Acute Mental Status Changes in the Intensive Care Unit

Posted by e-Medical PPT Monday, July 4, 2011
Abnormalities of mental function
Conciousness:
Arousal (awake?)
Awareness (responsive?)

Cognition:
Orientation (accurate perception of experiences)
Judgment and Reasoning (ability to process data and generate meaningful information)
Memory (ability to store and retrieve information)

Etiology of depressed level of consciousness
Substrate deficiencies (glucose, thiamine)
Meningoencephalitis or Mental illness (malingering, psychogenic coma)
Alcohol or Accident (CVA)
Seizures
Hyper-capnia, -glycemia, -thyroid, -thermia OR Hypo-xia, -tension, -thyroid, -thermia
Electrolyte abnormalities (hyperNa, hypoNa, hyperCa) and Encephalopathies
Drugs

Septic Encephalopahthy
Can be caused by any infection aside from CNS infections
Early sign of sepsis
Advanced cases progress to multiple abscesses throughout brain matter
Similar biochemical changes to hepatic encephalopathy
Increased aromatic amino acids, decreased branched chain amino acids in plasma

Delirium
Most common mental disorder in the hospitalized geriatric patient
Up to 87% of elderly pts
As many as 75% are not recognized by the physician caring for the patient
Characterized by:  acute mental status change and inattention and disorganized thought or altered level of consciousness -- Hallmark:  acute onset and fluctuating clinical course
Most often drug related (40%) - but all other organic causes must be ruled out

Hypoactive delirium:
Characterized by lethargy rather than agitation
Most common form in the elderly

Dementia and Delerium:
Both have attention deficits and disordered thought
Dementia is not acute and is not fluctuating
75% of delirium in hospital is superimposed on dementia
Hospitalization can cause transient or permanent decompensation in the functioning of a patient with preexisting dementia

Important to differentiate Delirium from DTs
Delirium Tremens

Alcohol withdrawal
Do not use haldol (lowers seizure threshold)
Benzodiazepines are primary treatment
Clonidine (alpha-2-agonist) for associated hypertension (also eases withdrawal centrally) \

Valium:   Onset 1-2 min, lasts as long as 12 hrs (active metabolite)
 10/10/10 (q8 hrs x 3)
Ativan: Slow onset (5-15 min) and longest duration (10-20hrs)
Versed: Fast onset, short acting
Lipid soluble, prolonged sedation if used long term

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