Guest Post: Review clinical picture prior to querying for altered mental status

by Robert S. Gold, MD

Determining when to seek clarification regarding patients with altered mental status can be tricky business. Patients who already have established dementia and are now off their baseline with an acute metabolic disorder such as UTI, physicians are typically good at documenting that fact. They also indicate when a family member indicates the patient’s behavior is different than normal or when the nursing home staff member indicates the patient’s mental status has changed.

CDI specialists, however, often have a difficult time determining whether the physician means to document a condition due to dementia or whether the patient’s confusion is due to an additional condition such as encephalophy on top of dementia.

It can be difficult for someone without first-hand experience with patients with senile dementia or Alzheimer’s disease or other degenerative brain disorder to visualize the variances that these folks have day-to-day and situation-to-situation. Whether this pertains to a member of your family or whether dealing with patients in a hospital or other care facility and trying to describe this in a note can be challenging, but I’ll give it a go.

Patients with many degenerative brain disorders respond with delirium, or withdrawal, or sleepiness (lethargy), to any change in their environment. Move a patient from a location where he feels comfortable to a different location that isn’t familiar, he can withdraw or get delirious. Furthermore, if they get a little dehydrated, they seem less responsive. Give them a glass of water (or a bolus of 500 ml of saline), they may perk up. It’s all part of the basic condition.

A true encephalopathy (the intent of ICD-9-CM codes in the 348 grouping) is to describe a toxic condition with the potential of causing permanent harm to the brain. These include many of the metabolic encephalopathies as exist in hepatic encephalopathy with ammonia running around, hypercalcemic encephalopathy with calcium in the 12 range, and metabolic encephalopathy that can occur with sepsis.

Metabolic encephalopathy due to a septic condition requires documentation of more than a slight alteration of consciousness as the patient with septic encephalopathy is already not perfusing the kidneys and other body organs. Look for elevations of creatinine (which may not yet be acute kidney injury) or the look for documentation about whether patient is breathing weird (may not yet be acute respiratory failure). These indicators reflect the fact that the patient is awfully sick. If that patient perks up after a little saline, it wasn’t septic encephalopathy. If it takes a couple of days of high powered antibiotics, maybe it was.

The other encephalopathies (toxicity to long term alcohol exposure, poisonings, Lyme encephalopathy, transmissible spongiform encephalopathy or Mad Cow disease, etc.) don’t apply to this case, so I won’t go into them.

Basically, CDI specialists should determine the patient’s response to initial treatment and the overall clinical picture of how sick the patient is before asking the physician about altered mental status. Maybe it was just Sun-downing Syndrome.

Editor’s note: Gold founded DCBA, Inc., in Atlanta, a consulting firm that provides physician-to-physician programs in CDI. The goals are data accuracy, profile management, and compliance in the inpatient and outpatient arenas. At the time of this article’s original release, he was a member of the ACDIS Advisory Board.