AUTHORS
Jared Ditkowsky, MD, Director, Geriatric Emergency Department, Hackensack University Medical Center, Hackensack, NJ
Michael Ullo, MD, FACEP, Medical Director, Quality & Patient Safety, Department of Emergency Medicine, Hackensack University Medical Center, Hackensack, NJ
PEER REVIEWER
Catherine A. Marco, MD, FACEP, Professor, Department of Emergency Medicine, Penn State Hershey Medical Center and Penn State College of Medicine
EXECUTIVE SUMMARY
- Altered mental status (AMS) describes a condition with impairment of the patient’s level of consciousness, cognition, and/or behavior.
- AMS can be acute, as with delirium, or chronic, like with dementia.
- At least 25% of emergency department (ED) patients older than 65 years of age have some form of AMS.
- Risk factors for delirium include low education attainment, poor functional status, advanced age, use of anticholinergic or psychotropic medications, malnutrition, visual/hearing impairment, and existence of comorbidities, such as stroke, liver disease, chronic kidney disease, or seizure disorder.
- Delirium is an acute change in attention or awareness, with either agitated or hypoactive behavior.
- Patients with an underlying dementia can have a sudden change due to a reversible medical condition, often an infection or electrolyte abnormality.
- Up to 30% of elderly ED patient may have depression, with about half exhibiting significant symptoms.
- Create a supportive environment for older adults to prevent environmentally induced/iatrogenic delirium.
Introduction
Altered mental status (AMS) is a common chief complaint for older adults in the emergency department (ED). AMS can manifest in different ways, making it difficult to have a universally accepted definition. For the purposes of this article, AMS will be defined as an impairment in a patient’s level of consciousness, cognition, or behavior.1 It has been estimated that at least 25% of all ED patients older than 65 years of age have some form of AMS.2
With an aging population, the emergency physician (EP) must understand the approach to mental status changes in the elderly. Most developed countries have adopted the chronological age of 65 years and older to define the geriatric population (also called older adults).3 By 2040, it is estimated that roughly 21.6% of American adults will fall into this demographic.4 This review will highlight common causes for changes in mental status for geriatric patients in the ED.
Although different models exist, AMS can be conceptually divided into acute and chronic manifestations. Acute manifestations include mild to moderate delirium (interchangeably referred to as acute altered mental status and acute brain dysfunction), more severe forms of delirium (such as agitation or aggression), and depression in consciousness (such as stupor and coma). Chronic causes of mental status changes may include dementia and psychiatric conditions. This paper will use this framework when discussing approaches and management of AMS in the geriatric population presenting to the ED.
While “altered mental status” frequently is encountered in the ED, it is essential to note that the term does not denote a specific presentation, disease, or disorder. Often, it is used synonymously with descriptors such as weakness, agitation, inappropriate behavior/aggression, disorientation, and inattention, among others. The ED often is the first point of contact with healthcare professionals for older adults with AMS. As such, the EP needs to approach these patients with confidence and expertise regarding diagnosing and managing underlying conditions that may be the etiology of a patient’s acute alteration in mental status.2
Approach
The initial evaluation of a patient with AMS in the ED should begin with determining stability. Depending on the severity of AMS, respiratory and hemodynamic stabilization may be necessary. In patients displaying significant acute disability, pupillary exams and assessment of responsiveness and blood glucose are part of the initial assessment.
For patients whose disability is severe enough that they cannot protect their airway, do not have a gag reflex, or have a Glasgow Coma Scale score of less than 8, consider rapid sequence intubation.5 As a part of the initial assessment, patients should be placed on a cardiac monitor and pulse oximeter. Intravenous access should be established early. Prompt recognition of abnormal vital signs is imperative. Patients may require a rectal temperature to accurately assess their core temperature.
Ingestions, such as opioid or benzodiazepine overdose, should be considered and intervened on rapidly if suspected. For stuporous or comatose patients, consider administering empiric thiamine (with concern for Wernicke-Korsakoff syndrome or beriberi), naloxone for opiate reversal, or dextrose for hypoglycemia.
Exposure is a critical component of the initial approach to the patient with AMS. Undressing the patient and examining them front to back by rolling onto the right and left side may detect signs of infection, trauma, and external medication patches contributing to the underlying pathology not apparent when the patient is dressed.
If there are signs of trauma, consider immobilizing the cervical spine. Additionally, if increased intracranial pressure is suspected, the patient’s head can be elevated to 30 degrees while awaiting additional testing and interventions, such as hypertonic saline, mannitol, or surgical decompression. Swift recognition of infectious etiology may prompt antibiotic administration and weight-based fluid resuscitation that can be tailored to the patient’s comorbidities.
After initial stabilization, a diagnostic approach to AMS should center on discovering causal etiology. A robust history may be complicated to gather from the patient with AMS. Patient proxies, such as family members, caretakers, and healthcare providers familiar with the patient, can be essential sources of information.
A detailed physical exam should be performed, focusing on common etiologies for AMS. For example, evidence of head trauma with changes in mental status should warrant consideration for intracranial hemorrhage. Findings such as pupillary changes or neurologic deficits may lead to an elevated suspicion of underlying neurological etiologies, such as ingestion, stroke, seizure, or encephalopathy. Crackles on auscultation of the lung may hint at an underlying disease of the lung parenchyma. Neck rigidity and fever in the setting of mental status change can be worrisome for meningitis or encephalitis. A comprehensive skin exam can detect lesions pointing toward an underlying infectious or autoimmune process. Similarly, new cardiac murmurs may indicate cardiomyopathy or endocarditis.6
The diagnostic workup should focus on suspected underlying pathology as indicated by history and physical exam. Laboratory testing is a routine aspect of the AMS workup and management. Assessing for electrolyte abnormalities, uremia, hepatic disease, and urinary infection is routine. When suspected, thyroid studies may be used to assess for hypothyroidism and hyperthyroidism. A 12-lead electrocardiogram and cardiac biomarkers can evaluate acute coronary syndrome as an underlying etiology of AMS. Furthermore, serum drug levels can be ordered if ingestion or subtherapeutic/supratherapeutic medication dosing is part of the EP’s differential.
Imaging studies also may assist in diagnosis. Computed tomography (CT) of the abdomen and pelvis should be considered to assess for intra-abdominal pathology in gastrointestinal complaints or abdominal tenderness. Chest radiography, such as X-ray or CT imaging, can assess for cardiopulmonary etiologies of AMS, such as pulmonary edema and pneumonia.
In patients without a clear underlying etiology of AMS, more resource-intensive diagnostics may be used, such as electroencephalogram (EEG) to assess for seizures, magnetic resonance imaging (MRI) to assess for stroke, and lumbar puncture to evaluate for meningitis.
CT imaging of the head should be obtained early for patients presenting with stupor or coma. This diagnostic modality can identify intracranial lesions such as mass or hemorrhage, which may be the etiology of the patient’s cognitive dysfunction. Most treatable causes of delirium are not intracranial, and, therefore, CT imaging should be performed on a case-by-case basis.
Excessive imaging may delay other diagnostics or imaging, or lead to false positives. However, in patients at risk for intracranial bleeding, those with hypertensive emergency, and those with known or suspected intracranial processes such as mass, hemorrhage, recent infarct, or suspected infection, it should be strongly considered. Because older adults often are at risk for the aforementioned, head CT may be more strongly considered when assessing AMS in this population.7
Ultimately, treatment will be guided based on the underlying etiology of AMS. Pharmacologic and nonpharmacologic interventions may be successful and should be tailored toward each clinical scenario.
Risk Factors
Multiple risk factors exist for the development of AMS in geriatric patients, many of which are interdependent and synergistic.2 Patients with advanced age, existing dementia or depression, and medical comorbidities represent a more vulnerable population. Conversely, the development of acute delirium is associated with an increased risk of dementia.
Demographic risk factors for delirium are broad: low education attainment, poor functional status, advanced age, use of anticholinergic or psychotropic medications, malnutrition, visual/hearing impairment, and existence of comorbidities, such as history of stroke, liver disease, chronic kidney disease, or seizure disorder.2 Many of these risk factors for delirium overlap with those for developing dementia and other chronic forms of altered mental status, such as socioeconomic resources, educational level, medical/psychiatric conditions, and functional status.8
Acute Altered Mental Status
Delirium, Stupor, and Coma
Acute altered mental status may be conceptually placed into one of three categories: delirium, stupor, and coma. Delirium is an umbrella term representing a cognitive dysfunction caused by an underlying physiologic condition.9 Patients with delirium exhibit a change in attention and awareness that typically manifests over a short period (hours to days). The presentation may range from subtle disturbances in attention to grossly disorganized psychomotor behavior. Upwards of 10% of older patients in the ED will present with delirium, and the diagnosis may be missed in up to 80% of patients.10,11
The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) lists five key features that characterize delirium.9 (See Table 1.)
Diagnosis of delirium is clinical and hallmarked by the acute onset of fluctuating attention deficits and cognitive abnormalities and can be conceptualized as “acute brain failure.” History-taking is paramount for establishing the diagnosis, and several screening tools have been developed to aid in early detection. The Geriatric Emergency Department Guidelines recommend the Delirium Triage Screen (DTS; http://eddelirium.org/delirium-assessment/dts-calculator/) and the Brief Confusion Assessment Method (bCAM; http://eddelirium.org/delirium-assessment/bcam-calculator/) as highly sensitive and specific screening instruments whose brevity makes them particularly well-suited in the ED setting.12
Careful history acquisition from the patient and collateral can help detect the underlying cause of delirium. The EP should assess the patient for underlying infectious conditions, such as urinary tract infections or pneumonia. Laboratory data can uncover underlying metabolic abnormalities, such as hypoglycemia and electrolyte imbalances, liver dysfunction, or acute coronary syndrome. Neurologic conditions, such as stroke, seizure, and intracranial hemorrhage, commonly can present with delirium. A comprehensive review of medication lists also is critical for evaluating this disorder.
Table 1. DSM Features of Delirium |
DSM: Diagnostic and Statistical Manual of Mental Disorders Adapted from: Amercian Psychiatric Association, DSM-5 Task Force. Diagnostic and Statistical Manual of Mental Disorders: DSM-5, 5th ed. American Psychiatric Publishing Inc.; 2013 |
The management of delirium is directed toward the underlying cause. For example, patients with sepsis should receive early antibiotic therapy. Acute pain should be treated promptly. Nonpharmacologic agents should be used to assist with cognitive and behavioral changes while treating the underlying cause. Elderly patients with delirium may benefit from frequent re-orientation, early mobilization, avoidance of restraints/leads/catheters, and adequate lighting.12 Safety companions or sitters should assist with patient care when appropriate. Antipsychotic agents are a controversial option for the management of acute delirium and should be used cautiously with careful consideration of the side effect profiles. In general, benzodiazepines carry significant risks when used in older adults and should be avoided when possible.
Stupor and coma represent a more severe form of acute brain dysfunction when compared to delirium. Although several definitions exist, they may be based on a Richmond Agitation Sedation Scale score (RASS) of -4 for stupor and -5 for coma. (See Table 2.) Stupor and coma occur in approximately 5% to 9% of older ED patients and are considered critical emergencies requiring immediate evaluation. Prompt assessment, stabilization, and management of these patients may be required because they represent significant disruptions of attention and awareness.2
Table 2. Richmond Agitation Sedation Scale (RASS) |
||
Score |
Description |
Test |
4 |
Combative |
Overly combative, violent, immediate danger to staff |
3 |
Very agitated |
Aggressive, pulls or removes restraints or tubes |
2 |
Agitated |
Frequent non-purposeful movements |
1 |
Restless |
Anxious but movements not aggressive or vigorous |
0 |
Alert and calm |
|
-1 |
Drowsy |
Sustained awakening > 10 sec to voice |
-2 |
Light sedation |
Briefly awakens < 10 sec with eye contract to voice |
-3 |
Moderate sedation |
Movement or eye opening without eye contact to voice |
-4 |
Deep sedation |
No response to voice, but movement or eye opening to physical stimulation |
-5 |
Unresponsive |
No response to voice or physical stimulation |
Used with permission from Sessler CN, Grap MJ, Brophy GM. Multidisciplinary management of sedation and analgesia in critical care. Semin Respir Crit Care Med 2001;22:211-226. © Georg Thieme Verlag KG. |
||
Metabolic Abnormalities
Electrolyte Derangements
Alterations in serum electrolytes, such as hyponatremia/hypernatremia and hypocalcemia/hypercalcemia, may contribute to acute brain dysfunction. Hyponatremia, in particular, is the most frequently encountered electrolyte disorder in hospitalized patients, with advanced age being a vital independent risk factor.13
Manifestations of hyponatremia, such as stupor, seizures, vomiting, gait imbalance, and cognitive impairment, are more pronounced in older adults.13,14 Clinical manifestations of hyponatremia are dependent on the acuity and rapidity of its development. Symptoms usually are present when the serum sodium level is below 125 mmol/L to 120 mmol/L. In the elderly, hyponatremia is independently associated with an increased risk of mortality.15 Hyponatremia may manifest due to medication use, such as thiazide or loop diuretics, psychotropic medications, and antiepileptics. In the elderly, the syndrome of inappropriate antidiuretic hormone (SIADH) remains a frequent cause of hyponatremia. This is thought to be due to increasing plasma vasopressin concentrations with aging.16 Other causes may include hypopituitarism and osmotic fluid shifts caused by hyperglycemia or decreased intake, typified by the “tea and toast” diet.13
Hypernatremia is another common cause of sodium derangements found in geriatric populations. It may be present in about 2% of hospitalized older adults, increases with advancing age, and is associated with significant morbidity and mortality in hospitalized patients.17,18 Older adults may be predisposed to hypernatremia due to decreased access to water, decreased total body water, and impaired thirst mechanisms.19,20 This risk is greater in patients with advanced dementia.18 Impaired long nephrons with age may impair the kidneys’ ability to excrete sodium in response to a load, further exacerbating the risk of hypernatremia.18
Symptoms of hypernatremia in older adults often are nonspecific and may not present until sodium levels are more than 160 mmol/L; they may be milder in the case of chronic hypernatremia.21 Treatment of hyponatremia and hypernatremia depends on volume status and underlying cause. Management often will require inpatient care.
Hypocalcemia is another relatively common electrolyte derangement in older adults. Symptoms often are neurological and can include psychosis, confusion, and depression. It also may lead to QTc prolongation as an early manifestation. Several common causes of hypocalcemia can occur in the geriatric population. Hypoparathyroidism can occur idiopathically or iatrogenically due to surgical disruption of the parathyroid glands. Changes in calcium-sensing receptors with age also can decrease serum calcium levels. Vitamin D deficiencies may be due to decreased sun exposure, dietary intake, and renal or hepatic dysfunction.
Other potential causes of hypocalcemia include hyperphosphatemia, present in those with impaired renal function or excessive tissue breakdown from pathologies such as rhabdomyolysis or tumor lysis, hypomagnesemia, rapid blood transfusion, and “hungry bone syndrome.” Management in the ED includes addressing underlying causes, such as discontinuation of contributing medications and administration of calcium salts.22
Like hypocalcemia, symptoms of hypercalcemia can be nonspecific, including nausea, vomiting, poor appetite, muscle weakness, fatigue, and confusion. The most common cause of hypercalcemia in adults is hyperparathyroidism. In the elderly, malignancy and significant immobilization also are frequent etiologies to consider.
Treatment is centered on intravenous fluids, with pharmaceutical interventions such as bisphosphonates and calcitonin considered depending on the serum calcium concentration and severity of symptoms. Dialysis may be considered in resistant, life-threatening cases.23
Renal Dysfunction
Both chronic and acute renal disease can contribute to AMS in elderly patients. Acute kidney injury, in particular, is a risk factor for delirium and coma, particularly in the setting of critical illness.24 Chronic kidney disease is associated with a high prevalence of neurological complications and cognitive impairment. Patients with chronic kidney disease are at higher risk for stroke and dementia. This may be due to vascular injury and/or uremic toxins contributing to neurodegenerative diseases. Patients with renal dysfunction also are at higher risk for new-onset and progression of dementia, as well as stroke.25,26
Uremia may have symptoms ranging from mild sensory disturbances to stupor and coma.27 Other metabolic changes causing AMS in patients with renal disease include electrolyte disturbances, particularly calcium and sodium derangements. Hypertensive encephalopathy in chronic kidney disease patients can present as delirium and should be treated with antihypertensives.
For patients with acute hypertension, particularly in end-stage kidney disease, a diagnosis of posterior reversible encephalopathy syndrome (PRES) should be considered. PRES often will manifest with headaches, seizures, and changes in mental status, and it may be associated with white matter changes in neuroimaging. Because many medications are metabolized by the kidneys, drug toxicity and polypharmacy should be considered as contributing causes of AMS, particularly in geriatric patients with renal disease.26
Hepatic Dysfunction and Thiamine Deficiency
Older adults are being diagnosed with advanced hepatic disease and cirrhosis with increasing frequency. Hepatic encephalopathy is a known complication of hepatic dysfunction, with manifestations ranging from mild cognitive impairment to advanced disorientation and coma. Although hepatic encephalopathy is associated with chronic cognitive impairment, such as Parkinson’s disease, dementia, and alcohol-related cognitive dysfunction, it may be treatable and reversible.28
Hepatic encephalopathy may be difficult to diagnose because mild symptoms such as sleep disturbance and difficulty concentrating may be the initial presenting signs. Should mild symptoms gradually progress, the time course may be like that of advancing dementia, leading to misdiagnosis. Exam findings in hepatic encephalopathy that may distinguish it from dementia include asterixis and extrapyramidal symptoms, such as parkinsonism, spastic paraparesis, and chorea. However, these symptoms may overlap with Parkinson’s disease or Lewy body dementia. A metabolic workup and assessment for hepatic dysfunction through imaging and potential hepatic biopsy will solidify the diagnosis.
Patients with liver dysfunction due to alcohol dependence may acquire a thiamine deficiency and, consequently, Wernicke encephalopathy. Wernicke encephalopathy represents an acute thiamine deficiency that may present with any gait ataxia, ocular exam abnormalities, and encephalopathy. In patients with repeated episodes of persistent Wernicke encephalopathy, Korsakoff syndrome may develop, resulting in both anterograde and retrograde memory loss. Treatment includes the repletion of thiamine.29
Thyroid Dysfunction
Thyroid dysfunction commonly is associated with psychiatric and cognitive disorders in adults.30 Elderly patients are particularly predisposed to both dementia and cognitive impairments as a result of hypothyroidism, which is considered a reversible dementia.31 Overt hyperthyroidism also may be linked to acute and chronic impairment of visuospatial organization and memory, as well as dementia in the elderly.32 Workup for acute changes in mental status or undiagnosed chronic changes should include assessment of thyroid function, with treatment targeted to the underlying pathology.
Medication Induced
Polypharmacy
Physiologic changes in geriatric patients make them susceptible to adverse consequences of medication use. Additionally, older adults tend to take more medications for chronic medical conditions, putting them at risk for significant drug-drug interactions. The American Geriatrics Society publishes a reference tool commonly known as the Beers Criteria. This tool contains a list of medications that may be “potentially inappropriate” for geriatric patients.33 Drugs in this list are categorized based on five categories:
• medications that are potentially inappropriate;
• medications potentially inappropriate in patients with certain diseases or syndromes;
• medications to be used with caution;
• medications with potentially inappropriate drug-drug interactions;
• medications whose dosages should be adjusted based on renal function.
The EP should consider the potential for adverse medication effects in geriatric patients. A detailed review of a patient’s home medication list can uncover the etiology of a change in mental status. Commonly implicated medications include narcotics, anticholinergics, and sedative-hypnotics.
Ingestions
Based on data from 2018, nearly 1 million adults of geriatric age may have a substance use disorder, and the proportion of admissions of older adults to substance abuse treatment facilities appears to be increasing. Physical and social changes, such as changes to drug metabolism and increased rates of mood disorders and chronic cognitive dysfunction in the elderly, may make them more vulnerable to substance misuse. Given these trends, acute ingestion and substance use disorders are important to consider in the differential for AMS in the older adult.34
Alcohol. Alcohol is the most commonly ingested drug in older adults. About 65% of individuals 65 years of age or older have reported signs of high-risk drinking, and more than 10% binge drink.35,36 Alcohol consumption in older adults is growing compared to younger cohorts. Alcohol use disorder is the most common reason for admission to addiction treatment centers for geriatric patients; this disease can put individuals at risk for diabetes, congestive heart failure, liver and bony abnormalities, mood disorders, cognitive dysfunction, and high blood pressure.35,37,38
The effects of alcohol in older adults may be pronounced due to equally rapid absorption compared to younger counterparts, with a loss of lean body mass reducing the volume of distribution. As a result, peak ethanol concentrations are increased. Interaction between alcohol and commonly prescribed drugs may lead to harmful consequences, particularly for drugs with narrow therapeutic indexes, such as warfarin or anticonvulsants.
Alcohol use in older adults may predispose them to several health conditions. Impaired balance and sensory regulation, with the addition of osteoporosis, may predispose elderly patients to falls and orthopedic injuries. Delirium may result due to acute ingestion of alcohol, as a result of withdrawal, or due to chronic effects of alcohol use such as Wernicke’s encephalopathy. Alcohol also may predispose patients to dementia, accompanied by cerebral atrophy.
Moderate to heavy drinking, both chronic and acute, may induce hypertension and increase stroke risk. Dysrhythmias may occur due to acute or chronic cardiomyopathy induced by binge/chronic alcohol abuse. Other common complications of alcohol use in older adults include nutritional deficiencies, immunosuppression leading to aspiration pneumonia and opportunistic infections, and a predisposition to cancers of the head, neck, and liver.39
Treatment of acute ingestion is primarily supportive. In older adults, care should be taken to make sure changes in mental status are not incorrectly ascribed solely to alcohol ingestion. Acute withdrawal typically is managed with benzodiazepines. Although there is a lack of literature related to best practices in administering benzodiazepines in alcohol withdrawal to geriatric patients, dose adjustments should be made on a case-by-case basis. Chronic alcohol use may be amenable to treatment from inpatient or outpatient treatment programs.39
Opioids.40 Opioids are naturally occurring compounds frequently prescribed for analgesia. Examples include morphine and codeine. Newer, synthetic opiate analogs include fentanyl and methadone. Tramadol acts on opioid receptors and blocks serotonin reuptake to produce analgesic effects. With mild toxicity, these agents can result in lethargy, while more profound toxicity and acute ingestion can present with respiratory depression or apnea.
Chronic health conditions, such as cancer and heart disease, may complicate persistent pain in older adults, often treated with opiate medications. Up to 9% of older adults may use prescription opioids for pain relief, and that rate may be rising.41,42 Use of nonprescription opiates, such as heroin, in older adults also is on the rise and may be encountered more commonly in the ED.43 When opioid intoxication is suspected, naloxone can be considered to improve depressed respirations and mental status.
Cannabis. Cannabis use in older adults has risen sharply in recent years. Given research suggesting marijuana may relieve symptoms of chronic pain, depression, sleep disorders, and malnutrition, many geriatric patients are using cannabis to alleviate symptoms of underlying medical conditions. Despite the potential benefits, regular use of marijuana is associated with chronic conditions, such as memory and cognitive dysfunction, depression, respiratory conditions, and impaired cardiovascular health.44 Furthermore, cannabis can interact with prescription drugs, worsening physiologic changes caused by the drugs, and further complicating issues of drug metabolism already present in older adults.34
Acute ingestion of cannabinoids can be characterized by euphoria, time and spatial perception distortion, and motor impairment. Negative psychological effects include induction of panic, depression, and fear; negative physiologic impacts may include tachycardia and postural hypotension. Respiratory depression and cognitive dysfunction may occur at higher doses. While the aforementioned symptoms may be tolerated well in younger patients, older adults may be more prone to the negative side effects.45
Cocaine/Sympathomimetics. Use of cocaine in the geriatric population is growing, leading to higher rates of hospitalization for older adults.46,47 Cocaine and other sympathomimetics frequently are associated with cardiovascular disease, including left ventricular hypertrophy, coronary ischemia, vasospasm, atherosclerosis, and arrhythmia. It also may be associated with cerebrovascular pathology, such as intracranial hemorrhage and stroke. Given their burden of comorbidity and physiologic changes compared to younger cohorts, older adults are more likely to be adversely affected by cocaine/sympathomimetic use.48 In addition to supportive care, benzodiazepines can be used cautiously to treat acute intoxication when necessary.
Anticholinergics. Anticholinergic agents frequently are found in both prescription and over-the-counter medications. Common drugs include antihistamines, antipsychotics, and tricyclic antidepressants. Toxicity from these medications can result in agitated delirium. Anticholinergic effects, such as mydriasis, tachycardia, anhidrosis, and flushed skin, also may be present.49
Sedative-Hypnotics.50 This class of medications commonly is prescribed for insomnia and anxiety. Agents include benzodiazepines, antidepressants, and skeletal muscle relaxants. Toxicity from these medications can result in extreme drowsiness, ataxia, and respiratory depression. Management of potential medication toxicity is mainly supportive, focusing on the ABCs (airway, breathing, and circulation) of resuscitation. Antidotes should be administered when clinically appropriate.
EPs should be mindful when prescribing medications to elderly patients in the ED and upon discharge. The lowest effective dose should be prescribed with a limited supply. Careful attention should be given to dose adjustments in renal and hepatic insufficiency patients.
Sepsis
Sepsis is a life-threatening syndrome caused by infection with a dysregulated host physiologic response.51 Clinical presentations can vary from subtle mental status changes to shock with multisystem organ failure. Mortality in elderly patients with severe sepsis and septic shock is between 50% and 60%. Additionally, age is an independent predictor of mortality.52
Early recognition of sepsis is paramount to clinical care. The respiratory system is the most common source of infection in patients with sepsis. Urinary and gastrointestinal sources also are commonly implicated. Older adults are more likely to develop infections from gram-negative organisms.53 A thorough history and physical exam in conjunction with laboratory data and radiologic imaging can make the diagnosis.
Meningitis can be a particularly challenging diagnosis in geriatric patients. The classic presentation of fever, headache, and AMS is not as common in older adults.54 Geriatric patients may present with reduced levels of consciousness ranging from lethargy to coma. Diagnosis typically is made via cerebrospinal fluid analysis after performing a lumbar puncture.
Regardless of the infectious source, sepsis is a life-threatening emergency that requires prompt treatment. Early administration of antibiotics upon recognition of sepsis is critical for patient care and improving patient outcomes.
Central Nervous System
Stroke
Stroke, or cerebrovascular accident, is cited as the third leading cause of morbidity and mortality in developed countries, particularly among geriatric patients. It may be classified as hemorrhagic or ischemic; each may present with AMS and require timely diagnosis and intervention.55 Stroke may induce stupor or coma if the pathology involves the reticular activating system. Rapidly progressive AMS may be observed with worsening edema from ischemic or hemorrhagic stroke or expanding hematoma in the case of hemorrhagic stroke.
AMS as a sole presenting symptom is not commonly associated with ischemic stroke. One study found that only 26% of patients suspected of having an acute stroke with no focal neurological impairment ultimately had a diagnosis of ischemia; fewer patients still received therapy, i.e., alteplase, for their diagnosis.56 Despite this, ischemic stroke still should be considered for geriatric patients with AMS. This is particularly true for patients with significantly impaired consciousness (severe delirium, stupor, or coma) who may be exhibiting signs of a large hemispheric infarction or brainstem stroke.57,58
Although AMS without focal neurological deficits is an uncommon presentation of ischemic stroke, it is a common complication that is associated with increased mortality and other adverse outcomes.59 Up to 25% of all stroke patients may exhibit AMS, leading to prolonged hospitalization and increased costs to the healthcare system. Furthermore, stroke patients presenting with delirium or other forms of AMS are less likely to be discharged home and frequently are referred to rehabilitation centers or nursing facilities.60 Given the morbidity, mortality, and healthcare resource utilization associated with stroke patients presenting with AMS, early diagnosis and intervention should be a component of the EP’s care.
Hemorrhagic stroke is a cause of AMS associated with severe morbidity and high mortality. Early diagnosis with CT imaging or lumbar puncture and treatment are essential given the potential for rapid expansion of hemorrhage, which may result in neurological dysfunction and waning mental status. Etiologies may range from long-standing hypertension, which leads to degeneration of arteries, most notably small penetrating arteries, cerebral amyloid angiopathy, traumatic injury, arterio-venous malformations, and ruptured aneurysms, among others.55
For both ischemic and hemorrhagic stroke in patients with AMS, initial evaluation often includes CT imaging of the head and neck. The CT may disclose vasogenic edema indicative of ischemic stroke or visualize hemorrhage. A CT angiogram may inform the EP of a vascular occlusion or reveal a source of hemorrhage. MRI is considered highly sensitive for both forms of stroke and may be necessary to make a formal diagnosis of stroke as the cause of a patient’s AMS.61 Stroke mimics are numerous and include pathologies ranging from metabolic disorders and infectious diseases to seizures and psychological etiologies. CT may alternatively disclose pathology that may mimic stroke, such as intracranial tumors or edema, presenting as delirium.
Management of stroke depends on the underlying etiology. Ischemic stroke may be amenable to thrombolytics or thrombectomy. Hemorrhagic stroke may require surgical decompression and hemostatic therapy. Blood pressure management should be considered in either scenario, and therapeutic goals may vary depending on the underlying etiology. The EP should discuss target goals early with appropriate consultants, such as neurology and neurosurgery.
Management of elevated intracranial pressure may help improve or prevent further deterioration of a patient’s mental status. Consider elevating the head of the patient’s bed to approximately 30 degrees. Osmotic agents, such as hypertonic saline and mannitol, can assist in intracranial pressure management. Maintaining normal carbon dioxide levels in the intubated patient also may help regulate intracranial pressure.61
Seizure
Epileptic seizures are a common neurological condition leading to presentation to the ED with AMS.62 They are the third most common neurological disorder in older adults after stroke and dementia, with their incidence increasing dramatically in individuals who are 60 years of age or older.63 As such, the EP must consider this diagnosis in the patient with AMS. The diagnosis of seizure may be difficult to make in the older adult, given increased rates of atypical symptoms and changes in the patient’s mental status, which can create a barrier to gathering an accurate history.
Acute symptomatic seizures may be secondary to infection, inflammatory disorder, central structural abnormality, metabolic derangements, or toxins. Patients also may present with primary, unprovoked seizures. Seizures may lead to AMS by a brief period of confusion after epileptic activity, referred to as a postictal state, or they may present with active convulsive or nonconvulsive seizure activity. AMS and confusion in the postictal period tend to last longer in the older adult population than in the general population.64
Geriatric patients are both more prone to developing an unprovoked seizure and to exhibiting recurrence of seizures. The most common cause of recurrent seizures in older adults is stroke-related and cryptogenic seizures, followed by brain tumors and dementia.65
New-onset seizures should be evaluated with laboratory testing, including a metabolic assessment and CT imaging of the head to assess for intracranial lesions. It is important to consider nonconvulsive seizure activity as a cause of AMS that may not be as obvious as their convulsive counterpart. Treatment with antiepileptic medication should be administered if suspected, and diagnosis may be made with EEG.
Patients with recurrent seizures should have levels of antiepileptics checked to ensure therapeutic levels. They also should be evaluated to ensure there are no alternative pathologies that may have led to the seizure activity, including infection, metabolic derangements, or toxic ingestions. CT of the head should be considered in patients in whom a new central neurological etiology is suspected or if there is a change in the pattern of their seizures. Lumbar puncture may be necessary to assess for infection or autoimmune encephalitis. MRI and EEG may contribute to the diagnosis.66
Acute seizure activity should be treated with benzodiazepines as first-line therapy. Fosphenytoin, barbiturates, valproate, and levetiracetam may be second-line agents. In the setting of intractable status epilepticus, intubation with antiepileptic and sedation infusion such as propofol may be necessary.67
Elderly patients are prone to experiencing adverse events after initiation of antiepileptic drugs, given physiologic changes affecting drug metabolism and high rates of medication interactions. As such, oral antiepileptics should be initiated cautiously, starting at a lower dose than typically would be given and titrating up gradually as needed.65
Alternative Diagnoses to Consider
In addition to the common etiologies of mental status discussed earlier, it is essential to consider the following diagnoses.
Cardiopulmonary
Elderly individuals are less likely to present with traditional symptoms of cardiopulmonary pathology. Myocardial infarction is less likely to present with a complaint of chest pain/discomfort and is more likely to present similar to stroke, syncope, or delirium.68 Other forms of cardiopulmonary disease, such as congestive heart failure and pulmonary edema, are associated with delirium in hospitalized patients.69
Pain
The presence of somatic pain may precipitate delirium in older adults. Appropriate pain control for this population may help to improve mental status. Selecting an appropriate medication is essential, as certain analgesics, such as opiates, can further worsen mental status changes.70 The EP should be selective in their choice of analgesics.
Simple pain medication such as acetaminophen or local methods such as regional nerve blocks should be considered when appropriate. Nonsteroidal anti-inflammatory drugs (NSAIDs) should be used with caution, given potential complications in older adults, such as renal failure, cardiovascular disease, and gastropathy.71 However, they may be considered in patients at high risk for developing delirium with alternative agents. When opioids are deemed the most appropriate option for pain control, lower potency opioids should be used before more potent opiates, such as morphine.72
Environmental/Iatrogenic Causes
The environment of many EDs may contribute to the worsening or development of delirium in vulnerable patients. Causes include prolonged immobilization on stretchers, sleep disruption due to noise and lighting, and disorientation due to a highly stimulating environment.73,74 The presence of medical equipment, such as indwelling urinary catheters and monitoring leads, also can lead to the development of acute altered mental status.75
The EP should create an environment that promotes mobilization and orientation to date and time, and minimize use of medical equipment to help prevent the development of delirium. Furthermore, ensuring access to food and water and sensory aids, such as glasses and hearing aids, may help prevent the development of delirium.
Other Causes
In addition to the causes discussed earlier, delirium can be precipitated by physiologic changes, such as hypoxia, hypercarbia, hypoglycemia/hyperglycemia (and other endocrine disorders), and hypothermia/hyperthermia. The EP must recognize these derangements as contributors to changes in a patient’s mental status and act to resolve the acute issue while addressing the underlying etiology.76
Chronic Altered Mental Status
Dementia. Unlike acute altered mental status, dementia is characterized by a cognitive decline that spans a more extended period. Gradual decline in attention, executive functioning, memory, and cognition that interfere with everyday activities are hallmarks of dementia.77 In the United States, Alzheimer’s disease and vascular dementia are the most common etiologies.78 The prevalence of dementia is approximately 10% in adults older than 64 years of age and 50% in adults older than 85 years of age.77 Older adults with dementia have higher rates of ED use and admission than those without cognitive impairment.80
Importantly, dementia represents a clinical syndrome that is variable and marked by a progressive decline in cognitive function. Caregivers often are the most critical historians when eliciting a history of a patient with dementia. Parkinson’s disease, Lewy body dementia, and normal pressure hydrocephalus are additional clinical conditions hallmarked by memory impairment.
Alzheimer’s Disease. Alzheimer’s disease is the most common cause of dementia that affects older adults.81 Most cases begin after age 65 years, with an increasing prevalence as patients age. The clinical course often is gradual, and memory impairment can progress insidiously. In addition to memory loss, patients may exhibit neuropsychiatric changes, sleep disturbances, and loss of executive functioning.
Vascular Dementia. Vascular dementia represents a spectrum of cognitive impairment typically caused by impaired cerebral blood flow. Dementia can develop in upward of 15% to 30% of patients after a stroke.82 Diagnosis is clinical, and neuroimaging can confirm the underlying presence of stroke.
Lewy Body Dementia. Lewy body dementia is an umbrella term used to describe dementia syndromes that share a histologic finding of Lewy bodies. Lewy bodies are eosinophilic intracytoplasmic inclusions that deposit in the deep cortical layers of the brain. This term reflects two disease states that are similar yet clinically distinct.
• Parkinson’s disease is a neurodegenerative disorder caused by a deficiency of dopamine within the basal ganglia. Symptoms include resting tremors, rigidity, bradykinesia, and postural instability.83 Approximately 30% of patients with Parkinson’s disease will develop dementia.84
• Dementia with Lewy bodies is increasingly becoming recognized as a distinct entity that is separate from Parkinson’s disease. Dementia with Lewy bodies has an earlier onset and progresses more rapidly than the dementia associated with Parkinson’s disease.
Normal pressure hydrocephalus is a type of communicating hydrocephalus associated with the triad of gait disturbance, urinary incontinence, and dementia. Normal pressure hydrocephalus is much rarer than the aforementioned dementia types.
Differentiating delirium from underlying dementia is of critical importance for the EP. While it may be difficult to detect clinically, validated and brief screening tools such as the Ottawa 3DY, Ottawa 4DY, and the Short Blessed Test may help inform this diagnosis.12,85 Table 3 depicts important historical and clinical features that can help distinguish the two clinical entities.
Table 3. Delirium and Dementia79,86 |
||
Feature |
Delirium |
Dementia |
Onset |
Sudden |
Slow and gradual |
Duration |
Days to weeks |
Progressive and permanent |
Attention |
Impaired |
Preserved* |
Level of consciousness |
Impaired |
Preserved* |
Goal of treatment |
Reverse symptoms |
Slow the progression |
* Can be impaired at advanced stages of dementia |
||
Similar to delirium, the EP needs to evaluate for any underlying medical conditions that may be impacting the cognitive function of a patient with dementia. A thorough history and physical should be undertaken to evaluate any reversible causes for mental status change. The management of the behavior and neurocognitive changes associated with dementia in the ED primarily is nonpharmacologic.
Depression. Depression is the single most common psychiatric diagnosis in people older than the age of 65 years; however, it often goes undiagnosed by clinicians. In addition to delirium and dementia, it represents a unique form of AMS. Approximately 27% to 32% of elderly ED patients may have depression, with 14% exhibiting significant symptoms.87 Given that depression is shown to increase healthcare resource use, including ED visits, and increase length of stay after hospital admission, it is important to recognize this diagnosis and intervene early.88
Depression will present in geriatric patients differently than in younger patients. Geriatric patients are more likely to exhibit somatic symptoms, display psychomotor retardation (often confused for dementia), and express sentiments of self-devaluation. Additionally, geriatric patients are at higher risk of completing a suicide attempt and are less likely to report dysphoria and depressed mood.89
Given the atypical presentation of depression and other psychiatric disorders in older adults, thought should be given to this diagnosis when considering the underlying etiology of a change in a patient’s mental status. To assist in diagnosis, rapid and effective validated screening tools, such as the ED-DSI (Emergency Department Depression Screening Instrument), exist to aid in the clinical setting.
Patients in whom depression is suspected should receive a prompt assessment by a trained specialist, such as a geriatrician or geriatric psychiatrist. It is important to note that while depression in older adults is common and can lead to AMS, it is a rare underlying cause and is a diagnosis of exclusion.2
Disposition
Many patients presenting with AMS will require hospital admission. Safe discharge planning for patients with continued AMS, particularly delirium, after workup and intervention requires that a clear, reversible etiology of AMS is identified, a safe plan for management of the underlying etiology exists, and the patient has sufficient social or medical support to assist with treatment and management until symptoms resolve.90
When admitting patients with delirium, specialized services should be engaged early. This may include admission to geriatric units, use of delirium management and consulting services, and early social work/case management engagement. Environmental and sensory components of patient care should be considered.
Evidence suggests interventions such as encouraging mobility, minimizing lead use and urinary bladder catheterization, providing cognitive stimulation and reorientation, and supporting regular sleep cycles may improve the resolution of delirium for inpatients, as well as cognition and health-related quality-of-life months.91,92 ED boarding time should be minimized for all geriatric patients, as it is associated with the development of AMS and delirium and may increase in-hospital mortality.93,94
Pearls and Pitfalls
• AMS in geriatric patients can be conceptualized as acute (dementia, stupor, or coma) or chronic (dementia, depression/primary psychiatric).
• When it is unclear if a patient has an acute change to their mental status, consider performing diagnostic screening, such as the Delirium Triage Screen, Brief Cognitive Assessment Method, or Cognitive Assessment Method.
• Given the broad differential for AMS in older adults, having a systematic approach to work-up and management may help rapidly identify treatable pathology.
• Polypharmacy and medication-induced delirium is easy to overlook. Be sure to complete a detailed medication history when evaluating patients with AMS.
• Geriatric patients represent a particularly vulnerable population susceptible to changes in mental status resulting from comorbidities, cognitive dysfunction, polypharmacy, and limited social support, among other risk factors.
• Subacute or chronic changes in mental status still may have a reversible underlying etiology. Avoid diagnostic anchoring on chronic conditions when patients have not had a complete work-up for their mental status.
• Collecting collateral information from facilities, family members, and caretakers will help gather what may otherwise be a difficult history, and, importantly, establish baseline mental and functional status for patients.
• Be sure to consider substance abuse and withdrawal, including alcohol, in the differential for AMS. The prevalence of substance use in geriatric patients is rising.
• Avoid environmentally induced/iatrogenic delirium by creating a supportive care environment for older adults. This includes encouraging social interaction, orienting patients to the time and date, avoiding unnecessary tethers and uncomfortable interventions such as catheterization, considering nonpharmacological approaches to agitation, and avoiding medication that may be inappropriate for geriatric patients.
• Patients with acute changes in mental status who do not have a discreetly identifiable cause amenable to treatment in the outpatient setting with social support should be admitted for further management.
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The emergency department often is the first point of contact with healthcare professionals for older adults with altered mental status. As such, the emergency physician needs to approach these patients with confidence and expertise regarding diagnosing and managing underlying conditions that may be the etiology of a patient’s acute alteration in mental status.
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