Toxic Metabolic Encephalopathy (TME)

Toxic metabolic encephalopathy is a type of brain disorder caused by a change in brain chemistry. This condition may result from illnesses or conditions that cause an imbalance of fluid, minerals (electrolytes), and other substances in the body that affect the way the brain functions.

It is not caused by brain damage or brain disease.

TME can cause confusion and other mental disturbances, which are generally referred to as delirium. Untreated delirium may lead to permanent mental changes or worsening medical conditions. Untreated delirium is a life-threatening condition that may need to be treated in the hospital.

What are the causes?

Possible causes of TME that can lead to delirium include:

• Short-term (acute) or long-term (chronic) disease of the kidney or liver.
• Not having enough fluid in the body (dehydration).
• Changes in the acid level (pH) of the blood.
• High or low levels of any of the following substances in the blood:
  • Calcium.
  • Salt (sodium).
  • Sugar (glucose).
  • Magnesium.
  • Phosphate.
• High body temperature.
• Not having enough oxygen in the blood.
• Low levels of B vitamins. This can result from alcohol abuse.
• Certain medicines, such as steroids and medicines that reduce the activity of the immune system (immunosuppressants).
• Certain infections.

What increases the risk?

You may have a higher risk for TME if you:

• Are elderly.
• Have dementia.
• Are in the hospital, especially in intensive care.
• Live in a nursing home.
• Had recent surgery.
• Have liver or kidney disease.
• Have poorly controlled diabetes.
• Have chronic medical problems, especially heart or lung disease.
• Are not getting enough fluids.
• Have poor nutrition.
• Abuse alcohol.

What are the signs or symptoms?

Symptoms of TME may include:

• Muscle stiffness or jerking (spasticity).
• Shaking (tremors).
• Flapping of the hands.
• Weakness.
• Clumsiness.
• Slowed breathing.
• Jerky movements that you cannot control (seizures).
• Not being able to stay awake (drowsiness).
• Not being able to pay attention.
• Loss of consciousness (coma).

Symptoms of delirium caused by TME include:

• Confusion.
• Difficulty focusing or concentrating, or inability to focus or concentrate.
• Not knowing where you are (disorientation).
• Seeing or hearing things that are not real (hallucinations).
• Fearfulness.
• False beliefs (delusions).
• Changes in mood or personality.
• Changes in speech, such as saying things that do not make sense.
• Memory loss.
• Irritability.
• Avoiding other people (withdrawal).
• Depression.
• Poor judgment.
• Changes in eating and sleeping patterns.
• Hyperactivity.
• Decreased alertness.
• General mistrust of others (paranoia).

Delirium may come and go. Symptoms of delirium may start suddenly or gradually, and they often get worse at night.

How is this diagnosed?

This condition is diagnosed based on:

• Your symptoms and behavior.
• An exam to check how you are thinking, feeling, and behaving (mental status exam). To diagnose delirium, the mental status exam must rule out other possible causes of TME, and must show:
  • Changes in attention and awareness.
  • Changes that develop over a short period of time and tend to come and go (fluctuate).
  • Changes in memory, language, and thinking that were not present before.
• A physical exam.
• Imaging tests, such as:
  • MRI.
  • CT scan.
• Blood tests to:
  • Measure liver and kidney function.
  • Check for a lack (deficiency) of vitamin B.
  • Check for changes in acid levels (pH) and changes in calcium, sodium, or magnesium levels in the blood.
  • Measure your blood sugar (glucose).
  • Measure your blood oxygen level.

How is this treated?

Treatment for TME depends on the cause, and it may include.

• Getting fluids through an IV tube.
• Regulating calcium, sodium, glucose, or magnesium levels in the body.
• Getting oxygen.
• Improving nutrition.
• Treating liver or kidney disease.
• Adjusting certain medicines.
• Treating infections.

If the cause is found and treated, delirium usually improves. Managing delirium may include:

• Keeping the room well-lit and quiet.
• Using calendars, pictures, and clocks to prevent disorientation.
• Having frequent checks from nursing staff and visits from caregivers.
• Wearing eyeglasses or a hearing aid, if needed.
• Physical therapy.
• Medicine to treat agitation, anxiety, hallucinations, or delusions.

Follow these instructions at home:

• Drink enough fluid to keep your urine clear or pale yellow.
• Take over-the-counter and prescription medicines only as told by your health care provider.
• Return to your normal activities as told by your health care provider. Ask your health care provider what activities are safe for you.
• Follow a healthy diet. Do not skip meals.
• Do not drink alcohol.
• Go to bed at the same time every night.
• Keep all follow-up visits as told by your health care provider. This is important.

Contact a health care provider if:

• You are unable to feed yourself or hydrate yourself.
• You need help at home.
• You start to feel clumsy.
• You start to have tremors or weakness.

Get help right away if:

• You have a seizure.
• You lose consciousness.
• You have trouble breathing.
• You do not feel able to care for yourself at home.
• You have a fever.
• You become disoriented at home.