Altered Mental Status in Older Emergency Department Patients

Abstract

SynopsisAltered mental status is a common chief complaint among older emergency department (ED) patients. Acute changes in mental status are more concerning and are usually secondary to delirium, stupor, and coma. These forms of acute brain dysfunction are commonly precipitated by an underlying medical illness that can be potentially life-threatening and are associated with a multitude of adverse outcomes. Though stupor and coma are easily identifiable, the clinical presentation of delirium can be subtle and is often missed without actively screening for it. For patients with acute brain dysfunction, the ED evaluation should focus on searching for the underlying etiology. Infection is one of the most common precipitants of delirium, but multiple etiologies may exist concurrently. Keywordsdelirium; coma; stupor emergency department; epidemiology; diagnosis; management IntroductionAltered mental status is a common chief complaint among older emergency department (ED) patients. Despite the frequency of this complaint, the term "altered mental status" is vague and has several synonyms such as confusion, not acting right, altered behavior, generalized weakness, lethargy, agitation, psychosis, disorientation, inappropriate behavior, inattention, and hallucination. 1 Such lack of standardized terminology not only hinders the assessment and appropriate management of patients with altered mental status, but also the advancement of knowledge through research.Altered mental status has varying time courses and degrees of severity. Acute changes in mental status are usually secondary to delirium, stupor, and coma, which are forms of acute brain dysfunction. These changes occur over a period of hours or days and are usually © 2012 Elsevier Inc. All rights reserved. Correspondence to: Jin H. Han, jin.h.han@vanderbilt.edu. Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. NIH Public Access NIH-PA Author ManuscriptNIH-PA Author Manuscript NIH-PA Author Manuscript precipitated by an underlying medical illness that is potentially life threatening. Chronic alterations in mental status (e.g. dementia) occur over a period of months and years and are less likely to be precipitated by a life-threatening illness. 2 For these reasons, acute changes in mental status will be the focus of this review. Altered mental status is rarely caused by psychiatric illnesses such as depression or schizophrenia, and in elder patients, these should be diagnoses of exclusion. Acute brain dysfunction (delirium, stupor, and coma) and their underlying etiology should be ruled out prior to considering any psychiatric d...

Knowledge, skills and attitudes of doctors towards assessing cognition in older patients in the emergency department

“…Failure of physicians to identify and highlight cognitive impairment can lead to disastrous consequences, including higher rates of rehospitalisation, prolonged hospitalisation and increased morbidity and mortality 15. Early diagnosis and treatment of dementia may result in slower cognitive decline and preserved function 16 17.…”

The Geriatric Emergency Department

“…At triage, older adults would be evaluated for signs of cognitive impairment, 25 risk of hospitalization, or having a return ED visit using short validated instruments such as the Identification of Seniors At Risk. 26 Given the high prevalence of delirium in hospitalized older adults, all patients would be formally tested for this condition during their clinical assessment.…”

Incidence of cholinesterase inhibitor therapy initiation among hospitalized patients

“…1,2 Delirium occurs in 20% of acute care patients and is 15 times more likely to occur in patients with prior dementia. 3 A hospitalized patient's baseline cognitive status can be difficult to ascertain in clinical practice, which makes it difficult to discriminate dementia from delirium or recognize dementia with superimposed delirium.…”