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Introduction   

Altered Mental Status (AMS) represents a critical challenge within the Emergency Department (ED), encapsulating a wide spectrum of conditions with varying chronicity and severity [1]. About 5% of patients in the emergency department arrive with altered mental status (AMS), a condition that is difficult to diagnose due to its numerous potential causes which translate to an elevated risk of death [5].

As a common chief complaint among the elderly, AMS is often an indication of acute brain dysfunction—manifesting as delirium, stupor, or coma—precipitated by underlying medical illnesses that can be life-threatening [2]. The urgency to address acute changes in AMS within the emergency room setting is paramount due to the potential for rapid deterioration and the associated adverse outcomes [3].

This review underscores the imperative for a rapid, methodical approach beginning with a primary and secondary survey focusing on life-threatening reversible causes, followed by a comprehensive systems-based analysis. Recognizing that AMS can result from a myriad of etiologies—from benign to critical—the evaluation process in the emergency department (ED) requires an extensive detailed history, physical examination, and the incorporation of laboratory and radiographic testing [5].

The pivotal role of the ED extends beyond initial management to include the diagnosis and initiation of lifesaving therapies. A structured, systematic approach to the assessment, diagnosis, and treatment of AMS, highlights the necessity for vigilance, comprehensive evaluation, and the initiation of intervention to mitigate the devastating outcomes associated with this complex clinical presentation [6].

Altered Mental Status (AMS) represents a complex constellation of clinical presentations that spotlights a constellation of cognitive, behavioral, and emotional disturbances [4]. Cognitive impairments associated with AMS can span disorientation, deficits in attention and language, memory disturbances, and executive functioning disruptions, often requiring a comprehensive mental status examination to decipher [7].

This level of detailed assessment not only facilitates the recognition of AMS but also aids in unraveling its root causes, enabling clinicians to formulate a precise and holistic differential diagnosis.

Definitions

Altered Mental Status (AMS) encompasses a collection of clinical manifestations instead of a singular diagnosis, encompassing cognitive dysfunctions, attentional disturbances, arousal irregularities, and reduced consciousness levels. Patients with AMS often present in emergency settings, yet the precise cause behind many cases remains unidentified [8].

Delirium is a condition marked by changes in attention, consciousness, and cognition, leading to diminished capacity to concentrate, maintain, or change focus [9]. It emerges and varies throughout the day. Delirium represents a critical result of various underlying causes. As defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), delirium is a sudden onset of attention and awareness disturbances that fluctuate over time involving other cognitive impairments [10].

Factors leading to delirium include physical illnesses or medication effects, with symptoms developing over several days [2]. The disorder may disrupt normal sleep-wake cycles, often intensifying at night, and characterized by varying levels of consciousness and rapid shifts in activity levels [2].

In emergency departments (ED), delirium affects 10% to 15% of elderly adults divided into three psychomotor subtypes: hyperactive, hypoactive, and mixed [11][12]. The hyperactive form includes restlessness, agitation, and excessive activity. Hypoactive delirium, which is more common and accounts for about 60% of cases includes decreased motor activity, lethargy, and drowsiness, making patients seem dazed [11][12]. Mixed delirium features characteristics of both hyperactivity and hypoactivity, with patients alternating between these states [11][12].

Dementia is a gradual decline in cognitive abilities over an extended duration. The DSM-5 categorizes dementia as a major neurocognitive disorder (MND) with a substantial deterioration in one or more cognitive areas [10]. These areas cover a wide range of cognitive functions, including attention, executive function, learning and memory, language abilities, perceptual-motor functions, and social cognition [10].

Dementia manifests through a deterioration in various cognitive areas, encompassing learning, memory, language, executive functioning, focused attention, perceptual-motor skills, and social awareness [13]. Alzheimer’s disease (AD) is the predominant type of dementia among older adults, representing 60% to 80% of dementia cases in this demographic [14].

A coma is a profound state of unconsciousness where individuals remain unresponsive with their eyes closed [15]. Coma signifies a form of brain dysfunction that can result from an issue within the central nervous system or from a systemic metabolic condition [15].

Case Study: Acute Altered Mental Status in an Elderly Patient

Patient Background: An 82-year-old female with a medical history of hypertension and type 2 diabetes presented to the Emergency Department (ED) accompanied by her son, due to episodes of confusion and agitation that started earlier in the day.

Clinical Presentation: Upon arrival, the patient appeared disheveled, unresponsive, and did not follow commands, indicative of an altered mental status. Her son reported she had been forgetful over the past few months, but her sudden decline was significant.

Initial Assessment: Vital signs revealed a blood pressure of 170/90 mmHg, heart rate of 102 beats per minute, respiratory rate of 22 breaths per minute, and a temperature of 37.8°C. Physical examination noted mild disorientation to time and place, fluctuating attention, and intermittent episodes of agitation. The patient was unable to perform the Six-Item Screen (SIS) test correctly and struggled with the WORLD test, indicating cognitive impairment.

Diagnostic Workup: Given the presentation of acute altered mental status, the ED team initiated a comprehensive workup to identify reversible causes.

Findings: Laboratory results revealed hyperglycemia (glucose of 280 mg/dL) without ketoacidosis, mild hyponatremia (Na 132 mEq/L), and a urinary tract infection (UTI) indicated by urinalysis. The CT scan showed no evidence of acute intracranial hemorrhage but noted generalized cerebral atrophy consistent with her age. The EKG showed sinus tachycardia without ischemic changes.

Management and Disposition: The patient received intravenous fluids for hydration, insulin for hyperglycemia, and antibiotics for the UTI.

Conclusion: This case underscores the complexity of managing elderly patients with acute altered mental status in the ED.

Differential Diagnosis

As patients present to the emergency department (ED) with altered mental status, healthcare professionals must differentiate potential diagnoses into three key categories: delirium, coma, and dementia [6]. Therefore, it is critical for providers to collect a comprehensive medical history from multiple sources and to be alert for minor indications that might suggest more serious underlying issues [34].

The range of potential differential diagnoses for altered mental status is wide. For emergency department patients exhibiting symptoms such as lethargy, anxiety, psychosis, and seizures, it is important to consider endocrine or metabolic causes [18].

Metabolic factors contributing to altered mental status encompass a range of conditions, including hypernatremia or hyponatremia and hyperglycemia or hypoglycemia, as well as hypercalcemia and thyroid function abnormalities such as hyperthyroidism or hypothyroidism [19].

Other significant contributors include hypoxia or hyperpnea, conditions like hepatic encephalopathy and uremic encephalopathy, and the effects of drug intoxication or withdrawal [20]. Wernicke encephalopathy is another critical condition to consider in the spectrum of metabolic causes affecting mental status [21][22].

Structural lesions and brain conditions contribute to the altered mental status differential, encompassing a variety of causes from primary or metastatic tumors, intracranial hemorrhages, and infections to cerebrovascular accidents and transient ischemic attacks [23]. Conditions such as meningitis, encephalitis, seizures, and the postictal state following a seizure further complicate the clinical picture [23].

Hypertensive encephalopathy, vasculitis, and cardiac issues including arrhythmias, heart failure, and endocarditis also play crucial roles [24]. Specific brain pathologies including brainstem lesions, epidural hematomas and abscesses, intracerebral hemorrhage, tumors, and abscesses, along with large hemispheric strokes, subarachnoid hemorrhage, and subdural hematoma, underscore the breadth of potential structural causes behind altered mental states [25].

Assessment

The patient’s arrival requires a comprehensive set of vital signs including a rectal temperature [23]. Should the patient exhibit a temperature exceeding 104° F, indicative of primary hyperthermia contributing to altered mental status, efforts to reduce the core temperature include employing evaporative cooling methods [26].

Given that hypoglycemia stands as a prevalent, life-threatening, yet reversible cause of altered mental status, obtaining blood glucose is critical [27]. For adults experiencing symptomatic hypoglycemia, the administration of 1 to 2 grams/kg of dextrose in the form of D50 [28]. Hypoglycemia, characterized by a low blood glucose level, stands as a leading cause of altered mental status among patients, regardless of their diabetes status [28]. Hypoglycemia accounts for 1 to 2 percent of prehospital emergencies and 7% of instances where patients refuse hospitalization [28].

In cases of hypothermia, where the patient’s temperature falls below 95° F, warming efforts should include a convective warming blanket like the Bair Hugger or similar methods [30]. Patients with moderate hypothermia have a core body temperature of 28 to 32 °C (82-90 °F). Cognitive decline and lethargy are common. CNS depression may lead to hyporeflexia, with the pupils being less responsive and dilated. Hypotension, bradycardia, and bradypnea may present [28].

For patients experiencing severe hypothermia, it is advisable to administer warmed intravenous fluids, with a preference for normal saline over lactated Ringer’s solution secondary to metabolization by a hypothermia-affected liver [29] [30]. In situations of severe hypothermia, employing more aggressive rewarming strategies might be necessary, including the use of warmed bladder irrigation, chest tube irrigation, peritoneal lavage, or even extracorporeal membrane oxygenation for critical cases [31] [32].

The most precise method for continuous core temperature monitoring is via the esophagus, although such equipment might not always be available in every medical facility [33]. As a practical alternative, temperature Foley catheters can monitor the patient’s temperature [33].

Primary Survey

The approach to patients with altered mental status can parallel the protocol used for trauma patients, summarized by the mnemonic “Airway, Breathing, Circulation, Disability, Exposure, Focused Assessment with Sonography for Trauma (FAST)” or ABCDEF (A-Airway, B-Breathing, C-Circulation, D-Disability, E-Expose/Examine, F-Full set of Vitals) [34][35] [39].

Initial steps should always prioritize the airway; treat every patient as if they have sustained trauma until proven otherwise, manage the head, and stabilize the cervical spine as needed. If the patient is not breathing, begin ventilation with a bag valve mask and prepare for potential airway management [36].

Before proceeding to intubation, investigate for signs or historical evidence of reversible conditions like opioid overdose, hypoglycemia, hypothermia, or hyperthermia [36] [64]. For patients who are breathing but show signs of hypoxia, use a non-rebreather mask to keep oxygen saturation levels between 88% and 90% [38]. In cases of opioid overdose providers can administer an initial naloxone dose of 0.4 mg to 2 mg IV, with the possibility of increasing the dose up to 10 mg if there is no response [37].

To evaluate a patient’s neurological status, the Glasgow Coma Scale (GCS) score is a common tool [16]. A GCS score below 8 may necessitate intubation for airway protection with the exclusion of reversible causes [16]. Circulation issues, indicated by cool or mottled extremities, require IV fluid resuscitation for hypotension [36].

Assess any signs of neurological deficits that might suggest a stroke or cerebral hemorrhage. Further examination should include searching for signs such as specific odors indicating toxic substance exposure, or any rash or ecchymosis pointing to infection or trauma, alongside a complete visual inspection for hidden injuries [40]. Providers can perform A FAST examination for patients suspected of trauma or intra-abdominal [39].

History of Present Illness

When gathering a history from a patient with altered mental status, the primary aim should be to ascertain the reasons for their admission to the emergency department (ED). Information from Emergency Medical Services (EMS) can be invaluable in shedding light on potential causes [35]. Family members or caregivers can offer insights into the patient’s normal state before the alteration, including a timeline of changes and relevant past medical history.

A critical part of assessing a patient with altered mental status is distinguishing between an acute medical or organic cause and a deterioration of a functional or psychiatric condition [41]. Disorientation and memory issues often point to an organic or neurological cause, whereas alterations in thought content might suggest a psychiatric origin [6][41]. Organic causes of confusion can present with visual hallucinations, in contrast to functional causes, which tend to involve auditory hallucinations [41].

Changes in behavior stemming from organic reasons occur with a rapid onset and can affect individuals of any age, while functional causes develop over weeks to months, and are more common in individuals aged 12 to 40 years [41]. Confusion of a medical nature often includes fluctuating consciousness and attention issues, whereas psychiatric patients are alert, exhibiting anxiety and agitation [42].

Family members, bystanders, or Emergency Medical Services (EMS) can be critical sources of information about what might have triggered an episode of altered mental status, revealing factors like recent stress, depressive episodes, infections, or a history of similar occurrences [35].

Physical Exam

Assessing a patient’s mental status involves several key observations: the difficulty in keeping the patient awake, the coherence and focus of their speech and thought, whether their speech deviates into unrelated areas, their orientation to time, place, and person, repetitive questioning, and responses to unseen stimuli [42].

Motor assessments include checking for weakness or pronator drift and conducting a cranial nerve examination, particularly noting pupil reactions and the presence of nystagmus [43][44]. The significance of the brainstem in maintaining consciousness means that a decreased level of consciousness combined with cranial nerve abnormalities often points to a brainstem lesion [45]. Evaluations for tremors or unusual reflexes, such as asterixis, palmomental reflex, or glabellar tap, are crucial since these signs often appear in withdrawal states or metabolic disorders like encephalopathy [46].

The cardiovascular examination can uncover arrhythmias, and murmurs suggesting endocarditis and peripheral circulation quality [47]. Abdominal examinations look for signs of portal hypertension, tenderness indicating potential sources of sepsis, and other conditions like appendicitis [48]. Genitourinary and rectal exams determine urine production, signs of infection, and possible gastrointestinal bleeding indicators [49].

Skin, extremity, and musculoskeletal examinations check for petechiae, dialysis grafts, injection marks, drug patches, jaundice, signs of meningitis or hemorrhage, trauma indicators, potential infection sources, and cancer signs like masses or lymphadenopathy [50]. These comprehensive evaluations are pivotal in distinguishing delirium, dementia, or psychosis, guiding further diagnostic testing to refine or confirm the differential diagnosis within each altered mental status category [23].

Vital signs play a key role in distinguishing between medical and psychiatric causes of altered mental status. Abnormal vital signs are associated with medical conditions, whereas psychiatric disorders might not affect vital signs to the same extent [51].

The presence of a fever or meeting the systemic inflammatory response syndrome (SIRS) criteria can point to an infection as the underlying cause of confusion in older patients [52]. Deviations in body temperature can indicate hyperthermia or hypothermia as contributing factors [52].

Neurologic signs such as nystagmus, focal neurological deficits, and evidence of trauma suggest a medical origin, whereas their absence might indicate a psychiatric diagnosis, with psychiatric conditions manifesting with purposeful movements [53]. Respiratory complications including a focal wheeze or rales during a lung examination could indicate underlying respiratory or cardiac issues, leading to oxygenation or carbon dioxide regulation problems that alter consciousness [54].

Observations of pupil sizes and eye movements are critical for identifying various toxidromes [53][55]. Encouraging the patient to walk, if possible, can also be informative; different patterns of ataxia can hint at a range of diagnoses from strokes to toxic exposures or overdoses.

In addition to these observations, other physical examination findings, including signs of physical trauma, the identification of an arteriovenous fistula, asterixis (a flapping tremor associated with metabolic disorders), cardiac murmurs, bone tenderness, thyroid abnormalities (such as goiter or proptosis), and skin rashes (petechial or ecchymosis), are invaluable in guiding further diagnostic efforts [50][56].

Mental Status Testing

In the emergency department (ED), when assessing a patient with altered mental status, several non-invasive bedside tests can complement the physical and neurological examination to evaluate cognitive function. Two straightforward assessments are the WORLD test and the Six-Item Screen (SIS) [6][57].

The WORLD test involves asking the patient to spell “world” forwards and backward, and then to arrange the letters in alphabetical order. The WORLD test has an 85% sensitivity, 88% specificity, and a 95% positive predictive value for the presence of dementia [6][23].

The SIS test starts with instructing the patient to remember and repeat three unrelated items (for example, “pen”, “orange”, and “cat”).

The SIS test has demonstrated a sensitivity of 94% and specificity of 86% in detecting cognitive issues in older patients presenting to the ED [6][57].

The Glasgow Coma Scale (GCS) is a numerical scale used to evaluate a patient’s level of consciousness by summing the scores from three distinct areas: eye-opening (E), verbal response (V), and motor response (M) [16]. The scale ranges from 3 to 15, where a score of 3 indicates the deepest level of unconsciousness and 15 signifies full alertness, responsiveness, and unimpaired cognitive function.

A GCS score of 15 indicates that the patient is awake, can communicate, and exhibits no signs of cognitive or memory issues. Scores of 13 or above are associated with mild brain injuries, scores between 9 and 12 suggest moderate brain injuries, and a score of 8 or below is indicative of severe brain injury [16].

The AVPU scale, representing Alert, Verbal, Pain, and Unresponsive, serves as a swift tool for evaluating a patient’s consciousness, responsiveness, or mental condition [58]. This scale is employed across a variety of medical contexts, such as in pre-hospital care, emergency departments, general hospital wards, and intensive care units.

Common Toxidromes

Recognizing and managing cases of altered mental status (AMS) associated with toxicological emergencies is a critical skill for healthcare professionals. The spectrum of toxicology-induced AMS in the ED encompasses conditions such as ethanol intoxication and withdrawal, opiate toxicity, salicylate poisoning, and various toxidromes including sympathomimetic, anticholinergic, and cholinergic syndromes [59][60].

Each presents distinctive vital sign abnormalities and clinical features, from hypothermia and bradycardia to hyperthermia and tachycardia, necessitating a nuanced approach to diagnosis and treatment. Furthermore, complications like beta-blocker and calcium channel blocker poisonings complicate the clinical picture with their effects on blood pressure and heart rate [63].

Ethanol intoxication may present with a range of symptoms from normal vital signs to hypothermia, low blood pressure, fast heart rate, slow breathing, and low oxygen levels, while ethanol withdrawal can range from mild, with normal vital signs, to severe, characterized by unstable vital signs, fast heart rate, and high blood pressure [61][62]. Opiate use often results in slow or shallow breathing, low oxygen levels, low blood pressure, and slow heart rate [64].

In contrast, salicylate poisoning is associated with fast breathing, fast heart rate, and increased body temperature [65]. Sympathomimetic toxidrome features increased heart rate, high blood pressure, and hyperthermia, similar to anticholinergics, which also cause fast heart rate and elevated temperature. Cholinergic syndrome, characterized by the SLUDGE and DUMBBBELS symptoms can lead to slow heart rate [66].

Beta-blocker and calcium channel blocker poisoning both result in low blood pressure and slow heart rate, with beta-blockers also causing low blood sugar and calcium channel blockers leading to high blood sugar [67].

Serotonin syndrome and neuroleptic malignant syndrome both cause high blood pressure, fast heart rate, rapid breathing, and elevated body temperature, with the onset speed distinguishing the two [68]. Sedative and hypnotic agents may lead to hypothermia, bradypnea, and hypotension [70].

Pathophysiology

Altered consciousness can arise from issues within the cerebral hemispheres, diencephalon, or brainstem regions including the tegmentum [69]. Lesions in specific areas such as the posterior hypothalamus, midbrain, or upper brain stem are among the smallest changes that can affect consciousness. The speed of lesion development impacts the extent of functional impairment; for instance, acute conditions like arterial hemorrhage or embolic stroke cause more significant deficits for their size compared to slower-developing issues like subdural hematomas or tumors [71].

Although unilateral hemispheric diseases do not affect consciousness, they can if they lead to increased intracranial pressure affecting both hemispheres, cause pressure differences leading to ischemia and herniation, or obstruct cerebrospinal fluid flow, resulting in hydrocephalus, brain edema, and reduced blood flow, thereby impairing both hemispheres [72].

The underlying mechanisms of altered mental status, including conditions like delirium, confusion, dementia, and coma differ by cause.

Electroencephalography (EEG) studies on patients with acute delirium have shown disturbances in global cortical function, marked by a slowdown in the normal alpha rhythm and the emergence of abnormal slow-wave activity [73]. These EEG patterns are consistent and have helped clarify diagnoses of delirium, indicating a possible common neural pathway for the condition. Acetylcholine, a neurotransmitter, and the reticular activating system, crucial for modulating alertness, plays a significant role in this context, especially as strokes or tumors affecting this brainstem area can directly cause coma [74].

The ascending reticular activating system, located in the midbrain, pons, and medulla, controls arousal from sleep [75]. Conditions including hypoglycemia or hypoxia can reduce acetylcholine production in the brain, correlating with delirium severity [76]. Alzheimer’s dementia involves neuronal loss in the cerebral cortex, increased amyloid deposits, and neurofibrillary tangles, whereas vascular dementia links to cerebrovascular disease and infarctions [77] [78].

Coma may result from a lack of essential neuronal substrates such as glucose in hypoglycemia or oxygen in hypoxia, or direct brain impacts like increased intracranial pressure in herniation syndromes [15]. Cerebral perfusion pressure (CPP), vital for brain function, depends on the mean arterial pressure (MAP) minus the intracranial pressure (ICP) [79]. Thus, any increase in ICP can lower CPP unless blood pressure rises to compensate, leading to coma [79]. Furthermore, severe arrhythmias or hypotension can reduce MAP to impair brain perfusion, affecting cardiac output, which is the product of stroke volume and heart rate, and altering MAP [80].

Clinical Signs and Symptoms

Key indicators of AMS encompass a spectrum of symptoms: a diminished focus or disorientation, noticeable shifts in movement, erratic or unclear speech, alterations in sleep patterns including disrupted sleep cycles or difficulty waking, and other manifestations like hallucinations and memory issues [2] [7] [81].

Individuals may also experience confusion, delusions, delayed reactions to external stimuli, and significant emotional changes ranging from depression to mania [2][7]. These signs highlight the complex and multifaceted nature of AMS, underlining its impact on an individual’s mental and physical state [81].

For patients showing signs of infection, administer antibiotics and fluid boluses according to weight, and consider steroids for those who are steroid-dependent. Explore toxic or metabolic causes like drug overdoses, withdrawal syndromes, or adverse drug interactions [81].

Conduct laboratory tests for serum electrolytes, liver and kidney function, and urinalysis. Use chest X-rays to rule out pneumonia and head CT scans to check for intracranial hemorrhage as potential causes of altered mental status. Further tests might include evaluating thyroid function, serum B12 levels, syphilis status, and performing a lumbar puncture to exclude meningitis or subarachnoid hemorrhage [81].

Management/Treatment

Acute Altered Mental Status (AMS) is a life-threatening condition that warrants immediate and comprehensive attention in emergency department (ED) settings, serving as a criterion for patient admission. According to the Emergency Severity Index (ESI) triage tool (4th edition), the classification of acute AMS triage level 1 includes (no response, indicating severe danger) and level 2 (characterized by lethargy, mental confusion, and disorientation) [82][83].

The therapeutic approach for AMS targets the root cause, ranging from symptomatic treatments like intubation or external pacing for respiratory or cardiac issues to antibiotics and fluid resuscitation for sepsis, glucose administration for hypoglycemia, or neurosurgical procedures for intracranial hemorrhages [7][8][17]. For delirious patients, environmental adjustments (e.g., lighting changes), psychosocial support, minimizing noise, and encouraging movement can help mitigate sundowning behaviors.

Acute sedation might necessitate haloperidol, with dosage adjustments for elderly patients, while benzodiazepines may be opted for immediate relief, albeit with caution in the elderly due to potential exacerbation of sundowning [84]. For long-term management of dementia with sundowning, consider donepezil or atypical antipsychotics [13][14][41].

Providers should evaluate airway, breathing, and circulation and stabilize these physiologic functions as needed [34][35]. If the patient’s Glasgow Coma Scale (GCS) score is below 8, they lack a gag reflex, or there are other indications they cannot protect their airway, proceed with rapid sequence intubation [16]. For patients displaying signs of decreased cerebral perfusion pressure (CPP) due to low heart rate or blood pressure, consider interventions like external pacing, defibrillation, or the use of vasopressors [80].

At the bedside, it is essential to perform checks on vital signs, ECG rhythm, and glucose levels. Administer naloxone for opioid overdose, dextrose for hypoglycemia, and thiamine for conditions like Wernicke-Korsakoff syndrome or beriberi [21][22]. Ensure cervical spine immobilization when suspecting trauma [34][35]. In cases where signs of brain herniation are present, such as the Cushing reflex or unilateral pupil dilation, elevate the head of the bed to 30 degrees, increase ventilation rates, and consider the use of mannitol along with neurosurgical consultation.

Laboratory Tests

Laboratory tests for patients with altered mental status should be comprehensive to explore all possible reversible causes, such as vascular (e.g., stroke), infectious (e.g., neurosyphilis), neoplastic (including primary and metastatic tumors, and paraneoplastic syndromes), degenerative (e.g., multiple sclerosis), inflammatory (e.g., vasculitis), endocrine (e.g., thyroid disorders), metabolic (e.g., thiamine deficiency), toxic (e.g., adverse medication effects), traumatic (e.g., dementia pugilistica), and other conditions like normal pressure hydrocephalus [34][81][88].

Essential laboratory tests include a complete blood count (CBC) with differential, a comprehensive chemistry panel that includes calcium, magnesium, phosphorus, and glucose levels, liver function tests (LFTs), thyroid function tests (TFTs), and measurements of B12, folate, and rapid plasma reagin (RPR) for syphilis screening [34] [81][88].

Tests for specific drug levels (such as digoxin, lithium, or alcohol), a urine drug screen, and urinalysis are also important [81][88]. When suspecting CNS infection or autoimmune encephalitis a lumbar puncture may be necessary for analyzing cerebrospinal fluid [85]. An electroencephalogram (EEG) can aid in diagnosing seizure disorders, and Creutzfeldt-Jakob disease, or in confirming a delirium diagnosis [86].

Life-Threatening Causes of Altered Mental Status

Any illness, whether localized or systemic, along with physiological stress, can contribute to altered mental status (AMS), affecting mood, behavior, and cognitive functions [2]. The severity of the underlying disturbance correlates with the risk of compromised central nervous system (CNS) function.

These disturbances can stem from various organ systems, cardiovascular and pulmonary systems, endocrine, metabolic, rheumatologic, or musculoskeletal, hematologic, gastrointestinal, and urogenital systems [2][3][6]. Certain conditions among these can be fatal if not identified and managed.

To aid in remembering these critical conditions, providers can use the mnemonic “rule out the WHIMPS.”

[34]

Disposition

Determining the next steps after an emergency department (ED) visit for patients presenting with Altered Mental Status (AMS) is as critical as the immediate care provided [2][3]. The decision on the most suitable care level post-ED depends on several factors: the severity and cause of AMS, its reversibility, and the patient’s baseline health status [6].

It is essential to consider the recurrence likelihood of the AMS episode and the patient’s access to supportive aftercare. Research indicates that AMS patients face a higher mortality risk after ED presentation compared to those with chest pain, underscoring the urgency of taking AMS symptoms and pursuing thorough etiological investigations [87].

Criteria for safe discharge include resolution of symptoms, a stable condition post-treatment, the presence of a supportive home environment, and the patient’s ability to comply with follow-up care [6].

Management of seizure disorders with low anticonvulsant levels, transient hypoglycemia in diabetic patients, and narcotic overdoses in the ED are potential discharges with safe follow-up [3][6]. The decision to admit to an ICU versus a hospital ward is based on the patient’s stability, AMS etiology, and institutional capabilities.

Conclusion

Altered Mental Status (AMS) within the Emergency Department (ED) is a multifaceted challenge that necessitates immediate and thorough attention due to its potential to signify serious, life-threatening conditions [2][3][5]. This review has outlined the essential steps for assessing, diagnosing, and managing AMS, emphasizing the importance of a methodical, systems-based approach to uncover the myriads of potential etiologies, ranging from metabolic disturbances to acute neurologic events.

The critical nature of AMS among the elderly underscores the need for emergency clinicians to identify and address the underlying causes to prevent adverse outcomes [41]. A comprehensive evaluation, including a detailed history, physical examination, and appropriate diagnostic testing, is paramount in managing AMS [5][6].

In certain cases, it is appropriate to discharge patients from the ED with identification and resolution of AMS and adequate follow-up. However, most patients will require inpatient hospitalization for further monitoring and management of their condition [6]. The decision-making process regarding patient disposition should involve a multidisciplinary approach, including consultation with the patient’s family or caregivers, to ensure a plan that addresses both medical needs and patient preferences [3][6].

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