Altered mental status

Background

• Alteration of arousal or content of consciousness or both
• Both cerebral cortices 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. CT/LP

DDX

1. Infection
   1. PNA, UTI, meningitis/encephalitis, sepsis
2. Metabolic
   1. Hypoglycemia
   2. Electrolyte abnormalities
   3. Hepatic encephalopathy
3. Neuro
   1. TIA/CVA
   2. Seizure or postictal state
   3. SAH/ICH/SDH
   4. CNS mass lesion
4. Cardiopulmonary
   1. CHF
   2. MI
   3. PE
   4. Hypoxia or CO2 narcosis
5. Drug-related
   1. ETOH ingestion
   2. ETOH or drug withdrawal
   3. Sedative-hypnotics
   4. Anticholinergics
   5. Narcotics
   6. Polypharmacy

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/ dementia

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
2. ?CT/LP

Treatment

• Treat underlying cause (if possible)

See Also

• Toxidromes
• Glasgow Coma Scale (GCS)

Source

Tintinalli