 mg PO BID
Nonpharmacologic Management Of
Delirium
•
•
•
•
•
•
Discontinue or decrease drugs
Supportive care and reorientation
Glasses/hearing aids
Attention to patient concerns & fears
Remove immobilizing lines and devices
Avoid restraints
Disposition
• Low threshold for admission
• Delirious patients discharged from ED more
likely to return and be hospitalized
• When admitted to the hospital, admission to a
specialized geriatric unit preferable
• Regardless of patient disposition, delirium
detected in ED should be communicated to the
physician at next stage of care
Quality Indicators For Cognitive Assessment
SAEM Geriatric Task Force
3. IF an older adult presenting to an ED is found
to have cognitive impairment that is a change
from baseline and is discharged home, THEN
the ED provider should document the
following:
– Support in the home environment to manage the
patient’s care
– A plan for medical follow-up
Conclusion
• In any patient with a change in mental status consider
delirium as possible diagnosis
• Consider altered mental state to be acute until proven
otherwise
• Delirium is very common in the ED and is often
missed
• Missing delirium can result in loss of a window of
opportunity to diagnosis and treat reversible medical
and surgical conditions that can present as delirium
References
1.
2.
3.
4.
5.
Terrell KM, Hustey FM, Hwang U, et al. Quality indicators for geriatric
emergency care. Acad Emerg Med 2009;16(5):441-449.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington, DC:
American Psychiatric Association, 2000.
Han JH, Zimmerman EE, Cutler N, et al. Delirium in older emergency
department patients: recognition, risk factors, and psychomotor subtypes.
Acad Emerg Med 2009;16(3):193–200.
Inouye SK, Charpentier PA. Precipitating factors for delirium in
hospitalized elderly persons: Predictive model and interrelationship with
baseline vulnerability. JAMA 1996;275(1):852-857.
Inouye SK, van Dyck CH, Alessi CA, et al. Clarifying confusion: The
Confusion Assessment Method: A new method for detection of delirium.
Ann Intern Med 1990;113(12):941-948.
References
6.
Pompei P, Foreman M, Cassel CK, et al. Detecting delirium among
hospitalized older patients. Arch Intern Med 1995;155(3):301-307.
7. Ely EW, Margolin R, Francis J, et al. Evaluation of delirium in critically ill
patients: Validation of the Confusion Assessment Method for the Intensive
Care Unit (CAM-ICU). Crit Care Med 2001;29(7):1370-1379.
8. Sessler CN, Gosnell MS, Grap MJ, et al. The Richmond Agitation-Sedation
Scale: Validity and reliability in adult intensive care unit patients. Am J Respir
Crit Care Med 2002;166(10):1338-1344.
9. Ely EW, Truman B, Shintani A, et al. Monitoring sedation status over time
in ICU patients: Reliability and validity of the Richmond Agitation-Sedation
Scale (RASS). JAMA 2003;289(22):2983-2991.
10. Gunther ML, Morandi A, Ely EW. Pathophysiology of delirium in the
intensive care unit. Crit Care Clin 2008;24(1):45-65.
11. Fong TG, Tulebaev SR, Inouye SK. Delirium in elderly adults: Diagnosis,
prevention and treatment. Nat Rev Neurol 2009;5(4):210-220.