Case 12: Tammy Polk

Consciousness: Dimensions

Arousal: Wakefulness

Awareness: Understanding of experience

Altered Mental Status (AMS) Classifications

Coma: No arousal + awareness

Unresponsive (Vegetative State): Arousal + no awareness

Minimally Conscious State: Arousal + minimal awareness

Delirium: Abnormal arousal + awareness

Consciousness: Attention

Requires sufficient arousal → Conscious processing

Consciousness: Concentration

Requires sufficient arousal → Conscious processing

Consciousness: Memory

Attention + concentration → Memory encoding + retrieval

Altered State of Consciousness: Etiology

Acute: Seconds to days → Delirium

Chronic: Month to years → Dementia

Altered State of Consciousness: Acute + Reversible

Vascular: Hypoxia

• Ischemic stroke

• Hemorrhage

Infectious:

• Meningoencephalitis

• Sepsis

Toxic + Metabolic:

• Drug intoxication + withdrawal

• Electrolyte + glucose imbalance

• Nutritional deficiency

Injury:

• TBI

• Edema

Psychiatric

Autoimmune conditions

Seizures

Altered State of Consciousness: Acute + Irreversible

Infectious:

• Prion diseases

Cumulative ischemic injury (vascular)

Altered State of Consciousness: Chronic + Reversible

Infectious:

• HIV

• Syphilis

Toxic:

• Alcohol-related

• Heavy metal exposure

Structural:

• Hydrocephalus

• Hematomas

Altered State of Consciousness: Chronic + Irreversible

Neurodegenerative + autoimmune conditions

• Alzheimer

• Parkinson + Lewy bodies

• Huntington

• MS

Structural:

• Brain atrophy

• Tumors

Altered State of Consciousness: Clinical Presentation

Confusion

Behaviour changes

Alertness changes

• Hyperalertness

• Somnolence: Drowsy + respond to mild stimuli

• Lethargy: Drowsy + respond to moderate stimuli

• Obtundation: Drowsy + respond to strong stimuli

• Stupor: Drowsy + respond to painful stimuli

Coma

Symptoms of Underlying Cause:

• Seizures

• Focal neurological deficits

• Toxidromes (toxicity)

• Tachypnea

• Resp depression

• Jaundice

• Pruritus

• Hypothyroidism + thyrotoxicity

Geriatric Presentation

Symptom constellation (nonspecific overlapping symptoms) with multiple causes

• Delirium

• Falls

• Urinary incontinence

• Functional decline

• Frailty

• Pressure ulcers

• Malnutrition

Geriatric Presentation: Risk Factors

Older age

Baseline cognitive impairment

Baseline functional impairment

Impaired mobility

Delirium: Description

Acute disturbance of mental state (attention + awareness impairments)

Delirium: Epidemiology

Risk factors…

• Older age (≥ 65 years) → Most common

• Preexisting cognitive impairment or dementia

• Chronic polypharmacy

• Substance use

Delirium: Etiology

DIMES

D: Drugs + Toxins → Polypharmacy

• Prescription

  • Anticholinergics

  • Benzos

  • Sedatives

  • Opioids

• Recreational drugs

  • Alcohol + withdrawal

I: Infectious

• UTIs: Most common in older adults

• Pneumonia

• Meningitis

• Skin

M: Metabolic → Most common

• DM → Diabetic ketoacidosis

• Hyper/hypothyroidism

• Organ (liver, kidney) failure

• Vit deficiencies

• Electrolyte abnormalities

E: Environmental

• Hypo/hyperthermia

• Hypoxia

S: Structural

• Hemorrhage

• Tumors

• TBI

• Urine retention + fecal loading

Delirium: Pathophysiology

Older age…

• Drugs, Toxins, Infection: Weak + leaky BBB = Increase toxin entry + injury

• Metabolic, Structural: Increased cumulative neuronal damage/death = Cognitive impairment + decline

• Infection: Cerebral inflammation = Cognition impairment

Delirium: Clinical Presentation

Altered level of awareness + attention

• Fluctuate throughout day

  • Sundowning: Worse in evening

• Reversible

Disorganized thinking

Hallucinations

Cognitive deficits

Agitation

Psychomotor activity alterations

Delirium: Investigations

Clinical diagnosis

• Criteria: DSM-5

1. Attention changes (inattention) + decreased awareness

2. Acute onset

3. Other cognitive disturbances (memory, orientation, language)

4. No other diagnoses possible

5. Underlying cause

Tools

Lab tests

Culture

Imaging

Toxicology study

Delirium Investigations: Tools

Mini-mental state exam

MOCHA

Delirium Investigations: Lab Tests

Glucose

Electrolytes

Urinalysis

• UTI

• Renal failure

TFTs

Delirium Investigations: Culture

Urine

Blood

Delirium Investigations: Imaging

CT/MRI

Delirium Investigations: Toxicology Study

Urine

Serum

Delirium: Treatment/Management

Treat underlying cause

Supportive care

Treat agitation/aggression

• Nonpharmacological

• Pharmacological

Delirium Management: Supportive Care

Fever control

Pain management (nonopioid)

IV fluids

Mobilization

Reorient pt (time, place, person)

Cognitive stimulation therapy

Delirium Management: Nonpharmacological Agitation Treatment

Support person with pt

Reverse agitation causes

• Dehydration

• Hunger

• Pain

De-escalate

Delirium Management: Pharmacological Agitation Treatment

For refractory

Antipsychotics

• Typical: Haloperidol

• Atypical: Risperidone, olanzapine

Sedation: Risk to self or others

Delirium: Prognosis

Recover in hours to days

Delirium: Complications

Prolonged cognitive impairment + functional decline

Increase morbidity + mortality

Forms: 1 + 2

Form 1: Physician completes for involuntary hold of pt in psychiatric facility for 72h

• Mental disorder/disorientation

• Threat to self or others

• No capacity

Form 2: Any person completes for involuntary assessment of pt by physician

Depression vs Major Neurocognitive Disorder (Dementia): Onset

Depression: Acute

Dementia: Gradual

Depression vs Dementia: Functional Impairment

Depression: Disproportionate to cognitive deficit

Dementia: Proportional to cognitive deficits

Depression vs Dementia: Pattern of Presentation

Depression: Emphasize difficulties/deficits

Dementia: Unaware of deficits