ALTERED MENTAL STATUS / DELIRIUM
Nick Szumski, MD. Reviewed by Joanna Jen, MD, PhD. 6/05 Ruben Guzman 5/10
This is probably the one of the most common consults here at UCLA.
Key historical points: Acuity (acute/subacute/chronic), onset (gradual/sudden/stepwise), progression (waxing and waning/fixed), associated features (hallucinations, hemiparesis, medication schedule), recent complaints (severe headache, stiff neck, chest pain). Why is patient in hospital? Any suggestion of cardiac, renal, or liver disease? Any recent surgery? Any new or change in medication?
Delirum risk factors: old age, underlying dementia, cardiac or orthopedic surgeries, ICU setting, decreased vision or hearing.
I. Commonly cited etiologies of delirium:
* Disease states:
- Vascular: SDH, stroke, ICH or SAH
- Infection: UTI, PNA, sepsis, encephalitis, meningitis
- Toxic: intoxication and overdose
Witdrawal (etoh, benzos, barbiturates, opiates)
- Trauma: concussion
- Autoimmune: SLE, Hashimoto’s encephalopathy, autoimmune limbic encephalitis, (abs against VGKC, NMDA, AMPA).
Electrolytes: hypo/hyperNa, Hypercalcemia, hypermagnesemia, hypophosphatemia.
Endocrine: hypo/hyperparathyroidism, hypo/hypercortisolism, hypo/hyperglycemia,
Hypoxia and hypercarbia
Vitamin deficiencies: thiamine, B12
Malnutrition (albumin <2)
Dehydration: BUN/creatinine ration > 18
Large brain tumors, carcinomatous meningitis
Paraneoplastic limbic encephalitis (abs vs Ma2, Hu, CV2/CRMPS, amphiphysin, VGKC, NMDA and AMPA receptors).
- Seizures: postictal state, nonconvulsive status epilepticus
- Structural: hydrocephalus
- Degenerative: dementia with Lewy bodies, other neurodegenerative
disorders usually are risk factors for delirium but another inciting cause is
- Psychiatry disease: in older adults this is rarely the cause.
* Iatrogenic precipitants:
- Urinary catheters
- Multiple procedures
- Sleep deprivation
- Untreated pain
- Drugs: any drug with anticholinergic properties, benzodiazepines, opiates,
antihistamines, antiepileptics, muscle relaxants, dopamine agonists, MAOi,
levodopa, steroids, NSAIDS, fluoroquinolones, cephalosporins, beta-blockers,
digitalis, lithium, calcineurin inhibitors.
- Surgery: thoracic (cardiac and noncardiac), vascular, hip replacement.
Source: continuum 2010; 16(2)
II. Key physical exam points:
Vital signs: Fever? Tachypnea? Tachycardia? Hypotension?
Signs of trauma (especially if “found down”)?
Rash (e.g. meningococcal or viral exanthema)?
Stigmata of heart failure (crackles)? Lung disease (clubbing)? Liver disease (caput, icterus/jaundice, asterixis)?
Papilledema and other signs of possible increased ICP (4th/6th nerve palsies)?
Abnormal movements (e.g. subtle hand/face twitching which may indicated non-convulsive status epilepticus)?
Focal findings on neurologic exam? (Don’t miss the “blown pupil”!)
Check alertness, orientation, attentiveness (try digit span or count backwards from 20 to 1)
o Lethargic – does not become fully alert, conversant but inattentive
o Stuporous – does not completely arouse to painful stimuli, little or no verbal response, may briefly obey commands when aroused by painful stimuli
o Comatose – no verbal or complet motor rexponses to any stimulus.
III. Basic approach to delirium:
Step 1 (all patients):
Assesment of airway, breathing and circulation; vital signs; blood glucose
level. If blood glucose low administer 100mg IM thiamine and then dextrose 1amp D50; consider
naloxone in the possibility of opiate overdose.
Step 2 (all patients)
- History (special attention to baseline cognitive status, medications,
symptoms of infection).
- Physical examination (special attention to signs of infection, careful
neurologic examination to rule out a focal deficit).
- CBC with diff, chem 10, Lytes including Ca, Mg, Phosp., LFTs including
albumin, UA and culture, blood cultures, urine toxicol screen, blood EtOH,
- CXR, ABG if indicated, EKG.
Step 3 (guided by findings on the initial evaluation).
- Brain imaging with MRI with diffusion and gad or CT
- Lumbar puncture (immediately after imaging if suspicion for meningitis).
Opening pressure, cell count with diff (tubes 1 and 4), glucose, protein,
viral/fungal /bacterial cultures. Consider VDRL, HSV-PCR, lyme ab, cocci
ab, AFB stain/culture, India inf prep base on clinical suspicion.
Step 4 (guided by findings on the initial evaluation).
- Serum ammonia, morning cortisol, thyroid function test, B12/folate, RPR
(reversible dementia labs, for chronic cases, consider checking MMA and
- Sedimentation rate, autoimmune serologies, thyroperoxidase and
- Extended toxicology screen: consider blood draw for medication levels:
phenobarbital, phenytoin, carbemazepine, valproic acid (does this patient
have epilepsy?); lithium, tricyclic antidepressants (does this patient have
access to psych medications?).
- EEG (perform sooner if high suspicion for convulsive or nonconvulsive
Source: continuum 2010; 16(2)
·Treat the underlying cause if known (e.g. Abx, O2, diuresis, AED’s, etc.)
·Good empirical ideas:
o Thiamine 100mg IM. Especially if patient history unknown, or includes EtOH use. Always give PRIOR to glucose to avoid precipitating Wernicke’s encephalopathy.
o 1 amp D50: Always give thiamine first.
o Consider Naloxone 1 amp (safe), flumazenil 0.2mg (repeat q 1 min up to 1mg – risk of precipitating benzo withdrawal seizures)
· If febrile, consider empiric CSF coverage: Rocephin, Vancomycin, ampicillin (Listeria), acyclovir as indicated. Don’t hold for LP if delayed.
· If signs of increased ICP, then scan before LP and consider mannitol (1-2g/kg bolus, 0.5-1g/kg q6h), Lasix, intubation -- hyperventilation (goal pCO2 = 30)
· If medications must be used in the treatment of delirium antipsychotics are the drug of choice, just remember there is a FDA’s black box warning of increased mortality in elderly patients. Try to avoid the use of benzos for management of agitation since this may disinhibit more the pt in the setting of agitation and in the elderly.
· Recommended meds:
Haloperidol: 0.5 mg to 1 mg BID: can also be gien IM. PO dose may be repeated after 4 hrs and IM dose after 60 min.
Seroquel: 25 mg BID. Case series demonstrating safety and probable efficacy. Often used for pts with baseline extrapyramidal syndromes.
V.Things to keep in mind:
· Usual players: anoxia/hypoxia, renal/hepatic dysfunction, CNS infection, systemic infection, medication overdose or side effect, drugs of abuse, hypoglycemia, metabolic derangement, UTI, exacerbation of underlying dementia or psychiatric disorder, sundowning, sleep deprivation, sensory overload or deprivation.
· DO NOT miss these:
o Verbal paraphasias? Poor understanding? -- Rule out stroke/bleed causing Wernicke’s aphasia.
o Ophthalmoplegia of any kind? Ataxia? EtOH history? -- Rule out Wernicke’s encephalopathy (thiamine 100mg IM is ALWAYS a good empiric idea)
o Subtle twitching? History of seizures? -- Rule out non-convulsive status
ANTIBODIES – Paraneoplastic
Steve Sykes, MD
Sources: 1. Darnell, et al. Paraneoplastic syndromes involving the nervous system. NEJM, October 2003.
2. Geyer, et al. Neurology for the boards, 2002.
ANTIBODIES – Miscellaneous
Steve Sykes, MD. Updated by Sarah Kremen, MD.
Darnell, et al. Paraneoplastic syndromes involving the nervous system. NEJM, October 2003.
Geyer, et al. Neurology for the boards, 2002.
Dan Arndt, MD and Susan Shaw, MD. Reviewed by Mario Mendez, MD, 6/06 .
Muscle membrane irritability:
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