diease

Altered Mental Status


OVERVIEW OF Altered Mental Status :

It is a neurological in which the brain cells become inactive and results in dementia and impaired cognitive functions, loss of memory. It  results in Confusion, lethargy, deliriumdementiaencephalopathy, and organic brain syndrome are all terms that have been used to refer to conditions hallmarked by mental status changes.


EPIDEMIOLOGY :

It accounts for the 60-70 % of the dementia cases and it is uncommon under the age of 45 yrs.


CAUSES :

  • Diseases or conditions in the body that can affect your brain and nervous system:
    • Hypoxia (low oxygen levels)
    • Low or high blood sugar levels, or diabetic ketoacidosis
    • Heart attack
    • Dehydration, low or high blood sodium levels
    • Thyroid or adrenal gland disease
    • Urinary tract infection or renal failure
  • Diseases or conditions within your skull:
    • Seizures
    • Head traumas, concussions
    • Brain tumors or strokes
    • Brain disease, such as encephalopathy
    • High altitude cerebral edema (brain tissue swelling at high altitude)
  • Other factors:
    • Burns
    • Hypothermia (low body temperature), hyperthermia (high body temperature), or heat stroke
    • Toxic plants, such as mushrooms
    • Carbon monoxide
    • Drug or alcohol withdrawal
    • Psychiatric problems

      The following patient are at greater risk:

      Cancer

HIV

Parkinsonism disorder

Dementia

Chronic liver disease

Hypothermia

Pituitary apoplexia

 


PATHOPHYSIOLOGY :

It is caused by the abnormal build up of proteins called prions(misfolded proteins) in the brain and also the conformational change of prions in the brains. The buildup of protein called amyloid protein and tau protein leads to the death of the brain cells. These proteins build up in the surface of the brain forming larger masses of cells called plaques.Twisted protein of another protein which is termed as tau results in tangled structure of protein.These plaque and tangled blocks the synaptic communication between the nerve cells and results is loss of brain function and prevents the brain from carrying out its action.This leads to the programmed cell death in the indivduals with deposition of amyloid fibrils in their brain.The slow and ongoing death of the cells starting in one area of the brain eventually sprading to other areas usually starts in the area which controls the memory and leading to the cause of the altered mental status.


COMMON CLINICAL SIGNS AND SYMPTOMS :

Symptoms:

Inability to recall the past events

Difficulty to recognize the family members

Difficult in finding the words and reading

Spatial or vision issues

Impaired reasoning /judgement skills

Movement difficulties and problems linked to smell perception is also seen in some cases

Involuntary muscle movements which are known as Myoclonus.

Psychosis

Obessessive compulsive disorder

Rambling speech

Cannot be aroused from sleep


DIAGNOSTIC :

It is usually diagnosed with the history of the patient and behavioural changes and impaired cognitive functions.

Complete blood test

Blood urea and creatinine levels should be checked.

Liver test

Partial thromboplastin and Prothrombin time should be checked to rule out the dysfunction of the clotting factors.

Electroencephalogram(EEG): the doctors might suggest EEG to detect any abnormalities in the brain.

Imaging tests: CT scan, MRI scan SPECTs and  PET scans help doctors locate the tumor and determine if it is cancerous or benign.

Neurological exam: During a neurological exam, your doctor will look for changes in your balance, coordination, mental status, hearing, vision and reflexes. These changes can point to the part of your brain that may be affected by a tumor.

Spinal tap:A doctor uses a small needle to remove fluid from around the spine. A laboratory examines this fluid to look for cancer cells. It is also known as lumbar puncture.

Single photon emission computed tomography

Positron emission tomography : It is used in early diagnosis of altered mental status.

Biomarker tests. A biomarker is a biological factor that can be measured to indicate the presence or absence of disease or the risk of developing a disease.

Neuropsychological test mainly to observe cognitive functions is done with MINI MENTAL STATE EXAMINATION


TREATMENT AND PROGNOSIS :

Airway: consider intubation if the airway appears compromised especially if the glassgow coma scale is less than 8.

Breathing: consider intubation.

Circulation: check the vitals signs.

Assess the nedd for intravenous access and fluids and oxygen and also monitors the electrocardiographic monitoring.

Rule out easily reversible conditions:

 Thiamine: 100 mg IV is usually given to rule out the wernicke’s psychosis.

50% dextrose (D50) can be given if severe hypoglycaemia occurs.

Naloxane Hydrochloride:

It should be suggested if an opiate overdose id detected. Rapid improvement in mental status with the administration of the naloxone is both diagnostic and therapeutic for opioid overdose.

If severe complications such as tumour, bleeding or abscess is present then neuroimaging followed by neurosurgery is indicated. Mannitol, steroids or intubation  with hyperventilation can be indiacted if increase in the intracranial pressure is detected.

Meningitis: if meningitis is suspected then antibiotics should be prescribed.

Status encephalopathy: Benzodiazepines are the first choic of drug. IV lorazepam, diazepam are the first line options. If seizure activity is not subsided then valproic acid or fosphenytoin can be administered.

Hypertensive encephalopathy:

Nitroprusside is often administered to reduce the systemic pressure.

To treat the delirium both Non pharmacological and pharmacological causes can be used.

Non pharmacological: Reorient the patients, maintain normal sleep wake cycle to the patients.

Pharmacological measures: Low doses of antipsychotics such as haloperidol, rispridone, planzapine and quietipine are preffered.

Benzodiazepines, Fomepizole can be used for alcohol withdrawal cases.

 


PROGNOSIS :

Prognosis is good when the symptoms are detected earlier and the treatment is done at an earlier stages.

Allow the patient to come out of their comfort zone and support them.

 


PREVENTION :

Promote good sleep habits.

Provide reassurance that is help the patient to understand what is happening around their environment

Follow good lifestyle habits and encourage taking healthy diet.

Encourage the movement for the patient

Have plenty of lightining and ventilation during day times.

Drink plenty of water and other fluids

If any symptoms such as the cough,fever pain or shortness of breath occurs, consult the physician


Medicines used in the Treatment :

Benzodiazepines such as Diazepam, Olanzepam,Lorazepam

Nalaxone hydrochloride

Mannitol

Fomepizole