Altered Mental Status: Connecting the Dots of Delirium, Dementia and Psychosis – Joyce Campbell

• Diagnostic challenges: Potential for involvement of one or more body systems
• Take away life-saving interventions to prevent or treat delirium
• Head to toe and diagnostic workup to identify cause
• Find out the latest EBP for treating dementia
• Be alert for common diseases and drugs causing AMS
• What about the mentally ill patient with delirium?

Attention Health Care Professionals!! You play a vital role in identifying and assisting with resolution of problems affecting patients with altered mental status. The patient that you treat for altered mental status may be the life you save.

Delirium… Dementia… Psychosis

When facing a patient with altered mental status, no doubt you have caught yourself saying, “What is going on?” It is time to STOP, LISTEN, LOOK and ACT. This seminar dissects altered mental status (AMS), to identify the problem and lead the way to problem resolution. The study of AMS is like taking a combination med-surg and neuropsychiatric course, as one must look at all body systems when evaluating potential causes of AMS.

Every day, patients present with altered mental status in a variety of settings….ED, ICU, med/surg, geriatric, psych units, rehab, long-term care. The list goes on! Connecting the dots and identifying the problem may be life saving for the patient. You will leave with new assessment tools and strategies to alter the course for your patient experiencing an altered mental status condition.

1. Recognize the “red flags” indicating potentially fatal outcomes.
2. Explain interventions to rapidly reverse the causes of AMS.
3. Differentiate between delirium, dementia and psychosis.
4. Identify the underlying causes of AMS.
5. Select between new tools for assessment and evaluation.
6. List the best diagnostic options to differentiate among possible causes.
7. Develop a treatment plan for the most common causes of AMS.
8. Analyze practice guidelines for prevention and management of pain, agitation and delirium.

Life-Threatening Causes of AMS: Prepare to Intervene

• Airway problems leading to hypoxia and CNS symptoms
• Gross assessment of disability: GCS or AVPU
• Rapid head to toe assessment
• Look for rapidly fixable causes
• History and physical… Asking the right questions
• Diagnostic work-up
• Coma and altered level of consciousness: Brain stem and cerebral hemispheres
• Predictive model for the risk of delirium in hospitalized older patients
• Intensive care delirium scanning checklist
• Confusion Assessment Method
• AACN Practice Alert
• Break down: Delirium, dementia and psychosis

Common Conditions Causing Delirium

• Medications – Adverse effects and interactions
  • Central acting agents
  • Sedative hypnotics
  • Anticonvulsants
  • Analgesics
  • GI agents
  • Antinauseants
  • Antibiotics
  • Psychotropic meds
  • Cardiac meds
  • OTC meds
  • Steroids

• Medications – withdrawal syndromes
• UTI
• Pneumonia
• Electrolyte disorders
• Endocrine crisis: Hyper/hypothyroid, adrenal, diabetic, Wilson’s disease
• Korsakoff syndrome
• Transient global amnesia
• Pain agitation

10 Life-Threatening Conditions Causing Delirium

• Hypoxia
• Hypoglycemia
• Encephalopathy: Hypertensive and Werniche’s
• Drug overdose
• Acute neuro: Meningitis, SAH and seizures
• CNS trauma
• Sepsis

Delirium: Don’t Forget These Possibilities:

• The patient with delirium related to structural changes
• Subdural hematoma
• Brain tumor
• Normal pressure hydrocephalus
• Stroke
• Infectious disease and SEPSIS: The ticking time bomb
• Not to be missed: Meningitis, encephalitis

Psychosis: Into Madness

• Major depressive disorder
• PHQ-9 screening instrument
• Post-partum depression
• Bipolar
• Schizophrenia
• Schizoaffective
• Delusions, illusions, hallucinations
• Positive and negative clinical manifestations
• Pharmacology and other treatments
• Personality Disorders
• Schizotypal Disorder
• A case of global amnesia

Dementia: The Work-Up

• History
• Mini mental
• Sweet 16 Cognitive assessment tool
• Radiological diagnostic work-up
• Delirium plus dementia
• Alzheimer work-up
• Lewy body
• Chronic traumatic encephalopathy

Interventions for the Common Problems

• Memory loss and confusion
• Reduced concentration
• Hallucinations
• Agitation
• Sleep disturbance
• Inability to carry out ADLs

Expanding the Window of Care: Current Research