Seminars in Neurology最新文献

Patients undergoing solid-organ transplantation (SOT) face a tumultuous journey. Prior to transplant, their medical course is characterized by organ dysfunction, diminished quality of life, and reliance on organ support, all of which are endured in hopes of reaching the haven of organ transplantation. Peritransplant altered mental status may indicate neurologic insults acquired during transplant and may have long-lasting consequences. Even years after transplant, these patients are at heightened risk for neurologic dysfunction from a myriad of metabolic, toxic, and infectious causes. This review provides a comprehensive examination of causes, diagnostic approaches, neuroimaging findings, and management strategies for altered mental status in SOT recipients. Given their complexity and the numerous etiologies for neurologic dysfunction, liver transplant patients are a chief focus in this review; however, we also review lesser-known contributors to neurological injury across various transplant types. From hepatic encephalopathy to cerebral edema, seizures, and infections, this review highlights the importance of recognizing and managing pre- and posttransplant neurological complications to optimize patient outcomes.

Delirium and dementia are common causes of cognitive impairment in older adults. They are distinct but interrelated. Delirium, an acute confusional state, has been linked to the chronic and progressive loss of cognitive ability seen in dementia. Individuals with dementia are at higher risk for delirium, and delirium itself is a risk factor for incident dementia. Additionally, delirium in individuals with dementia can hasten underlying cognitive decline. In this review, we summarize recent literature linking these conditions, including epidemiological, clinicopathological, neuroimaging, biomarker, and experimental evidence supporting the intersection between these conditions. Strategies for evaluation and diagnosis that focus on distinguishing delirium from dementia in clinical settings and recommendations for delirium prevention interventions for patients with dementia are presented. We also discuss studies that provide evidence that delirium may be a modifiable risk factor for dementia and consider the impact of delirium prevention interventions on long-term outcomes.

Mental status is the collection of an individual's consciousness, perception, emotion, memory, and cognition at a particular point in time, which is inferred by the clinician through careful observation and interaction. The pediatric mental status assessment must be approached with an understanding of cognitive, language, and psychosocial development. Alterations must then be comprehensively and clearly described. Delirium is a phenotypic diagnosis with a specific set of criteria in the DSM and is a serious neurocognitive disorder caused by physiologic changes due to illness, injury, toxins, medications, and/or substances. Recognition of delirium in children is improved by monitoring of predisposing risks and precipitating factors, as well as the regular use of validated pediatric screening tools. Management of delirium is focused on treatment of the underlying etiology, prevention of iatrogenic deliriogenic factors, and patient safety.

Acute encephalopathy is a common presenting symptom in the emergency room and complicates many hospital and intensive care unit admissions. The evaluation of patients with encephalopathy poses several challenges: limited history and examination due to the patient's mental status, broad differential diagnosis of systemic and neurologic etiologies, low yield of neurodiagnostic testing due to the high base rate of systemic causes, and the importance of identifying less common neurologic causes of encephalopathy that can be life-threatening if not identified and treated. This article discusses the differential diagnosis of acute encephalopathy, presents an approach to the history and examination in a patient with encephalopathy, reviews the literature on the yield of neurodiagnostic testing in this population, and provides a diagnostic framework for the evaluation of patients with altered mental status.

Consultation liaison psychiatrists are frequently asked to evaluate patients with altered mental status (AMS). Psychiatrists have unique perspectives and approaches to care for confused patients, particularly optimizing facilitation of care and maintaining vigilance for diagnostic overshadowing. Psychiatrists also offer expertise in primary psychiatric illnesses that can overlap with AMS, and the most common etiology of AMS is delirium. In this article, we provide a consultation liaison psychiatrist perspective on AMS and related psychiatric conditions in addition to delirium. Manic and psychotic episodes have primary and secondary etiologies, with some symptoms that can overlap with delirium. Catatonia, neuroleptic malignant syndrome, and serotonin syndrome are potentially fatal emergencies, and require prompt index of suspicion to optimize clinical outcomes. Trauma sequelae, functional neurologic disorders, and dissociative disorders can present as puzzling cases that require psychiatric facilitation of care. Additionally, AMS is sometimes due to substance intoxication and withdrawal in the hospital. A nonstigmatizing approach to evaluation and management of delirium and AMS can ensure optimal patient care experiences and outcomes.

Altered mental status (AMS) is a syndrome posing substantial burden to patients in the intensive care unit (ICU) in both prevalence and intensity. Unfortunately, ICU patients are often diagnosed merely with syndromic labels, particularly the duo of toxic-metabolic encephalopathy (TME) and delirium. Before applying a nonspecific diagnostic label, every patient with AMS should be evaluated for specific, treatable diseases affecting the central nervous system. This review offers a structured approach to increase the probability of identifying specific causal etiologies of AMS in the critically ill. We provide tips for bedside assessment in the challenging ICU environment and review the role and yield of common neurodiagnostic procedures, including specialized bedside modalities of diagnostic utility in unstable patients. We briefly review two common etiologies of TME (uremic and septic encephalopathies), and then review a selection of high-yield toxicologic, neurologic, and infectious causes of AMS in the ICU, with an emphasis on those that require deliberate consideration as they elude routine screening. The final section lays out an approach to the various etiologies of AMS in the critically ill.

The evaluation and diagnosis of altered mental status in the pregnant or postpartum patient largely parallels the approach used for any other patient; however, there are several critical differences including that some neuroobstetric diagnoses require emergent delivery of the fetus. Being familiar with the physiological changes and medical complications of pregnancy and delivery is therefore essential. This review first addresses pregnancy-specific disorders that may result in altered mental status, such as the hypertensive disorders of pregnancy and pregnancy-related metabolic and endocrinopathies. The focus then shifts to the complex physiologic changes in pregnancy and how these changes contribute to the distinct epidemiology of pregnancy-related cerebrovascular complications like intracranial hemorrhage, ischemic stroke, and reversible cerebral vasoconstriction syndrome. Medical disorders that are not unique to pregnancy, such as infections and autoimmune conditions, may present de novo or worsen during pregnancy and the peripartum period and require a thoughtful approach to diagnosis and management. Finally, the unique nervous system complications of obstetric anesthesia are explored. In each section, there is a focus not only on diagnosis and syndrome recognition but also on the emergent treatment needed to reverse these complications, bearing in mind the unique physiology of the pregnant patient.

Delirium has been recognized, documented, and examined for centuries. In 500 BC Hippocrates described hyper- and hypoactive forms of delirium. As medicine, surgery, and critical care have accelerated over the last century, so too has our understanding of delirium and its profound risks to patients, families, and health care teams. It has also been increasingly understood that it is the accumulation of risk factors that ultimately precipitates delirium and nonpharmacological interventions to reduce these risks remain the cornerstone of delirium prevention and management. However, over the last three decades, these nonpharmacological strategies have moved from a single-component approach to a multicomponent approach, targeting multiple risk factors. Additionally, our understanding of what constitutes a risk factor for delirium has evolved, and in particular, it has been recognized that delirium can sometimes be a byproduct of our interventions and health care systems. In the surgical setting, for example, optimization of risk factors prior to surgery, when possible, is now seen as a key way to prevent postoperative delirium. Similarly, critical care medicine now operates with the appreciation of the profound risk to patients of prolonged mechanical ventilation, sedation, and immobilization and seeks to minimize each to reduce the risk of delirium, among other negative effects. The future of delirium prevention and management lies in both better implementation of best practices that have been defined over the last three decades as well as taking more of a whole patient view. This includes harnessing the electronic medical record, artificial intelligence, and so on to risk assess and individualize care for each patient; restructuring care to reduce deliriogenic practices and care environments; redefining what usual care looks like (e.g., utilizing music and involving loved ones, etc.); policy changes to change systematic priorities. In this paper, we will explore the past, present, and future of nonpharmacological prevention and management of delirium across care settings.

Disorders of consciousness represent altered mental status at its most severe, comprising a continuum between coma, the vegetative state/unresponsive wakefulness syndrome, the minimally conscious state, and emergence from the minimally conscious state. Patients often transition between these levels throughout their recovery, and determining a patient's current level can be challenging, particularly in the acute care setting. Although healthcare providers have classically relied on a bedside neurological exam or the Glasgow Coma Scale to aid with assessment of consciousness, studies have identified multiple limitations of doing so. Neurobehavioral assessment measures, such as the Coma Recovery Scale-Revised, have been developed to address these shortcomings. Each behavioral metric has strengths as well as weaknesses when applied in the acute care setting. In this review, we appraise common assessment approaches, outline alternative measures for fine-tuning these assessments in the acute care setting, and highlight strategies for implementing these practices in an interdisciplinary manner.