Updates In Critical Care Psychiatry-2022: The Differential Diagnosis for Altered (Hypoactive) Mental Status in Critically Ill Patients

Friday, November 11, 2022

2:15 PM – 3:45 PM

Location: Salon East

CE: 1.5 CME

Lead Speaker(s)

Jose R. Maldonado, FACLP, FACFE

John & Terry Levin Family Endowed Professor of Medicine
Stanford Medicine
Menlo Park, California

PDF

Speaker(s)

Jordan Rosen, MD

Psychiatrist
Brigham and Women's Hospital
Boston, Massachusetts

PDF
Jeffrey Zabinski, MD

Psychiatrist
Columbia University Medical Center
New York, New York

PDF
Durga Roy, MD, FACLP

Associate Professor
Johns Hopkins University School of Medicine
Baltimore, Maryland

PDF

Abstract: Alterations in mental status (AMS) are a common presentation in the intensive care units (ICUs). Diagnosing a patient with a change in mental status can be a daunting challenge. Some presentations are clear; a patient who is postictal after a seizure or a diabetic patient who is hypoglycemic. At times, the clinical picture is more subtle and not easily identified. Altered mental status (AMS) is not a disease: it is a symptom. Causes run the gamut from easily reversible conditions (e.g., hypoglycemia, hypoxemia, delirium) to permanent (intracranial hemorrhage) and from the relatively benign (e.g., medication toxicity, non-convulsive status) to life threatening conditions (e.g., meningitis or encephalitis). Developing a structured and systematic approach to these cases will help you develop and streamline the diagnostic workup and management of these patients with AMS. This presentation is intended to provide physicians with the background and tools to assess and differentiate among the most common neuropsychiatric conditions constituting the differential diagnosis for AMS among CCU patients, including hypoactive delirium, non-convulsive status, psychoactive substance effects, and other alterations in awareness, such as coma, minimally conscious states and akinetic mutism).

Dr Maldonado will discuss the particulars of hypoactive delirium, its causes, and consequences, and will discuss the best assessments and treatment modalities. Hypoactive delirium is the most difficult to recognize and accurately diagnose, and by far the most common motoric type of delirium. It also has the greatest morbidity and mortality rate. This presentation will serve as the basis for all the other disorders included in this presentation, representing the differential diagnosis for each other’s condition.

Dr Zabinski will discuss Nonconvulsive status epilepticus (NCSE), a complex disorder with multiple subtypes that can present a vexing challenge in neurologic and psychiatric evaluation of altered mental status, particularly in cases with notable psychiatric comorbidity in the inpatient setting. This review will look at the range of neuropsychiatric presentations with approaches to differential, evaluation, and treatment from the perspective of a consultation psychiatrist.

Dr. Rosen will describe the pathophysiology and issues that present with accumulation of common sedatives and analgesics that can lead to delayed awakening and ICU-acquired neuropathy and myopathy. He will then address common questions that arise once these conditions are present.

Dr. Durga Roy will review alterations in mental state that may arise from coma, minimally conscious state, post-traumatic confusional state and akinetic mutism. She will present the phenomenology, diagnostic workup as well as challenges and dilemmas in managing these patients. A focus on neurocircuitry, functional resting-state networks and other neuroimaging findings will be discussed along with an evidence-based review of pharmacologic and behavioral interventions used in these scenarios.

Learning Objectives:

Define non-convulsive status epilepticus (NCSE) and identify common neuropsychiatric symptoms.
Explain the conditions and risk factors of delayed awakening and ICU-acquired neuropathy and myopathy.
After this symposium, participants will be able to recognize the signs, symptoms, and diagnostic work up for patients presenting with coma, minimally conscious state, post-traumatic confusional state and akinetic mutism.