Metabolic

encephalopathy:
what is the main cause?
dr. Tri Pudy Asmarawati, Sp.PD, FINASIM
KSM Penyakit Dalam RS Unair
 altered mental
delirium
status

Introduction confusion encephalopathy

acute
acute brain
confusional
failure
state
Definition

• Delirium (DSM-IV)
• Acute development ( over hours or days)
• Disturbance of consciousness and attention
• Change in cognition (memory, orientation,
language) and/or perceptual disturbance
• Fluctuating
• Caused by medical condition
Definition

• The Confusion Assessmet Method (CAM) → sensitivity

94-100%, specificity 90-95% for the diagnosis of
delirium:
• Acute onset and fluctuating course, AND
• Inattention, PLUS
• Disorganized thinking, OR
• Altered level of consciousness/alertness
Epidemiology

• Delirium in hospitalized patients range from 10 to >50%

• Higher rates in elderly patients and patients undergoing hip
surgery
• Elderly in ICU : high rates of delirium → approach75%
• Up to 1/3 delirious inpatients are not recognized
• Delirium in ICU : important manifestation of organ dysfunction
CHARACTERISTICS
DELIRIUM
• acute “confusional state”
• abrupt onset, fluctuating, short
• inattention
• impaired recent & immediate memory
• global cognitive/perceptual disturbance
• altered level of consciousness
• disorientation
• disorganized thinking
• psychomotor agitation
• hallucination (particularly visual)
• sleep-wake disturbance
DEMENTIA
• chronic “confusional state”
• insidious, slowly progressive
• normally attentive, until later stages
• prominent, progressive memory disturbance
• cognitive dysfunction (aphasia, apraxia, &
agnosia)
• normal consciousness, until late stages
• orientation maintained, until middle to late stages
• impaired executive function and judgement
• may have apraxia
• misperception usually absent
Common Etiologies of Delirium
Toxins

• Prescription medication : anticholinergic properties, narcotics,

benzodiazepines
• Drugs of abuse: alcohol intoxication and alcohol withdrawal, opiates,
ecstasy, LSD, GHB, PCP, ketamine, cocaine, "bath salts" marijuana, etc
• Poisons: inhalants, carbon monoxide, ethylene glycol, pesticides
Endocrine Conditions

• Hyperthyroidism, hypothyroidism
• Hyperparathyroidsm
• Adrenal insufficiency
 hypoglycemia, Anemia
hyperglycemia

Pulmonary
Cardiac failure:
failure hypoxemia and
Etiologies of hypercarbia
Delirium: Renal failure
Metabolic Liver failure

condition Electrolyte Vitamin deficiencies: B12

disturbances thiamine, folate, niacin

Dehydration
and
hyponatremia, hypernatremia, hypercalcemia, hypocalcemia, hypomagnesemia, malnutrition
hypothermia and hyperthermia
Etiologies of Delirium:
Infection
Systemic infection:
• urinary tract infections
• pneumonia
• skin and soft tissue infections
• sepsis

CNS infections:
• meningitis
• encephalitis
• brain abscess
Etiologies of Delirium:
Cerebrovascular Disorders
• Global hypoperfusion states
• Hypertensive encephalopathy
• Focal ischemic strokes and hemorrhage: nondominant
parietal and thalamic lesions
Neoplastic Disorders
• Diffuse metastases to the brain
• Gliomatosis cerebri
• Carcinomatous meningitis
• CNS lymphoma
 Autoimmune Disorders

• CNS vasculitis
• Cerebral lupus
• Neurologic paraneoplastic and autoimmune
encephalitis

Etiologies Seizure-Related Disorders

of Delirium: • Nonconvulsive status epilepticus

• Intermittent seizures with prolonged postictal
states

Hospitalization

• Terminal end-of-life delirium

Presentation
History
• Baseline mental status
• Rapidity and consistency
• Previous history of delirium, psychiatric disorders, or stroke
• History of falls or head injury
• Medication
• Alcohol use

Physical examination
• identify possible precipitating cause or evidence of focal neurologic process
• Evidence of infection, dehydration, and head trauma
• Fecal or urinary retention
• Repeated examination: motor activity, alertness, attentiveness, speech
Test for cognitive dysfunction
The Mini Mental State Examination
(MMSE)
The Short Blessed Test (SBT)
Score <24 → abnormal
False positives occur in advanced age
and poor education
more time efficient
Score <9 : normal
Serial exam more useful (fluctuation)
As a baseline examination on
admission
Short
Blessed
Test (SBT)
Physical examination

• Repeated examination of patient behavior are important:

• Motor activity: agitation or retardation?
• Alertness
• Attentiveness: maintaining focus during conversation, easily
distracted?
• Speech : content and flow of thought
 Lab Evaluation

• Urinalysis
• BGA/pulse oximetry
• Electrolytes (including Ca)
• BUN and creatinine
• Glucose
• Liver panel
• Complete blood count
Work up • ECG

Consider when appropriate

• toksikologi, VDRL, HIV

Lumbar puncture/EEG

• meningoencephalitis
 Chest X-Ray

• rule out pneumonia

Noncontrast CT scan
Imaging
evaluation • if there are new focal neurologic deficits
• history of fall

MRI

• for further evaluation

 Prevention and early intervention

Increasing mobility & activity

Prevent sleep deprivation/interruption

Full hydration

Reverse hearing and/or visual impairment

Treatment Review medication
“Primarily supportive until
the underlying precipitant
Maximize the safety of f the surrounding
are identified and
environment
eliminated if possible”
Avoid physical restrain if possible

Treat pain

Evaluate sensory input

• avoid sensory extremes, familiar faced, use windows &

visible clock/calendar
• Provide nutrition at appropriate times
 Neuroleptic agents

• Haloperidol
• Atypical antipsychotics: risperidone,
Medication olanzapin
only indicated for
disruptive/harmful Benzodiazepines
behaviors
• can be useful adjuncts to antipsychotic
agents for severe agitation, insomnia,
and withdrawal syndromes
 Determination of baseline mental status is
critical

All patients at risk of delirium (elderly) should

have a mental status exam

History provided by other family members may

Key points be extremely helpful

Use nonpharmacologic methods as much as

possible to control delirium

If behavioral management requires medication,

use antipsychotics before using sedatives
Thank you