Altered Mental Status
Aaron Abramovitz, MD
Defining altered mental status
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Change in level of consciousness
Describe exactly how the patient is behaving when
presenting a case with ‘altered mental status’.
Coma
Lethargy
Delirium
Mania/Psychosis
Differential Diagnosis
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The differential is quite broad.
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PAST MEDICAL HISTORY is the best predictor
of the cause of altered mental status.
Triage severity of impairment based on Glasgow
Coma Score, vital signs, and ability to protect
airway.
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Coma
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This necessitates ACLS protocol. Airway, breathing,
circulation. (hypoventilation, hypoperfusion)
Check vitals. (hypotension, hypoxemia)
Always examine pupils. (stroke, narcotic overdose)
Check point of care glucose. (hypoglycemia)
Get arterial blood gas. (hypoxemia, hypercapnea)
Check 12-lead EKG. (arrhythmia)
Intubate the patient to protect the airway and make sure
there is good IV access.
Coma
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Now that you control the breathing and
hemodynamics, it’s time to THINK.
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Get a STAT head CT while you’re thinking.
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Most of the time, coma will result from one of the
causes in the previous slides.
If not, further studies to consider: lumbar
puncture, EEG, toxin screen… use your clinical
judgment.
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Lethargy
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This may require ACLS protocol and management as
above. If vital signs are stable and the patient is
protecting the airway, THINK.
Always examine pupils. (stroke, narcotic overdose)
Check point of care glucose. (hypoglycemia)
Get arterial blood gas. (hypoxemia, hypercapnea)
PAST MEDICAL HISTORY is the best predictor of the
cause of altered mental status.
Lethargy
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Some considerations:
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Recent medication administration.
Respiratory failure (esp. hypercapnea).
Metabolic cause (esp. liver disease).
Illicit drug use and/or withdrawal.
CNS infection or stroke.
If you can’t figure it out, get a STAT head CT and
THINK more.
 Once again, consider EEG, lumbar puncture, and
toxin screen.
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The Patient Must be Stable for CT
Delirium
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Core features:
• Disturbance in consciousness – inability to focus,
sustain or shift attention.
• Disturbance in cognition – problem solving and/or
memory impairment; perceptual disturbance.
• Slow onset (hours to days) and fluctuation.
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Often associated:
• Hallucinations and/or delusions.
• Disruption of sleep/wake cycle.
• Inappropriate emotional states.
Delirium
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Check vitals. (hypoxemia, hypotension)
If the patient is hemodynamically stable, THINK.
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PAST MEDICAL HISTORY is the best
predictor of the cause of altered mental status.
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You will usually know the cause of delirium
because it is often the primary presenting illness.
Delirium
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Hyperactive
• Agitated, verbose, hallucinations/delusions.
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Hypoactive
• Flat affect, non-verbal, ‘depressed’.
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These will share the core features of delirium. To
distinguish hypoactive delirium from depression,
perform MMSE, Short Blessed, Trails A, etc.
Delirium
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Delirium represents neurotransmitter/synaptic
dysregulation in the brain, brought on by
metabolic stress.
 It is more likely in people with underlying brain
disease (vascular, dementia, trauma).
 Delirium is associated with RR 3-11 for 6 month
mortality in ICU patients.
Delirium
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Therapy:
1) Protect the patient from harm
• Place a sitter to redirect the patient. Avoid restraints.
• If agitated, use typical antipsychotics PRN to sedate.
– AVOID BENZODIAZEPINES.
• Minimize lines, tubes, and frequently reorient.
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2) Regulate sleep/wake cycle
• Lights on during the day and reorientation.
• Risperidal 1-2mg QHS to ensure sleep. The
antipsychotic will speed recovery.
Mania/Psychosis
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Check vitals. (hypoxemia, hypotension)
If the patient is hemodynamically stable, THINK.
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PAST MEDICAL HISTORY is the best
predictor of the cause of altered mental status.
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This may initially be hard to separate from
delirium, so pursue medical workup as
appropriate.
Mania/Psychosis
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Psychiatric illness and drug intoxication are the
major DDx for manic behavior.
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This can be distinguished from delirium because
the patient will often have intact problem
solving/memory and be able to focus attention
appropriately.
Mania/Psychosis
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If the patient is violent or agitated, use a
combination of benzodiazepine and antipsychotic.
• “10 and 4” for big men and “5 and 2” for little old
ladies. IM administration is effective.
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Call psychiatry.
Rapid Fire Cases
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Coma (why?):
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fevers, stiff neck
found down at party
NPO diabetic
INR 10.5
COPD exacerbation
dilaudid PCA
ran out of Keppra
tracheostomy patient
Rapid Fire Cases
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Lethargy (why?):
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UTI, fevers
inpatient insomniac
end stage liver disease
last drink two days ago
missed dialysis x1 week
football practice in the sun
motor vehicle collision
Some Final Thoughts
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When you are unsure, be systematic. You cannot
go wrong with A, B, C evaluation.
You can get a lot of information from noncontrast head CT and ABGs. Use these tools
frequently.
If meningitis is on the differential, get an LP.
Some Final Thoughts
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Once delirium is identified, have a plan for
treating it. You can regulate sleep/wake cycle
and treat disorganized behavior effectively with
scheduled risperidal 1-2mg QHS.
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Avoid polypharmacy in patients with delirium—
this makes it more difficult to manage.