A Patient With Altered Mental Status

A Patient with Altered Mental Status
Solomon Seth Sallfors PGY2

SUBJECTIVE
Chief Complaint:
Altered Mental Status 1-2 days
History of Presenting Illness:
87 year old Caucasian woman
History of HLD, MI, Mild cognitive decline,
recurrent UTIs, chronic pain

On the morning of presentation, the patient had
been discovered at home in bed, after last
being seen well approximately 48 hours
before presentation. Patients family member
went to check on her after not being able to
reach her by phone. Initially, patient was nonresponsive and unable to be revived with
verbal or painful stimuli. Family called EMS
who brought her to the ER.

Sometime before arrival, the patient was briefly
semi-conscious, no more than an hour, during
which she non-sensically repeated the phases
I dont know and what.
Subsequently, she became non-responsive
again.

According to the family, patient was independent in
ADLs (dressing, cooking, taking medications), lived
alone in a private residence, and was grossly normal
in cognitive function except possible diagnosis with
mild cognitive decline.
Patient had last been known to be well by her
daughter, who had called her mother in the evening
2 days prior to explain that the daughter would
vacationing the next few days and not able to check
on her. No provision was made to check on her in the
interim.

Early triage indicates patient has a fever.

REVIEW OF SYSTEMS
Unable to assess due to altered mental
status.
According to the family, she had
complained of no new symptoms in the
preceding 2 weeks.

NKDA
Surgeries: Unable to assess. No mention in
Medical record.
Social: Unable to assess. Medical record
indicates no alcohol, tobacco or illicit drugs.
PMH: HTN, HLD, Mild cognitive decline, Chronic
pain, recurent UTIs
Family Medical History: Dementia, MI (family
doesnt know details)

Medications (Provided by family)
Bactrim DS
Pravastatin
Aricept (Donepezil)
Cymbalta
Doses and schedule not available.

Differential Diagnosis
Cerebral infarction/TIA
Sepsis
Meningitis/encephalitis
Intoxication
Metabolic

OBJECTIVE
Vitals
At admit: 178/72, 100.8 TEMP, 24RR, 83HR,
95% RA
During exam: 134/78, 98.9 TEMP, 20RR, 72HR,
95% RA

PHYSICAL EXAM:
Constitutional: Examined in the right lateral decubitus position. Elderly
woman in obvious distress, who is non-responsive, with labored
open-mouth breathing. She is thin with muscle mass appropriate for
age and gender. Back is arched in extension.
Skin: Non-diaphoretic, fair turgor, not-excessively oily or excessively
dry, no petechae, no diffuse erythema, or obvious ulcers or lesions.
HE: Atraumatic, normocephalic, Pupils 3mm, sclera non-icteric,
conjunctiva non-injected, no strabismus or nystagmus,
ENT: No exudate or erythema; posterior pharynx could not be
visualized.
Neck: increased tone, no rigidity, No JVD, no cervical
lymphadenopathy, trachea midline; thyroid, parotid, and
submandibular glands are non-enlarged. Brudzinskis couldnt be
tested.

PHYSICAL EXAM CONT.
CV: Regular rate and rhythmn; no murmur, heave or thrill;
PMI at mid clavicular line;
Lungs: Labored open mouth breathing, good air movement
in , no wheeze rales or rhonchi, no dullness to percussion
Abdomen: Scaphoid, no surgical scars, no visible pulsations,
soft, no guarding or rigidity, hypoactive bowel sounds,
Musculoskeletal: No acute tissue texture changes, no acute
somatic dysfunctions, major joints are non swollen and
non erythematous, major muscle groups normal size
Extremities: Pulses 2/4, equal and symmetrical bilaterally,
capillary refill <2 seconds.

PHYSICAL EXAM CONT.
Neuro: Mental status: Non-responsive. She is mostly silent with
occasional groans.
CN: Mostly unable to assess. PERRL. Extra-ocular muscles unable to
assess. No facial droop or ptosis. Gag reflex unable to access.
Teeth were clenched. Shoulder shug and SCM could not be tested.
Motor: Patient is . Some spontaneous movement of limbs.
Withdraws limbs in response to pain. Cerebellar signs and gait
could not tested. Strength could not be tested. No spasticity or
rigidity.
Reflexes: patellar +2 bilateally, other DTR could not be tested,
negative Babinski,
Sensory: withdraws to painful stimuli (pinching, IV sticking),
propioception not tested.

LABS

Diagnoses
Acute encephalopathy, uncertain etiology, mostly likely stroke or
infection. Superimposed on mild cognitive decline.
--Atorvastatin 40mg if starts taking PO
--ABG
--MRI in AM (or earlier) if patient can remain still
--Neurology consult
--Permissive HTN
--Supportive, neuro checks
SIRS. With fever and tachypnea.
Acute Fever. Asso elevated lactate.
--Zosyn 3.375 mg
--Blood cultures, CXR, UA
--ID consult

Head CT

Routine Troponin was drawn.

Additional Diagnosis
NSTEMI. With elevated troponins and no EKG changes.
--Lovenox 1mg/kg BID
--Aspirin 300mg rectally once
--ECHO
--Other meds were held because she was not taking
orals.
Lopressor, atorvastatin, Plavix, nitro (BP was borderline)
--Cardio consult
Acute encephalopathy, Secondary NSTEMI.
--same as previous, Seroquel 25mg HS for aggitation

Review of medical record disclosed that during
her prior heart attack, she also presented
mentally altered, approximately 1 year before.

Discussion
AMS from AMI is not unheard of.
Confusion or altered mental status is the presenting
manifestation of AMI in up to 20% of patients >85 years
old.
The clinical features of acute MI vary by age.
--very elderly patients are less likely to report chest pain.
--more likely to have silent or unrecognized MIs, as well
as MIs without ST-segment elevation
(Rich, Epidemiology)

Elderly over 75 compared to younger
patients:
more likely to have an NSTEMI rather than
an ST elevation MI
more frequently have an atypical
presentation, including silent or unrecognized
MI
presenting symptoms: syncope, weakness,
or confusion (delirium).

Epidemiology of AMI
60 -65 % of MIs occur in patients 65 years of
age
33 % occur in patients 75 years of age
1/3, 1/3, 1/3 for groups <65, 65-75, >75
80% of all deaths related to MI occur in
persons 65
(Beall, Uptodate)
>75 years of age (6% of US population): 60%
of myocardial infarction (MI)related deaths
(Alexander)

AMI by Age
<65 yo
65-75 yo
>75 yo
6% of population is over
75yo.

Elderly over 75 compared to younger
patients:
more likely to have an NSTEMI rather than
an ST elevation MI
more frequently have an atypical
presentation, including silent or unrecognized
MI
presenting symptoms: syncope, weakness,
or
confusion (delirium).
higher in-hospital mortality (19 versus 5%).

Prognosis and Complications
Delays in diagnosis have been well-documented and often lead to delays
in therapy.
Some of the worse outcomes after acute MI probably result from
comorbidities in elderly patients, but also can be attributed in part to a
lower likelihood of receiving potentially beneficial therapies due
to concerns about toxicity. Therapies such as beta blockers,
percutaneous coronary intervention, or coronary artery bypass grafting
are all utilized to a lesser degree in elderly patients.
A retrospective review of almost 57,000 patients with a non-ST elevation
ACS found that after adjustment, patients (including those 75 years of
age) who received more recommended therapies had lower inhospital mortality rates than those who did not. Thus, although
concern about risks and side effects is appropriate and it is not clear
that adjustment accounted for all risk factors, older age alone should
not be an indication to withhold recommended therapy.

Elderly patients with non-ST elevation ACS (defined
as >75 years) should receive the same treatment as
younger patients with the following cautions:
--The patient's general health, comorbidities,
cognitive status, and life expectancy
--Increased sensitivity to hypotension-inducing drugs
--Altered drug pharmacokinetics should be
considered.
--Calculate creatinine clearance for all patients 75
years of age, especially with lovenox dosing.
(Breall, Uptodate)

Elderly patients with acute MI are more likely
than younger patients to experience heart
failure, atrial fibrillation, cardiac rupture, and
shock, all of which are associated with
increased mortality.
(Rich, Epidemiology)
More likely to have heart failure associated with
the MI (40 versus 14%), the risk for which
increases progressively with age, from 36% in
those 65-69, to 65% in those 85.
(Breall, Uptodate)

BACK TO OUR PATIENT
Patient began to regain consciousness later the
same day. She was weak and slightly confused
but could ambulate with assistance for
bathroom functions.
She remembered going to bed the prior evening
without symptoms.
She was oriented, luicid.

Patient was seen by multiple cardiologists.
Diagnosed with NSTEMI.
Given troponins and late EKG changes
(flattened T-waves), patient was offered heart
catheterization. Troponins were not trending
down after 24 hrs.
But ultimately she elected to be transferred to
another institution for catheterization due to
established relationship with a cardiologist

Incidentally
Echocardiogram:
There is apical septal, apical and inferioapical
hypokenesis with normal function of the basal
to mid segments consistent with Takotsubo
cardiomyopathy.
Otherwise normal.

Objectives
Awareness of this less-widely known presentation of AMI,
namely AMS
AMS, confusion, delirium
Awareness of atypical presentations of AMI in elderly
Atypical chest pain, dyspnea, AMS
Awareness of need for early diagnosis and treatment
Higher morbidity and mortality in elderly
If possible, treat like younger patients.
Dont be complacent.
If patient looks sick and has chest pain,
--suspect AMI (Sallfors rule).
References
Hien Nguyen, MD; Connie Le, MD; Hanh Nguyen, MD; Nam-Tran Nguyen . Altered Mental Status in an
Elderly Woman with Concurrent Takotsubo Syndrome and Polymyalgia Rheumatica: A Case of Treatable
Geriatric Delirium. The Permanente Journal (Winter 2012) 16:1.
Rich, Michael W., MD. Epidemiology, Clinical Features, and Prognosis of Acute Myocardial Infarction in the
Elderly. THE AMERICAN JOURNAL OF GERIATRIC CARDIOLOGY. (2006) 15: 1.
Alexander, Karen P., MD; et all. Acute Coronary Care in the Elderly, Part I NonST-SegmentElevation Acute
Coronary Syndromes. Circulation. (2007) 115:2549-2569.
Breall, Jeffrey. Overview of the acute management of unstable angina and non-ST elevation myocardial
infarction. Uptodate.com.
Caren G. Solomon, MD, et all. Comparison of Clinical Presentation of Acute Myocardial Infarction in Patients
Older Than 65 Years of Age to Younger Patients: The Multicenter Chest Pain Study Experience.
AMERICAN JOURNAL OF CARDIOLOGY VOLUME 63. Pg 773.
Chung-Lieh Hung, et all. ATYPICAL CHEST PAIN IN THE ELDERLY: PREVALENCE, POSSIBLE MECHANISMS AND
PROGNOSIS. International Journal of Gerontology (March 2010). 4:1
Ayman El-Menyar , et all. Atypical presentation of acute coronary syndrome: A significant independent
predictor of in-hospital mortality. Journal of Cardiology (2011) 57, 165171.

A Patient With Altered Mental Status

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A Patient with Altered Mental Status

Solomon Seth Sallfors PGY2