Presented by eCare/eLTC

Nadia Yusufi, DNP

Identify the symptoms associated with Acute Mental Status and Behavior Changes

Identify the proper time to contact a provider

Identify the proper assessment steps to take what to report to the provider

Identify when it is safe to manage the resident in the facility

Confused 80 year old male

Does not answer questions appropriately. Usually easy-going but the past 24 hours has had anger outbursts, agitated easily

◦ Patient was discharged a week ago from the hospital post left hip replacement and CHF to SNH.

◦ Has history of DM type 2, HTN, CHF, and pain

◦ Some medications were changed in the hospital including for CHF and DM.

◦ Currently on lisinopril, metoprolol, Coumadin for a month following the hip replacement.

◦ Acetaminophen as needed for his pain.

Exam:

◦ pulse 100/min, respirations 24/min, blood pressure 160/80/min, SpO2 93 RA, tympanic temperature 99.4°F. Glucose 70

◦ Lungs: diminished, expiratory wheeze

◦ Heart: slightly irregular, 2 + pitting edema LE, PP present

So what could be causing the change in mental status/behavior?

Tramua: Brain laceration/injuryConcussionDepressed skull fractureHead traumaBrain, contusionBrain injury, massiveDiffuse axonal injury/Acute brain traumaShaken Baby SyndromeElectromagnetic, Physics, trauma, Radiation CausesAsphyxia/suffocationDrowning, fresh waterDrowning, sea waterDrowning/Near- drowningHeat exhaustion/prostrationHeat strokeEncephalopathy/postanoxicHypoxiaHypoxic environmentHypothermia, accidental/exposureElectrocution/lightning strikeHigh altitude cerebral edemaDecompression sicknessHigh altitude pulmonary edemaIatrogenic, Self Induced DisordersWater intoxicationHypothermic anesthesiaHyponatremia correction, rapidSurgical, Procedure ComplicationAnesthesia, generalBrain surgeryInfectious Disorders (Specific Agent)Pneumonia, bacterialAIDS MeningoencephalitisEncephalitis, herpes simplexEncephalitis, secondary viralEncephalitis, viralMeningitis BacterialMeningitis, aseptic/viralMeningitis, HemophilusMeningitis, pneumococcalMeningococcal meningitisPneumonia/BronchopneumoniaPneumonia, acute lobarPneumonia, pneumococcalTyphoid feverMeningitis, tuberculosisAmebic (Naegleria) meningoencephalitisBacterial overwhelming sepsisCandidiasis systemicChickenpox encephalitisEncephalitis, bacterial/cerebritisEncephalitis, Dawsons/inclusion bodyEncephalitis, Eastern equineEncephalitis, mumpsEncephalitis, Murray valleyEncephalitis, non-viralEncephalitis, St Louis BEncephalitis, Western equineGram negative (e coli) meningitisHistoplasmosis meningitisKunjin viral encephalitisLa Crosse viral encephalitisLegionella meningoencephalitisLeptospiral meningitisLeptospirosis/severe (Weils) typeListeria meningitisLyme meningoencephalitisMalaria, cerebralMeningitis, candidaMeningitis, Coxacki viralMeningitis, echo viralMeningitis, staphylococcus aureusMononucleosis encephalitisPlague meningitisPost-viral/infectious encephalopathyPrimary bacterial peritonitis/ascitesRabiesReyes syndromeRussian tick-bourne encephalitisToxic shock syndromeTrichinella meningoencephalitisTyphus, acute/epidemicWest Nile fever/encephalitisBrucellosisLegionaires diseaseListeria monocytogenes/listeriosisMeningitis, fungalRocky mountain spotted feverToxoplasma meningoencephalitisCreutzfeld-Jakob diseaseMeningitis, cryptococcalPsittacosis/ornithosisSleeping sickness/trypanosomiasisToxoplasmosis, cerebralEncephalitis, CaliforniaEncephalitis, equine, VenezuelanEncephalitis, Japanese BEncephalitis, powassanMalariaMeningitis, coccidioidomycosisNipah virus/encephalitisPlague, bubonicTularemia meningitisPoliomyelitis, acuteFungus brain abscessLeptospirosis IctohemorrhagicaInfected organ, AbscessesInfectionsAbscess, intracranialBacteremia/SepticemiaBrain abscessEmbolism, septic, cerebralEndocarditis, infectiveMeningoencephalitisPneumonia, aspirationSepsisSepsis, overwhelmingSeptic shockUrosepsis/septicemiaEncephalomyelitis, acuteEncephalopathy/secondary/toxic/sepsisNecrotizing fasciitis/mixedBrain stem encephalitisEncephalitisMeningitisPneumoniaGranulomatous, Inflammatory DisordersHemorrhagic pancreatitis, necrotizingPancreatitis/resp distress syndromeNeoplastic DisordersHypercalcemia of malignancyMetastatic brain diseaseBrain stem tumorBrain tumorFrontal lobe tumorMedulloblastomaMeningeal carcinomatosisParietal lobe tumorPrimary CNS lymphomaTemporal lobe tumorBrain tumor , malignant (astrocytoma)CraniopharyngiomaGlioblastoma multiformeInsulinoma/Islet cell tumorMeningiomaPontine gliomaChoroid plexus, papillomaAllergic, Collagen, Auto-Immune DisordersEncephalitis, hemorrhagic, acuteEncephalitis, post viralEncephalomyelitis, necrotizing hem. ac.Encephalomyelitis, post-infectiousStevens-Johnson syndromeTransfusion reaction, hemolyticLupus cerebritisPolyarteritis nodosaBehcet's syndromeHashimotos EncephalitisMetabolic, Storage DisordersHypoglycemia, reactive diabeticDiabetic ketoacidosis/comaHyperosmolar hyperglycemic coma, nonketNeonatal hyperbilirubinemiaMetabolic disordersMethemoglobinemia, HereditaryPorphyria, acute intermittentGlutaric aciduria/AcidemiaUrea cycle/metabolic disorderMethemoglobinemia, acquired/toxicBiochemical DisordersEncephalopathy, hypoglycemicHypoglycemia, infantileAcid/Base derangementAcidosisHypercalcemiaHypercapnea HypercarbiaHypernatremiaHyperosmolalityHypocalcemiaHyponatremiaLactic acidosisMetabolic encephalopathyHypoxia, systemic, chronicHypoglycemiaPontine myelinolysis, centralDeficiency DisordersDehydration and feverDehydrationWernicke's encephalopathyMalnutrition/StarvationPellagra/niacin deficiencyMarchiafava-Bignami syndromeCongenital, Developmental DisordersNephrogenic diabetes insipidusHereditary, Familial, Genetic DisordersMELAS EncephalopathyVan Bogaert encephalitisUsage, Degenerative, Necrosis, Age Related DisordersAlzheimer's syndromeDementia, Lewy-body typeMultiple sclerosisRelational, Mental, Psychiatric Disorders Conversion disorderManiaHypoglycemia, factitiousCatatoniaManic deleriumAnatomic, Foreign Body, Structural DisordersAcute subdural hematoma/hemorrhageBrain compressionEpidural hematomaIntracerebral hematomaIntraventricular brain hemorrhageSubdural hematomaTamponade, cardiacBrain stem herniation/peduncle/tonsilsFat embolismSuperior vena cava syndromeIntracranial mass effectArteriosclerotic, Vascular, Venous DisordersCerebral vascular accidentCerebral embolismCerebral hemorrhageCerebral vein thrombosis/phlebitisIntracerebral hemorrhageMyocardial infarction, acuteSubarachnoid hemorrhageTransient cerebral ischemia attackCerebral infarct/EncephalomalaciaBrain stem infarctCavernous sinus thrombosisCerebral/Venous sinus thrombophlebitisSuperior sagittal sinus thrombosisVertebrobasilar artery dissectionFunctional, Physiologic Variant DisordersHyperpyrexiaSleep deprivationVegetative, Autonomic, Endocrine DisordersCardiac arrestSyncopeSyncope, vasovagalArrhythmiasCardiogenic shockConvulsion/grand mal seizureEpilepsyHypoglycemia, functionalIncreased intracranial pressureSeizure disorderHyperthermiaHypotensionOrthostatic hypotensionPost-ictal statusThyrotoxicosis (Graves disease)Hypothyroidism (myxedema)Encephalopathy, hypertensiveHypertension, malignantMalignant hyperthermiaMyxedema comaMyxedema madness/psychosisStokes-Adams attacksThyrotoxic crisisComplete heart blockInappropriate ADH secretionVertebrobasilar migraine syndromeHypothyroidism, juvenileNarcolepsyPickwick's syndromeReference to Organ SystemShockCerebral edemaDisseminated intravascular coagulopathyHepatic encephalopathyHypovolemic shockRenal Failure AcuteRespiratory distress (adult) syndromeBrain disordersRespiratory failure/Pulmonary insufficiencyEmphysema/COPD/Chronic lung diseaseCerebral thrombotic thrombocytopeniaHepatorenal syndromeRenal Failure ChronicUremic encephalopathyEncephalopathyHyperviscosity syndromePernicious anemiaPontine lesion/disorderThrombotic thrombocytopenic purpuraCombined system disease/pernicious an.Fever Unknown OriginReversable Posterior Encephalopathy SyndromePathophysiologicSepsis encephalopathy/elderlyCardiac output reductionCerebral depressed functionsDrugsMedication/drugsBenzodiazepines Administration/ToxicitySedative drugs Administration/ToxicityDigitalis toxicity/poisoningHypoglycemia, diabetic/treatmentInsulin overdose/exogenousIntoxication/overdose syndromeSalicylate intoxication/overdoseTricyclic overdoseBarbiturate/sedative abuse/dependentDrug induced Hypoglycemia.Oral hypoglycemic Administration/Toxicity/effectInsulin (Humulin/Novulin) Administration/ToxicityIsoniazid (INH/Nydrazid) Administration/ToxicityErgot toxicityIsoniazid hepatitisMilk-alkali syndromePoisoning (Specific Agent)Opiate overdose toxidromeKitchen gas/propane exposureAlcohol/Ethanol ingestion/intakeAlcohol amnestic disorderAlcohol induced hypoglycemiaAlcohol intoxication, acuteAlcohol seizure (rum fits)Cholinergic crisis toxidromeDelirium tremensInsecticide/organophosphate typeOverdose, drug/alcoholPoisoningSnakebite (neurotoxic/coral/cobra type)Snakebite (rattlesnake/pit viper type)Alcohol withdrawalHallucinogen abuseLead poisoning in childrenSmoke inhalationHeroin/morphine usage/addictionCyanide/Hydrogen cyanide exposure/poisoningVomiting CBW agent (Dm/Da/Dc) Weapon exposureArsine gas (Hydrogen arsenide) poisoningCarbon monoxide poisoning/exposureDiethylene Glycol poisoningEthylene glycol [Antifreeze] ingestionInsecticide/pesticide poisoningIntentional poisoningIsopropyl alcohol ingestion/poisoningMustard gas exposure/poisoningNerve gas exposureAluminum toxicity/syndromeAmmonia exposure/inhalationHydrogen sulfide poisoning/inhalationInsecticide/chlorinated/non-ester's inhLead poisoningLead encephalopathyNitrogen narcotic actionCarbon disulfide inhalant/poisoningChlorine gas poisoningMethane gas poisoning/asphyxiaCarbon dioxide gas inhalation/asphyxiaOrgan Poisoning (Intoxication)Neuroleptic malignant syndrome

Need to consider all the systems to figure out what is causing the change in mental status, behavior.

Causes: Many disorders/diseases, drugs, trauma etc.

Broad perspective in mind to avoid missing something

Need a through assessment including accurate vital signs, exam

Increased confusion

Decreased level of consciousness

Unable to perform usual activities

Agitation

Delusions or hallucinations

Unresponsiveness

New or worsened memory loss

Physical aggression (e.g. biting, hitting, kicking, spitting etc)

Physical symptoms, non-aggressive (e.g. inappropriate disrobing or voiding, repetitious mannerisms, wandering or attempts to elope)

Verbal aggression (e.g. cursing, screaming, etc…)

Verbal symptoms, non-aggressive (e.g. repetitive calling out or requests for attention, constant complaining or whining, etc…)

Social withdrawal (e.g. isolation, apathy)

Depression (e.g. crying, hopelessness, not eating, multiple

somatic complaints)

Mental Status

Functional Status

Cardiovascular

Respiratory

Gastrointestinal/abdomen

Genitourinary

Skin

Pain

Acute Mental Status Change Not eating or drinking Acute decline in ADL abilities New cough, abnormal lung sounds Nausea, vomiting, diarrhea Abdominal distension or tenderness Edema New or worsened incontinence, pain with urination, blood in urine New skin condition (e.g. rash, redness suggesting cellulitis, signs of infection around existing wound/pressure ulcer) Unrelieved pain New irregular pulse

Changes in Behavior Danger to self or others Suicidal ideation Symptoms or signs of pain Not eating or drinking at all Acute decline in ADL abilities Nausea, vomiting, diarrhea Abdominal distention or tenderness New cough, abnormal lung sounds New or worsened incontinence, pain with urination or

blood in urine New skin condition (e.g. rash, redness suggesting

cellulitis, signs of infection around existing wound or pressure ulcer)

Unrelieved pain

Obtain a through history

Perform physical examination

Blood work (CBC, BMP, others as indicated)

Portable chest X-ray (if indicated)

Urinalysis and C+S (if indicated)

WBC > 14,000 or neutrophils > 90%

Infiltrate or pneumonia on chest X-ray

Urine results suggest infection and symptoms or signs present

Monitor vital signs, fluid intake/ urine output every 4-8 hours

Oral, IV or subcutaneous fluids if needed for hydration

Check and follow up results of labs ordered

Consider non-pharmacologic interventions (e.g. sensory, environmental, exercise, others that have been effective for this resident in the past)

Evaluate for unmet needs, environmental factors, other non-medical causes

Pain management

Update advance care plan and directives if appropriate

Fever Definition

◦ One temp > 100˚F ( > 37.8˚C )

◦ Two temps >99˚F (>37.2˚C) oral or >99.5˚F (>37.5˚C) rectal

◦ Increase in temp of 2˚F ( 1.1˚C ) over baseline

Take Vital Signs

◦ BP, pulse, apical HR (if pulse irregular)

◦ Respirations

◦ Oxygen saturation

◦ Finger stick glucose (diabetics)

Evaluate s/s for immediate notification

Notify provider

Acute mental status change

Not eating or drinking

Acute decline in ADL abilities

New cough, abnormal lung sounds

Nausea, vomiting, diarrhea

Abdominal distension or tenderness

New or worsened incontinence, pain with urination, blood in urine

Very low urinary output

New skin condition (e.g. rash, redness suggesting cellulitis, signs of infection around existing wound/pressure ulcer)

Unrelieved pain

Portable chest X-ray

Urinalysis and C&S if indicated

Blood work (Complete Blood Count, Basic

Metabolic Panel)

Stool specimen for culture and C. Difficile

assay (diarrhea)

Nasal Pharyngeal swab for influenza

Critical values in blood count or metabolic panel

WBC > 14,000 or neutrophils > 90% Infiltrate or pneumonia on chest X-ray Positive C. Diff Positive flu result on swab Urine results suggest infection and symptoms or signs present

Management in Facility: ◦ Monitor vital signs, fluid intake/urine output every 4-

8 hrs for 24-72 hrs ◦ Do not give acetaminophen unless necessary for

comfort (it can mask fever), or until source of fever known

◦ If on diuretic, consider holding ◦ Oral, IV or subcutaneous fluids if needed for hydration ◦ Update advance care plan and directives if appropriate

Monitor Response ◦ Vital signs criteria met ◦ Worsening condition and/or immediate notification

criteria met

Reviewed symptoms associated with Acute Mental Status and Behavior Changes.

Identified the proper time to contact a provider

Preform the proper assessment and know the steps to take to report to the provider

Know when it is safe to manage the resident in the facility

Any questions?

SD Board of Social Work Examiners has approved this program for .1 CEU’s or 1 Contact Hour. Program Number 493

High, K.P., Bradley, S.F., Gravenstein, S., Mehr, D.R. ; Quagliarello, V. J., Richards, C. & Yoshikawa, T. T. (2009). Clinical Practice Guideline for the evaluation of fever and infection in older adult residents of long‐term care facilities: 2008 Update by the Infectious Diseases Society of America. Journal of the American Geriatrics Society, 57(3)7, 375- 394.

Interact. (2014). Care path mental status change. Retrieved from

http://interact2.net/docs/INTERACTVersion4.0 Tools/INTERACT 4.0 NH Tools 6_17_15/148604 Care_Path_MENTAL_STATUS_CHANGE_v10.pdf

Interact. (2014). Care path behavior change. Retrieved from

http://interact2.net/docs/INTERACTVersion 4.0Tools/INTERACT V4 Care Path Behavior Change Dec 10.pdf

Interact. (2014). Care path fever. Retrieved from

http://interact2.net/docs/INTERACT Version 4.0 Tools/INTERACT 4.0 NH Tools 6_17_15/148604 Care_Path_FEVER_v10.pdf