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== Background ==
{{AdultPage|altered mental status (peds)}}
*Alteration of arousal or content of consciousness or both
==Background==
*Both cerebral cortices or brainstem must be affected  
*Altered mental status (AMS) is one of the most common and challenging presentations in the ED
*Delirium vs dementia vs psych
*Encompasses a spectrum from mild confusion to deep [[coma]]
*May include alteration of arousal (level of consciousness), awareness, thought content, memory, or attention
*Both cerebral cortices or the brainstem reticular activating system must be affected
*Key distinctions:
**[[Delirium]]: Acute, fluctuating alteration in attention and awareness; typically reversible
**[[Dementia]]: Chronic, progressive cognitive decline; not typically an ED diagnosis
**Psychiatric: Diagnosis of exclusion — always rule out organic causes first
*Must quickly determine if the altered state is from '''diffuse''' (metabolic/toxic) or '''focal''' (structural/vascular) impairment


=== Delirium ===
==Clinical Features==
==== Clinical Features ====
*History from family/EMS/bystanders is critical:
#Impairment of arousal and content of consciousness  
**Baseline mental status and functional level
#Generally develops over days
**Onset (sudden vs gradual), preceding symptoms, recent medications/substances
#Symptoms may be intermittent and vary in severity
**Medical history: diabetes, liver/kidney disease, seizures, psychiatric history, substance use
*Physical exam priorities:
**Vital signs: Fever (infection, toxidrome), hypothermia, hypo/hypertension, tachycardia, hypoxia
**'''Glucose:''' Point-of-care immediately
**Neurologic exam:
***Level of consciousness ([[Glasgow Coma Scale]])
***Pupil size and reactivity
***Focal deficits (hemiparesis, facial droop, gaze preference) → suggests structural lesion
***Diffuse findings (no lateralizing signs) → suggests metabolic/toxic cause
**Skin: Needle tracks, jaundice, rash (meningococcemia, petechiae), diaphoresis, dryness
**Odor: Alcohol, fruity (DKA), fetor hepaticus
**Meningeal signs: Nuchal rigidity (meningitis, SAH)


==== Workup ====
==Differential Diagnosis==
#CBC
{{AMS DDX}}
#Chemistry
#LFTs
#UA
#CXR
#?Utox
#?CT/LP


==== DDX ====
==Evaluation==
#A
{{AMS workup}}
##Alcohol
#E
##Electrolytes
##Encephalopathy (hepatic, hypertensive)
#I
##Insulin (hypoglycemia)
##
#O
##Opiates
#U
##Uremia
#T
##Trauma
##Tox
##Thyrotoxicosis
#I
##Infection
###PNA, UTI, meningitis/encephalitis, sepsis
#P
##Psych
#S
##Seizure
##Stroke


==== Treatment ====
*Additional workup based on clinical suspicion:
*Treat underlying cause
**CT head without contrast — if trauma, focal deficits, no clear metabolic cause, or concern for hemorrhage
**Lumbar puncture — if meningitis/encephalitis suspected (after CT if indicated)
**'''EEG''' — if nonconvulsive status epilepticus suspected (prolonged postictal state, subtle motor activity)
**CT angiography — if acute stroke suspected
**Toxicology screen — urine drug screen; consider serum levels (ethanol, salicylate, acetaminophen, lithium)
**Blood gas (VBG/ABG) — for acid-base disturbances, CO levels
**Ammonia — if hepatic encephalopathy suspected
**Thyroid function — if no other cause identified (myxedema coma, thyroid storm)
**Cortisol — if adrenal crisis suspected


=== Dementia ===
==Management==
==== Clinical Features ====
*ABCs first:
#Loss of mental capacity
**Protect airway — intubate if GCS ≤8 or unable to protect airway
#Slow and steady course
**O2, IV access, continuous monitoring
#Hallucinations, delusions, repetitive behaviors, and depression are all common
*Immediate interventions:
#May coexist w/ delirium
**[[Dextrose]] (D50 50 mL IV or D10 titrated) if hypoglycemic
#Poor score on Mini-Mental State Exam
**[[Thiamine]] 100 mg IV (give before or with glucose)
**[[Naloxone]] 0.4-2 mg IV if opioid toxicity suspected
*Patients with focal findings may have a surgically treatable cause → emergent imaging
*Treat the underlying cause once identified
*Avoid sedation/restraints if possible until organic cause excluded; use the least restrictive means necessary for safety


==== DDX ====
==Disposition==
#Degenerative
*Admit to ICU:
##Alzheimer's disease
**GCS ≤12, declining mental status
##Huntington's disease
**Intubated patients
##Parkinson's disease
**Hemodynamic instability
#Vascular
**Suspected CNS infection or stroke requiring acute intervention
##Multiple infarcts
*Admit to floor:
##Hypoperfusion (MI, profound hypotension)
**AMS with identified cause requiring ongoing treatment/monitoring (e.g., metabolic correction)
##Subdural hematoma
**Elderly with new-onset delirium requiring workup
##SAH
*Discharge:
#Infectious
**Fully resolved AMS with clearly identified and treated benign cause (e.g., hypoglycemia corrected, alcohol intoxication sobered)
##Meningitis (sequelae of bacterial, fungal, or tubercular)
**Reliable follow-up arranged
##Neurosyphilis
**Safe discharge environment
##Viral encephalitis (herpes, HIV), Creutzfeldt-Jakob disease
#Inflammatory
##SLE
##Demyelinating disease
#Neoplastic
##Primary tumors / metastatic disease
##Carcinomatous meningitis
##Paraneoplastic syndromes
#Traumatic
##Traumatic brain injury
##Subdural hematoma
#Toxic
##ETOH
##Meds (anticholinergics, polypharmacy)
#Metabolic
##B12 or folate deficiency
##Thyroid disease
##Uremia
#Psychiatric
##Depression (pseudodementia)
#Hydrocephalic
##Normal-pressure hydrocephalus (communicating hydrocephalus)
##Noncommunicating hydrocephalus


==== Work-Up ====
== Calculators ==
#Must rule-out treatable causes of dementia / delirium (see DDX)
{{GCS_Calculator}}
##CBC
##Chemistry
##LFTs
##UA
##CXR
##?Utox
##?CT/LP


==== Treatment ====
==See Also==
*Treat underlying cause (if possible)
*[[Altered mental status (peds)]]
*[[Coma]]
*[[Delirium]]
*[[Glasgow Coma Scale]]
*[[Syncope]]


== See Also ==
==References==
*[[Toxidromes]]
<references/>
*[[Glasgow Coma Scale (GCS)]]
[[Category:Neurology]]
*[[Altered Mental Status (AMS) (Peds)]]
[[Category:Symptoms]]
 
== Source  ==
Tintinalli
 
[[Category:Neuro]]

Revisión actual - 09:26 22 mar 2026

This page is for adult patients. For pediatric patients, see: altered mental status (peds)

Background

  • Altered mental status (AMS) is one of the most common and challenging presentations in the ED
  • Encompasses a spectrum from mild confusion to deep coma
  • May include alteration of arousal (level of consciousness), awareness, thought content, memory, or attention
  • Both cerebral cortices or the brainstem reticular activating system must be affected
  • Key distinctions:
    • Delirium: Acute, fluctuating alteration in attention and awareness; typically reversible
    • Dementia: Chronic, progressive cognitive decline; not typically an ED diagnosis
    • Psychiatric: Diagnosis of exclusion — always rule out organic causes first
  • Must quickly determine if the altered state is from diffuse (metabolic/toxic) or focal (structural/vascular) impairment

Clinical Features

  • History from family/EMS/bystanders is critical:
    • Baseline mental status and functional level
    • Onset (sudden vs gradual), preceding symptoms, recent medications/substances
    • Medical history: diabetes, liver/kidney disease, seizures, psychiatric history, substance use
  • Physical exam priorities:
    • Vital signs: Fever (infection, toxidrome), hypothermia, hypo/hypertension, tachycardia, hypoxia
    • Glucose: Point-of-care immediately
    • Neurologic exam:
      • Level of consciousness (Glasgow Coma Scale)
      • Pupil size and reactivity
      • Focal deficits (hemiparesis, facial droop, gaze preference) → suggests structural lesion
      • Diffuse findings (no lateralizing signs) → suggests metabolic/toxic cause
    • Skin: Needle tracks, jaundice, rash (meningococcemia, petechiae), diaphoresis, dryness
    • Odor: Alcohol, fruity (DKA), fetor hepaticus
    • Meningeal signs: Nuchal rigidity (meningitis, SAH)

Differential Diagnosis

Altered mental status

Diffuse brain dysfunction

Primary CNS disease or trauma

Psychiatric

Evaluation

AMS Workup

Common Orders


Consider Based on Clinical Situation

  • Additional workup based on clinical suspicion:
    • CT head without contrast — if trauma, focal deficits, no clear metabolic cause, or concern for hemorrhage
    • Lumbar puncture — if meningitis/encephalitis suspected (after CT if indicated)
    • EEG — if nonconvulsive status epilepticus suspected (prolonged postictal state, subtle motor activity)
    • CT angiography — if acute stroke suspected
    • Toxicology screen — urine drug screen; consider serum levels (ethanol, salicylate, acetaminophen, lithium)
    • Blood gas (VBG/ABG) — for acid-base disturbances, CO levels
    • Ammonia — if hepatic encephalopathy suspected
    • Thyroid function — if no other cause identified (myxedema coma, thyroid storm)
    • Cortisol — if adrenal crisis suspected

Management

  • ABCs first:
    • Protect airway — intubate if GCS ≤8 or unable to protect airway
    • O2, IV access, continuous monitoring
  • Immediate interventions:
    • Dextrose (D50 50 mL IV or D10 titrated) if hypoglycemic
    • Thiamine 100 mg IV (give before or with glucose)
    • Naloxone 0.4-2 mg IV if opioid toxicity suspected
  • Patients with focal findings may have a surgically treatable cause → emergent imaging
  • Treat the underlying cause once identified
  • Avoid sedation/restraints if possible until organic cause excluded; use the least restrictive means necessary for safety

Disposition

  • Admit to ICU:
    • GCS ≤12, declining mental status
    • Intubated patients
    • Hemodynamic instability
    • Suspected CNS infection or stroke requiring acute intervention
  • Admit to floor:
    • AMS with identified cause requiring ongoing treatment/monitoring (e.g., metabolic correction)
    • Elderly with new-onset delirium requiring workup
  • Discharge:
    • Fully resolved AMS with clearly identified and treated benign cause (e.g., hypoglycemia corrected, alcohol intoxication sobered)
    • Reliable follow-up arranged
    • Safe discharge environment

Calculators

Glasgow Coma Scale (GCS)

Glasgow Coma Scale Calculator
Component Response Points
Eye Opening (E) Spontaneous +4
To verbal command +3
To pain +2
No eye opening +1
Verbal Response (V) Oriented +5
Confused +4
Inappropriate words +3
Incomprehensible sounds +2
No verbal response +1
Motor Response (M) Obeys commands +6
Localizes pain +5
Withdrawal from pain +4
Flexion to pain (decorticate) +3
Extension to pain (decerebrate) +2
No motor response +1
GCS Score / 15
Interpretation
13–15 Mild brain injury
9–12 Moderate brain injury
3–8 Severe brain injury — consider intubation if unable to protect airway
References
  • Teasdale G, Jennett B. Assessment of coma and impaired consciousness. Lancet. 1974;2:81-84. PMID 4136544.
  • Teasdale G et al. The Glasgow Coma Scale at 40 years. Lancet Neurol. 2014;13:844-854. PMID 25030516.

See Also

References

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