Metabolic encephalopathy diagnosis and management

Overview of the diagnosis and management of metabolic encephalopathy for third year medical students in the Personalized Education Program portion of the third year curriculum at SIU Medicine

1. Metabolic Encephalopathy

2. Robert Robinson, MD, FACP No Disclosures

3. Objectives Clinical Cases

4. 77 year old lost in Parking Lot Wandering Does not know how he got there Cannot find car Oriented to person Knows address Brought to ED by EMS for evaluation

5. 77 year old lost in Parking Lot

6. Definition- DSM-V

7. 77 year old lost in Parking Lot

8. 77 year old lost in Parking Lot CT Head CBC BMP UA Urine toxicology Blood alcohol level Chest X-ray EKG Cardiac enzymes

9. 77 year old lost in Parking Lot CT Head CBC BMP UA Urine toxicology Blood alcohol level Chest X-ray EKG Cardiac enzymes Discuss patient with primary care provider

10. Definition- DSM-V

11. 77 year old lost in Parking Lot Not metabolic encephalopathy Progression of dementia

12. 62 year old 2 days postop Confused Tolerated pain meds on POD #1 No significant PMHx SHx – Family denies alcohol/drugs Exam Confused, inattentive Febrile Tachycardia Hypertensive Tremor Diaphoretic

13. Prevalence in Hospitals J Am Geriatr Soc. 1992;40(8):829 . , J Gen Intern Med. 1998;13(4):234.

14. CAM (Confusion Assessment Method) Features Acute onset and fluctuating course Inattention Disorganized Thinking OR Altered level of consciousness Most common assessment tool Superior to MMSE Sensitivity 94-100% Specificity 90-95% J Am Geriatr Soc. 2008;56(5):823.

15. Risk Factors Dementia Stroke Parkinson’s Disease Sensory impairment Critical illness Sleep deprivation

16. Precipitating Factors

17. Collision of Factors

18. 62 year old 2 days postop Confused Tolerated pain meds on POD #1 No significant PMHx SHx – History of alcohol abuse Exam Confused, inattentive Febrile Tachycardia Hypertensive Tremor Diaphoretic

19. Differential Diagnosis?

20. Medications as a Cause CNS Drugs. 1996; 5:103.

21. Prescription drugs Take a thorough drug history Call pharmacies Review medication administration record (MAR) Pay close attention to drug changes Consider drug withdrawal

22. Common precipitating drugs Narcotics Benzodiazepines Muscle relaxers Antipsychotics Antidepressants Antibiotics

23. Consider checking levels Anti-seizure medications Digoxin Theophylline Lithium

24. Over The Counter drugs Take a thorough drug history Antihistamines (including H2 blockers) Alternative medicines Analgesics Sleep aids

25. Recreational drugs Take a thorough drug history Alcohol (consider withdrawal...) Stimulants Sedatives Narcotics “Designer drugs” - MDMA , MDPV

26. MDMA – Ecstasy, Molly Delirium, agitation Hyponatremia Hyperthermia Liver injury Rhabdomyolysis Serotonin syndrome (with SSRI, MAOI) 3,4-methylenedioxymethamphetamine

27. MDPV – Bath Salts Delirium, agitation Hypertension Tachycardia Seizures Psychosis Methylenedioxypyrovalerone

28. Synthetic cannabis – Spice, K2 Delirium Psychosis Hypertension Myocardial infarction Stroke Seizures

29. 62 year old 2 days postop Metabolic Encephalopathy Drug history Narcotics for pain control (New) Possible chronic alcohol use

30. Differential Diagnosis?

31. Laboratory Evaluation For most patients CBC BMP TSH UA + Culture Consider ABG Toxicology screening Drug levels CMP B12 Folate RPR

32. Imaging Studies Tailor studies based on history/exam Chest x-ray CT of brain MRI of brain

33. CT without neurological findings Acta Neurol Scand . 2008;118(4):245.

34. Other studies Tailor studies based on history/exam Lumbar puncture EEG

35. Non-convulsive Status Epilepticus Epilepsy Res. 1994;18(2):155., Neurology. 2004;62(10):1743.

36. 62 year old 2 days postop Metabolic Encephalopathy Drug history Narcotics for pain control (New) Possible chronic alcohol use Labs unremarkable

37. 6 7 year old in ICU Admitted for septic shock and UTI On vent Reducing sedation Agitated Combative

38. Differential Diagnosis?

39. Definition- DSM-V

40. How to assess ICU patients

41. CAM-ICU Features Acute onset and fluctuating course Inattention Disorganized Thinking OR Altered level of consciousness

42. CAM-ICU – Onset and Course Is there evidence of an acute change in mental status from the patient’s baseline? OR Has the patient had any fluctuation in mental status in the past 24 hours as evidenced by fluctuation on a sedation/level of consciousness scale (i.e., RASS/SAS), GCS, or previous delirium assessment?

43. CAM-ICU – Inattention Say to the patient, “I am going to read you a series of 10 letters. Whenever you hear the letter ‘A,’ indicate by squeezing my hand.” Read letters from the following letter list in a normal tone 3 seconds apart. S A V E A H A A R T or C A S A B L A N C A or A B A D B A D A A Y Errors are counted when patient fails to squeeze on the letter “A” and when the patient squeezes on any letter other than “A.” Two or more errors qualifies for inattention.

44. CAM-ICU – Disorganized Thinking Ask the following Yes/No questions Will a stone float on water? Are there fish in the sea? Does one pound weigh more than two pounds? Can you use a hammer to pound a nail? Say to patient: “Hold up this many fingers” (Hold 2 fingers in front of patient) “Now do the same thing with the other hand” More than one error qualifies for disorganized thinking

45. CAM – Altered level of consciousness Present if the RASS score is anything other than alert and calm (zero)

46. Differential Diagnosis?

47. 6 7 year old in ICU Admitted for septic shock and UTI On vent Reducing sedation Agitated Combative

48. Treatment

49. Treatment & Prevention

50. Physical Restraints 3x more likely to have persistent delirium Increased risk for Falls Pressure ulcers Increased agitation Arch Intern Med. 2007;167(13):1406.

51. Benzodiazepines Commonly used in treatment of delirium No clear evidence of benefit Cochrane Database Syst Rev. 2009;

52. Neuroleptic Medications

53. Neuroleptic Medications Haloperidol Haloperidol + Quetiapine Risperidone Olanzapine Quetiapine Cochrane Database Syst Rev. 2007 Crit Care Med. 2010;38(2): 419 J Hosp Med. 2013 Apr;8(4): 215-20

54. Haloperidol + Quetiapine Efficacy and safety of quetiapine in critically ill patients with delirium: A prospective, multicenter, randomized, double-blind, placebo-controlled pilot study *. Devlin, John; Roberts, Russel ; Fong, Jeffrey; Skrobik , Yoanna ; Riker, Richard; Hill, Nicholas; Robbins, Tracey; Garpestad , Erik Critical Care Medicine. 38(2):419-427, February 2010. DOI: 10.1097/CCM.0b013e3181b9e302

55. Haloperidol vs. Quetiapine Maneeton B, Maneeton N, Srisurapanont M, Chittawatanarat K. Quetiapine versus haloperidol in the treatment of delirium: a double-blind, randomized, controlled trial . Drug Des Devel Ther . 2013 Jul 24;7:657-67.

56. Haloperidol vs. Newer Neuroleptics Hyung -Jun Yoon, Kyoung -Min Park, Won-Jung Choi, Soo-Hee Choi, Jin-Young Park, Jae-Jin Kim and Jeong -Ho Seok Efficacy and safety of haloperidol versus atypical antipsychotic medications in the treatment of delirium BMC Psychiatry 2013, 13 :240 

57. Frequency of ADEs BMC Psychiatry 2013, 13 :240

58. Prevention

59. Treatment & Prevention

60. Risk Factors for Delirium Dementia Stroke Parkinson’s Disease Sensory impairment Critical illness Sleep deprivation

61. Modifying risk factors Orientation Sleep Mobilization Glasses Hearing aids Cochrane Database Syst Rev. 2014;1:CD009537 Promising data from small studies

62. Avoiding precipitating factors High risk drugs Withdrawal syndromes Metabolic disturbances Manage Pain

63. Prophylaxis

64. Risperidone Anaesth Intensive Care. 2007 Oct;35(5):714-9., Anesthesiology. 2012 May;116(5):987-97.

65. Olanzapine Psychosomatics. 2010 Sep-Oct;51(5):409-18.

66. Melatonin Saudi J Anaesth . 2010 Sep;4(3):169-73 ., Int J Geriatr Psychiatry. 2011 Jul;26(7):687-94

67. Ramelteon JAMA Psychiatry. 2014 Apr;71(4):397-403.

68. Male found unresponsive Brought to ED by police Unknown identity No history Disheveled Smells strongly of alcohol Snoring No signs of trauma Vitals stable

69. Differential Diagnosis?

70. Precipitating Factors

71. Collision of Factors

72. Male found unresponsive Brought to ED by police Unknown identity No history Disheveled Smells strongly of alcohol Snoring No signs of trauma Vitals stable Alcohol Intoxication

73. Male found unresponsive Brought to ED by police Unknown identity No history Disheveled Smells strongly of alcohol Snoring No signs of trauma Vitals stable Alcohol Intoxication Thiamine deficiency

74. Male found unresponsive Brought to ED by police Unknown identity No history Disheveled Smells strongly of alcohol Snoring No signs of trauma Vitals stable Alcohol Intoxication Thiamine deficiency Aspiration pneumonia

75. Male found unresponsive Brought to ED by police Unknown identity No history Disheveled Smells strongly of alcohol Snoring No signs of trauma Vitals stable Alcohol Intoxication Thiamine deficiency Aspiration pneumonia Subdural hematoma

76. Precipitating Factors