Altered mental status: Difference between revisions

Latest revision as of 22:45, 27 March 2024

This page is for adult patients. For pediatric patients, see: altered mental status (peds)

Background

Acute alteration in brain function
- May include alteration of arousal or awareness, thought content, memory, or attention
Both cerebral cortices or brainstem must be affected
Delirium vs dementia vs other organic pathology vs functional (psychiatric)
Must quickly determine if coma is from diffuse or focal impairment

Clinical Features

Depends on cause
- Diffuse brain dysfunction - lack of focal findings
- Focal brain dysfunction - hemiparesis, loss of motor tone, loss of ocular reflexes
Important to differentiate diffuse brain dysfunction from localized lesion as a patient may appear confused due to visual deficit, dysphasia, etc.

Differential Diagnosis

Altered mental status

Diffuse brain dysfunction

Hypoxic encephalopathy
Acute toxic-metabolic encephalopathy (Delirium)
- Hypoglycemia
- Hyperosmolar state (e.g., hyperglycemia)
- Electrolyte Abnormalities (hypernatremia or hyponatremia, hypercalcemia)
- Organ system failure
- Hepatic Encephalopathy
- Uremia/Renal Failure
- Endocrine (Addison's disease, Cushing syndrome, hypothyroidism, myxedema coma, thyroid storm)
- Hypoxia
- CO2 narcosis
Hypertensive Encephalopathy
Toxins
TTP / Thrombotic thrombocytopenic purpura
Alcohol withdrawal
Drug reactions (NMS, Serotonin Syndrome)
Environmental causes
- Hypothermia
- Hyperthermia
Deficiency state
- Wernicke encephalopathy
- Subacute Combined Degeneration of Spinal Cord (B12 deficiency)
- Vitamin D Deficiency
- Zinc Deficiency
Sepsis
Osmotic demyelination syndrome (central pontine myelinolysis)
Limbic encephalitis

Primary CNS disease or trauma

Direct CNS trauma
- Diffuse axonal injury
- Subdural/epidural hematoma
Vascular disease
- Intraparenchymal hemorrhage
SAH
Stroke
- Hemispheric, brainstem
CNS infections
Neoplasms
- Paraneoplastic Limbic encephalitis
- Malignant Meningitis
- Pancreatic Insulinoma
Seizures
- Nonconvulsive status epilepticus
- Postictal state
Dementia

Psychiatric

Evaluation

AMS Workup

Common Orders

Point of care glucose
CBC
Chemistry
LFTs
UA
CXR
Utox
ECG
Head CT
CAM score

Consider Based on Clinical Situation

Blood and urine cultures
Ammonia level
Tylenol/Aspirin level
LP
Serum Osm
Coags
Cortisol
ABG/VBG
CO level

Management

Patients with focal findings may have surgically treatable cause
Coma cocktail
- Glucose, thiamine, naloxone
Treat underlying cause

Disposition

Most frequently admission, unless of a chronic and known etiology

References

Authors:

@@ Line 1: / Line 1: @@
+{{Adult top}} [[altered mental status (peds)]]
 ==Background==
-*Alteration of arousal or content of consciousness or both
+*Acute alteration in brain function
-*Delirium vs dementia vs psych
+**May include alteration of arousal or awareness, thought content, memory, or attention
+*Both cerebral cortices or brainstem must be affected
+*[[Delirium]] vs [[dementia]] vs other organic pathology vs functional (psychiatric)
+*Must quickly determine if [[coma]] is from diffuse or focal impairment
-===Delirium===
+==Clinical Features==
-====Clinical Features====
+*Depends on cause
-#Impairment of arousal and content of consciousness
+**Diffuse brain dysfunction - lack of focal findings
-#Generally develops over days
+**[[focal neuro deficits|Focal brain dysfunction]] - hemiparesis, loss of motor tone, loss of ocular reflexes
-#Symptoms may be intermittent and vary in severity
+*Important to differentiate diffuse brain dysfunction from localized lesion as a patient may appear confused due to visual deficit, dysphasia, etc.
-====Workup====
+==Differential Diagnosis==
-#CBC
+{{AMS DDX}}
-#Chemistry
-#LFTs
-#UA
-#CXR
-#CT/LP
-====DDX====
+==Evaluation==
-#Infection
+{{AMS workup}}
-##PNA, UTI, meningitis/encephalitis, sepsis
-#Metabolic
-##Hypoglycemia
-##Electrolyte abnormalities
-##Hepatic encephalopathy
-#Neuro
-##TIA/CVA
-##Seizure or postictal state
-##SAH/ICH/SDH
-##CNS mass lesion
-#Cardiopulmonary
-##CHF
-##MI
-##PE
-##Hypoxia or CO2 narcosis
-#Drug-related
-##ETOH ingestion
-##ETOH or drug withdrawal
-##Sedative-hypnotics
-##Anticholinergics
-##Narcotics
-##Polypharmacy
-====Treatment====
+==Management==
+*Patients with focal findings may have surgically treatable cause
+*Coma cocktail
+**[[dextrose|Glucose]], [[thiamine]], [[naloxone]]
 *Treat underlying cause
-===Dementia===
+==Disposition==
-====Clinical Features====
+*Most frequently admission, unless of a chronic and known etiology
-#Loss of mental capacity
-#Slow and steady course
-#Hallucinations, delusions, repetitive behaviors, and depression are all common
-====DDX====
-#Degenerative
-##Alzheimer's disease
-##Huntington's disease
-##Parkinson's disease
-#Vascular
-##Multiple infarcts
-##Hypoperfusion (MI, profound hypotension)
-##Subdural hematoma
-##SAH
-#Infectious
-##Meningitis (sequelae of bacterial, fungal, or tubercular)
-##Neurosyphilis
-##Viral encephalitis (herpes, HIV), Creutzfeldt-Jakob disease
-#Inflammatory
-##SLE
-##Demyelinating disease
-#Neoplastic
-##Primary tumors / metastatic disease
-##Carcinomatous meningitis
-##Paraneoplastic syndromes
-#Traumatic
-##Traumatic brain injury
-##Subdural hematoma
-#Toxic
-##ETOH
-##Meds (anticholinergics, polypharmacy)
-#Metabolic
-##B12 or folate deficiency
-##Thyroid disease
-##Uremia
-#Psychiatric
-##Depression (pseudodementia)
-#Hydrocephalic
-##Normal-pressure hydrocephalus (communicating hydrocephalus)
-##Noncommunicating hydrocephalus
 ==See Also==
-*[[Toxidromes]]
+*[[Toxicology (Main)]]
+*[[Glasgow Coma Scale (GCS)]]
-==Source ==
+*[[Altered mental status (peds)]]
-Tintinalli
+*[[AVPU Scale]]
+*[[Brain Death]]
-[[Category:Neuro]]
+==References==
+<references/>
+[[Category:Neurology]]
+[[Category:Symptoms]]