11 Things: At a Glance
- You might be overdiagnosing transient ischemic attacks (TIA).
- Early mobilization after a stroke might be better for some patients.
- MRI is the best tool to evaluate TIA patients.
- Consider focal seizure or complex partial seizure as one of the possible causes of confusion or speech disturbance, or both.
- Tracking the time a hospitalized patient was last seen to be normal is crucial.
- Consider neuromuscular disorders when a patient presents with weakness.
- Urinary tract infections (UTIs) are not the only cause of altered mental status.
- Take care in distinguishing aphasia from general confusion.
- A simple checklist might eliminate the need to consult the neurologist.
- Calling a neurologist earlier is way better than calling later.
- Hire a neurohospitalist if your institution doesn’t have one already.
When a patient is admitted to the hospital with neurological symptoms, such as altered mental status, he or she might not be the only one who is confused. Hospitalists might be a little confused, too.
Of all the subspecialties to which hospitalists are exposed, none might make them more uncomfortable than neurology. Because of what often is a dearth of training in this area, and because of the vexing and sometimes fleeting nature of symptoms, hospitalists might be inclined to lean on neurologists more than other specialists.
The Hospitalist spoke with a half-dozen experts, gathering their words of guidance and clinical tips. Here’s hoping they give you a little extra confidence the next time you see a patient with altered mental status.
You might be overdiagnosing transient ischemic attacks (TIA).
Ira Chang, MD, a neurohospitalist with Blue Sky Neurology in Englewood, Colo., and assistant clinical professor at the University of Colorado Health Sciences Center in Denver, says TIA is all too commonly a go-to diagnosis, frequently when there’s another cause.
“I think that hospitalists, and maybe medical internists in general, are very quick to diagnose anything that has a neurologic symptom that comes and goes as a TIA,” she says. “Patients have to have specific neurologic symptoms that we think are due to arterial blood flow or ischemia problems.”
Near-fainting spells and dizzy spells involving confusion commonly are diagnosed as TIA when these symptoms could be due to “a number of other causes,” Dr. Chang adds.
Kevin Barrett, MD, assistant professor of neurology and a neurohospitalist at Mayo Clinic in Jacksonville, Fla., says the suspicion of a TIA should be greater if the patient is older or has traditional cardiovascular risk factors, such as hyptertension, diabetes, hyperlipidemia, or tobacco use.
A TIA typically causes symptoms referable to common arterial distributions. Carotid-distribution TIA often causes ipsilateral loss of vision and contralateral weakness or numbness. Posterior-circulation TIAs bring on symptoms such as ataxia, unilateral or bilateral limb weakness, diplopia, and slurred or slow speech.
TIA diagnoses can be tricky even for those trained in neurology, Dr. Barrett says.
“Even among fellowship-trained vascular neurologists, TIA can be a challenging diagnosis, often with poor inter-observer agreement,” he notes.
Early mobilization after a stroke might be better for some patients.
After receiving tissue plasminogen activator (tPA) therapy for stroke, patients historically were kept on bed rest for 24 hours to reduce the risk of hemorrhage. Evidence now is coming to light that some patients might benefit from getting out of bed sooner, Dr. Barrett says.1
“We’re learning that in selected patients, they can actually be mobilized at 12 hours,” he says. “In some cases, that would not only reduce the risk of complications related to immobilization like DVT but shorten length of stay. These are all important metrics for anybody who practices primarily within an inpatient setting.”
Early mobilization generally is more suitable for patients with less severe deficits and who are hemodynamically stable.
MRI is the best tool to evaluate TIA patients.
TIA patients who have transient symptoms and normal diffusion-weighted imaging (DWI) abnormalities on an MRI are at a very low risk. “Less than 1% of those patients have a stroke within the subsequent seven days,” Dr. Barrett says.2 “But those patients who do have a DWI abnormality, they’re at very high risk: 7.1% at seven days.
“The utility of MRI following TIA is becoming very much apparent. It is something that hospitalists should be aware of.”
Consider focal seizure or complex partial seizure as one of the possible causes of confusion or speech disturbance, or both.
Patients experiencing confusion or speech disturbance or altered mentation—particularly if they’re elderly or have dementia—could be having a partial seizure, Dr. Chang says. Dementia patients have a 10% to 15% incidence of complex partial seizures, she says.
“I see that underdiagnosed a lot,” she says. “They keep coming back, and everybody diagnoses them with TIAs. So they keep getting put on aspirin, and they get switched to Aggrenox [to prevent clotting]. They keep coming back with the same symptoms.”
Tracking the time a hospitalized patient was last seen to be normal is crucial.
About 10% to 15% of strokes occur in patients who are in the hospital.
“While a lot of those strokes are perioperative, there also are patients who are going to be on hospitalist services,” says Eric Adelman, MD, assistant professor of neurology at the University of Michigan in Ann Arbor.
Hospitalists should note that patients suffering strokes are found not just in the ED but also on the floor, where all the tools for treatment might not be as readily available. That makes those cases a challenge and makes forethought that much more important, Dr. Adelman says.
“It’s a matter of trying to track down last normal times,” he says. “If they’re eligible for tPA and they’re within the therapeutic window, we should be able to do that within a hospital.”
Establishing a neurological baseline is particularly important for patients who are at higher stroke risk, like those with atrial fibrillation and other cardiovascular risk factors.
“In case something does happen,” Dr. Adelman says, “at least you have a baseline so you can [know that] at time X, we knew they had full strength in their right arm, and now they don’t.”
Consider neuromuscular disorders when a patient presents with weakness.
It’s safe to say some hospitalists might miss a neuromuscular disorder, Dr. Chang says.
“A lot of disorders that are harder for hospitalists to diagnose and that tend to take longer to call a neurologist [on] are things that are due to myasthenia gravis [a breakdown between nerves and muscles leading to muscle fatigue], myopathy, or ALS,” she says. “Many patients present with weakness. I think a lot of times there will be a lot of tests on and a lot of treatment for general medical conditions that can cause weakness.”
And that might be a case of misdirected attention. Patients with weakness accompanied by persistent swallowing problems, slurred speech with no other obvious cause, or the inability to lift their head off the bed without an obvious cause may end up with a neuromuscular diagnosis, she says.
It would be helpful to have a neurologist’s input in these cases, she says, where “nothing’s getting better, and three, four, five days later, the patient’s still weak.
“I think a neurologist would be more in tune with something like that,” she adds.
Urinary tract infections (UTIs) are not the only cause of altered mental status.
That might seem obvious, but too often, a UTI can be pegged as the source of altered mental status when it should not be, Dr. Chang says.
“We get a lot of people who come in with confusion and they have a slightly abnormal urinalysis and they diagnose them with UTI,” Dr. Chang says. “And it turns out that they actually had a stroke or they had a seizure.”
Significantly altered mentation should show a significantly abnormal urine with a positive culture, she says. “They ought to have significant laboratory support for a urinary tract infection.”
Dr. Barrett says a neurologic review of systems, or at least a neurologic exam, should be the physician’s guide.
“Those are key parts of a hospitalist’s practice,” he says, “because that’s what’s truly going to guide them to consider primary neurological causes of altered mental status.”
Take care in distinguishing aphasia from general confusion.
If a patient is still talking and is fairly fluent, that doesn’t mean they aren’t suffering from certain types of aphasia, a disorder caused by damage to parts of the brain that control language, Dr. Adelman says.
“Oftentimes, when you’re dealing with a patient with confusion, you want to make sure that it’s confusion, or encephalopathy, rather than a focal neurologic problem like aphasia,” he says. “Frequently patients with aphasia will have other symptoms such as a facial drop or weakness in the arm, but stroke can present as isolated aphasia.”
A good habit to get into is to determine whether the patient can repeat a phrase, follow a command, or name objects, he says. If they can, they probably do not have aphasia.
“The thing that you worry about with aphasia, particularly acute onset aphasia, is an ischemic stroke,” Dr. Adelman says.
A simple checklist might eliminate the need to consult the neurologist.
When Edgar Kenton, MD, now director of the stroke program at Geisinger Health System in Danville, Pa., was at Emory University Hospital in Atlanta, he found he was getting snowed under with consults from hospitalists. There were about 15 hospitalists for just one or two neurologists.
“There was no way I was able to see these patients, particularly in follow-up, because you might get five consults every day,” he says. “By the middle of the week, that’s 15 consults. You don’t get a chance to go back and see the patients because you’re just going from one consult to the other.”
The situation improved with a checklist of things to consider when a patient presents with altered mental status. Before seeking a consult, neurologists suggested the hospitalists check the electrolytes, blood pressure, and urine, and use CT scans as a screening test. That might uncover the root of the patient’s problems. If those are clear, by all means get the neurologist involved, he says.
“We were able to educate the hospitalists so they knew when to call; they knew when it was beyond their expertise to take care of the patient, so we weren’t getting called for every patient with altered mental status when all they needed to do was to check the electrolytes,” Dr. Kenton says.
Calling a neurologist earlier is way better than calling later.
Once the decision is made to consult with a neurologist, the consult should be done right away, Dr. Kenton says, not after a few days when symptoms don’t appear to be improving.
“We’ll get the call on a Friday afternoon because they thought, finally, ‘Well, you know, we need to get neurology involved because we a) haven’t solved the problem and b) there may be some other tests we should be getting,’” he says of common situations. “That has been a problem. If you don’t have a neurohospitalist involved day by day, working with the patient and the general hospitalist, neurology becomes an afterthought.”
He says accurate and early diagnosis is paramount to the patient.
“If the diagnosis is delayed, obviously there’s more insult to the patients, more persistent insult,” he says, noting the timing is particularly important in neurological conditions “because things can get bad in a hurry.”
He strongly urges hospitalists to consult with a neurologist before ordering an entire battery of tests.
At Geisinger, neurologists are encouraging hospitalists to chat informally with neurosurgeons about cases for guidance at the outset rather than after several days.
Hire a neurohospitalist if your institution doesn’t have one already.
At the top of the list of Dr. Kenton’s suggestions on caring for hospitalized neurology patients is this declaration: “Get a neurohospitalist.”
“It’s important to have the neurologist involved from the time the patient’s admitted,” he says. “That’s the value of connecting the general hospitalist with neurologists.”
S. Andrew Josephson, MD, director of the neurohospitalist program at the University of California at San Francisco, says his colleagues are team players and improve patient care.
“Neurology consultations can be called very quickly, and a nice partnership can develop between internal medicine hospitalists and neurohospitalists to care for those patients who have those medical and neurologic problems,” he says.
He also says having a neurohospitalist on board can ease some of the tension.
“No longer if there’s a neurologic condition does a hospitalist have to think about, ‘Well, does this rise to the level of something that I need to get the neurologist to drive across the city to come see?’” he explains. “‘Or is this something we should try to manage ourselves?’”
Tom Collins is a freelance writer in South Florida.
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- Giles MF, Albers GW, Amarenco P, et al. Early stroke risk and ABCD2 score performance in tissue- vs. time-defined TIA: a multicenter study. Neurology. 2011;77(13):1222-1228.
- Zinchuk AV, Flanagan EP, Tubridy NJ, Miller WA, McCullough LD. Attitudes of US medical trainees towards neurology education: “Neurophobia”—a global issue. BMC Med Educ. 2010;10:49.