RTC--Altered Mental Status16 July 2010

Sources: Stern: Massachusetts General Hospital Comprehensive Clinical Psychiatry, 1st edition

© 2008 Mosby

http://www.merck.com/mkgr/mmg/sec5/ch40/ch40a.jsp

JJ Smith

Dementia• Dementia is characterized by cognitive decline

and a normal sensorium (e.g., delirium is absent)

• Leading cause of institutionalization among the elderly

• Can be progressive and usually impairs function

• Most common causes:• Alzheimer’s

• Vascular dementia

http://www.merck.com/mkgr/mmg/sec5/ch40/ch40a. jsp

Categories of DementiaMild

• short-term memory impaired as well as word finding

• apathy and reduced executive functions

Moderate

• Ability to perform daily activities is impaired

• Cannot learn new information and psychosis occurs in ~25%

Severe

• cannot perform basic functions (eat/toilet) and dependent

• usually these people are institutionalized unless there is significant family availability

http://www.merck.com/mkgr/mmg/sec5/ch40/ch40a. jsp

Delirium• Impaired attention

• Impaired concentration

• Impaired memory

• Fluctuation of consciousness

• Disorientation

• Hallucinations

• Incoherent speech

• Agitation

The Washington Manual of Medical Therapeutics, 29th edition

Delirium• If a patient is overly distractible or otherwise

unable to maintain attention, the diagnosis is likely to be delirium

• Abrupt onset, physical symptoms or signs suggesting an acute disorder, moment-to- moment variability, psychomotor changes

http://www.merck.com/mkgr/mmg/sec5/ch40/ch40a. jsp

The Mental Status Exam• General appearance and behavior: grooming, posture, movements,

mannerisms, and eye contact

• Speech: rate, flow, latency, coherence, logic, and prosody

• Affect: range, intensity, lability

• Mood: euthymic, elevated, depressed, irritable, anxious

• Perception: illusions and hallucinations

• Thought (coherence and lucidity): form and content (illusions, hallucinations, and delusions)

• Safety: suicidal, homicidal, self-injurious ideas, impulses, and plans

Stern: Massachusetts General Hospital Comprehensive Clinical Psychiatry, 1st edition© 2008 Mosby

The Mental Status Exam (cont’d)Cognition• Level of consciousness

• Orientation

• Attention and concentration

• Memory (registration, recent and remote)

• Calculation

• Abstraction

• Judgment

• InsightStern: Massachusetts General Hospital Comprehensive Clinical Psychiatry, 1st edition

© 2008 Mosby

Conditions Frequently Associated with Delirium

I WATCH DEATH

• Infectious or Iatrogenica imperfecta

• Withdrawal

• Trauma

• CNS pathology

• Hypoxia

• Deficiencies

• Endocrinopathies

• Acute vascular

• Toxins or drugs

• Heavy metals

Stern: Massachusetts General Hospital Comprehensive Clinical Psychiatry, 1st edition© 2008 Mosby

20916. . . . . . . .!@#$*&$!

• “Dr. McMasters, Mrs. M is saying that she is seeing green cats and dogs. I think she may be altered. . . . . . . ”

Lesson #1• Know the past medical history on all

your patients like the back of your hand

• You must clarify medication dosage and past psychiatric history

• Everything that is essential move to IV equivalent or if able to take liquids see if it can be crushed or mixed into a slurry

Potential Treatment Options

• Haldol (with caveats)

• Olanzapine

• Benzodiazepines (with caveats)

Rapid response. . . . . .really??

• “Dr. Kensinger, Mrs. H is non- responsive to verbal stimuli and curled up in bed. . . .and her gaze is fixed. . . . plus she is kind of sweaty. . . . . . .”

Lesson #2• Have a quick differential going in your

head as you move to the bedside

• Pay attention to your check-out

• ‘Preventive’ rounds—walk around and see the patients yourself--“keep ‘em alive ‘til 0705”—Riordan, Earl, Rauth, Borkon et al.

Quick review: Life threatening causes of

delirium

• SAH / SDH

• PE (hypoxia)

• CVA

• Withdrawal