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INTRODUCTION

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Altered Mental Status is one of the most frequently encountered admitting diagnosis in hospitals across the world, in large part due to the wide range of conditions affecting cognitive function. For the same reason, the descriptive and diagnostic value of “Altered Mental Status” in isolation is of little value to the hospital clinician as almost any medical condition can present with some degree of mental status change. In this chapter we will outline an approach to neurologic presentations associated with a change in mental status, and highlight the appropriate use of simple and well-established terminology. An emphasis will be further placed on always associating a diagnosis of “Altered Mental Status” with a better descriptive terminology to facilitate the appropriate therapeutic approach and improve patient outcomes.

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CASE 22-1

A 75-year-old woman with a history of hypertension and hyperlipidemia presents acutely to the emergency department complaining of blurry vision and sleepiness. She had woken up around 7 a.m. on the day of admission feeling more drowsy than usual, and when walking to the bathroom, she noticed that she was unable to see clearly. Her husband called 911, and a stroke code was called for “Altered Mental Status.”

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CASE 22-2

A 75-year-old gentleman with a history of hypertension, hyperlipidemia, and atrial fibrillation was in his usual state of health on a Sunday afternoon when he suddenly became drowsy, complaining of blurry vision. He was taken to the emergency department and a stroke code was called for “Altered Mental Status.”

One of these cases is a neurologic emergency, whereas the other is entirely benign. While the availability of specialty services may mitigate the hospital physician’s need to be able to distinguish one from the other, a major goal of this chapter is to review simple diagnostic tools to enable all physicians to make a more refined diagnosis related to changes in mental status, and thereby expedite and improve patient care.

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HOW DO WE APPROACH A PATIENT PRESENTING ACUTELY WITH A CHANGE IN MENTAL STATUS?

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STEP 1—Obtain an accurate history

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The first step is to obtain a pertinent history. As elementary as this may seem, an incomplete history is one of the prime sources of most unnecessary testing and specialty consultations in the hospital setting. Despite its critical importance, a busy hospital practice with an emphasis on appropriate triage can make obtaining an accurate history challenging. But a pertinent medical history does not take long, and is absolutely essential to instituting the appropriate therapy. From a neurologic perspective, pertinent information includes:

  1. A detailed description of current symptoms

  2. Are the symptoms acute?

  3. Have the symptoms occurred previously?

  4. Are there any symptom triggers?

  5. Are there other associated symptoms?

  6. Are there significant medical problems that may contribute?

  7. Have any new medications been started recently?

  8. Does the patient take medications that can affect cognitive function?

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Whether a patient’s change in mental ...

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