Altered mental status (geriatrics)

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

Encephalitis

  • Mental status changes - personality/behavior changes
  • Unlikely to have fevers, meningismus
  • High risk: same for meningitis, live near water

Meningitis

  • 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 NSG, alcoholism, recent sinusitis

Pneumonia

  • False negative CXR ~15-20%
  • High morbidity

UTI

  • Very common etiology for altered mental status in elderly
  • Straight cath UA
  • Resistant organisms likely, look up old urine culture + sensetivity
  • High risk: pelvic relaxation, indwelling foley >2wks (check for one), BPH, history prostate cancer

Cholecystitis

  • May not have RUQ pain or GI symptoms
  • Ask about history of gallstones/US RUQ

Skin/Soft Tissue

  • Completly undress to examine
  • Often decubs present
    • Old photos helpful
  • Consider fistula, osteo, necrotizing

Metabolic/Toxic/Polypharmacy

Withdrawl/Overdose

  • Chronic opiate/Benzo/Ambien use
  • EtOH abuse - may not experience tremors in withdrawal

Polypharmacy

  • NSAIDS - may be taking multiple
    • Long term ASA
  • Steroids
  • Sedative/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
  • Ca/Mg/Phos

See Also

References

ACEP Academic Affairs Committee Geriatric Video lecture series SAEM Academy of Geriatric Emergency Medicine

Authors:

Ross Donaldson