Altered mental status (geriatrics): Difference between revisions
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==Background== | ==Background== | ||
*Elderly patients present differently with common issues | *Elderly patients present differently with common issues | ||
*Unique aspects of elderly | *Unique aspects of elderly altered mental status | ||
*See [[ | *See [[altered mental status]] for complete differential list | ||
*Dementia should be diagnosis of exclusion | *[[Dementia]] should be diagnosis of exclusion | ||
==Infectious== | ==Infectious== | ||
'''Encephalitis''' | '''[[Encephalitis]]''' | ||
*Mental status changes - personality/behavior changes | *Mental status changes - personality/behavior changes | ||
*Unlikely to have | *Unlikely to have [[fever]]s, meningismus | ||
*High risk: same for meningitis, live near water | *High risk: same for meningitis, live near water | ||
'''Meningitis''' | '''[[Meningitis]]''' | ||
*Usually other etiology for | *Usually other etiology for altered mental status, but if negative workup do LP | ||
*Consider [[Ampicillin]] for listeria | *Consider [[Ampicillin]] for [[listeria]] | ||
*Consider acyclovir for HSV | *Consider [[acyclovir]] for [[HSV]] | ||
*High risk: HIV, DM, malignancy, s/p [[ceftriaxone]], prior | *High risk: [[HIV]], [[DM]], malignancy, s/p [[ceftriaxone]], prior neurosurgery, [[alcoholism]], recent [[sinusitis]] | ||
'''Pneumonia''' | '''[[Pneumonia]]''' | ||
*False negative CXR ~15-20% | *False negative [[CXR]] ~15-20% | ||
*High morbidity | *High morbidity | ||
'''UTI''' | '''[[UTI]]''' | ||
*Very common etiology for | *Very common etiology for altered mental status in elderly | ||
*Straight cath UA | *Straight cath [[UA]] | ||
*Resistant organisms likely, look up old | *Resistant organisms likely, look up old urine culture + sensitivity | ||
*High risk: pelvic relaxation, indwelling foley >2wks (check for one), BPH, history prostate | *High risk: pelvic relaxation, indwelling foley >2wks (check for one!), BPH, history prostate cancer | ||
'''Cholecystitis''' | '''[[Cholecystitis]]''' | ||
*May not have RUQ pain or GI symptoms | *May not have [[RUQ pain]] or GI symptoms | ||
*Ask about history of gallstones/US RUQ | *Ask about history of gallstones/[[RUQ Ultrasound|US RUQ]] | ||
'''Skin/Soft Tissue''' | '''Skin/Soft Tissue''' | ||
* | *Completely undress to examine | ||
*Often | *Often [[decubitus ulcers]] present | ||
**Old photos helpful | **Old photos helpful | ||
*Consider fistula, | *Consider fistula, [[osteomyelitis]], [[necrotizing fasciitis]] | ||
==Metabolic/Toxic/Polypharmacy== | ==Metabolic/Toxic/Polypharmacy== | ||
''' | '''Withdrawal/Overdose''' | ||
*Chronic | *Chronic [[opioid]]/[[benzodiazepine]]/[[zolpidem]] (Ambien) use | ||
* | *[[ETOH abuse]] - may not experience [[tremor]]s in [[ETOH withdrawal]] | ||
'''Polypharmacy''' | '''Polypharmacy''' | ||
*NSAIDS - may be taking multiple | *[[NSAIDS]] - may be taking multiple | ||
**Long term ASA | **Long term [[ASA]] | ||
*Steroids | *[[Steroids]] | ||
* | *[[Sedatives]]/Psychoactives | ||
*Anticholinergics - many OTC | *[[Anticholinergics]] - many OTC | ||
**Meperidine, cimetidine, ranitidine, TCAs, antiparkinson, antipsychotics, diphenhydramine | **[[Meperidine]], [[cimetidine]], [[ranitidine]], [[TCAs]], antiparkinson, [[antipsychotics]], [[diphenhydramine]] | ||
**Dietary - teas, supplements | **Dietary - teas, supplements | ||
'''Other''' | '''Other''' | ||
*Cardiac Ischemia - no chest pain needed | *[[Cardiac Ischemia]] - no chest pain needed | ||
*Seizure v Post ictal | *[[Seizure]] v Post ictal | ||
*Urinary retention - uremia | *[[Urinary retention]] - [[uremia]] | ||
*Fecal impaction | *[[Fecal impaction]] | ||
*Occult mesenteric ischemia | *Occult [[mesenteric ischemia]] | ||
*Ca/Mg/Phos | *[[Electrolyte abnormalities]] (e.g. Ca/Mg/Phos) | ||
==See Also== | ==See Also== | ||
*[[Altered Mental Status]] | *[[Altered Mental Status]] | ||
*[[Geriatrics (Main)]] | *[[Geriatrics (Main)]] | ||
*https://www.aliem.com/2013/08/a-time-based-approach-to-elderly-patients-with-altered-mental-status/ | |||
==References== | ==References== | ||
| Line 72: | Line 73: | ||
[[Category:Neurology]] | [[Category:Neurology]] | ||
[[Category:Misc/General]] | [[Category:Misc/General]] | ||
[[Category:Symptoms]] | |||
Latest revision as of 20:34, 1 October 2019
Background
- Elderly patients present differently with common issues
- Unique aspects of elderly altered mental status
- See altered mental status for complete differential list
- Dementia should be diagnosis of exclusion
Infectious
- Mental status changes - personality/behavior changes
- Unlikely to have fevers, meningismus
- High risk: same for meningitis, live near water
- Usually other etiology for altered mental status, but if negative workup do LP
- Consider Ampicillin for listeria
- Consider acyclovir for HSV
- High risk: HIV, DM, malignancy, s/p ceftriaxone, prior neurosurgery, alcoholism, recent sinusitis
- False negative CXR ~15-20%
- High morbidity
- Very common etiology for altered mental status in elderly
- Straight cath UA
- Resistant organisms likely, look up old urine culture + sensitivity
- High risk: pelvic relaxation, indwelling foley >2wks (check for one!), BPH, history prostate cancer
Skin/Soft Tissue
- Completely undress to examine
- Often decubitus ulcers present
- Old photos helpful
- Consider fistula, osteomyelitis, necrotizing fasciitis
Metabolic/Toxic/Polypharmacy
Withdrawal/Overdose
- Chronic opioid/benzodiazepine/zolpidem (Ambien) use
- ETOH abuse - may not experience tremors in ETOH withdrawal
Polypharmacy
- NSAIDS - may be taking multiple
- Long term ASA
- Steroids
- Sedatives/Psychoactives
- Anticholinergics - many OTC
- Meperidine, cimetidine, ranitidine, TCAs, antiparkinson, antipsychotics, diphenhydramine
- Dietary - teas, supplements
Other
- Cardiac Ischemia - no chest pain needed
- Seizure v Post ictal
- Urinary retention - uremia
- Fecal impaction
- Occult mesenteric ischemia
- Electrolyte abnormalities (e.g. Ca/Mg/Phos)
See Also
- Altered Mental Status
- Geriatrics (Main)
- https://www.aliem.com/2013/08/a-time-based-approach-to-elderly-patients-with-altered-mental-status/
References
ACEP Academic Affairs Committee Geriatric Video lecture series SAEM Academy of Geriatric Emergency Medicine