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Altered Mental Status (AMS)

Aisha Suara

Background

  • Definition: change in a pt’s baseline cognition. Medical diagnosis is encephalopathy

    • Can be hypoactive (lethargic) or hyperactive (agitated)

  • Risk factors: Functional impairment (hard of hearing, visually impaired, bed-bound), age > 75, dementia/neurodegenerative diseases, prior brain injury (stroke, TBI), depression, ETOH/substance use disorder, sensory impairment, recent surgery

Etiologies: Consider MOVE STUPID mnemonic

  • Metabolic (Hypo/hypernatremia, Hypercalcemia)

  • Oxygen (Hypoxia)

  • Vascular (CVA, Bleed, MI, CHF)

  • Endocrine (Hypoglycemia, Thyroid, Adrenal)

  • Seizure (postictal state)

  • Trauma

  • Uremia

  • Psychiatric

  • Infection

  • Drugs – intoxication, withdrawal, or medications

  • Delirium – see “Delirium” section in psychiatry

Evaluation

  • Consider broad toxic, metabolic, and infectious workup as appropriate

    • TSH, Vit B1 (whole blood), Vitamin B12, CBC, CMP, BCx, UA with rfx UCx, CXR, VBG, Glucose, UDS, ± RPR

  • Review medications

    • Beer’s Criteria, sedatives, anticholinergics, benzos/EtOH toxicity or withdrawal

  • Head imaging in the setting of focal neurologic findings: if acute focal deficits, consider activating stroke alert

    • Start with CT Head – ischemic strokes take up to 24 hours to show up on CT
    • Consider MRI if high concern for stroke, inflammatory changes or infection

  • LP should be performed if there is any concern for meningitis

  • EEG is reasonable with fluctuating mental status or seizure-like activity

Management

  • Management of underlying etiology

  • Consider empiric thiamine supplementation

  • See "Delirium" in section in psychiatry for nonpharmacologic and pharmacologic management