Table of Contents
1. Introduction
2. History and Physical
3. Investigations
4. Delirium
5. Dementia
6. Coma
7. Psychiatric Illness
Introduction
Mental status is a comprehensive aggregate that reflects the patient’s level of consciousness, attention, cognition, orientation, as well as their communicative ability.
Altered mental status has a very broad differential diagnosis and it is important to have an approach to these presentations as it will allow physicians to individualize their management to treat and reverse the cause(s) of altered mental status as it is a clinical syndrome associated with high morbidity and mortality.
The most common causes of altered mental status that emergency physicians encounter are delirium and dementia, however often the cause can be multifactorial.
History and Physical
History of Presenting Illness
Due to the limitations of interviewing the patient, history is often obtained from family, friends, caregivers, witnesses or paramedics who can confirm the time course of symptoms. This information can provide more context on:
- The duration/acuity of the patient’s symptoms
- Whether any trauma/insult/injury occurred that preceded the change in the patient’s symptoms
- Or if there are any co-morbid health conditions that could alter mental status (ex: poor blood sugar control in diabetes)
Depending on the symptoms described, a focused history adapted to the systems of interest could then be elicited. A review of systems is also necessary to make sure one does not miss a potential etiology of the patient’s altered mental status.
Medications and Substances
It is also important to obtain a detailed medication history, including any over the counter supplements or herbal supplements:
- Rule out drug toxicity/interactions as the cause of an altered mental status.
- Many drugs and substances (ex: alcohol, cocaine, marijuana) can cross the blood-brain barrier and alter a patient’s mental status.
It is also important to determine from a thorough medication history:
- The patient’s typical dose
- Frequency of use
- Missed doses
- Last dose
If a medication, substance or supplement is determined to be the cause of the patient’s altered mental status, a focused psychiatric history assessing mood, anxiety and psychotic symptoms should also be obtained in order to differentiate between psychiatric and drug-related causes of their symptoms. Whether the symptoms are the result of side effects, intoxication, withdrawal, unintentional overdose or suicidal ideations/attempt should also be further explored on history.
Past Medical History
There are many causes of altered mental status. These are just some of the past medical conditions that should be reviewed during a history:
- Cardiovascular disease
- Cerebrovascular disease
- Diabetes
- Hypertension
- Seizures/epilepsy
- Liver disease
- Kidney disease
Past Surgical History
Complications of surgery, especially a recent one, could also be a contributing cause to altered mental status.
Physical Exam
Please note: If the patient needs to be immobilized in a cervical spine collar due to signs of a traumatic brain or neck injury, this will be determined based on Canadian C-Spine Rules. Based on these rules, these patients should be immobilized in a cervical spine collar prior to conducting any examination of the patient.
It is important to start with a primary survey, adopting a similar approach to trauma patients. This will also help rule out more life-threatening causes of an altered mental status, for example ischemic brain injury secondary to a traumatic head injury.
- Airway:
- Are they able to talk?
- Is their airway patent and protected?
- Is there significant orofacial swelling or bleeding?
- Is there stridor or dysphonia?
2. Breathing:
- Are there breath sounds? Are they diminished or asymmetric?
- Is there symmetrical expansion of the chest?
- Is there increased work of breathing? Wheeze or crackles?
3. Circulation:
- Do they have peripheral pulses? Symmetrical? Capillary refill?
- Any signs of physical injuries to their chest, abdomen, pelvis, or limbs?
- Is their heart compensating with an increased rate for decreased blood pressure?
- Any murmurs? Any muffled heart sounds?
- Are there signs of shock?
4. Disability/neurological deficit:
- What is their Glasgow Coma Scale (GCS)? What are their best eye, verbal and motor responses?
- Are their pupils equal and reactive to light?
- Any gross motor deficits with asymmetrical features?
- Any signs of a spinal cord injury?
5. Exposure:
- Any injuries to the neck and back?
- Any step deformities?
Depending on the findings from a primary survey, the most life-threatening injuries will be identified. After completing a secondary survey examining for any other injuries or contributing causes to a patient’s altered mental status, other ancillary tests like CT scans can be performed.
| Eye Response | Verbal Response | Motor Response |
| 4 – Eyes open spontaneously | 5 – Oriented | 6 – Obeys commands |
| 3 – Eyes open to verbal command | 4 – Confused, able to form sentences and answer questions | 5 – Localizes pain |
| 2 – Eyes open to pain | 3 – Inappropriate responses, words discernible | 4 – Withdrawal from pain |
| 1 – No response | 2 – Incomprehensible sounds or speech | 3 – Abnormal/spastic flexion to pain |
| 1 – No response | 2 – Extensor/rigid response to pain | |
| 1 – No response | ||
Mental Status Exam
For more details, please see psychiatric illnesses section.
Please note: in practical settings, a mental status exam is not routinely performed within the ED as it is time-consuming and is usually reserved for patients with a likely psychiatric presentation.
There are some good delirium scores we can use, like REDEEM, which can provide important information on the patient’s mental status.
Investigations
Ordering tests should be guided by the specific case, as well as finding a treatable cause of a patient’s altered mental status. Laboratory work to order can include:
- Serum glucose
- Electrolytes
- Blood urea nitrogen
- Creatinine
- Urinalysis
- Complete blood count
- Blood cultures
- Liver function tests (AST, ALT, ALP, bilirubin)
- Thyroid function (TSH)
- Arterial blood gas analysis
- Cerebrospinal fluid analysis
- Serum drug level of medication
- Ethanol/salicylate/aspirin level
- Urine drug toxicology
- Vitamin B12/folate/thiamine level
- C-reactive protein (CRP)
- Troponin
Other studies to order could include:
- Chest X-ray
- Echocardiogram
- ECG
- CT scan(s) of the head, neck and spine
- Lumbar puncture (generally recommended to be performed after CT scan of the head has ruled out increased intracranial pressure)
Delirium
Delirium is an acutely transient disorder characterized by impairment of attention and cognition. Sleep-wake cycles are disturbed. It can present with a fluctuating level of consciousness and/or confusion. It is a constellation of signs and symptoms due to an underlying cause as opposed to being a distinct disease. It may begin abruptly, but by definition lasts for less than 1 month.
It may affect to varying degrees:(1) Attention, (2) Perception, (3) Thinking, and (4) Memory.
Alertness is reduced, as shown by difficulties maintaining attention and concentration.
It can cause perceptual disturbances in a patient’s mental status, most commonly visual hallucinations, but auditory hallucinations may also be present.
Contrary to popular belief, it does not always result in psychomotor agitation. It also often presents with psychomotor retardation. Activity levels may be increased, decreased, or alternate between the extremes of agitation and somnolence.
Evidence of organic disease such as tachycardia, hypertension, tremor, asterixis, sweating or emotional outbursts may also be present.
Risk factors include:
- Advanced age
- Underlying dementia
- Sensory impairment ex: hearing loss/poor vision
- Comorbid illness
- Polypharmacy
It has numerous causes, including:
- Drugs/toxins/withdrawal
- Electrolyte disturbances
- Infection
- Lack of sensory input
- Disturbances to sleep-wake cycles
- Intracranial pathology
- Metabolic conditions
- Cardiac conditions
- Urinary problems
Diagnostic work-up should include these laboratory tests and measurements:
- Vital signs, including O2 saturation
- Arterial blood gas
- Blood glucose
- Electrolytes
- Kidney function
- Liver function
- Thyroid function
- Urinalysis
It is helpful to compare delirium with dementia and psychiatric illnesses, as shown in Table 1 below:
Table 1. Comparison of delirium with dementia and psychiatric illness.
| Characteristic | Delirium | Dementia | Psychiatric Illness |
| Onset | Sudden | Insidious | Sudden |
| 24h Course | Fluctuating | Stable | Stable |
| Consciousness | Reduced | Alert | Alert |
| Attention | Disordered | Normal | May be disordered |
| Orientation | Impaired | Often impaired | May be impaired |
| Cognition | Disordered | Impaired | May be impaired |
| Hallucinations | Visual and/or auditory | Often absent | Usually auditory |
| Delusions | Transient, poorly organized | Usually absent | Sustained |
| Movements | Tremor may be present, asterixis | Often absent | Sometimes present, jerky/spastic movements |
Delirium Care and Disposition:
- Treatment is directed at the underlying cause. The differential diagnosis of delirium is listed in Table 2 below.
- Environmental manipulation such as appropriate lighting and psychosocial support may help put the patient at ease. Lack of sensory input can be an aggravating factor for patients. Similarly, disruptions to sleep-wake cycles, for example not dimming the lights at night while the patient is sleeping may also aggravate delirium. Other good strategies for putting the patient at ease include having the family at the bedside, placing the patient by the window, providing the patient with hearing aids and pictures of their family, and putting the date on the whiteboard in their room.
- Sedation is sometimes needed to relieve severe agitation. The antipsychotic Haloperidol 5 to 10 mg PO or IM is a common first choice. The dose should be reduced in older adults. The benzodiazepine Lorazepam 0.5 to 2 mg PO or IM may also be used with haloperidol. Use of benzodiazepines should be judicious given that there is a risk of respiratory depression. For this reason, any patient administered benzodiazepines should be carefully monitored.
- Unless a readily reversible cause for acute mental status change is identified and corrected, and there is a return to baseline mental status, patients should be admitted for further evaluation and treatment.
Table 2. Differential diagnosis of delirium.
| Drug/toxin-related |
|
| Infection |
|
| Metabolic |
|
| Neurologic |
|
| Cardiopulmonary |
|
Dementia
Slowly progressive impairment of cognitive function while alertness remains intact. There are numerous causes of dementia, as shown in Table 3.
Short-term memory is more commonly affected, white long-term memory may be preserved.
Progression of symptoms may include:
- Memory loss/forgetfulness
- Disorientation
- Anxiety
- Depression
- Personality changes
- Speech difficulties (aphasia)
- Difficulty naming objects (agnosia)
- Comprehension difficulties
- Difficulty with skilled tasks (apraxia)
- Difficulties with social interactions
- Inability to care for oneself
Alzheimer’s and vascular dementia are the two of the most common causes of dementia and may closely resemble each other and be hard to distinguish clinically.
- Patients with vascular dementia may have exaggerated or asymmetric reflexes, gait abnormalities, or focal extremity weakness. A sudden onset of cognitive impairment may suggest vascular dementia. There must also be signs of a temporal relation between a previous stroke and dementia developing within 3 months.
- A slow, progressive impairment of memory and orientation with preservation of motor function and speech is characteristic of the onset of Alzheimer’s.
Other causes of dementia may have other unique features:
- Increased motor tone, muscle rigidity, slowed movements, or tremors may suggest Parkinson’s.
- Decreased motor tone, muscle flaccidity and loss of control of motor movements may suggest Huntington’s.
Table 3. Different causes of dementia.
| Degenerative |
|
| Vascular |
|
| Infectious |
|
| Inflammatory |
|
| Neoplastic |
|
| Traumatic |
|
| Toxic |
|
| Metabolic |
|
| Psychiatric |
|
| Structural |
|
Dementia Care and Disposition:
- Only about 1% of patients have a treatable form of dementia where the underlying process can be reversed. For example, Vitamin B12 deficiency is a reversible cause of dementia. In most cases however, unfortunately the cause of dementia is irreversible.
- Antipsychotic medications have been used to manage psychotic and non-psychotic behaviour among Alzheimer patients but have adverse effects (ex: worsening of cognitive function). These medications should be reserved for patients with persistent psychotic features or disruptive or violent behaviour.
- Treatment of vascular dementia is limited to management of risk factors, including hypertension.
- All types of dementia may benefit from environmental or psychosocial interventions similar to those employed for delirium patients.
- Most patients with a new diagnosis of dementia will require admission for further evaluation and management. Appropriate steps to coordinate care with relevant consultants/providers should be considered (ex: transition care services, long-term care facility).
- Patients with long-standing symptoms, consistent caregivers, and reliable follow-up may be discharged for outpatient evaluation after life-threatening conditions have been excluded.
- The existence of comorbidity, a rapidly progressive or atypical course, or an unsafe or uncertain living situation warrants admission to the appropriate service.
Coma
A coma is a deep state of prolonged unconsciousness in which a person cannot be awakened, fails to respond normally to painful stimuli, light, or sound, lacks a normal wake-sleep cycle and does not initiate voluntary actions.
Most brain functions, including alertness, language, and self-awareness, are impaired. Its clinical features may vary with the extent of the coma and its etiology. The causes can be divided into 2 larger categories:
- Diffuse central nervous system (CNS) dysfunction
- Structural coma arising from primary CNS dysfunction.
In most cases, physical examination findings will be symmetrical with various neurological deficits, reflecting the diffuse insult to the brain.
- Pupils can be small but reactive in some cases, but may also be fixed and dilated, or asymmetric in other etiologies such as intracranial hemorrhage.
- Coma resulting from localized lesions or hemorrhage often present with progressive hemiparesis and asymmetry of muscle tone and reflexes.
- Depending on the location of the lesion and/or which cranial nerves are affected, eyes may deviate towards the side of the lesion or away from it.
- Posterior lesions of the brain often cause abrupt coma, abnormal extensor posturing, loss of pupillary reflexes, and impaired extraocular movements.
The potential causes of a comatose state are numerous and are listed in Table 4.
Collateral history is crucial in determining the etiology of coma:
- Valuable sources of information may include paramedics, caregivers, family, bystanders, and electronic medical records.
- Establishing the time period during which the coma developed is important. An abrupt onset for instance would suggest a catastrophic process such as an intracranial hemorrhage. A more gradual progression of symptoms may result from a metabolic process or tumour.
Physical examination of comatose patients can be challenging:
- Vital signs should be carefully assessed.
- A detailed examination may reveal signs of trauma or evidence of a toxic insult.
- A detailed neurological examination may not be feasible. However, assessment of cranial nerves via pupillary examination and testing brainstem reflexes may reveal a focal CNS lesion that is potentially treatable with surgery.
- Extensor or flexor posturing are non-specific but suggest profound CNS dysfunction.
Laboratory work may include any test given the numerous etiologies and limited information available on history and physical examination.
A CT scan of the head is recommended almost universally because some intracranial processes may be corrected by emergency surgery or suggest irreversible damage.
Table 4. Differential diagnosis of coma.
| Coma from diffusely occurring process affecting the brain |
|
| Coma from primary CNS disease or trauma |
|
- Treatment of coma involves identification of the etiology and targeting it with a specific treatment. Readily reversible causes of coma like hypoglycemia, hypoxia, and opioid overdose should be identified and promptly treated.
- Stabilization of airway, ventilation and circulation is critical and should be the #1 priority and can be done in conjunction with your primary survey of the patient. Endotracheal intubation may be indicated to protect the airway.
- If elevated intracranial pressure is suspected, urgent neurosurgical consultation should be requested. Signs of elevated intracranial pressure may follow Cushing’s triad (widened pulse pressures, bradycardia, irregular respirations).
- Patients with readily reversible causes of coma, such as insulin-induced hypoglycemia, may be discharged if treatment is initiated, the patient returns to baseline mental status, the cause of the episode is clear, and the patient has reliable care at home and access to timely follow-up.
- In all other cases, admission to the appropriate service is warranted for further evaluation and treatment. In many cases, this may signify an admission to the intensive care unit (ICU) given the severity of the patient’s clinical state.
Psychiatric Illness
Psychiatric illnesses can present similarly to other generalized medical conditions. It is important to complete a thorough diagnostic work-up (as seen previously) to rule out generalized medical conditions before considering a primary psychiatric disorder as the most likely diagnosis. It is also important to consider that psychiatric illnesses can often present concurrently with a generalized medical condition, for example depression comorbid with a neurological condition. There are also many reversible medical conditions that might present as a behavioural abnormality. Many of these causes were mentioned in the previous sections.
Depending on the hospital site, generally a full medical assessment, work-up and stabilization is completed before a full psychiatric history and assessment is conducted, but sometimes these can be done simultaneously when the patient is more medically stable and/or presents with risk factors identifiable on history that are more likely to be of a primary psychiatric origin, and would thus be better suited to completing a psychiatric assessment.
The elements of a good psychiatric history include:
- Identification: patient name, age, demographics, family, living situation, job status, financial supports
- Sources of information: patient interview, collateral, chart review
- Mode of presentation to the hospital: voluntarily, ambulance or police escort
- History of presenting illness: situation, stressors, symptoms (depression, psychosis, mania, anxiety, trauma), supports (family, friends, financial, housing, other)
- Substance use: type (alcohol, cigarettes, marijuana, stimulants, opioids, hallucinogens, other), frequency, amount, last use, route of administration (smoked, injection, snorted, other), withdrawal symptoms, abstinence periods, willingness to decrease use
- Safety: suicidal/homicidal ideations, presence or absence of an organized plan, risk factors (substances, impulsive behaviour, access to firearms, previous attempts, lack of supports, etc.), affected parties (duty to warn)
- Past psychiatric history: hospitalizations, suicide attempts, medications/treatments, diagnoses
- Past medical/surgical history: head injuries, concussions, seizures
- Medications
- Allergies
- Family history: mental illness, suicide attempts/completion
- Personal & social history (sometimes skipped in the emergency department): birth, development, childhood, education, work, relationships.
A Mental Status Exam is also recommended and can yield a lot of information about a patient’s psychiatric condition.
- Appearance (body habitus, clothing, hygiene, grooming)
- Behaviour/Body Language/Eye Contact (cooperative, settled, irritable, agitated, engaged, poorly engaged)
- Speech (rate, rhythm, volume, and tone)
- Emotion/Affect (irritable, anxious, angry, depressed, euphoric, reactive)
- Perception: hallucinations (visual, auditory, tactile, gustatory)
- Thought process (organized, disorganized, linear, goal-directed, guarded)
- Thought content (delusions, suicidal/homicidal ideations)
- Insight/judgment (poor, limited, good)
- Cognition (orientation, attention, alertness, memory)
- Language (vocabulary, pronunciation, comprehension)
Cognitive tests like the Montreal Cognitive Assessment (MoCA) are not routinely performed in the Emergency Department but can be utilized for more stable patients with altered mental status.
Various clues on mental status examination can sometimes provide information on the etiology of the patient’s symptoms, but a broad differential diagnosis is still advised given the potential for the patient’s mental status to change over time.
- Impaired language could suggest a neurological etiology.
- Visual hallucinations could suggest a medical etiology.
- Auditory hallucinations could suggest a psychiatric condition.
- Impaired cognitive performance on the MoCA or a similar test could suggest a medical etiology.
- Profound physical symptoms (ex: decreased motor tone) could suggest a medical etiology.
The possible psychiatric diagnoses, listed in Table 5 below, are numerous and sometimes diagnostic clarity will not be possible within the confined time period of the emergency department, and may only be achieved either after a psychiatric admission or admission to another hospital service (ex: medical detox). In the context of substance use, it may be difficult to determine if the psychiatric presentation is due to a primary psychiatric disorder or due to the effects of the substance. Only once the substance is cleared from the patient’s system can there be better diagnostic certainty about the etiology of the patient’s symptoms.
Table 5. Differential diagnosis of psychiatric causes of altered mental status.
|
Mood disorders |
|
|
Psychotic disorders |
|
|
Adverse effects of psychiatric drugs |
|
|
Substance use |
|
|
Other |
|
Psychiatric Illness Care and Disposition:
- Patients demonstrating violent behaviour towards themselves or others should be restrained by physical or chemical means, or if not possible, placed in a secure unit. Certifying the patient as an involuntary patient under any relevant mental health legislation should also be done, if available. Physical restraint, which should never be done without chemical restraint due to the risks of exacerbating the patient’s condition, should be accomplished by security personnel that are adequately trained. Five people are typically employed, with 1 person assigned to each of the person’s extremities, and the leader by their head.
- For chemical restraint, Lorazepam 1 to 2 mg sublingually or intramuscularly is a safe dose of this benzodiazepine sedative that can be titrated as needed for effect. Haloperidol 2.5 to 5 mg intramuscularly is an antipsychotic drug that can also be administered and can be given concurrently with lorazepam. The anticholinergic drug Benztropine 1 to 2 mg should also be readily available in case any neuroleptic side effects such as dystonia develop.
- Physical restraint should always be considered a last resort (verbal redirection and orientation should be first attempted), and when employed, should not be unnecessarily prolonged, so as to avoid provoking further agitation or muscular injury, including rhabdomyolysis.
- Suicidal and homicidal or violent patients should be disrobed and searched for potentially dangerous items. Any personal belongings that could be used as either a weapon or mean for a suicide attempt should be confiscated from these patients.
- Patients with a safety risk should also be under as frequent observation from the nursing team as possible, especially in the case of the actively suicidal or homicidal patient.
- The clinician should approach the violent patient with a non-threatening voice and posture while avoiding excessive eye contact. The room’s exit should be easily accessible to both the patient and the clinician. The clinician should also avoid interviewing the patient alone and should set boundaries on what constitutes acceptable behaviour from the patient.
- Suicidal patients should be approached in an empathetic and compassionate manner, with the physician clarifying that the goal is to help the individual.
- After an appropriate history, mental status examination, physical examination, laboratory evaluation, and imaging studies (if performed) have excluded a medical cause for an individual’s altered behaviour, a psychiatric consultation should be obtained.
- Patients judged to be at high risk to themselves or others or who are unable to effectively care for themselves while alone should be admitted to a psychiatric unit or facility for definitive care.
- Patients demonstrating a medical etiology for their altered behaviour should receive appropriate medical therapy targeting the specific disorder, whether it mandates hospital admission or outpatient treatment. Hospital admission is necessary if the disorder is not readily reversible, is likely to recur or progress, or if the patient’s behaviour continues to put them at risk to themselves or others if they were to return home. If legal means exist to certify the patient as an involuntary inpatient, this should also be considered.
Sources:
- Emergency Medicine Manual, 6th Edition, John Ma, David Cline, Judith Tintinalli, Gabor Kelen, Stephan Stapczynski. Ch. 16 and 22, pp. 679-685, 879-887.
- Change in Mental Status, Laryssa Patti and Mohit Gupta, StatPearls, NCBI.
- Synopsis of Psychiatry, 12th Edition, Benjamin Sadock, Virginia Sadock and Pedro Ruiz. Ch. 3, pp. 726-781.
Author: Kurt Ebeling, Medical Student, University of Alberta, Canada
Reviewed with Emergency Medicine and Psychiatry residents and staff at the University of Alberta.
