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
Attention
Fluctuates
Stable and
progressive
Steady
Sensorium
Impaired
Intact until late
Cognitive
Globally impaired Poor short term
memory
Visual
Simple Delusions
Hallucinations
Perception
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
Tasks
Attention
Span
“Cloudy
Consciousness”
decreased
retain
impaired
decreased
Lethargy
decreased
retain
impaired
decreased
Obtundation
decreased
decreased
Requires
stimulus
decreased
Stupor
decreased
decreased
Requires
constant
stimulus
decreased
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…

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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,

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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



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
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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?
–

If unable to take PO and has IV access, then give
use IV dextrose
–


Three glucose tabs will raise blood sugar by 50.
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.
2.
3.
4.
5.
Hypoventilation
Shunt
Increased Diffusion Gradient
Decreased FiO2
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…
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SIRS: >1 of the following manifestations:
–
–
–
–
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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
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

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
RA
HR 66
RR 16
BP 96/60 SAT 98%
•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
awareness
Shortened attention
span; impaired
addition or subtraction
Mild asterixis or
tremor
2
Lethargic
Disoriented;
inappropriate behavior
Obvious asterixis;
slurred speech
3
Somnolent but
arousable
Gross disorientation;
bizarre behavior
Muscular rigidity and
clonus; Hyperreflexia
4
Coma
Coma
Decerebrate
posturing
HE Precipitants
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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
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Meningitis
– Bacterial
– Viral
– Aseptic
Encephalitis
Toxoplasmosis
JC virus
West Nile Virus
Lumbar Puncture

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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
Pathogens
Antimicrobials
2-50 years
N. meningitidis,
S. pneumoniae
Vancomycin plus a thirdgeneration cephalosporin
> 50 years
S. pneumoniae,
N. meningitidis,
L. monocytogenes,
Vancomycin plus ampicillin plus a
third-generation cephalosporin
> 50 years w/
suppression
Above + pseudomonas
Vancomycin plus ampicillin plus
meropenem/cefepime
****Add dexamethasone if suspected S. pneumo****
Seizures

Status epilepticus
–
–
–
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Non-convulsive status
–
–

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
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)
–

Benzodiazepines
–
–
–

Check fingerstick glucose/give amp D50 empirically
Diazepam 5-10 mg per minute
Lorazepam 4-8 mg
Terminate ~75% of seizures
}
Be prepared for
airway management
and ICU transfer
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
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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)