Neeta Garg, MD, on Neurological Diagnostic Testing Among Elderly Adults With Acute Altered Mental Status

In this podcast, Dr Garg discusses the findings from her recent study on neurological diagnostic testing among elderly adult patients with acute altered mental status. This study was featured in the 2020 American Academy of Neurology Science Highlights.

Additional Resources:

Lau HL, Gonzalez L, Bailey M, et al. Neurological diagnostic testing in elderly patients with acute altered mental status. Neurology. 2020;94(15 suppl.). https://n.neurology.org/content/94/15_Supplement/982

For more podcasts like this, visit Neurology Consultant.

Neeta Garg, MD, is a multiple sclerosis specialist and director of Quality and Patient Safety in the Department of Neurology at the University of Miami Miller School of Medicine.

TRANSCRIPT:

Christina Vogt: Hello everyone, and welcome back to another podcast. I’m Christina Vogt, associate editor of the Consultant360 Specialty Network. I’m joined by Dr. Neeta Garg, who is a multiple sclerosis specialist and director of Quality and Patient Safety for the Department of Neurology at the University of Miami Miller School of Medicine.

Today, we’ll be discussing her study, “Neurological Diagnostic Testing in Elderly Patients with Acute Altered Mental Status.”

So first, what prompted you and your colleagues to perform this study?

Dr Garg: One of my roles as a quality director for Neurology is to oversee in patient care, and most of this takes place at a hospital in Miami called Jackson Memorial Hospital. This is a tertiary care hospital with a very high volume of inpatient for neurology, and through my work on the inpatient side, where I also function as neuro-hospitalist for about 6 weeks a year, I really got interested in this topic because many of our inpatient neurology consults fall into one of these 3 major diagnostic categories: so, we have a lot of seizure patients, stroke is a big one, and then we have elderly patients who come with what’s called altered mental status or confusion.

So that's a very common reason for consultation, and as you take care of these patients, you realize that many of these patients probably have non-neurological problems prompting the state of confusion, and it's well described in literature. And we know from our personal experience as well, working as a neurologist with these patients, that many times the diagnosis is not directly related to any acute neurological problem–for example, stroke or infection, meningitis, or brain tumor. So, mind you, these conditions can also result in confusion state in elderly, but by far, majority of cases are due to what's called a systemic or medical condition. For example, a UTI or medication side effect or electrolyte imbalance, sugar being too high or low–things like that, which ultimately result in presentation being neurological, but the cause in most cases is not directly related to neurological disease.

Christina Vogt: Could you discuss the key findings from your study?

Dr Garg: The findings from our study can be described very simply in one line that, as we expected, most patients, when we looked at the diagnosis, the primary cause for their confusion or delirium state–the reason or diagnosis in most cases was not directly related to a primary neurological condition, so many of these patients–more than three-quarters–ended up being due to, as suspected, either a drug side effect or electrolyte abnormality–for example, sodium or other electrolytes being low or high or from other infectious causes. So, that was the highlight of our study, finding that a majority of these cases fell into medical categories when we looked at the direct cause for delirium or confusion in patients, and we looked at mostly elderly patients–so, our age criteria was over 60 in the study.

We found majority of cases were due to medical conditions or infectious causes, and we looked at the predictors of readmission, and that also fell into systemic disease category, like patients having one or more systemic conditions like diabetes, hypertension, heart disease, were more likely to be admitted–readmitted within 30 days. So, that was another related study. So, I've been very interested in this topic because I think it has huge implications for management and health care costs because, as you know, we will discuss further later on that these patients undergo extensive and expensive testing. Most cases actually have low yield because, as we expect, majority of cases are not because of neurological causes. And not only does it add to cost, but also prolongs their length of stay and adds to patient care not being optimal for these groups of patients.

Christina Vogt: What direction should future research take now after this study?

Dr Garg: So, we have a quality improvement project on this topic. After we looked at the readmission rate and utilization of all these newer diagnostic testing, including MRI, EEG, and some patients a spinal tap, which is a really invasive test. So, our goal is to standardize care for these patients when we are called–our trainees, residents, and fellows are called for a consultation for this particular diagnosis or condition called acute mental status or acute confusion or encephalopathy. We plan to have a standardized care pathway so we can triage high risk patients who, on our screening questionnaire would have lower risk of having a neurological condition as a cause for their changing mental status.

So, these patients can be carefully monitored with less amount of testing initially if there's a clear trigger, for example, a UTI or pneumonia or sodium or sugar abnormalities on blood testing–these patients can be watched for at least 24 hours or 48 hours and not undergo these expensive and often low-yield tests, and if their condition improves after correction of these metabolic and infectious triggers, then probably we can avoid these patients having these tests.

For example, every patient who comes to emergency room or is admitted in the hospital and has any change in mental status–almost 100% of these would have a CT scan imaging of the head, which is good and reassuring for the direct providers, which mostly include hospitalists and internists. But really, as I said, the yield is quite low. And in the majority of cases, it doesn't give you a clue to what may be causing the symptoms and as you know, CT scan, costs aside, also adds to radiation exposure to these patients, and t elderly patients especially are at higher risk of being readmitted either from their neurological condition or because of other medical issues or procedures that they undergo. So, every time they come to the hospital and have any kind of change in mental status, it will result in a CAT scan, which not only does not help, but adds to cost and harm to the patient.

Christina Vogt: What are the key takeaways neurologists should keep in mind about this topic?

Dr Garg: I would say the main takeaway message is that we know from literature and our own experience that the majority of elderly patients, when they have an acute or sub-acute change in their mental status or they become suddenly confused, whether it's an ER visit or during hospitalization, the cause tends to be a medical abnormality or condition or systemic infection of some sort or the medications is a big, huge factor, too. As you know, polypharmacy as it's called–having people on multiple medications, especially sedating medications, painkillers–can make patients in older age groups very susceptible to the side effects, especially if they use in combination.

So, careful review of medical history and medication list, routine laboratory testing to see if there's glucose level, sodium level, and other kidney function, liver function etc. are normal, then you can proceed with a higher specialized testing, including a CT scan or MRI imaging of the brain or even, in some cases, EEG which is usually used to diagnose seizures, and spinal tap when you suspect infection involving the brain, such as meningitis.

So, these highly specialized tests can be utilized in a more appropriate manner. If you triage, the highest patients based careful review of the medical history, medication list, and screening laboratory tests, which almost every patient has once they come to a hospital, whether it's emergency room or whether they are admitted to a hospital. These things are already available for the provider, whether they are the primary care team or the neurology consulting team. So, having assessment in a stepwise manner really would help not only avoiding these tests, but also optimizing care because if you diagnose the patient's condition more accurately and rapidly, then the care is going to be better, and outcomes hopefully will be better.

On the other hand, if these patients undergo these tests, and whether they are unrevealing or negative and don't give a clue to the cause, but you may find some other, what we call incidental or asymptomatic findings, which can lead to further testing, and that just prolongs not only the length of stay, but cost and also aggravation to the patients. So, a lot of it is education to the primary care team, which mostly consists of internists and hospitalists or ER physicians. So, one of the next steps that we plan to take at Jackson Memorial Hospital where we would implement this clinical care pathway–the first step would be to educate these teams and have them on board because they are the primary and main stakeholders in this. They are the ones who see the patient firsthand and call for consultation and, while waiting for neurology consultation to be done, invariably these tests are ordered.

Christina Vogt: Thanks again for joining me today, Dr. Garg. For more podcasts like this, visit Consultant360.com.