Altered Mental Status in

Older ED PatientsAnita Chopra MD FACPDirector, NJ Institute for

Successful AgingUMDNJ-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.

A. Opiate overdose due to excessive use of oxycodoneB. Subdural hematomaC. Medication-induced deliriumD. Alcohol intoxicationE. Dementia-related sundown phenomenon

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. 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.

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. CBC.B. Electrolytes.C. Blood sugar.D. Urine analysis.E. CT of the head.

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?

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 (16-36% 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 - Stupor– Normal - Coma– Lethargic/somnolent

• 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

Delirium Dementia

Onset Acute Insidious

Duration Hours to days Months to years

Course Fluctuating Slowly progressive

Attention Poor Usually unaffected

Consciousness

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 in-hospital 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

Han JH, Zimmerman EE, Cutler N, et al. Acad Emerg Med 2009;16(3):193–200.

Hypoactive delirium and mixed-type delirium seem to be the predominant subtypes in older patients

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 DeliriumInterrelationship between patient vulnerability and

precipitating factors

Predisposing Factors/Vulnerability

Precipitating Factors/Insults

Low Vulnerability

High Vulnerability

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 co-

morbid 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 ERSeveral 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

AND2. Lack of attention

AND EITHER

3. Disorganized thinking4. 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.

Sensitivity: 94-100%Specificity: 90-95%

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.orgVideo Source: icudelirium.org. Copyright © 2002, E. Wesley Ely, MD, MPH and Vanderbilt University, all rights reserved

Richmond Agitation-Sedation Scale

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.

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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

Gunther ML, Morandi A, Ely EW. Crit Care Clin 2008;24(1):45-65.

Fong TG, Tulebaev SR, Inouye SK. Nat Rev Neurol 2009;5(4):210-220

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 Force3. 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. Terrell KM, Hustey FM, Hwang U, et al. Quality indicators for geriatric emergency care. Acad Emerg Med 2009;16(5):441-449.

2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association, 2000.

3. 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.

4. 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.

5. 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.

References6. 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.