Altered mental status: Difference between revisions

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{{Adult top}} [[altered mental status (peds)]]
==Background==
==Background==
*Alteration of arousal or content of consciousness or both
*Acute alteration in brain function
*Both cerebral cortices or brainstem must be affected
**May include alteration of arousal or awareness, thought content, memory, or attention
*Delirium vs dementia vs psych
*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
#?Utox
#?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
*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
#May coexist w/ delirium
#Poor score on Mini-Mental State Exam
 
====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
 
====Work-Up====
#Must rule-out treatable causes of dementia / delirium (see DDX)
##CBC
##Chemistry
##LFTs
##UA
##CXR
##?Utox
##?CT/LP
 
====Treatment====
*Treat underlying cause (if possible)


==See Also==
==See Also==
*[[Toxidromes]]
*[[Toxicology (Main)]]  
*[[Glasgow Coma Scale (GCS)]]
*[[Glasgow Coma Scale (GCS)]]
*[[Altered mental status (peds)]]
*[[AVPU Scale]]
*[[Brain Death]]


==Source ==
==References==
Tintinalli
<references/>
 
[[Category:Neurology]]
[[Category:Neuro]]
[[Category:Symptoms]]

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

Primary CNS disease or trauma

Psychiatric

Evaluation

AMS Workup

Common Orders

Consider Based on Clinical Situation

Management

  • Patients with focal findings may have surgically treatable cause
  • Coma cocktail
  • Treat underlying cause

Disposition

  • Most frequently admission, unless of a chronic and known etiology

See Also

References

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