ALTERED MENTAL STATUS   55A

An 82-year-old woman with mild dementia is hospitalized in the intensive care unit (ICU) for urosepsis and treated with intravenous antibiotics. On hospital day 3, despite improvement of her sepsis, she becomes acutely confused. Her other medications include opiates for pain and diphenhydramine for insomnia. On physical examination, she is alert and can remember her name but has poor attention and believes that she is in a grocery store and that the year is 1952. Her neurologic examination findings are otherwise normal. She appears agitated and has been aggressive with the nursing staff. On subsequent examination later in the day, her symptoms are significantly better.

What are the salient features of this patient’s problem? How do you think through her problem?

Salient features: Elderly woman with underlying dementia; ICU admission; confusion despite appropriate treatment of underlying disease; opioid and anticholinergic use; disoriented with poor attention; non-focal neurologic examination; agitation; waxing and waning course

How to think through: Altered mental status is common among patients, disarming for clinicians, and alarming to families. A patient in the emergency department with altered mental status requires a broad diagnostic approach. We have more information about this hospitalized patient. What is the term for her constellation of features? (Delirium.) What are the defining features of delirium? (Acute onset or waxing and waning course and inattention and one of the following: disorganized thinking or altered level of consciousness.) How is attention assessed? (Serial 7s or spelling WORLD backwards.) What are common risk factors that predispose patients to delirium? (Baseline cognitive impairment, older age, severe illness, pain, presence of a Foley catheter, use of restraints, and polypharmacy.) What are the three most common medicine classes that contribute to delirium in elderly adults? (Benzodiazepines, opioids, and anticholinergics.) How should this patient be managed? (Discontinue medications with central nervous system [CNS] activity when possible. Nonpharmacologic interventions are the mainstay, including frequent reorientation of patient; family involvement; darkness and quiet at night, minimizing vital signs and other disruptions; manual tasks for distraction during daytime. Use of neuroleptic medications is controversial [because of increased mortality] and so is limited to patients with agitation that places them at risk of harm or that causes distress.)

ALTERED MENTAL STATUS   55B

What are the essentials of diagnosis and general considerations regarding altered mental status?

Essentials of Diagnosis

Altered mental status broadly refers to an change in level of consciousness and can include delirium, stupor, and coma.

Delirium is a transient global disorder of attention, often as a result of a systemic problem.

Stuporous patients respond only to repeated vigorous stimuli; comatose patients are unarousable and unresponsive.

General Considerations

Delirium may be a primary brain disease or a secondary manifestation of some general disorder.

Delirium can coexist with dementia and should be considered a syndrome of acute brain dysfunction analogous to acute kidney injury.

Coma is a major complication of serious CNS disorders.

Abrupt onset of coma suggests intracerebral hemorrhage or brainstem stroke.

Stay updated, free articles. Join our Telegram channel

Join