Altered mental status

Background

• Alteration of arousal or content of consciousness or both
• Both cerebral cortices or brainstem must be affected
• Delirium vs dementia vs psych
• Must quickly determine if coma is from diffuse or focal impairment
• Peds
  • Most common causes are toxic ingestion, infection, and child-abuse induced trauma

Clinical Features

• Depends on cause
  • Diffuse brain dysfunction - lack of focal findings
  • Focal brain dysfunction - hemiparesis, loss of motor tone, loss of ocular reflexes

DDX

1. Diffuse brain dysfunction
   1. Encephalopathies
      1. Hypoxic encephalopathy
      2. Metabolic encephalopathy
         1. Hypoglycemia
         2. Hyperosmolar state (e.g., hyperglycemia)
         3. Electrolyte abnormalities (hypernatremia or hyponatremia, hypercalcemia)
         4. Organ system failure
         5. Hepatic encephalopathy
         6. Uremia/renal failure
         7. Endocrine (Addison disease, hypothyroidism)
         8. Hypoxia
         9. CO2 narcosis
      3. Hypertensive encephalopathy
   2. Toxins
   3. Drug reactions (NMS)
   4. Environmental causes
      1. Hypothermia
      2. Hyperthermia
   5. Deficiency state
      1. Wernicke encephalopathy
   6. Sepsis
2. Primary CNS disease or trauma
   1. Direct CNS trauma
      1. Diffuse axonal injury
      2. Subdural/epidural hematoma
   2. Vascular disease
      1. Intraparenchymal hemorrhage
   3. SAH
   4. Infarction
      1. Hemispheric, brainstem
   5. CNS infections
   6. Neoplasms
   7. Seizures
      1. Nonconvulsive status epilepticus
         1. Consider if motor activity of seizure has stopped but pt is not alert w/in 30min
      2. Postictal state

Work-Up

• Head CT

Treatment

• Pts w/ focal findings may have surgically treatable cause
• Coma cocktail
  • Glucose, thiamine, naloxone

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. ?Utox
7. ?CT/LP

DDX

1. A
   1. Alcohol
2. E
   1. Electrolytes
   2. Encephalopathy (hepatic, hypertensive)
3. I
   1. Insulin (hypoglycemia)
4. O
   1. Opiates
5. U
   1. Uremia
6. T
   1. Trauma
   2. Tox
   3. Thyrotoxicosis
7. I
   1. Infection
      1. PNA, UTI, meningitis/encephalitis, sepsis
8. P
   1. Psych
9. S
   1. Seizure
   2. Stroke

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/ delirium
5. Poor score on Mini-Mental State Exam

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
   6. ?Utox
   7. ?CT/LP

Treatment

• Treat underlying cause (if possible)

See Also

• Toxicology (Main)
• Glasgow Coma Scale (GCS)
• Altered Mental Status (AMS) (Peds)
• AVPU Scale
• Brain Death

Source

Tintinalli