How to manage altered mental status in multiple sclerosis (MS) patients?

Management of Altered Mental Status in Multiple Sclerosis Patients

Brain MRI without and with IV contrast is the first-line imaging test for evaluating altered mental status in multiple sclerosis patients, as it can detect disease progression, new lesions, and rule out other causes of neurological deterioration. 1

Initial Assessment

When evaluating altered mental status (AMS) in MS patients, consider:

• MS-specific causes:

  • Disease progression/new lesions
  • Medication side effects
  • Pseudoexacerbation due to infection
  • Cognitive impairment

• Non-MS causes:

  • Infection (urinary tract, respiratory)
  • Metabolic derangements
  • Medication effects/interactions
  • Other neurological conditions

Diagnostic Approach

1. Clinical evaluation:

   • Assess for focal neurological deficits
   • Check vital signs (fever may indicate infection)
   • Review medication history (particularly disease-modifying therapies)
   • Evaluate for signs of infection

2. Laboratory testing:

   • Complete blood count
   • Basic metabolic panel
   • Liver function tests
   • Urinalysis
   • Blood cultures if febrile
   • Thyroid function tests

3. Neuroimaging:

   • MRI brain without and with IV contrast is superior for detecting MS disease activity, small ischemic infarcts, subtle cases of subarachnoid hemorrhage, encephalitis, and focal cerebral edema 1, 2
   • CT head without contrast may be appropriate for initial rapid assessment if there is concern for acute intracranial pathology requiring immediate intervention 1

Management Strategies

MS Disease Activity

• If new or enhancing lesions are found:
  • Consider high-dose corticosteroids (methylprednisolone 1g IV daily for 3-5 days)
  • Evaluate current disease-modifying therapy and consider escalation if appropriate 3

Medication-Related Causes

• Review all medications for potential neuropsychiatric effects
• Disease-modifying therapies can cause various neuropsychiatric symptoms
• Consider temporary discontinuation of suspected medications
• Monitor for Neuroleptic Malignant Syndrome if patient is on antipsychotics 1

Infection Management

• Treat identified infections promptly
• Consider empiric antibiotics if infection is strongly suspected
• Remember that infections can trigger MS pseudoexacerbations

Psychiatric Considerations

• MS patients have higher rates of psychiatric disorders, particularly mood disorders 4
• MS patients with mood or anxiety disorders are almost five times more likely to have poor adherence to disease-modifying therapies 5
• Consider psychiatric consultation for patients with prominent mood or psychotic symptoms

Special Considerations

• Cognitive impairment: Common in MS and may contribute to altered mental status; formal neuropsychological testing may be beneficial
• Treatment adherence: Poor adherence to disease-modifying therapies is associated with memory difficulties, anxiety, depression, neuroticism, and low conscientiousness 5
• Manic symptoms: MS patients presenting with psychiatric symptoms are more likely to present with histories of mania and manic psychosis 4

Common Pitfalls

• Attributing all neuropsychiatric symptoms to MS without considering other causes
• Failing to recognize that psychiatric symptoms may precede MS diagnosis 4
• Overlooking medication side effects or interactions
• Missing infections that can exacerbate MS symptoms
• Overreliance on normal neuroimaging when clinical suspicion remains high 2

By following this structured approach, clinicians can effectively evaluate and manage altered mental status in MS patients, addressing both MS-specific and non-MS causes to improve outcomes.