Altered Mental Status (AMS)

Aisha Suara

Background 

  • Definition: change in a pt’s baseline cognition. Medical diagnosis is encephalopathy
    • Can be hypoactive (lethargic) or hyperactive (agitated)
  • Risk factors: Functional impairment (hard of hearing, visually impaired, bed-bound), age > 75, dementia/neurodegenerative diseases, prior brain injury (stroke, TBI), depression, ETOH/substance use disorder, sensory impairment, recent surgery

Etiologies

Consider MOVE STUPID mnemonic 

  • Metabolic (Hypo/hypernatremia, Hypercalcemia)
  • Oxygen (Hypoxia)
  • Vascular (Ischemic stroke, hemorrhage, MI, CHF)
  • Endocrine (Hypoglycemia, Thyroid, Adrenal)
  • Seizure (Postictal state)
  • Trauma
  • Uremia
  • Psychiatric
  • Infection
  • Drugs (Intoxication, withdrawal, or medications)
  • Delirium – see “Delirium” section in psychiatry

Evaluation 

  • Consider broad toxic, metabolic, and infectious workup as appropriate.
  • CBC, CMP, BCx, UA with reflex UCx, CXR, Glucose, TSH, UDS, VBG, Vit B1 (whole blood), Vitamin B12, +/- RPR, HIV.
  • Review medications.
  • Beer’s Criteria, sedatives, anticholinergics, benzos/EtOH toxicity or withdrawal.
  • Head imaging in the setting of focal neurologic findings: if acute focal deficits, activate stroke alert.
  • Start with CT Head noncontrast – ischemic strokes take up to 24 hours to show up.
  • Consider CTA head/neck and MRI if high concern for stroke. MRI if high concern for inflammatory changes or infection.
  • LP should be performed if there is any concern for meningitis.
  • EEG for fluctuating mental status or seizure-like activity.

Management 

  • Management of underlying etiology.
  • Consider empiric high-dose thiamine supplementation (IV 500 mg TID x 3-5 days).
  • See "Delirium" in section in psychiatry for nonpharmacologic and pharmacologic management.
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