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RTC--Altered Mental Status16 July 2010
Sources: Stern: Massachusetts General Hospital Comprehensive Clinical Psychiatry, 1st edition
© 2008 Mosby
http://www.merck.com/mkgr/mmg/sec5/ch40/ch40a.jsp
JJ Smith
Dementia• Dementia is characterized by cognitive decline
and a normal sensorium (e.g., delirium is absent)
• Leading cause of institutionalization among the elderly
• Can be progressive and usually impairs function
• Most common causes:• Alzheimer’s
• Vascular dementia
http://www.merck.com/mkgr/mmg/sec5/ch40/ch40a. jsp
Categories of DementiaMild
• short-term memory impaired as well as word finding
• apathy and reduced executive functions
Moderate
• Ability to perform daily activities is impaired
• Cannot learn new information and psychosis occurs in ~25%
Severe
• cannot perform basic functions (eat/toilet) and dependent
• usually these people are institutionalized unless there is significant family availability
http://www.merck.com/mkgr/mmg/sec5/ch40/ch40a. jsp
Delirium• Impaired attention
• Impaired concentration
• Impaired memory
• Fluctuation of consciousness
• Disorientation
• Hallucinations
• Incoherent speech
• Agitation
The Washington Manual of Medical Therapeutics, 29th edition
Delirium• If a patient is overly distractible or otherwise
unable to maintain attention, the diagnosis is likely to be delirium
• Abrupt onset, physical symptoms or signs suggesting an acute disorder, moment-to- moment variability, psychomotor changes
http://www.merck.com/mkgr/mmg/sec5/ch40/ch40a. jsp
The Mental Status Exam• General appearance and behavior: grooming, posture, movements,
mannerisms, and eye contact
• Speech: rate, flow, latency, coherence, logic, and prosody
• Affect: range, intensity, lability
• Mood: euthymic, elevated, depressed, irritable, anxious
• Perception: illusions and hallucinations
• Thought (coherence and lucidity): form and content (illusions, hallucinations, and delusions)
• Safety: suicidal, homicidal, self-injurious ideas, impulses, and plans
Stern: Massachusetts General Hospital Comprehensive Clinical Psychiatry, 1st edition© 2008 Mosby
The Mental Status Exam (cont’d)Cognition• Level of consciousness
• Orientation
• Attention and concentration
• Memory (registration, recent and remote)
• Calculation
• Abstraction
• Judgment
• InsightStern: Massachusetts General Hospital Comprehensive Clinical Psychiatry, 1st edition
© 2008 Mosby
Conditions Frequently Associated with Delirium
I WATCH DEATH
• Infectious or Iatrogenica imperfecta
• Withdrawal
• Trauma
• CNS pathology
• Hypoxia
• Deficiencies
• Endocrinopathies
• Acute vascular
• Toxins or drugs
• Heavy metals
Stern: Massachusetts General Hospital Comprehensive Clinical Psychiatry, 1st edition© 2008 Mosby
20916. . . . . . . .!@#$*&$!
• “Dr. McMasters, Mrs. M is saying that she is seeing green cats and dogs. I think she may be altered. . . . . . . ”
Lesson #1• Know the past medical history on all
your patients like the back of your hand
• You must clarify medication dosage and past psychiatric history
• Everything that is essential move to IV equivalent or if able to take liquids see if it can be crushed or mixed into a slurry
Potential Treatment Options
• Haldol (with caveats)
• Olanzapine
• Benzodiazepines (with caveats)
Rapid response. . . . . .really??
• “Dr. Kensinger, Mrs. H is non- responsive to verbal stimuli and curled up in bed. . . .and her gaze is fixed. . . . plus she is kind of sweaty. . . . . . .”
Lesson #2• Have a quick differential going in your
head as you move to the bedside
• Pay attention to your check-out
• ‘Preventive’ rounds—walk around and see the patients yourself--“keep ‘em alive ‘til 0705”—Riordan, Earl, Rauth, Borkon et al.
Quick review: Life threatening causes of
delirium
• SAH / SDH
• PE (hypoxia)
• CVA
• Withdrawal