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 Dementia Acute, due to a proximate cause Altered Mental Status Often has altered arousal Shared Etiologies B12 Deficiency B1 Deficiency B6 Deficiency Thyroid Disorders Chronic, neurodegenerative process Altered Mental Status Arousal not affected (until late)
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? 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.Obtain neuroimaging B.Start Aricept C.Check B12 & TSH D.A&B E.B&C F.A&C G.All of the above
More Info What is this called? B12: 461 TSH: 2.6 Reference ranges B12: 250-1000 TSH: 0.47-4.68 What is this called? B12: 168 TSH: 3.9 Binswanger s Dementia Reversible dementia due to B12 Deficiency (vs. metabolic encephalopathy?)
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? Arousal Calculation Alertness Language Mental Status Orientation Memory Fund of Knowledge Attention
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?.