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

• 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)

References

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