Altered Mental Status


First thing to do:

R/O or Tx for

Differential Dx
System Dx Workup
CNS Stroke* or transient ischemic attack CT, MRI, Drug levels.
Migraine
Seizure* or postictal state
Subarachnoid hemorrhage
Intracranial hemorrhage
Central nervous system mass lesion (Tumor/Infection)
Subdural hematoma
Cardiopulmonary CHF* CXR, Pro-BNP
Myocardial Infarct* EKG, CE
Pulmonary Embolism* D-Dimer, CTA
Hypoxia or CO2 narcosis Pulse Ox?
GI Cirrhosis* NH Level
Metabolic/toxic Hypoglycemia Finger stick
Alcohol ingestion * Blood Alcohol level
Electrolyte abnormalities CMP
Hepatic encephalopathy (Cirrhosis*) NH Level
Thyroid disorders TSH, free T3/T4
Alcohol  or drug Withdrawal* UDS, Blood Alcohol level, Acetaminophen and Salicylate level
Infectious Pneumonia* CXR, Pulse Ox, Sputum cult, ABx
Urinary tract infection UA w/C&S
Meningitis* or encephalitis LP, CT/MRI
Sepsis See Sepsis page



 
Features of Delirium, Dementia, and Psychiatric Disorder
Characteristic Delirium Dementia Psychiatric Disorder
Onset Over days Insidious Sudden
Course over 24 h Fluctuating Stable Stable
Consciousness Reduced or hyperalert Alert Alert
Attention Disordered Normal May be disordered
Cognition Disordered Impaired May be impaired
Orientation Impaired Often impaired May be impaired
Hallucinations Visual and/or auditory Often absent Usually auditory
Delusions Transient, poorly organized Usually absent Sustained
Movements Asterixis, tremor may be present Often absent Absent


Background

Diagnosis

Etiologies

Differential Dx

Treatment

  1. ABCs
  2. Accucheck; dextrose as needed
  3. Pulse oximetry
  4. Naloxone up to 2 mg IVP (esp. if resp. depression, pinpoint pupils)
  5. Thiamine 100 mg
  6. Flumazenil (controversial: only w/ known benzodiazepine OD; no other co-ingestants, no chronic benzodiazepine use & no seizure disorder, otherwise may precipitate uncontrollable seizure)
  7. CT scan
  8. Rx underlying disorder

Disposition

  1. Admit for workup & Rx


Classification of Dementia by Cause

Degenerative 
  Alzheimer's disease
  Huntington's disease
  Parkinson's disease, others
Vascular 
  Multiple infarcts
  Hypoperfusion (cardiac arrest, profound hypotension, others)
  Subdural hematoma
  Subarachnoid hemorrhage
Infectious 
  Meningitis (sequelae of bacterial, fungal, or tubercular)
  Neurosyphilis
  Viral encephalitis (herpes, human immunodeficiency virus), Creutzfeldt-Jakob disease
Inflammatory 
  Systemic lupus erythematosus
  Demyelinating disease, others
Neoplastic 
  Primary tumors and metastatic disease
  Carcinomatous meningitis
  Paraneoplastic syndromes
Traumatic 
  Traumatic brain injury
  Subdural hematoma
Toxic 
  Alcohol
  Medications (anticholinergics, polypharmacy)
Metabolic 
  Vitamin B12 or folate deficiency
 
  Thyroid disease
  Uremia, others
Psychiatric 
  Depression (pseudodementia)
Hydrocephalic 
  Normal-pressure hydrocephalus (communicating hydrocephalus)
  Noncommunicating hydrocephalus
 

 

Six Elements of Mental Status Evaluation

Appearance, behavior, and attitude 
  Is dress appropriate?
  Is motor behavior at rest appropriate?
  Is the speech pattern normal?
Disorders of thought 
  Are the thoughts logical and realistic?
  Are false beliefs or delusions present?
  Are suicidal or homicidal thoughts present?
Disorders of perception 
  Are hallucinations present?
Mood and affect 
  What is the prevailing mood?
  Is the emotional content appropriate for the setting?
Insight and judgment 
  Does the patient understand the circumstances surrounding the visit?
Sensorium and intelligence 
  Is the level of consciousness normal?
  Is cognition or intellectual functioning impaired?
 

Mini-Mental State Examination

Maximum Score Score  
    Orientation 
5 ( ) What is the: (year) (season) (date) (day) (month)?
5 ( ) Where are we: (state) (county) (town) (hospital) (floor)?
    Registration 
3 ( ) Name three objects; ask patient to repeat.
    Attention and Calculation 
5 ( ) The serial 7 test; 1 point for each correct. Stop after five answers. Option: spell "world" backward.
    Recall 
3 ( ) Ask for the three objects named above. 1 point scored for each object correctly recalled.
    Language 
9 ( ) Name a pencil and watch. (2 points)
    Repeat the following: "No ifs, ands, or buts." (1 point)
    Follow three-stage command: "Take a paper in your right hand, fold it in half, and put it on the floor." (3 points)
    Read and follow the following printed command:
      "Close your eyes." (1 point)
      "Write a sentence." (1 point)
      "Copy this design." (1 point)
Scoring: A score of 23 may indicate the presence of dementia or another cognitive disorder and suggests the need for further testing and evaluation. 
Instructions for Administering the Mini-Mental State Examination
Orientation: Ask for the date. Specifically ask for any omitted information. 1 point for each correct answer. 
Registration: Ask permission to test memory. Name three unrelated objects clearly and slowly about 1 s apart. After you have said all three, ask the patient to repeat. The first repetition determines the score. In order to test recall (discussed below) repeat the items in order up to six times, until the patient can repeat all three. If the patient is unable to do this, recall can't be tested. 
Attention and calculation: Ask the patient to begin with 100 and count backward by 7. Stop after five subtractions and score correct answers. If the patient cannot calculate, ask him or her to spell world backward. The score is the number of letters in correct order. 
Recall: Ask the patient if he or she can recall the three words the patient was previously asked to remember. Score 0–3. 
Language
  Naming: Show the patient a wristwatch and pencil and ask name. Score 0–2. 
  Repetition: Ask the patient to repeat a sentence. Allow one trial. Score 0 or 1. 
  Three-stage command: Give the patient a piece of paper and repeat the command. Score 1 point for each portion of the command correctly performed. 
  Reading: Print clearly on a piece of paper in large letters the command "Close your eyes." Ask the patient to read and perform the command. Score 1 point if the eyes are closed. 
  Writing: Give the patient a blank piece of paper and ask him or her to write a sentence of his or her own choosing. It must contain a subject and a verb to be scored 1 point. Punctuation does not matter for scoring purposes. 
  Copying: On a clean piece of paper, draw intersecting pentagons, each side 1 in., and ask the patient to copy exactly. All 10 angles must be present and the two figures must intersect to score 1 point. Any rotation of the figures or tremor is ignored. 
 

The Quick Confusion Scale

Item Score (Number Correct) x (Weight) = (Total)
What year is it now? 0 or 1 (Score 1 if correct, 0 if incorrect) x 2 = _____
What month is it? 0 or 1 x 2 = _____
(Present memory phrase):        
  Repeat this phrase after me and remember it:        
  "John Brown, 42 Market Street, New York."         
About what time is it? (Answer correct if within 1 h.) 0 or 1 x 2 = _____
Count backward from 20 to 1. 0, 1, or 2 x 1 = _____
Say the months in reverse. 0, 1, or 2 x 1 = _____
Repeat the memory phrase (each underlined portion correct is worth 1 point). 0, 1, 2, 3, 4, or 5 x 1 = _____
Final score is the sum of the totals.     = _____
Notes: 
15 is the top score; a score <15 may indicate the need for additional assessment. 
Scores highest number in category indicates correct response; lower scoring indicates increased number of errors.
Item 1. What year is it now? Score 1 if answered correctly, 0 if incorrect.
Item 2. What month is it? Score 1 if answered correctly, 0 if incorrect.
Item 3. About what time is it? Answer considered correct if within 1 h; score 1 if correct, 0 if incorrect.
Item 4. Count backward from 20 to 1. Score 2 if correctly performed; score 1 if one error, score 0 if 2 or more errors.
Item 5. Say the months in reverse. Score 2 if correctly performed; score 1 if one error, score 0 if 2 or more errors.
Item 6. Repeat memory phrase: "John Brown, 42 Market Street, New York."  Each underlined portion correctly recalled is worth 1 point in scoring; score 5 if correctly performed; each error drops score by 1.
Final score is the sum of the weighted totals; items 1, 2, and 3 are multiplied by 2 and summed with the other item scores to yield the final score.
 



Source: Tintinalle ED 7th