MS7 Altered mental status and delerium

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Author:
jknell
ID:
207518
Filename:
MS7 Altered mental status and delerium
Updated:
2013-03-15 18:05:52
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Multisystem disorder
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Description:
Altered mental status and delerium
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  1. Delirium
    Definition
    • Syndrome composed of disturbances of consciousness, attention (arousal), and cognition, with abrupt onset and fluctuating course
    • Etiology: related to medical causes
    • -Increased in elderly population
  2. Altered mental status
    Ddx
    "MOVE STUPID"

    • -Metabolic → thiamin B12
    • -Oxygen (lack of)
    • -Vascular (hypertensive emergency)
    • -Endocrine/Electrolytes - diabetes, hyper-/hypo-Na, Ca
    • -Seizures/Structural - hydrocephalus, post ictal
    • -Trauma/Tumor
    • -Uremia
    • -Psychiatric
    • -Infection
    • -Drugs
  3. Approach to altered mental status
    • Easily treatable/reversible altered mental status:
    • -Thiamin deficiency → thiamin
    • -Hypoglycemia → D50
    • -Opiate overdose → Naloxone

    • Rule out life threatening conditions:
    • -Abnormal neurologic exam: mass effect, tumor
    • -Fever, HA, nuchal rigidity, AMS: r/o meningitis
    • -Status epilepticus: benzodiazepines
    • -Hypertensive emergency: anti-hypertensives
    • -Hyperthermia: cooling measures
  4. Delirium
    impact
    • Affects 15-50% of hospitalized patients
    • 37% of postoperative patients
    • Unrecognized in 70% of patients
    • Increased length-of-stay (5-8 extra days/pt)
    • loss of independence
  5. Delirium
    clinical features
    • Disturbances of consciousness, arousal, awareness
    • Attention disturbances
    • Disorientation
    • Cognitive disturbances
    • Perceptual disturbances
    • Disorganized thinking 
    • Delusions
    • Psychomotor disturbances
    • Sleep-wake cycle disturbances
    • Acute onset, fluctuating course
  6. Risk factors for delirium
    • Patient:
    • -Age > 65
    • -Dementia
    • -Functional dependence or immobility
    • -Multiple comorbidities
    • -Multiple medications
    • -Chronic renal disease
    • -Visual or hearing impairment

    • Situation:
    • -infection at hospital admission
    • -Electrolyte abnormalities
    • -Hypoxia, hypoglycemia
    • -Medications
    • -Neurologic disorder
    • -Untreated pain
    • -Dehydration

    • Environment:
    • -Excessive noise
    • -Interrupted sleep
    • -Unnecessary stimuli
    • -Urinary catheter
    • -Physical restraints
  7. Assessing risk
    • Risks:
    • -Cognitive impairment
    • -Severe illness
    • -High BUN/creatinine
    • -Visual impairment

    • Probable outcomes:
    • -0 points: low risk 10%
    • -1-2 points: moderate risk 25%
    • -3-4 points: high risk 80%
  8. Delirium vs depression
    • Hypoactive delirium:
    • -Hypoaroused, drowsy
    • -Abrupt onset

    • Depression:
    • -Normal level of arousal
    • -Gradual onset
  9. Confusion assessment method (CAM)
    • I. Acute change and fluctuation in mental status from patient's baseline
    • II. Inattention: dificulty focusing attention
    • III. Disorganized thinking
    • IV. Altered level of consciousness (hyperalert, lethargic, stupor, etc.)

    • (+) CAM - presence of delirium;
    • I, II, AND either III or IV
  10. HELP intervention
    • Delirium can be prevented (...)
    • 10% incidence in intervention group
    • 15% incidence in control group
  11. Nonpharmacologic interventions
    • Minimize catheters, IV lines, restraints
    • Mobilize patient
    • Monitor nutrition
    • Hearing & visual aids
    • Pain control
    • Correct dehydration
    • Address bowel & bladder issues
    • Sleep-wake cycle
    • Reorient patient
    • Rule out infection
  12. Pharmacologic intervention/prevention
    • Haloperidol
    • Little evidence for antipsychotics for patients with mild, non-agitated delirium
    • Avoid 'unopposed' benzodiazepines

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