metabolic encephalopathy diagnosis and management

Robert Robinson, MD, FACP

No Disclosures

OBJECTIVES

Definition

Risk Factors

Treatment

Prognosis

Clinical

Cases

77 YEAR OLD LOST IN PARKING LOT

• Wandering

• Does not know how he got there

• Cannot find car

• Oriented to person

• Knows address

• Brought to ED by EMS for evaluation


Diagnosis

History

Exam

Tests

DEFINITION- DSM-V

Metabolic Encephalopathy

Acute Onset

Attention

Awareness

Cognition

Not neurocognitive

disorder

Evidence of a medical cause


Diagnosis

History

Exam

Tests


• CT Head

• CBC

• BMP

• UA

• Urine toxicology

• Blood alcohol level

• Chest X-ray

• EKG

• Cardiac enzymes


• CT Head

• CBC

• BMP

• UA

• Urine toxicology

• Blood alcohol level

• Chest X-ray

• EKG

• Cardiac enzymes

• Discuss patient with primary care provider

DEFINITION- DSM-V


Acute Onset

Attention

Awareness

Cognition

Not neurocognitive

disorder



• Not metabolic encephalopathy

• Progression of dementia

62 YEAR OLD 2 DAYS POSTOP

• Confused

• Tolerated pain meds on POD #1

• No significant PMHx

• SHx – Family denies alcohol/drugs

• Exam

• Confused, inattentive

• Febrile

• Tachycardia

• Hypertensive

• Tremor

• Diaphoretic

PREVALENCE IN HOSPITALS


30%

J Am Geriatr Soc. 1992;40(8):829. , J Gen Intern Med. 1998;13(4):234.

CAM (CONFUSION ASSESSMENT METHOD)

Features

Acute onset and fluctuating course

Inattention

Disorganized Thinking

OR

Altered level of consciousness

• Most common assessment tool

• Superior to MMSE

• Sensitivity 94-100%

• Specificity 90-95%

J Am Geriatr Soc. 2008;56(5):823.

RISK FACTORS

Dementia

Stroke

Parkinson’s Disease

Sensory impairment

Critical illness

Sleep deprivation

PRECIPITATING FACTORS

Metabolic

EncephalopathyDrugs

Infection

MetabolicCNS

Disorder

Organ Failure

Physical Disorder

COLLISION OF FACTORS

Chronic Conditions Acute Illness

Environment Medications



• Confused

• Tolerated pain meds on POD #1

• No significant PMHx

• SHx – History of alcohol abuse

• Exam

• Confused, inattentive

• Febrile

• Tachycardia

• Hypertensive

• Tremor

• Diaphoretic

Differential Diagnosis?

MEDICATIONS AS A CAUSE

Medications30%

CNS Drugs. 1996; 5:103.

Drugs

PrescriptionOver the counter

Recreational

PRESCRIPTION DRUGS

• Take a thorough drug history• Call pharmacies

• Review medication administration record (MAR)

• Pay close attention to drug changes

• Consider drug withdrawal

COMMON PRECIPITATING DRUGS

• Narcotics

• Benzodiazepines

• Muscle relaxers

• Antipsychotics

• Antidepressants

• Antibiotics

CONSIDER CHECKING LEVELS

• Anti-seizure medications

• Digoxin

• Theophylline

• Lithium

Drugs


Recreational

OVER THE COUNTER DRUGS

• Take a thorough drug history• Antihistamines (including H2 blockers)

• Alternative medicines

• Analgesics

• Sleep aids

Drugs


Recreational

RECREATIONAL DRUGS

• Take a thorough drug history• Alcohol (consider withdrawal...)

• Stimulants

• Sedatives

• Narcotics

• “Designer drugs” - MDMA, MDPV

MDMA – ECSTASY, MOLLY

• Delirium, agitation

• Hyponatremia

• Hyperthermia

• Liver injury

• Rhabdomyolysis

• Serotonin syndrome (with SSRI, MAOI)

3,4-methylenedioxymethamphetamine

MDPV – BATH SALTS

• Delirium, agitation

• Hypertension

• Tachycardia

• Seizures

• Psychosis

Methylenedioxypyrovalerone

SYNTHETIC CANNABIS – SPICE, K2

• Delirium

• Psychosis

• Hypertension

• Myocardial infarction

• Stroke

• Seizures


• Metabolic Encephalopathy

• Drug history• Narcotics for pain control (New)

• Possible chronic alcohol use

LABORATORY EVALUATION

• For most patients• CBC

• BMP

• TSH

• UA + Culture

• Consider• ABG

• Toxicology screening

• Drug levels

• CMP

• B12

• Folate

• RPR

IMAGING STUDIES

• Tailor studies based on history/exam• Chest x-ray

• CT of brain

• MRI of brain

CT WITHOUT NEUROLOGICAL FINDINGS

Posive CT Findings

4%96%

Acta Neurol Scand. 2008;118(4):245.

OTHER STUDIES

• Tailor studies based on history/exam• Lumbar puncture

• EEG

NON-CONVULSIVE STATUS EPILEPTICUS

0%

10%

20%

30%

40%

Privitera 1994 Claassen 2004

Epilepsy Res. 1994;18(2):155., Neurology. 2004;62(10):1743.


• Metabolic Encephalopathy

• Drug history• Narcotics for pain control (New)

• Possible chronic alcohol use

• Labs unremarkable

67 YEAR OLD IN ICU

• Admitted for septic shock and UTI

• On vent

• Reducing sedation• Agitated

• Combative

DEFINITION- DSM-V


Acute Onset

Attention

Awareness

Cognition

Not neurocognitive

disorder


How to assess ICU patients

CAM-ICU

Features

Acute onset and fluctuating course

Inattention

Disorganized Thinking

OR

Altered level of consciousness

CAM-ICU – ONSET AND COURSE

Is there evidence of an acute change in mental status from the patient’s baseline?

OR

Has the patient had any fluctuation in mental status in the past 24 hours as evidenced by fluctuation on a sedation/level of consciousness scale (i.e., RASS/SAS), GCS, or previous delirium assessment?

CAM-ICU – INATTENTION

Say to the patient, “I am going to read you a series of 10 letters. Whenever you hear the letter ‘A,’ indicate by squeezing my hand.”

Read letters from the following letter list in a normal tone 3 seconds apart.

S A V E A H A A R T or C A S A B L A N C A or A B A D B A D A A Y

Errors are counted when patient fails to squeeze on the letter “A” and when the patient squeezes on any letter other than “A.”

Two or more errors qualifies for inattention.

CAM-ICU – DISORGANIZED THINKING

Ask the following Yes/No questionsWill a stone float on water?

Are there fish in the sea?

Does one pound weigh more than two pounds?

Can you use a hammer to pound a nail?

Say to patient: “Hold up this many fingers” (Hold 2 fingers in front of patient) “Now do the same thing with the other hand”

More than one error qualifies for disorganized thinking

CAM – ALTERED LEVEL OF CONSCIOUSNESS

Present if the RASS score is anything other than alert and calm (zero)

67 YEAR OLD IN ICU

• Admitted for septic shock and UTI

• On vent

• Reducing sedation• Agitated

• Combative

Treatment

TREATMENT & PREVENTION

Behavior Management

Precipitating Factors

Risk Factors

PHYSICAL RESTRAINTS

• 3x more likely to have persistent delirium

• Increased risk for• Falls

• Pressure ulcers

• Increased agitation

Arch Intern Med. 2007;167(13):1406.

BENZODIAZEPINES

• Commonly used in treatment of delirium

• No clear evidence of benefit

Cochrane Database Syst Rev. 2009;

Neuroleptic Medications

NEUROLEPTIC MEDICATIONS

• Haloperidol

• Haloperidol + Quetiapine

• Risperidone

• Olanzapine

• Quetiapine

Cochrane Database Syst Rev. 2007

Crit Care Med. 2010;38(2):419

J Hosp Med. 2013 Apr;8(4):215-20

HALOPERIDOL + QUETIAPINE

Efficacy and safety of quetiapine in critically ill patients with delirium: A prospective, multicenter, randomized, double-blind, placebo-controlled pilot study *.Devlin, John; Roberts, Russel; Fong, Jeffrey; Skrobik, Yoanna; Riker, Richard; Hill, Nicholas; Robbins, Tracey; Garpestad, Erik

Critical Care Medicine. 38(2):419-427, February 2010.DOI: 10.1097/CCM.0b013e3181b9e302

HALOPERIDOL VS. QUETIAPINE

Maneeton B, Maneeton N, Srisurapanont M, Chittawatanarat K.

Quetiapine versus haloperidol in the treatment of delirium: a double-blind, randomized, controlled trial.

Drug Des Devel Ther. 2013 Jul 24;7:657-67.

HALOPERIDOL VS. NEWER NEUROLEPTICS

Hyung-Jun Yoon, Kyoung-Min Park, Won-Jung Choi, Soo-Hee Choi, Jin-Young Park, Jae-Jin Kim and

Jeong-Ho Seok

Efficacy and safety of haloperidol versus atypical antipsychotic medications in the treatment of

delirium

BMC Psychiatry 2013, 13:240

FREQUENCY OF ADES

80%

Adverse Drug Event20%

BMC Psychiatry 2013, 13:240

Prevention

TREATMENT & PREVENTION

Behavior Management

Precipitating Factors

Risk Factors

RISK FACTORS FOR DELIRIUM

• Dementia

• Stroke

• Parkinson’s Disease

• Sensory impairment

• Critical illness

• Sleep deprivation

MODIFYING RISK FACTORS

• Orientation

• Sleep

• Mobilization

• Glasses

• Hearing aids

Cochrane Database Syst Rev. 2014;1:CD009537

Promising data from small studies

AVOIDING PRECIPITATING FACTORS

• High risk drugs

• Withdrawal syndromes

• Metabolic disturbances

• Manage Pain

Prophylaxis

RISPERIDONE

0%

10%

20%

30%

40%

Hakim 2012 Prakanrattana 2007

Risperidone

Placebo

Anaesth Intensive Care. 2007 Oct;35(5):714-9., Anesthesiology. 2012 May;116(5):987-97.

OLANZAPINE

0%

10%

20%

30%

40%

50%

Larsen 2010

Olanzapine

Placebo

Psychosomatics. 2010 Sep-Oct;51(5):409-18.

MELATONIN

0%

10%

20%

30%

40%

Sultan 2010 Al-Aama 2011

Melatonin

Placebo

Saudi J Anaesth. 2010 Sep;4(3):169-73., Int J Geriatr Psychiatry. 2011 Jul;26(7):687-94

RAMELTEON

0%

10%

20%

30%

40%

Hatta 2014

Ramelteon

Placebo

JAMA Psychiatry. 2014 Apr;71(4):397-403.

MALE FOUND UNRESPONSIVE

• Brought to ED by police• Unknown identity

• No history

• Disheveled

• Smells strongly of alcohol

• Snoring

• No signs of trauma

• Vitals stable


Metabolic

EncephalopathyDrugs

Infection

MetabolicCNS

Disorder

Organ Failure

Physical Disorder

COLLISION OF FACTORS

Chronic Conditions Acute Illness

Environment Medications




• No history

• Disheveled


• Snoring


• Vitals stable

• Alcohol Intoxication



• No history

• Disheveled


• Snoring


• Vitals stable


• Thiamine deficiency



• No history

• Disheveled


• Snoring


• Vitals stable



• Aspiration pneumonia



• No history

• Disheveled


• Snoring


• Vitals stable



• Aspiration pneumonia

• Subdural hematoma


Metabolic

EncephalopathyDrugs

Infection

MetabolicCNS

Disorder

Organ Failure

Physical Disorder

metabolic encephalopathy diagnosis and management

Healthcare