Acute Mental Status Changes[1]


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Acute Mental Status Changes[1]

  1. 1. Acute Mental Status Changes in the Intensive Care Unit Danagra Georgia Ikossi, MD Stanford General Surgery Resident 10/24/2006
  2. 2. Just because you’re nuts, it doesn’t mean you’re not sick… the ongoing search for organic causes <ul><li>Brief review of Delirium, Seizures and Stroke </li></ul><ul><li>“ ICU Psychosis” </li></ul><ul><ul><li>How do you know if they’re confused? (J. Am. Ger. Soc. 2005) </li></ul></ul><ul><ul><li>Why do they become delirious? (Critical Care 2001) </li></ul></ul><ul><ul><li>Does delirium portend a poor outcome? (JAMA 2004) </li></ul></ul><ul><ul><li>Geriatrics: Delirium plus dementia, what to do? (J. Am. Ger. Soc. 2005) </li></ul></ul>
  3. 3. Disorders of Mentation <ul><li>Abnormalities of mental function </li></ul><ul><ul><li>Conciousness: </li></ul></ul><ul><ul><ul><li>Arousal (awake?) </li></ul></ul></ul><ul><ul><ul><li>Awareness (responsive?) </li></ul></ul></ul><ul><ul><li>Cognition: </li></ul></ul><ul><ul><ul><li>Orientation (accurate perception of experiences) </li></ul></ul></ul><ul><ul><ul><li>Judgment and Reasoning (ability to process data and generate meaningful information) </li></ul></ul></ul><ul><ul><ul><li>Memory (ability to store and retrieve information) </li></ul></ul></ul>
  4. 4. <ul><li>Levels of Conciousness </li></ul><ul><ul><li>Awake: aroused and aware </li></ul></ul><ul><ul><li>Somnolent: easily aroused and aware </li></ul></ul><ul><ul><li>Stuporous: aroused with difficulty, impaired awareness </li></ul></ul><ul><ul><li>Comatose: unarousable and unaware </li></ul></ul><ul><ul><li>Vegetative state: aroused but unaware </li></ul></ul>
  5. 5. <ul><li>Etiology of depressed level of consciousness </li></ul><ul><li>In non head injured patients </li></ul><ul><ul><li>SMASHED </li></ul></ul><ul><ul><li>S ubstrate deficiencies (glucose, thiamine) </li></ul></ul><ul><ul><li>M eningoencephalitis or M ental illness (malingering, psychogenic coma) </li></ul></ul><ul><ul><li>A lcohol or A ccident (CVA) </li></ul></ul><ul><ul><li>S eizures </li></ul></ul><ul><ul><li>H yper-capnia, -glycemia, -thyroid, -thermia OR H ypo-xia, -tension, -thyroid, -thermia </li></ul></ul><ul><ul><li>E lectrolyte abnormalities (hyperNa, hypoNa, hyperCa) and E ncephalopathies </li></ul></ul><ul><ul><li>D rugs </li></ul></ul>
  6. 6. Glascow Coma Scale: GCS Max 15 Min 3 “ T” denotes intubation Eye Opening 4 Spontaneous 3 To Speech 2 To Pain 1 None Verbal 5 Oriented 4 Confused 3 Inappropriate 2 Incomprehensible 1 None 1 None 2 Abnormal Extension 3 Abnormal Flexion 4 Withdraws 5 Localizes 6 Obeys Commands Motor
  7. 7. <ul><li>Predictive value of GCS </li></ul><ul><ul><li>at 1 hour: GCS <6, 70% will not regain “satisfactory neurologic recovery” </li></ul></ul><ul><ul><li>At 3 days, GCS<6, 100% negative outcome </li></ul></ul>
  8. 8. <ul><li>Septic Encephalopahthy </li></ul><ul><ul><li>Can be caused by any infection aside from CNS infections </li></ul></ul><ul><ul><li>Early sign of sepsis </li></ul></ul><ul><ul><li>Advanced cases progress to multiple abscesses throughout brain matter </li></ul></ul><ul><ul><li>Similar biochemical changes to hepatic encephalopathy </li></ul></ul><ul><ul><ul><li>Increased aromatic amino acids, decreased branched chain amino acids in plasma </li></ul></ul></ul>
  9. 9. Delirium <ul><li>Most common mental disorder in the hospitalized geriatric patient </li></ul><ul><li>Up to 87% of elderly pts </li></ul><ul><li>As many as 75% are not recognized by the physician caring for the patient </li></ul><ul><li>Characterized by: acute mental status change and inattention and disorganized thought or altered level of consciousness -- Hallmark: acute onset and fluctuating clinical course </li></ul><ul><li>Most often drug related (40%) - but all other organic causes must be ruled out </li></ul>
  10. 10. DSM-IV Diagnosis of Delirium <ul><li>A. Reduced ability to maintain and shift attention to external stimuli </li></ul><ul><li>B. Disorganized thinking, as indicated by rambling, irrelevant, or incoherent speech </li></ul><ul><li>C. At least two of the following: </li></ul><ul><li>1. Reduced level of consciousness </li></ul><ul><li>2. Perceptual disturbances: misinterpretations, illusions, or hallucinations </li></ul><ul><li>3. Disturbance of sleep–wake cycle with insomnia or daytime sleepiness </li></ul><ul><li>4. Increased or decreased psychomotor activity </li></ul><ul><li>5. Disorientation to time, place, or person </li></ul><ul><li>6. Memory impairment </li></ul><ul><li>D. Abrupt onset of symptoms (hours to days), with daily fluctuation </li></ul><ul><li>E. Either one of the following: </li></ul><ul><li>1. Evidence from history, physical examination, or laboratory tests of specific organic etiologic factor(s) </li></ul><ul><li>2. Exclusion of non-organic mental disorders when no etiologic organic factor can be identified </li></ul>
  11. 11. Delirium <ul><li>Hypoactive delirium: </li></ul><ul><ul><li>Characterized by lethargy rather than agitation </li></ul></ul><ul><ul><li>Most common form in the elderly </li></ul></ul><ul><li>Dementia and Delerium: </li></ul><ul><ul><li>Both have attention deficits and disordered thought </li></ul></ul><ul><ul><li>Dementia is not acute and is not fluctuating </li></ul></ul><ul><ul><li>75% of delirium in hospital is superimposed on dementia </li></ul></ul><ul><ul><li>Hospitalization can cause transient or permanent decompensation in the functioning of a patient with preexisting dementia </li></ul></ul>
  12. 12. Delirium <ul><li>Management </li></ul><ul><ul><li>identify and eradicate the cause </li></ul></ul><ul><ul><li>Sedatives for patient protection </li></ul></ul><ul><ul><li>Post-op use haloperidol </li></ul></ul><ul><ul><ul><li>Recommends: </li></ul></ul></ul><ul><ul><ul><ul><li>mild anxiety – 0.5 to 2mg </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Moderate – 5-10mg </li></ul></ul></ul></ul><ul><ul><ul><ul><li>severe 10-20mg </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Double the dose if no response in 20 minutes and redose. Add ativan if partial response.) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>THIS IS MUCH MORE THAN WE USE </li></ul></ul></ul></ul><ul><ul><li>“ Maldonado Protocol” </li></ul></ul><ul><ul><li>AKA: H2A </li></ul></ul><ul><ul><li>4am, 10am, 4pm, 10pm </li></ul></ul><ul><ul><li>increased dose at 10pm for </li></ul></ul><ul><ul><li>sleep-wake cycle preservation </li></ul></ul><ul><ul><li>typically start at 2&1mg </li></ul></ul>
  13. 13. Important to differentiate Delirium from DTs <ul><li>Delirium Tremens </li></ul><ul><ul><li>Alcohol withdrawal </li></ul></ul><ul><ul><li>Do not use haldol (lowers seizure threshold) </li></ul></ul><ul><ul><li>Benzodiazepines are primary treatment </li></ul></ul><ul><ul><li>Clonidine (alpha-2-agonist) for associated hypertension (also eases withdrawal centrally) </li></ul></ul><ul><ul><li>Valium: Onset 1-2 min, lasts as long as 12 hrs (active metabolite) </li></ul></ul><ul><ul><ul><li>10/10/10 (q8 hrs x 3) </li></ul></ul></ul><ul><ul><li>Ativan: Slow onset (5-15 min) and longest duration (10-20hrs) </li></ul></ul><ul><ul><li>Versed: Fast onset, short acting </li></ul></ul><ul><ul><ul><li>Lipid soluble, prolonged sedation if used long term </li></ul></ul></ul>
  14. 14. Cocaine Related Delirium <ul><li>Treated like Delirium Tremens </li></ul><ul><li>Benzos, not haldol </li></ul>
  15. 15. Who becomes delirious? <ul><li>Prospective analysis of over 800 ICU patients in Turkish hospital </li></ul><ul><li>11% rate of DSM diagnosis of delirium </li></ul><ul><li>Collected clinical data and performed stepwise conditional logistic regression to identify predictors of development of delirium (compared to controls) </li></ul><ul><ul><li>Infection, fever, hypotension, anemia, and “respiratory diseases”. </li></ul></ul><ul><ul><li>Hypocalcemia, hyponatremia, uremia, increased hepatic enzymes, hyperamylasemia, hyperbilirubinemia, metabolic acidosis </li></ul></ul>Aldemir et al Critical Care 2001
  16. 16. Delirium, Dementia or Both? <ul><li>Delirium is a risk factor for increased ICU and Hospital length of stay </li></ul><ul><li>In the geriatric population, becomes difficult to differentiate between underlying dementia and delirium </li></ul><ul><li>Group at Brown did a prospective study of 118 patients in ICU </li></ul><ul><li>Baseline dementia diagnosis given by family on Blessed Dementia Scale </li></ul><ul><li>Delirium diagnosed by CAM and CAM-ICU scales </li></ul>Ely et al JAGS, May 2003
  17. 17. <ul><ul><li>Blessed-Dementia Scale </li></ul></ul><ul><ul><li>Activity One point for each, unless otherwise indicated. </li></ul></ul><ul><ul><li>CHANGES IN PERFORMANCE OF EVERYDAY ACTIVITIES </li></ul></ul><ul><ul><li>Inability to perform household tasks </li></ul></ul><ul><ul><li>Inability to cope with small sums of money </li></ul></ul><ul><ul><li>Inability to remember shortlist of items; for example, in shopping list </li></ul></ul><ul><ul><li>Inability to find way about indoors </li></ul></ul><ul><ul><li>Inability to find way about familiar streets </li></ul></ul><ul><ul><li>  more… </li></ul></ul><ul><ul><li>CHANGES IN HABITS </li></ul></ul><ul><ul><li>Eating </li></ul></ul><ul><ul><li>Dressing </li></ul></ul><ul><ul><li>Sphincter control </li></ul></ul><ul><ul><li>CHANGES IN PERSONALITY, INTERESTS, DRIVE </li></ul></ul><ul><ul><li>Increased rigidity </li></ul></ul><ul><ul><li>Increased egocentricity </li></ul></ul><ul><ul><li>Impairment of regard of feeling for others </li></ul></ul><ul><ul><li>Coarsening of affect </li></ul></ul><ul><ul><li>More…. </li></ul></ul>
  18. 18. <ul><li>CAM ICU SCORE </li></ul><ul><li>1. Acute Onset or Fluctuating Course Absent Present </li></ul><ul><li>acute change in mental status from baseline? OR did the abnormal behavior fluctuate during the past 24 hours? </li></ul><ul><li>2. Inattention Absent Present </li></ul><ul><li>Did the patient have difficulty focusing attention as evidenced by scores less than 8 on either the auditory or visual component of the Attention Screening Examination (ASE)? </li></ul><ul><li>3. Disorganized Thinking Absent Present </li></ul><ul><li>Does the patient have disorganized or incoherent thinking as evidenced by incorrect answers to 2 or more of the following 4 questions and/or demonstrate an inability to follow commands? </li></ul><ul><li>Questions (Alternate Set A and Set B): 2 sets of logic questions (does a stone float? Does a leaf float?) </li></ul><ul><li>4. Altered Level of Consciousness Absent Present </li></ul><ul><li>Is the patient’s level of consciousness anything other than alert (e.g. vigilant, lethargic or stuporous), or is VAMASS < or > 3 (and not decreased due to sedation)? </li></ul><ul><ul><li>Alert : Looks around spontaneously, fully aware of environment, interacts appropriately. </li></ul></ul><ul><ul><li>Vigilant : Hyperalert. </li></ul></ul><ul><ul><li>Lethargic : Drowsy but easily aroused. Unaware of some elements in the environment, or no appropriate spontaneous interaction with interviewer. Becomes fully aware and appropriate with minimal noxious stimulation. </li></ul></ul><ul><ul><li>Stupor : Becomes incompletely aware with strong noxious stimulation. Can be aroused only by vigorous and repeated stimuli. As soon as stimulus removed, subject lapses back into unresponsive state. </li></ul></ul><ul><li>Overall CAM ICU Score: </li></ul><ul><li>If 1 + 2, and either 3 or 4 is present, patient has delirium. Yes No </li></ul>
  19. 19. <ul><li>30% of pts had baseline dementia </li></ul><ul><li>14% were depressed </li></ul><ul><li>31% had delirium on first interview </li></ul><ul><li>70% had delirium sometime during hospitalization </li></ul><ul><li>Most ICU delirium persisted after leaving ICU </li></ul><ul><li>Patients with dementia had 2.4x risk of developing delirium during hospital stay compared to matched pts without delirium </li></ul>
  20. 20. Delirium and mortality <ul><li>275 patients over 1 year, prospectively enrolled, CAM-ICU and Richmond Agitation-Sedation scale used </li></ul><ul><li>81% delirious at some point during ICU stay </li></ul><ul><li>Compared to well matched controls: </li></ul><ul><li>Increased mortality (34% vs 15%) </li></ul><ul><li>Increased length of stay (by 10 days on average) </li></ul><ul><li>Adjusted Hazard Ratios: 3.4 for mortality and 2.0 for LOS </li></ul>
  21. 21. Perspective on ICU Psychosis <ul><li>Until the 1990s, ICU pts were sedated and paralyzed and the changes in mental status went unrecognized </li></ul><ul><li>Once the deleterious effects of longterm paralysis and sedation were realized, there was a decrease in the use of paralytics and sedatives </li></ul><ul><li>It was realized that patients had changes in mental status </li></ul><ul><li>Risk factors include: preexisting mental illness, severity of illness, advanced age, medical comorbidity, sleep deprivation and medications </li></ul>Polderman Critical Care 2005
  22. 22. <ul><li>‘ ICU psychosis’ was almost ‘normal’consequence of prolonged ICU stay </li></ul><ul><li>Diagnosis is challenging with hypoactive delirium (more common) </li></ul><ul><li>Many intensivists use a “wait and see” approach to treatment </li></ul><ul><li>Others use Haldol liberally – beware the side effects, EPS </li></ul>
  23. 23. <ul><li>Authors suggest: </li></ul><ul><ul><li>Basic prevention: Avoid sleep deprivation, increase cognitive stimulation, talk to the patient, play music, early mobilization, avoid dehydration, electrolyte disturbances, and hypoxia </li></ul></ul><ul><ul><li>High index of suspicion, frequent screening </li></ul></ul><ul><ul><li>Treatment should be more prompt (prevent sequelae) </li></ul></ul><ul><ul><li>Stop offending drugs (benzos and narcotics misused to treat “confusion”) </li></ul></ul><ul><ul><li>Treat with antipsychotics – drug of choice remains haloperidol </li></ul></ul><ul><ul><ul><li>Monitor for prolonged QT </li></ul></ul></ul><ul><ul><ul><li>Interacts with multiple othe drugs common in ICU </li></ul></ul></ul><ul><ul><li>Neuroleptics not well studied in the ICU may be helpful in non-agtated delerium (risperdol, olanzapine, ziprasidone) </li></ul></ul>
  24. 24. AACM and SCCM Guidelines Critical Care Medicine 2001 <ul><li>Recommendation: Grade B: Routine use of CAM-ICU by nursing to diagnose delerium </li></ul><ul><li>Drugs: </li></ul><ul><ul><li>Haldol works by antagonizing dopamine effects in cerebrum and basal ganglia </li></ul></ul><ul><ul><ul><li>Half life is 18-58 hours </li></ul></ul></ul><ul><ul><ul><li>Dose dependent QT prolongation, increases risk of ventricular arrhythmias, 3.6% Torsades de Pointes </li></ul></ul></ul><ul><ul><ul><li>Doses of 20mg at a time have been associated with ventricular arrhythmias </li></ul></ul></ul><ul><ul><ul><li>Pre-exisiting cardiac disease increases the risk </li></ul></ul></ul><ul><ul><ul><li>EPS risk is higher with PO haldol and BZOs can mask EPS </li></ul></ul></ul><ul><ul><ul><li>EPS symptoms can be seen days after stopping drug </li></ul></ul></ul><ul><ul><ul><li>Can last for 2 weeks in self-limited cases </li></ul></ul></ul><ul><ul><ul><li>Treat by d/c haldol, give diphenhydramine or benztropine mesylate. </li></ul></ul></ul>
  25. 25. <ul><ul><ul><li>Haldol also associated with 50% of neuroleptic malignant cases </li></ul></ul></ul><ul><ul><ul><li>Chlorpromazine more anticholinergic, hypotensive effects </li></ul></ul></ul><ul><ul><ul><li>Droperidol gives frightening dreams and hypotension by direct vasodilation </li></ul></ul></ul><ul><ul><li>Recommendation: Grade C: Haldol for chemical treatment of delirium </li></ul></ul>AACM and SCCM Guidelines Critical Care Medicine 2001
  26. 26. <ul><li>Recommendation: Grade B: non-pharmacologic methods to increase and improve sleep with sedative/hypnotics as adjuncts. </li></ul><ul><li>Titrate the environmental stimuli </li></ul><ul><li>Sleep environment should be assessed </li></ul><ul><li>Ear plugs help </li></ul><ul><li>Single bed rooms, quiet time </li></ul><ul><li>Day/night lighting and noise levels </li></ul><ul><li>Relaxation techniques </li></ul><ul><ul><li>deep breathing exercises </li></ul></ul><ul><ul><li>music therapy </li></ul></ul><ul><ul><li>massage for 5-10 minutes </li></ul></ul>AACM and SCCM Guidelines Critical Care Medicine 2001
  27. 27. Seizures <ul><li>Second most common neurologic complication in ICU </li></ul><ul><li>Movements </li></ul><ul><ul><li>Tonic contractions (sustained contractions) </li></ul></ul><ul><ul><li>Atonic contraction (no movement) </li></ul></ul><ul><ul><li>Clonic contraction (periodic contractions with regular frequency and amplitude) </li></ul></ul><ul><ul><li>Myoclonus (periodic contractions with irregular amplitude and frequency) </li></ul></ul><ul><ul><li>Automatisms (lipsmacking, chewing, etc) </li></ul></ul>
  28. 28. <ul><li>Generalized Seizures </li></ul><ul><ul><li>Symetric and syncrhonous electrical discharge of the entire cerebral cortex </li></ul></ul><ul><ul><li>May or may not be accompanied by muscular contraction (if none, absence or petit-mal) </li></ul></ul><ul><li>Partial Seizures </li></ul><ul><ul><li>Electrical discharges that are confined to a restricted part of cortex </li></ul></ul><ul><ul><li>Simple partial (does not impair consciousness) </li></ul></ul><ul><ul><li>Complex partial (does impair consciousness) </li></ul></ul><ul><ul><ul><li>Temporal lobe seizures: motionless stare and automatisms </li></ul></ul></ul><ul><ul><ul><li>Epilepsia partialis continua: persistent tonic-clonic movements of facial and limb muscles unilaterally </li></ul></ul></ul><ul><li>Status Epilepticus </li></ul><ul><ul><li>more than 30 minutes of continuous seizure activity </li></ul></ul><ul><ul><li>2 or more sequential seizures without intervening consciousness </li></ul></ul>
  29. 29. New Onset Seizures <ul><li>Drug intoxication </li></ul><ul><li>(amphetamies, cocaine, phenocyclidine, cipro, imipenam, lidocaine, PCN, theophylline, TCA) </li></ul><ul><li>Drug withdrawal (EtOH, BZO, Barbiturates, Opiates) </li></ul><ul><li>Infection (Meningoencephalitis, abscess) </li></ul><ul><li>Ischemia (focal or diffuse) </li></ul><ul><li>Space occupying lesion (tumors or bleeds) </li></ul><ul><li>Metabolic derrangement </li></ul><ul><li>(hepatic encephalopathy, uremia, hypo-glycemia, -natremia, -calcemia) </li></ul>
  30. 30. <ul><li>Evaluation: </li></ul><ul><ul><li>Examination looking for lateralizing signs </li></ul></ul><ul><ul><li>Review of medications </li></ul></ul><ul><ul><li>Imaging (CT) </li></ul></ul><ul><ul><li>Procedural diagnostics (LP, labs, blood cultures) </li></ul></ul><ul><li>Management: </li></ul><ul><ul><li>BZO </li></ul></ul><ul><ul><li>Valium 0.2mg/kg IV stops 80% of seizures within 5 min, effect lasts 30 min </li></ul></ul><ul><ul><li>Ativan 0.1mg/kg is as effective and lasts 12-24hrs </li></ul></ul><ul><ul><li>Dilantin 20mg/kg following valium, aim for 20mg/l therapeutic serum level </li></ul></ul>
  31. 31. Stroke <ul><li>Acute neurologic disorder </li></ul><ul><li>Nontraumatic brain injury, vascular origin </li></ul><ul><li>Focal findings (not global) </li></ul><ul><li>Persists for more than 24 hours </li></ul><ul><li>80% ischemic, 20% of which are embolic </li></ul><ul><ul><li>Most thrombi are mural, LA, LV, DVT with PFO </li></ul></ul><ul><li>TIA: transient ischemic attack, focal deficits resolve in less than 24 hours (ischemia rather than infarction) </li></ul><ul><li>Minor Stroke = RIND (reversible ischemic neurologic deficit) resolves within 3 weeks of event </li></ul><ul><li>Major Stroke = deficits persist for more than 3 weeks </li></ul>
  32. 32. <ul><li>Evaluation: common things you’ll see at the bedside </li></ul><ul><ul><li>Full neuro exam, looking for focal deficits </li></ul></ul><ul><ul><li>Seixures in 10% of cases, focal and within first 24 hours </li></ul></ul><ul><ul><li>Fever in 50% of strokes (not with TIA) – look for other sources </li></ul></ul><ul><ul><li>Coma and LOC are not common – more likely hemorrhage, massive infarct with edema, brainstem infarction, seizure (absence) or postictal state </li></ul></ul><ul><ul><li>Aphasia – Left MCA distribution </li></ul></ul><ul><ul><li>Weakness in contralateral limbs (can also have other metabolic causes) </li></ul></ul>
  33. 33. Diagnostic Studies <ul><li>Time is brain </li></ul><ul><li>Coags, Chemistries: hypoglycemia, hyponatremia, ARF </li></ul><ul><li>ECG: Afib? </li></ul><ul><li>CT head: 70% sensitivity for infarct, 90% for hemorrhage - critical to distinguish btwn these </li></ul><ul><li>Better if after 24 hours for infarct </li></ul><ul><li>MRI: more sensitive esp for brainstem and cerebellar strokes </li></ul>
  34. 34. Diagnostics and Treatment <ul><li>ICP: monitoring not recommended routinely </li></ul><ul><ul><li>Elevate HOB 30 degrees </li></ul></ul><ul><ul><li>Do not use measures that will decrease CBF </li></ul></ul><ul><ul><li>minimize suctioning (  HTN) </li></ul></ul><ul><ul><li>Do not hyperventilate (reduces CBF) </li></ul></ul><ul><ul><li>Steroids not recommended </li></ul></ul><ul><ul><li>Hyperosmolar therapy can be used if edema is severe (Mannitol, HTS) </li></ul></ul>