Altered mental status (geriatrics)

Background

• Elderly patients present differently with common issues
• Unique aspects of elderly AMS
• See AMS for complete differntial 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 etilogy for AMS, 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 AMS in elderly
• straight cath
• resistant organisms likely, look up old UCx + sensetivity
• high risk: pelvic relaxation, indwelling foley >2wks (check for one), BPH, hx prostate CA

Cholecystitis

• may not have RUQ pain or GI sxs
• ask about hx 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

• Altered Mental Status
• Geriatrics (Main)

Source

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