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@KingsIoPPN @TheLancetPsych @NeuroCov @Tim_R_Nicholson @tompollak @rcpsych 1/

Trying to understand the case definition section here.

"altered mental status (defined as an acute alteration in
personality, behaviour, cognition, or consciousness) ... "

altered mental status then divided into:
@KingsIoPPN @TheLancetPsych @NeuroCov @Tim_R_Nicholson @tompollak @rcpsych 2/

(a) (encephalopathy, encephalitis—
defined as encephalopathy with evidence of inflammation
in the CNS [CSF white cell count >5 cells per µL, protein
>0·45 g/dL, or MRI consistent with inflammation],
seizures [clinical or electroencephalographic evidence],

and ...
@KingsIoPPN @TheLancetPsych @NeuroCov @Tim_R_Nicholson @tompollak @rcpsych 3/

(b) neuropsychiatric syndromes notified through psychiatrists or neuropsychiatrists [psychosis, neurocognitive dementia-like syndrome, personality change, catatonia, mania, anxiety or depression, chronic fatigue syndrome, and post-traumatic stress disorder]);
@KingsIoPPN @TheLancetPsych @NeuroCov @Tim_R_Nicholson @tompollak @rcpsych 4/

"153 unique cases that met the clinical case definitions by clinicians in the UK"
@KingsIoPPN @TheLancetPsych @NeuroCov @Tim_R_Nicholson @tompollak @rcpsych 5/

"data on reporting physician specialty were available
for 150 patients: 61 (41%) were stroke physicians,
39 (26%) were neurologists, 26 (17%) were psychiatrists
or neuropsychiatrists, 23 (15%) were acute medicine or
other physicians, and one (1%) was a general practitioner."
@KingsIoPPN @TheLancetPsych @NeuroCov @Tim_R_Nicholson @tompollak @rcpsych 6/

"Beyond cerebrovascular events, 39 (31%) of 125 patients presented with altered mental status, comprising nine (23%) patients with unspecified encephalopathy..."
@KingsIoPPN @TheLancetPsych @NeuroCov @Tim_R_Nicholson @tompollak @rcpsych 7/

"The remaining 23 (59%) patients with altered mental status fulfilled the clinical case definitions for psychiatric Dx as classified by the notifying psychiatrist or neuropsychiatrist."

"Only 2 (9%) of 23 patients had exacerbations of existing enduring mental illness."
@KingsIoPPN @TheLancetPsych @NeuroCov @Tim_R_Nicholson @tompollak @rcpsych 8/

"Ten (43%) of 23 patients with neuropsychiatric disorders had new-onset psychosis, six (26%) had a neurocognitive (dementia-like) syndrome, and seven (30%) had an other psychiatric disorder, including one case of catatonia and one case of mania."
@KingsIoPPN @TheLancetPsych @NeuroCov @Tim_R_Nicholson @tompollak @rcpsych 9/

"we identified a large proportion of cases of acute alteration in mental status, comprising neurological syndromic diagnoses such as encephalopathy and encephalitis and primary psychiatric syndromic diagnoses, such as psychosis."
@KingsIoPPN @TheLancetPsych @NeuroCov @Tim_R_Nicholson @tompollak @rcpsych 10/

"Altered mental status is common in patients admitted
to hospital with severe infection, especially in those
requiring intensive care management.

"However, this symptom typically predominates in older groups, ... "
@KingsIoPPN @TheLancetPsych @NeuroCov @Tim_R_Nicholson @tompollak @rcpsych 11/

" ... and might reflect an unmasking of latent neurocognitive degenerative disease or multiple medical comorbidities, often in association with sepsis, hypoxia, and the requirement for polypharmacy and sedative medications."
@KingsIoPPN @TheLancetPsych @NeuroCov @Tim_R_Nicholson @tompollak @rcpsych 12/

"The large number of patients with altered mental status might reflect increased access to neuropsychiatry or psychiatry review for younger patients, and increased attribution of altered mental status to delirium in older patients."
@KingsIoPPN @TheLancetPsych @NeuroCov @Tim_R_Nicholson @tompollak @rcpsych 13/

This study is of great interest with respect especially to the cerebrovascular & confirmed encephalitis findings.

From a diagnostic and data-sharing point of view the 'altered mental status' construct is important.
@KingsIoPPN @TheLancetPsych @NeuroCov @Tim_R_Nicholson @tompollak @rcpsych 14/

The line " ... increased attribution of altered mental status to delirium in older patients."

I am wondering if #delirium was considered as a diagnosis in this study? Was it recorded as such?
@KingsIoPPN @TheLancetPsych @NeuroCov @Tim_R_Nicholson @tompollak @rcpsych 15/

Are talking about #delirium as a Dx used by some doctors but not others, who use other terms like 'altered mental status'; 'new-onset psychosis', 'neurocognitive (dementia-like) syndrome'

Or, are these different clinical entities?
@KingsIoPPN @TheLancetPsych @NeuroCov @Tim_R_Nicholson @tompollak @rcpsych 16/

It's interesting because there is already quite a literature on #delirium as a presenting feature of #COVID19.

Eg. medrxiv.org/content/10.110…
@KingsIoPPN @TheLancetPsych @NeuroCov @Tim_R_Nicholson @tompollak @rcpsych 17/

It's also interesting in the context of a new paper with consensus guidelines from 10 societies on the nomenclature of delirium and encephalopathy which was published recently: pubmed.ncbi.nlm.nih.gov/32055887/
@KingsIoPPN @TheLancetPsych @NeuroCov @Tim_R_Nicholson @tompollak @rcpsych 18/

This paper found almost complete segregation of the academic literature on delirium & encephalopathy - see picture.
@KingsIoPPN @TheLancetPsych @NeuroCov @Tim_R_Nicholson @tompollak @rcpsych 19/

It matters in #COVID19 infection because if some groups of doctors are using 'altered mental status' as a starting point but not progressing to DSM-5 #delirium where appropriate, & others are, then treatment pathways & communication with pts & families will be inconsistent.
@KingsIoPPN @TheLancetPsych @NeuroCov @Tim_R_Nicholson @tompollak @rcpsych 20/

So can I ask the authors if they think that DSM-5 #delirium was present but labelled differently?

Eg. 'unspecified encephalopathy', 'new onset psychosis', 'neurocognitive (dementia-like) syndrome'.

Or, are these other entities that don't fit DSM-5 #delirium criteria?
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