Here, we have altered mental status and coma.
There are so many different times through a
pathology that you’ve heard the term altered mental
status. What the heck does that mean?
Well, before we get into any of that, these are
some of the important questions that you want to
ask your patient, or ask yourself when you’re going
through level of consciousness versus cognition.
So, please pay attention. What do you need to be
“awake”? Bilateral cortices. The brainstem,
specifically, the reticular activating system, the
RAS. What do you need for intact cognition?
You need to be awake and functional networks.
The first question with awake would then determine
your level of consciousness. You need your cortices
and you need your brainstem. If it’s cognition,
you need functioning. These are two important questions
you ask yourself to see whether or not you’re
on the side of consciousness or cognition. Now, we
will look at a particular scale known as the
Glasgow coma scale. This scale is divided in three
categories. Eye opening response, verbal response
and motor response. If you add the points of each
category, you get a score. The maximum score is 15
and the minimum is 3. Let' look at the three different
categories in more detail. If the patient is
opening their eyes spontaneously,they get 4 points.
If they open the eyes to speech, 3 points.
If they open the eyes only after you apply a painful
stimulus, 2 points. And if they don't open the eyes, 1 point.
When you evaluate the verbal response, now the
maximum score is 5 when the patient is oriented to
time, place and person. If the patient is confused,
they get 4 points. If they use inappropriate words,
3 points. If they make incomprehensible sounds,
2 points. And if there is no response, 1 point.
In the evaluation of motor response, the maximum
score is 6 when the patient obeys commands.
When they move to localized pain, they get 5 points.
When they exhibit flexion withdrawal from pain,
4 points. For abnormal flexion, 3 points. For
abnormal extension, 2 points. And for no response, 1 point.
So, as you can understand, if the patient has no
eye opening, no verbal or motor response, the score is 3.
It can never get below 3. Glasgow coma scale was
developed mainly for trauma issues. But it can be used
as a tool to evaluate consciousness in other
circumstances as well. The score above or below
8 has profound predictive value in multiple situations.
Delirium, encephalopathy, altered mental status.
The key features of delirium are the following.
Acute onset, fluctuating course, disorganized
thinking, altered level of consciousness.
Here, we have inattention or easily being distractible,
and we have underlying medical cause, usually, when
we think about a delirium. The key features.
The prevalence, 10% to 15% of older, what’s
known as medical patients at admission.
An addition of 5% to 30% develop delirium in the
hospital. And we have up to two-thirds of cases
are unrecognized, or perhaps even,
misdiagnosed with delirium.
Metabolic. Electrolyte abnormalities, your sodium,
potassium, magnesium, especially what we talked about.
Glucose derangement, metabolically. Hypo or
hyperglycemia. Hepatic failure. You have that
ammonia which may then be shunted into the head
resulting in what’s known as your hepatic encephalopathy.
Uremia. Uremia, often times associated with
what’s known as your altered mental status.
Thyroid dysfunction, hypothyroidism or thyrotoxicosis,
or adrenal insufficiency such as Addison’s disease.
Metabolic causes of delirium/altered mental status.
Diffuse causes of delirium/altered mental status
include drugs such as alcohol, narcotics,
or even from withdrawal or environmental neurotoxins,
including carbon monoxide and organophosphate.
Think of pesticides and such, please.
Remember this is diffuse, so therefore, hypoxia.
So, if there is a diminished oxygen delivery via
pulmonary or cardiovascular system, then diffusely,
we have a problem and may result
in altered mental status.
Other cause of diffuse. We’ll talk about meningitis,
infectious, encephalitis. Systemic type of infections
such as, for example, sepsis taking place secondary
to urinary tract infection. Nutritional deficiency
such as B12. If your patient is an alcoholic, there
is every possibility of Wernicke-Korsakoff,
thiamine deficiency. Other causes, subarachnoid
hemorrhage. We talked about carcinomatous meningitis,
usually subacute though, and something called
non-convulsive status epilepticus or post-ictal state.
All causes of diffuse delirium or altered mental
status. Long list of differentials, a lot of these
we’ve talked about prior. It’s a nice little
place to kind of like summarize those issues.
Focal/structural causes of delirium. So not so much
diffuse, focal. Large lesion causing edema and
mass effect. For example, stroke, ischemic or
hemorrhagic. Remember with stroke, we have
approximately 85% of your stroke, which is
then being caused by ischemic events.
Tumors and abscesses may result in focal destruction.
Smaller focal lesions in certain areas may
initially present as delirium. For example, we have
aphasic syndromes, occipital lesions or pontine lesions.
So, what’s the clinical approach that you want to
take with altered mental status? Always review
the history. Review meds, lab screen, imaging, EEG,
treatment targeted to a specific etiology,
and supportive environmental changes are extremely
important. For example, if your patient was in a
state of carbon monoxide environment, or let’s
say there was increased alcohol consumption,
so on and so forth.