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Common Causes of Altered Mental Status in the Elderly
Nicole Cimino-Fiallos, MD | December 27, 2021
| Contributor Information
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Image of common causes of altered mental status in the elderly courtesy of Nicole Cimino-Fiallos, MD, FAAEM, FACEP.
Common Causes of Altered Mental Status in the Elderly
Nicole Cimino-Fiallos, MD | December 27, 2021 | Contributor Information
Altered mental status is a broad category that applies to geriatric patients who have a change in cognition or level of consciousness (LOC). Rapid diagnosis is key in seniors who present to the emergency department (ED) with altered mental status, as the cause may be a life-threatening condition.
Table courtesy of Nicole Cimino-Fiallos, MD, FAAEM, FACEP.
Common Causes of Altered Mental Status in the Elderly
Nicole Cimino-Fiallos, MD | December 27, 2021 | Contributor Information
Delirium
Delirium occurs in 7%-10% of geriatric patients in the ED.[1,2] It presents as an acute change in consciousness and loss of cognition that waxes and wanes. Delirium is easier to recognize in patients who become hyperactive; "quiet" delirium may be more difficult to identify.
Delirium is often mistaken for dementia, but the risk of morbidity for delirium is high; therefore, clinicians should make an effort to identify delirium, if present.
Table courtesy of Nicole Cimino-Fiallos, MD, FAAEM, FACEP.
Common Causes of Altered Mental Status in the Elderly
Nicole Cimino-Fiallos, MD | December 27, 2021 | Contributor Information
Delirium can be hard to detect, so clinicians should utilize a screening tool to evaluate for this serious condition. Tests such as the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) are popular in the ED as they are short and easy to use.[3,4] These validated screening tests evaluate the patient's LOC and focus on the presence of fluctuating mental status, inattention, and disorganized thinking. They can help providers look for delirium in a systematic way.
Adapted image from Medscape. Information from Shenvi C, Kennedy M, Austin CA, et al. Ann Emerg Med. 2020;75(2):135-45. PMID:31563402.
Common Causes of Altered Mental Status in the Elderly
Nicole Cimino-Fiallos, MD | December 27, 2021 | Contributor Information
The ADEPT (Assess, Diagnose, Evaluate, Prevent, Treat) tool offers a standardized approach to the diagnosis and treatment of delirium and its causes[5]:
Assess – Establish the patient's baseline mental status and when it changed.
Diagnose – Delirium is typically acute in onset and includes waxing and waning symptoms, inattention, altered cognition, or a change in level of awareness.
Evaluate – A history and physical exam should help to elucidate a cause for the patient's delirium. Most patients should undergo an electrocardiogram, complete blood cell count, metabolic panel, point-of-care glucose level test, and a urinalysis with culture.
Prevent – Avoiding sedative or opiate medications when possible and administering home medications on schedule can help to prevent delirium.
Treat – Treatment of delirium involves addressing the cause and avoiding interventions that may worsen delirium.
Image of an acute stroke in the caudate nucleus courtesy of Nicole Cimino-Fiallos, MD, FAAEM, FACEP.
Common Causes of Altered Mental Status in the Elderly
Nicole Cimino-Fiallos, MD | December 27, 2021 | Contributor Information
Strokes
Most strokes do not impact a patient's LOC or mental state; however, some strokes can cause altered mental status.[6]
Occlusion of the distal portion of the basilar artery can manifest with change in LOC. Bilateral thalamic infarcts can also affect the LOC or cause sudden-onset memory loss. A vertical gaze palsy may provide a clue to the diagnosis. Strokes in the occipital lobe or nondominant parietal lobe can present as confusion.
Image of a large subdural hematoma with evidence of midline shift and lateral ventricle distortion courtesy of Nicole Cimino-Fiallos, MD, FAAEM, FACEP.
Common Causes of Altered Mental Status in the Elderly
Nicole Cimino-Fiallos, MD | December 27, 2021 | Contributor Information
Older adults who have a history of a recent fall or who use anticoagulants and present to the ED with confusion should be evaluated for the possibility of a subdural hematoma.[7] Patients on anticoagulant or antiplatelet agents can have spontaneous bleeding events and may not report a history of trauma.
Initial treatment of subdural hematomas revolves around lowering the intracranial pressure.[7] A neurosurgeon should be consulted if a subdural bleed is identified in the ED.
Common Causes of Altered Mental Status in the Elderly
Nicole Cimino-Fiallos, MD | December 27, 2021 | Contributor Information
Normal Pressure Hydrocephalus
Normal pressure hydrocephalus (NPH) has an average age of onset of 70 years, and its incidence increases after age 80 years.[8] Patients with NPH usually present with impaired cognition, changes in gait (symmetric), and urinary incontinence that progressively worsen over 3 or more months.
Obtain a computed tomography (CT) scan, which will show ventriculomegaly, but ventriculomegaly alone should not trigger an NPH workup.[8] Rather, the diagnosis should be pursued in patients with suspicious clinical findings, such as impaired executive thinking and memory.
Adapted image from Mendez JA, Arias CR, Sanchez D, Pesci LM, Lopez BS, Lopez R, Castro E. Cases J. 2009;2:8271. [Open access.] PMID: 19918410, PMCID: PMC2769420. [CC 3.0 Unported license (CC by 3.0).]
Common Causes of Altered Mental Status in the Elderly
Nicole Cimino-Fiallos, MD | December 27, 2021 | Contributor Information
Wernicke Encephalopathy
Wernicke encephalopathy (WE) is caused by thiamine deficiency and can present as changes in gait, altered mental status, and ophthalmoplegia (shown).[9] Classically associated with patients suffering from alcoholism, this illness can be overlooked in other patients at risk for thiamine deficiency, such as those with cancer or malnutrition. Alcoholic patients are more likely to present with cerebellar symptoms, whereas patients without alcoholism more frequently experience ocular symptoms and altered mental status.[9]
A lacunar stroke as seen on a magnetic resonance image (MRI). Image from Wikimedia Commons / Ptrump 16. [CC by-SA 4.0 International license (CC by-SA 4.0).]
Common Causes of Altered Mental Status in the Elderly
Nicole Cimino-Fiallos, MD | December 27, 2021 | Contributor Information
Hypertensive Encephalopathy
Altered mental status can be the only presenting sign of hypertensive encephalopathy (HE), or it may be accompanied by signs/symptoms including loss of vision, headache, and seizures.[10] If not rapidly diagnosed and treated, HE can result in coma and death.
If HE is suspected, administer intravenous (IV) antihypertensive medications to reduce blood pressure by 25% immediately, and to a blood pressure of 160/110 mmHg within the first 6 hours of presentation.[10] Nicardipine, sodium nitroprusside, labetalol, and enalapril are reasonable primary agents.
Image of a petechial rash commonly seen in meningitis, from Wikimedia Commons / DrFO.Jr.Tn. [CC by-SA 3.0.]
Common Causes of Altered Mental Status in the Elderly
Nicole Cimino-Fiallos, MD | December 27, 2021 | Contributor Information
Infections
Bacterial meningitis
The incidence of bacterial meningitis has declined since the advent of the Haemophilus influenza type B and pneumococcal conjugate vaccines, but mortality from this disease remains around 20% for seniors.[11]
Consider performing a lumbar puncture in any elderly patient with an acute, unexplained mental status change, even if they are afebrile.
Chest CT scan revealing a right upper lobar pneumonia in a geriatric patient who presented to the ED with confusion and hypoxia courtesy of Nicole Cimino-Fiallos, MD, FAAEM, FACEP.
Common Causes of Altered Mental Status in the Elderly
Nicole Cimino-Fiallos, MD | December 27, 2021 | Contributor Information
Sepsis
Careful screening for infection is an important part of the workup of all geriatric patients with altered mental status, as early diagnosis and treatment are critical to improving survival. Mortality remains over 20% in those with sepsis and altered mental status.[12]
Left: Color-enhanced severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus particles from the National Institute of Allergy and Infectious Diseases (NIAID) via Flickr. [CC Attribution 2.0 Generic license (CC by 2.0).] Right: Chest X-ray depicting coronavirus disease 2019 (COVID-19) pneumonia from Wikimedia Commons / Hellerhoff [CC by-SA 3.0.]
Common Causes of Altered Mental Status in the Elderly
Nicole Cimino-Fiallos, MD | December 27, 2021 | Contributor Information
Altered mental status is frequently reported in older adults infected with COVID-19.[13] SARS-CoV-19 exhibits neuroinvasive properties. Patients may experience headache, nausea, and vomiting. Encephalitis and meningitis from COVID-19 are rare, but altered mental status and delirium are common in older adults and may present prior to respiratory symptoms.[13]
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Author
Nicole Cimino-Fiallos, MD, FAAEM, FACEP
Emergency Medicine Specialist
US Acute Care Solutions;
Assistant Medical Director
Emergency Department
Meritus Medical Center
Hagerstown, MD
Disclosure: Nicole Cimino-Fiallos, MD, FAAEM, FACEP, has disclosed no relevant financial relationships.
Editor
Olivia Wong, DO
Section Editor
Medscape Drugs & Diseases
New York, NY
Disclosure: Olivia Wong, DO, has disclosed no relevant financial relationships.
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References
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Khan BA, Perkins AJ, Gao S, et al. The Confusion Assessment Method for the ICU-7 Delirium Severity Scale: a novel delirium severity instrument for use in the ICU. Crit Care Med. 2017 May;45(5):851-7. PMID: 28263192
De J, Wand AP. Delirium screening: a systematic review of delirium screening tools in hospitalized patients. Gerontologist. 2015 Dec;55(6):1079-99. PMID: 26543179
Shenvi C, Kennedy M, Austin CA, Wilson MP, Gerardi M, Schneider S. Managing delirium and agitation in the older emergency department patient: the ADEPT Tool. Ann Emerg Med. 2020 Feb;75(2):136-45. PMID: 31563402
Anathhanam S, Hassan A. Mimics and chameleons in stroke. Clin Med (Lond). 2017 Apr;17(2):156-60. PMID: 28365629
Fomchenko EI, Gilmore EJ, Matouk CC, Gerrard JL, Sheth KN. Management of subdural hematomas: part I. Medical management of subdural hematomas. Curr Treat Options Neurol. 2018 Jun 23;20(8):28. PMID: 29936548
Williams MA, Malm J. Diagnosis and treatment of idiopathic normal pressure hydrocephalus. Continuum (Minneap Minn). 2016 Apr;22(2 Dementia):579-99. PMID: 27042909
Chamorro AJ, Roson-Hernandez B, Medina-Garcia JA, et al, for the Wernicke-SEMI Group; Alcohol and Alcoholism Group; Spanish Society of Internal Medicine (SEMI). Differences between alcoholic and nonalcoholic patients with Wernicke encephalopathy: a multicenter observational study. Mayo Clin Proc. 2017 Jun;92(6):899-907. PMID: 28578781
Liang SY. Sepsis and other infectious disease emergencies in the elderly. Emerg Med Clin North Am. 2016 Aug;34(3):501-22. PMID: 27475012
Annane D, Sharshar T. Cognitive decline after sepsis. Lancet Respir Med. 2015 Jan;3(1):61-9. PMID: 25434614
Oommen A, Thomas J, Parmar P, et al. altered mental status: an important but overlooked presenting symptom of COVID-19 in older adults. Am J Geriatr Psychiatry. 2021 Nov;29(11):1166-70. PMID: 34257003
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