Encephalopathy

David M. Ermak, DO

Assistant Professor of Neurology

Objectives

• Conduct a proper evaluation of mental status

• Evaluate and investigate encephalopathy and

the common causes

• Appreciate documentation pitfalls

Mental Status vs.

Consciousness

• “Consciousness is the state of full awareness of

the self and one’s relationship to the

environment.” – Plum & Posner

–Divided into two major arms

• Content – the sum of all functions at a cortical level

including cognition and affect

• Arousal – the level of stimulation needed to

maintain alertness & attention

• Mental Status

–Combination of Consciousness and Cognition

Mental Status

Plum and Posner

• Attention and Alertness

• Orientation and Grasp

• Cognition

• Memory

• Affect

• Perception

Traditional

Documentation• Arousal

• Alertness

• Orientation

• Attention/Concentration

• Memory

– Recent and remote

• Fund of Knowledge

• Speech

– Expression/reception

• Calculations

Content of the Mental Status

Examination

• Arousal and alertness (awake, asleep, arousable to voice, etc.)

• Orientation to time, place, person, situation

• Attention (serial 7’s or WORLD backwards)

• Memory

– Recent (3-5 word registration and recall)

– Remote (past history, details of life, etc.)

• Fund of Knowledge (not necessarily intelligence, but something like that)

• Speech

– Naming objects, repeating phrases, following commands, spontaneous speech

• Calculations (math problems, 57 minus 9, 24 x 3, etc.)

Example Documentation

Normal Example

• AOx4,

• remote memory intact to details of PMHx,

• registration and recall 3/3,

• normal fund of knowledge appropriate for age and level of education,

• attention and concentration normal by serial 7’s,

• calculation intact,

• speech fluent with no expressive aphasia, follows multi-step commands.

Abnormal Example

• Awake, alert, oriented to self and place but not to time or circumstance,

• remote memory intact,

• registration 3/3 but delayed recall 1/3,

• unable to perform serial 7’s or WORLD backwards,

• adequate fund of knowledge present,

• spontaneous speech limited but names objects to confrontation, repetition normal, follows only single step commands and displays perseveration

Name that disorder!

• 68 y/o M with two days of “not being himself” according to his wife

• Exam:

– Appears somnolent but easily arouses to voice however requires repeated stimulation to maintain arousal,

– oriented to self and place but not to time or circumstance,

– remote memory intact,

– registration 3/3 but delayed recall 1/3, unable to perform serial 7’s or WORLD backwards,

– adequate fund of knowledge present,

– spontaneous speech limited but names objects to confrontation, repetition normal, follows only single step commands and displays perseveration

A.Altered Mental Status

B.Confusion

C.Dementia

D.Delirium

E.Encephalopathy

TSH: 16.2

Which one? Why?

A.Altered Mental Status

B.Confusion

C.Dementia

D.Delirium

E.Encephalopathy

• Symptom, not a disease/disorder

• Symptom, not a disease/disorder

• Enduring and progressive

• Term restricted to psychiatric d/o

• YES, metabolic, in fact.

Delirium?

• This is a term used frequently in literature and clinical documentation

• BUT, it doesn’t mean anything useful to you in the coding world

• YES, Delirium is (for all intents and purposes) equal to Encephalopathy… kinda sorta

• BUT, you don’t get paid if you write delirium

• How can we help stop you from writing the wrong word?

Clearing it up

• The National Institutes of Health (NIH) further defines encephalopathy as:

– “Encephalopathy is a term for any diffuse disease of the brain that alters brain function or structure. Encephalopathy may be caused by infectious agent (bacteria, virus, or prion), metabolic or mitochondrial dysfunction, brain tumor or increased pressure in the skull, prolonged exposure to toxic elements (including solvents, drugs, radiation, paints, industrial chemicals, and certain metals), chronic progressive trauma, poor nutrition, or lack of oxygen or blood flow to the brain. The hallmark of encephalopathy is an altered mental state. Depending on the type and severity of encephalopathy, common neurological symptoms are progressive loss of memory and cognitive ability, subtle personality changes, inability to concentrate, lethargy, and progressive loss of consciousness.”

• Delirium is a term used in the DSM-V with no mention of encephalopathy

• “Encephalopathy should be reserved for patients who are experiencing confusion and altered mental status, etc. from an underlying pathophysiological cause. Delirium should be reserved for patients with an underlying psychiatric condition.”

– Allen Frady, RN, BSN, CCS, CCDS, AHIMA Approved ICD-10-CM/PCS Trainer

• https://www.icd10monitor.com/encephalopathy-and-delirium-tomato-tomatoe-potato-potatoe

Name that disorder!

• 32 y/o M presents to ED with his girlfriend because he’s “acting weird.”

– Awake, alert, orientedx3, registration and recall 3/3, normal fund of knowledge although patient states he is smarter than all the doctors in the hospital, speech is pressured, displays tangential thought processes, no aphasia, follows commands, difficult to remain on task as he frequently redirects the questioning and repeatedly refuses to answer questions due to concerns that the NSA is listening.

A. Altered Mental Status

B. Confusion

C. Dementia

D. Delirium

E. Encephalopathy

Name that disorder!

• 56 y/o M brought in by wife because he’s “acting strange” for the last 24 hours.

– Awake but restless, alert, orientedx3, registration 3/3, recall 2/3, normal fund of knowledge, remote memory appears intact, displays perseveration, requires frequent redirection, able to follow only single step commands, displays paucity of spontaneous speech and has trouble with object naming.

Temp 37.8

HR 110

BP 130/80

WBC 9K

RR 18

A. Altered Mental Status

B. Confusion

C. Dementia

D. Delirium

E. Encephalopathy

Continued

• What do you want to do

next?

A.Perform a stroke work-up

B.Perform an LP

C.Provide reassurance for his normal

MRI

D.Obtain a brain biopsy

VITAMINS D C

• Vascular

– Ischemia/hypoxia

– Hemorrhage

– Hypertension

• Infectious

– Meningitis, encephalitis, abscess

– Systemic

• Trauma/Toxins

– Drugs (Rx and nonRx)

– Heavy metals

• Autoimmune

– Hashimoto’s, NMDA-R, VGKC, Lupus, MS

• Metabolic

– Uremic, hepatic, glycemic, lactic acid, mitochondrial d/o

– Nutritional: B12, B1, B6

– Endocrinologic: Thyroid

• Idiopathic

• Neoplastic

– Primary or metastatic tumors

• Seizure

– Ictal or post-ictal

• Degenerative

• Congenital

– Hydrocephalus

Encephalopathy vs. Dementia

Encephalopathy

• Acute, due to a

proximate cause

• Altered Mental Status

• Often has altered

arousal

Dementia

• Chronic,

neurodegenerative

process

• Altered Mental Status

• Arousal not affected

(until late)Shared Etiologies

B12 Deficiency

B1 Deficiency

B6 Deficiency

Thyroid Disorders

Name that disorder!

• 86 y/o F presents to clinic with daughter who complains that the patient has a poor memory which has been going on for the last 6-12 months.

– Awake, alert, oriented to person, but not to place or time.

– Registration 3/3, recall 0/3.

– Attention span intact to WORLD backwards.

– Names objects, repeats phrases, follows commands.

– Able to provide details about past medical history but unable to state President’s name.

A.Altered Mental Status

B.Confusion

C.Dementia

D.Delirium

E.Encephalopathy

What’s the next step?

A.Obtain neuroimaging

B.Start Aricept

C.Check B12 & TSH

D.A&B

E.B&C

F.A&C

G.All of the above

• 86 y/o F presents to clinic with daughter who complains that the patient has a poor memory which has been going on for the last 6-12 months.

– Awake, alert, oriented to person, but not to place or time.

– Registration 3/3, recall 0/3.

– Attention span intact to WORLD backwards.

– Names objects, repeats phrases, follows commands.

– Able to provide details about past medical history but unable to state President’s name.

More Info

• B12: 461

• TSH: 2.6

• What is this called? • What is this called?

• B12: 168

• TSH: 3.9

Binswanger’s Dementia Reversible dementia due to B12

Deficiency (vs. metabolic

encephalopathy?)

Reference

ranges

B12: 250-1000

TSH: 0.47-4.68

Name that disorder!

• 75 y/o F with AF, HTN, DMII brought in by husband because of confusion

– Awake and Alert, oriented x0

– When presented with a pen she calls it a “fen”’, chair=“share”, cup=“nup”

– Follows commands

– Otherwise unable to participate in mental status testing

A. Altered Mental Status

B. Confusion

C. Dementia

D. Delirium

E. Encephalopathy

F. Aphasia

Confusion?

Mental Status

Arousal

Alertness

Orientation

Attention

Fund of Knowledge

Memory

Language

Calculation

Documentation

• Avoid Symptoms as PDx

– Altered mental status is the hallmark symptom of Encephaloapthy

• Restrict use of “delirium” to psychiatric disorders

• Provide underlying etiology

– Metabolic

– Toxic

– Traumatic

– Septic/Infectious

– Hypertensive

– Hypoxic-ischemic

• Any number of things can be called “Confusion”

– Identifying the specifics is what ultimately leads to a true diagnosis

Thank you. Questions?

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