Altered mental status

Background

• Alteration of arousal or content of consciousness or both
• Both cerebral cortices or brainstem must be affected
• Delirium vs dementia vs psych

Delirium

Clinical Features

1. Impairment of arousal and content of consciousness
2. Generally develops over days
3. Symptoms may be intermittent and vary in severity

Workup

1. CBC
2. Chemistry
3. LFTs
4. UA
5. CXR
6. ?Utox
7. ?CT/LP

DDX

1. A
   1. Alcohol
2. E
   1. Electrolytes
   2. Encephalopathy (hepatic, hypertensive)
3. I
   1. Insulin (hypoglycemia)
4. O
   1. Opiates
5. U
   1. Uremia
6. T
   1. Trauma
   2. Tox
   3. Thyrotoxicosis
7. I
   1. Infection
      1. PNA, UTI, meningitis/encephalitis, sepsis
8. P
   1. Psych
9. S
   1. Seizure
   2. Stroke

Treatment

• Treat underlying cause

Dementia

Clinical Features

1. Loss of mental capacity
2. Slow and steady course
3. Hallucinations, delusions, repetitive behaviors, and depression are all common
4. May coexist w/ delirium
5. Poor score on Mini-Mental State Exam

DDX

1. Degenerative
   1. Alzheimer's disease
   2. Huntington's disease
   3. Parkinson's disease
2. Vascular
   1. Multiple infarcts
   2. Hypoperfusion (MI, profound hypotension)
   3. Subdural hematoma
   4. SAH
3. Infectious
   1. Meningitis (sequelae of bacterial, fungal, or tubercular)
   2. Neurosyphilis
   3. Viral encephalitis (herpes, HIV), Creutzfeldt-Jakob disease
4. Inflammatory
   1. SLE
   2. Demyelinating disease
5. Neoplastic
   1. Primary tumors / metastatic disease
   2. Carcinomatous meningitis
   3. Paraneoplastic syndromes
6. Traumatic
   1. Traumatic brain injury
   2. Subdural hematoma
7. Toxic
   1. ETOH
   2. Meds (anticholinergics, polypharmacy)
8. Metabolic
   1. B12 or folate deficiency
   2. Thyroid disease
   3. Uremia
9. Psychiatric
   1. Depression (pseudodementia)
10. Hydrocephalic
    1. Normal-pressure hydrocephalus (communicating hydrocephalus)
    2. Noncommunicating hydrocephalus

Work-Up

1. Must rule-out treatable causes of dementia / delirium (see DDX)
   1. CBC
   2. Chemistry
   3. LFTs
   4. UA
   5. CXR
   6. ?Utox
   7. ?CT/LP

Treatment

• Treat underlying cause (if possible)

See Also

• Toxicology (Main)
• Glasgow Coma Scale (GCS)
• Altered Mental Status (AMS) (Peds)
• Coma

Source

Tintinalli