Recent-Onset Altered Mental Status: Evaluation and Management

 

Am Fam Physician. 2021 Nov ;104(5):461-470.

Author disclosure: No relevant financial affiliations.

Potential precipitating factors for the recent onset of altered mental status (AMS) include primary central nervous system insults, systemic infections, metabolic disturbances, toxin exposure, medications, chronic systemic diseases, and psychiatric conditions. Delirium is also an important manifestation of AMS, especially in older people who are hospitalized. Clinicians should identify and treat reversible causes of the AMS, some of which require urgent intervention to minimize morbidity and mortality. A history and physical examination guide diagnostic testing. Laboratory testing, chest radiography, and electrocardiography help diagnose infections, metabolic disturbances, toxins, and systemic conditions. Neuroimaging with computed tomography or magnetic resonance imaging should be performed when the initial evaluation does not identify a cause or raises concern for intracranial pathology. Lumbar puncture and electroencephalography are also important diagnostic tests in the evaluation of AMS. Patients at increased risk of AMS benefit from preventive measures. The underlying etiology determines the definitive treatment. When intervention is needed to control patient behaviors that threaten themselves or others, nonpharmacologic interventions are preferred to medications. Physical restraints should rarely be used and only for the shortest time possible. Medications should be used only when nonpharmacologic treatments are ineffective.

Altered mental status (AMS) can present as changes in consciousness, appearance, behavior, mood, affect, motor activity, or cognitive function.13 Recent changes are the focus of this article and are approached differently than chronic changes. Recent changes occur within seconds to days and usually pose a more immediate threat to a patient's well-being than chronic changes.24

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Delirium is common but frequently overlooked, and it is associated with serious medical conditions; therefore, screening should always be considered in patients with acute AMS, especially in those at high risk.6,9,11

C

Systematic review, narrative review, and expert consensus

Unless the etiology is clear and the risk of intracranial pathology is low, neuroimaging should be part of the initial assessment of recent changes in mental status. Noncontrast computed tomography of the head is the initial study for most patients.1214

C

Expert consensus

Electroencephalography is an important study to rule out nonconvulsive seizures, which may occur in 8% to 30% of patients with AMS without an obvious cause.16

C

Evidence-based review

When patients are at risk of AMS or delirium, nonpharmacologic preventive measures decrease incidence, especially in those who are hospitalized. The use of multiple measures through a multidisciplinary team approach is most effective.6,9,11

B

Systematic review, narrative reviews, and expert consensus

Medication to manage behaviors associated with AMS should be used only when nonpharmacologic measures are ineffective, and then only when it is essential to control behavior. Studies evaluating the effectiveness of medications used for their sedative effects yield conflicting results, and these medications may cause harm due to adverse effects.11,23,24

C

Systematic reviews, cohort study, and expert consensus


AMS = altered mental status.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

The Authors

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BRIAN VEAUTHIER, MD, is the program director of the University of Wyoming Family Medicine Residency Program, Casper....

JAIME R. HORNECKER, PharmD, BCPS, BCACP, CDCES, DPLA, is a clinical professor at the University of Wyoming School of Pharmacy and the Family Medicine Residency Program.

TABITHA THRASHER, DO, is the program director of the University of Wyoming Geriatric Fellowship and a clinical assistant faculty member at the University of Wyoming Family Medicine Residency Program.

Author disclosure: No relevant financial affiliations.

Address correspondence to Brian Veauthier, MD, 1522 E. A St., Casper, WY 82601 (email: bveauthi@uwyo.edu). Reprints are not available from the authors.

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