AMS

Delirium & Altered Mental Status (AMS)

Background

  • Why delirium matters:
    • Increased morbidity
    • Hospital complications, falls, infection, prolonged mechanical ventilation
    • ADL dependence and long-term functional impairment
    • Long-term cognitive impairment
    • Psychiatric (depression 4x more common than PTSD) and impaired Quality of Life
  • Departure from pt’s baseline cognition: hypoactive (lethargic) or hyperactive (agitated)
  • Risk factors:
    • Functional impairment
    • Age > 75
    • Dementia
    • Depression
    • ETOH use disorder
    • Sensory impairment
    • Surgery (repair of aortic aneurysm, trauma, NSGY, thoracic surgery)
  • Consider MOVE STUPID mnemonic:
    • Metabolic (Hypo/hypernatremia, Hypercalcemia)
    • Oxygen (Hypoxia)
    • Vascular (CVA, Bleed, MI, CHF)
    • Endocrine (Hypoglycemia, Thyroid)
    • Seizure (postictal state)
    • Trauma (concussion)
    • Uremia
    • Psychogenic
    • Infection
    • Drugs - intoxication or withdrawal

 

Evaluation

  • Screening Tools:
    • Wards: bCAM: Brief-Confusion Assessment Method
    • ICU: CAM-ICU: Confusion Assessment Method for ICU
  • Broad toxic/metabolic/infectious workup
    • TSH, Vitamin B12, CMP, UA, chest X-ray, seasonal infection testing
  • Review of medications-> sedatives, anticholinergics, central alpha agonists/antagonists, benzos/EtOH toxicity or withdrawal (check home med list to ensure something like chronic benzos weren’t held on admission) 
  • Head imaging in the setting of focal neurologic findings
    • CT helps to identify hemorrhage and large structural lesions; strokes take up to 24 hours to show up on CT
      • Some strokes can cause AMS without other obvious focal signs
    • MRI: stroke, inflammatory changes or infectious changes more clearly w/ contrast
  • LP should be performed if there is any concern for meningitis
    • For meningitis, empirically treat with acyclovir/vanc/CTX at minimum, + ampicillin if old or young for Listeria coverage
  • EEG is reasonable with fluctuating mental status or seizure-like activity
  • Catatonia (Bush-Francis scale is a 24-point scale that covers features of catatonia)

 

 

Management

  • First line, Nonpharmacologic interventions: HOMMEEESS
    • Hydration/nutrition:
      • Ensure patient fed, hold diuretics if poor PO intake, rule out constipation and urinary retention
    • Orientation
    • Mobilize out of bed 3x/daily as able, PT/OT
    • Manage pain
    • Eliminate unnecessary devices (restraints, catheters, tele, lines) and meds
    • Environmental modification
      • Minimize devices, lights on/windows open during day
    • Engage family
    • Sensory restoration: use eyeglasses and hearing aids and reorient
    • Sleep protocol
      • Minimize nighttime vitals, earplugs, sleep mask and no TV at nigh
  • ​​​​​​​​​​​​​​Second line, Pharmacologic approaches, see "Management of Agitation"