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
- 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