Altered Mental Status- Delirium and Dementia

Definition/Etiology:

Altered mental status is a change in mental function. It stems from certain illnesses, disorders and injuries affecting your brain. The change is often temporary, but can quickly become life-threatening.

• Delirium
  • Acute brain dysfunction starts suddenly (over a period of one to two days) and symptoms often also vary a lot over
    the day.
  • Cause
    • Drug toxicity/ETOH withdrawal
    • Infection (UTI, Sepsis)
    • Electrolyte Imbalance (NA+)
    • Liver Failure
    • Recent CVA
• Dementia
  • Deterioration symptoms of a large group of illnesses that cause a progressive decline in functioning.
  • Cause
    • Age – chronic vascular changes
    • Brain Tumors
    • Alzheimer’s

Pathophysiology:

• Pathophysiology is dependent on etiology.
• Cognitive Decline
• Deterioration
  • Emotional control
  • Social behavior
  • Memory
  • Orientation
  • Judgment

Noticing: Assessment & Recognizing Cues:

• Delirium
  • Fluctuating LOC
  • Vital signs altered
  • Attention difficulty
  • Slurred speech
  • Agitated
  • Hallucinations
• Dementia
  • Normal LOC
  • Vital signs stable
  • Remembering difficulty
  • Forget words
  • Apathetic
• Shared Cues
  • Disorganized sleep

Interpreting: Analyzing & Planning:

• Diagnostics are much more helpful in Delirium r/t finding underlying cause
• Labs
  • Urine drug screen
  • Blood Alcohol level
  • Cultures – Infection
  • CMP – Electrolytes
  • Ammonia Level – Liver
• Diagnostics
  • Imaging
    • For underlying causes
    • Example MRI
      • Stroke = Delirium
      • Chronic vascular changes = Dementia

Responding: Patient Interventions & Taking Action:

• Common interventions
  • Pain/Agitation
  • Support Sleep Cycle
    • Cluster activities, alarms/noise, keep voice down at night
  • Support Safety
  • Avoid Restraints
  • Glasses/Hearing aids
• Delirium
  • Notify Pharmacy – med review
  • Confusion Assessment Method (CAM)-ICU
    • tool is validated for the identification of delirium in the ICU among older patients
• Decrease Agitation
  • Antipsychotics (Hadol)
    • Used less but still tested
    • Control dopamine receptors
  • ETOH = Benzodiazepines okay
  • Overdose = Antidotes
• Dementia
  • Slow Progression with Medications
    • Cholinesterase inhibitors (Aricept)
      • Supports neuron communicating
    • N-methyl-D-aspartate blockers (Namenda)
      • regulates glutamate (learning and memory)

Reflecting: Evaluating Patient Outcomes:

• Delirium
  • Patient is oriented to person, time, and place
  • Patient does not demonstrate signs or symptoms of anxiety, fear, and confusion
  • Patient responds to simple, concrete questions
• Dementia
  • Patient’s safety was considered
  • Encouraging mobility = better function outcomes
  • Feel safe and unthreatened

Linchpins (Key Points):

• Notice – Onset
  • Onset fast or slow will point to either delirium or dementia
• Interpret Labs & Imaging
  • Labs – Delirium based
  • Imaging – helps with underlying cause
• Respond
  • Etiology
    • Delirium -treat underlying cause
    • Dementia – slow down progression
• Reflect
  • Patient Stable & Safe