Seizures as a cause of altered mental status

A Medical Incapacity Hold Policy Reduces Inappropriate Use of Involuntary Psychiatric Holds While Protecting Patients From Harm

BACKGROUND

The use of involuntary psychiatric holds (IPH) to detain patients who lack the capacity to make health care decisions due to nonpsychiatric conditions is common. While this practice prevents patient harm, it also deprives civil liberties, risks liability for false imprisonment, and may hinder disposition. Medical incapacity hold (MIH) policies, which establish institutional criteria and processes for detaining patients who lack capacity but do not meet criteria for an IPH, provide a potential solution.

METHODS

A retrospective chart review was conducted on adult medical/surgical inpatients placed on an IPH or MIH over the 1-year periods before and after implementation of a MIH policy at an academic medical center. The primary outcome was frequency of IPH utilization in patients who did not qualify for an IPH as determined by 2 independent physician reviewers. A Cohen's kappa was calculated to determine inter-rater reliability. Differences in patient demographics and outcomes were compared using a Student's t-test, Wilcoxon rank-sum test, and Pearson chi-square test (α = 0.05).

RESULTS

The Cohen's kappa was 0.72 indicating substantial agreement. Seventy MIHs were placed after implementation (mean duration 4.3 days). Before MIH implementation, 17.6% of IPHs were placed on non-qualifying patients, which decreased to 3.9% following MIH implementation (p < 0.01). The average length of stay for patients on an IPH or MIH did not change following MIH implementation. No instances of patient elopement, grievances, or litigation were found.

CONCLUSION

MIH policies benefit both patients lacking capacity and the health care systems seeking to protect them while avoiding inappropriate use of IPHs.

Overuse of Head Computed Tomography in Cirrhosis With Altered Mental Status

BACKGROUND

Head computed tomography (CT) scans are ordered in patients with cirrhosis along with altered mental status (AMS) during admission, often, despite lack of evidence of any structural abnormality. Thus, we aimed to examine the use of head CT scans in patients with cirrhosis along with AMS and to correlate scan abnormalities with causes of AMS and physical findings.

MATERIALS AND METHODS

We defined AMS as having impaired cognition, diminished attention, reduced awareness or altered level of consciousness or all of these, and categorized AMS into the following groups: hepatic encephalopathy (HE), sepsis or infectious, metabolic, exogenous drugs or toxins, structural lesions or psychiatric abnormalities. The primary outcome was presence of any structural brain lesion on head CT scan in patients with cirrhosis along with AMS with correlation of focal neurologic deficits, specifically in patients with HE.

RESULTS

In total, 349 of 1,218 patients with cirrhosis who were admitted to the hospital had AMS; HE was the most common cause of AMS (164 of 349, 47%). A total of 64% (223 of 349) of patients with cirrhosis along with AMS underwent head CT scanning on admission, including 99 of 164 (60%) patients with HE. No patient with HE had focal neurologic findings, or a focal abnormality on head CT scan. Of the patients with focal abnormalities on CT scans, 100% had focal neurologic findings. Patients with cirrhosis along with AMS undergoing head CT scan had similar mortality (76 of 223, 34%) as those with AMS not undergoing head CT scans (47 of 126, 37%; P = nonsignificant).

CONCLUSIONS

Nearly two-thirds of patients with cirrhosis along with AMS had head CT scans performed on admission; all patients with a structural lesion on head CT scan had abnormal neurologic examinations. The data suggest that routine brain imaging in patients with cirrhosis that do not have focal neurologic findings is likely not indicated.

Approach to syncope and altered mental status

Children who present with an episode of altered mental status, whether transient or persistent, present a diagnostic challenge for practitioners. This article describes some of the more common causes of altered mental status and delineates a rational approach to these patients. This will help practitioners recognize the life-threatening causes of these frightening presentations as well as help avoid unnecessary testing for the more benign causes.

Nonconvulsive status epilepticus in hepatic encephalopathy

We discuss a case of a 64-year-old male with a history of liver failure presenting with altered mental status, initially diagnosed with hepatic encephalopathy but ultimately diagnosed with nonconvulsive status epilepticus (NCSE) by electroencephalogram (EEG). NCSE is a difficult diagnosis to make, given no clear consensus on diagnostic criteria. Especially in the intensive care unit setting of persistent altered mental status with no clear etiology, NCSE must be considered in the differential diagnosis, as the consequences of delayed diagnosis and treatment can be substantial. EEG can be useful in the evaluation of patients with hepatic encephalopathy who have persistently altered levels of consciousness despite optimal medical management.