Dr. Barrett
Dr. Adelman
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.”