Altered mental status (geriatrics): Difference between revisions

Latest revision as of 09:26, 22 March 2026

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 neurosurgery, 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 + sensitivity
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

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)

References

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

Authors:

@@ Line 1: / Line 1: @@
 ==Background==
 *Elderly patients present differently with common issues
-*Unique aspects of elderly AMS
+*Unique aspects of elderly altered mental status
-*See AMS for complete list
+*See [[altered mental status]] for complete differential list
+*[[Dementia]] should be diagnosis of exclusion
 ==Infectious==
-'''Encephalitis'''
+[[Encephalitis]]
-*mental status changes - personality/behavior changes
+*Mental status changes - personality/behavior changes
-*unlikely to have fevers, meningismus
+*Unlikely to have [[fever]]s, meningismus
-*high risk: same for meningitis, live near water
+*High risk: same for meningitis, live near water
-'''Meningitis'''
+[[Meningitis]]
-*usually other etilogy for AMS, but if negative workup do LP
+*Usually other etiology for altered mental status, but if negative workup do LP
-*consider ampicillin for listeria
+*Consider [[Ampicillin]] for [[listeria]]
-*consider acyclovir for HSV
+*Consider [[acyclovir]] for [[HSV]]
-*high risk: HIV, DM, Malignancy, s/p ctx, prior NSG, alcoholism, recent sinusitis
+*High risk: [[HIV]], [[DM]], malignancy, s/p [[ceftriaxone]], prior neurosurgery, [[alcoholism]], recent [[sinusitis]]
-'''Pneumonia'''
+[[Pneumonia]]
-*false negative CXR ~15-20%
+*False negative [[CXR]] ~15-20%
-*high morbidity
+*High morbidity
-'''UTI'''
+[[UTI]]
-*very common etiology for AMS in elderly
+*Very common etiology for altered mental status in elderly
-*resistant organisms likely, look up old UCx + sensetivity
+*Straight cath [[UA]]
-*high risk: pelvic relaxation, indwelling foley >2wks (check for one), BPH, hx prostate CA
+*Resistant organisms likely, look up old urine culture + sensitivity
+*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/[[RUQ Ultrasound|US RUQ]]
-'''Cholecystitis'''
+Skin/Soft Tissue
-* may not have RUQ pain or GI sxs
+*Completely undress to examine
-* ask about hx of gallstones/US RUQ
+*Often [[decubitus ulcers]] present
+**Old photos helpful
+*Consider fistula, [[osteomyelitis]], [[necrotizing fasciitis]]
 ==Metabolic/Toxic/Polypharmacy==
-'''Withdrawl/Overdose'''
+Withdrawal/Overdose
-*chronic opiate/Benzo/Ambien use
+*Chronic [[opioid]]/[[benzodiazepine]]/[[zolpidem]] (Ambien) use
-*Etoh abuse - may not experience tremors in withdrawl
+*[[ETOH abuse]] - may not experience [[tremor]]s in [[ETOH withdrawal]]
-'''Polypharmacy'''
+Polypharmacy
-*NSAIDS - may be taking multiple
+*[[NSAIDS]] - may be taking multiple
-**long term ASA
+**Long term [[ASA]]
-*Steroids
+*[[Steroids]]
-*Sedative/Psychoactives
+*[[Sedatives]]/Psychoactives
-*Anticholinergics- many OTC
+*[[Anticholinergics]] - many OTC
-**meperidine, cimetidine, ranitidine, TCAs, antiparkinson, antipsychotics, benadryl
+**[[Meperidine]], [[cimetidine]], [[ranitidine]], [[TCAs]], antiparkinson, [[antipsychotics]], [[diphenhydramine]]
-**dietary - teas
+**Dietary - teas, supplements
-'''Other'''
-*Seizure v Post ictal
-*urinary retention - uremia
-*fecal impaction
-*occult mesenteric ischemia
+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)
-==DDx==
+==See Also==
+*[[Altered Mental Status]]
+*[[Geriatrics (Main)]]
+*https://www.aliem.com/2013/08/a-time-based-approach-to-elderly-patients-with-altered-mental-status/
-==Treatment==
+==References==
+<references/>
+ACEP Academic Affairs Committee Geriatric Video lecture series
-==Disposition==
+SAEM Academy of Geriatric Emergency Medicine
-==See Also==
-==Source==
+[[Category:Neurology]]
+[[Category:Misc/General]]
+[[Category:Symptoms]]