Altered Mental Status in Older Patients in the Emergency Department

https://doi.org/10.1016/j.cger.2012.09.005Get rights and content

Section snippets

Key Points

  • Altered mental status is a common chief complaint among older patients in the emergency department (ED).

  • Patients with acute changes in mental status are likely to have delirium, stupor, and coma, and these changes are commonly precipitated by an underlying medical illness that can be potentially life-threatening.

  • Although stupor and coma are easily identifiable, the clinical presentation of delirium can be subtle and is often missed without actively screening for it.

  • The ED management of patients

The spectrum of acute brain dysfunction

Delirium, stupor, and coma represent a broad spectrum of acute brain dysfunction (Fig. 1) and are associated with an impairment of consciousness. There are 2 interrelated domains of neurologic function that are related to consciousness: content and level (also known as arousal) of consciousness.6 The content of consciousness has many components such as orientation, perception, executive function, and memory, and is mediated at the cortical level. The level (or arousal) of consciousness

Risk factors for developing acute brain dysfunction

The etiology of delirium (and other forms of acute brain dysfunction) involves a complex interplay between patient vulnerability (or predisposing) factors and precipitating factors (Fig. 2).41, 42, 43 Patients who are highly vulnerable (eg, a 92-year-old with severe dementia, poor functional status, and multiple comorbidities) will require a relatively benign insult to develop delirium. For these highly vulnerable patients, a simple urinary tract infection or small dose of narcotic medication

The effect of acute brain dysfunction in the emergency department on outcomes

There is a dearth of data with regard to acute brain dysfunction in the ED and its effect on patients’ outcomes. Much of what is known is based on studies conducted in older hospitalized patients. Studies investigating the role of stupor and coma are mainly limited to the intensive care unit setting. It is clear that the development of stupor and coma portend adverse outcomes; multiple studies have observed that these patients are more likely to die and have poor functional outcomes regardless

Underrecognition of delirium in the emergency department

Because of the severity of impairment observed, emergency physicians readily recognize stupor and coma with little difficulty. However, emergency physicians miss delirium in 57% to 83% of the cases,10, 12, 13, 14, 15, 16, 17 because its clinical presentation can be subtle and can be missed if it is not actively sought. Missing delirium is considered by many to be a medical error and may have important downstream implications for clinical care.108 Patients with delirium may be unable to provide

Assessment of the dysfunctional brain in the emergency department

In any ED patient with acute alterations in mental status, the first step is to assess for the level of consciousness using a validated arousal scale such as the RASS. If the patient is in a sleeplike state, it is necessary to determine the intensity of stimulation that is needed to arouse the patient.6 If a patient is unarousable to loud voice and vigorous shaking, a painful stimulus should be introduced, but every effort should be made to avoid causing tissue damage. Painful stimuli can be

Initial management of patients with altered mental status in the emergency department

When a patient with altered mental status arrives to the ED, the first step is to determine whether this patient is critically ill or not. As the level of consciousness becomes more disturbed (ie, RASS −5 or RASS +4), the index of suspicion for a life-threatening illness that precipitated the acute change in mental status should similarly increase; this is particularly the case for patients who are stuporous and comatose. These patients should become the emergency physician’s immediate

The diagnostic evaluation of patients with acute brain dysfunction

In patients with delirium, stupor, or coma, the diagnostic evaluation should be focused on uncovering the underlying etiology. Although other causes of acute brain dysfunction are common, the emergency physician’s first priority is to consider life-threatening causes. Life-threatening causes of acute brain dysfunction can be remembered using the mnemonic device “WHHHHIMPS” (Box 4).73 Many of these life-threatening causes such as hypoglycemia or hypoxemia can be ruled out within the initial

Emergency department management of patients with delirium

The single most effective treatment for acute brain dysfunction is to diagnose and treat the underlying etiology. Beyond this, the clinical management of acute brain dysfunction is unclear, especially for delirium, and is secondary to the limited evidence available. Delirium care is slowly evolving, and nonpharmacologic and pharmacologic interventions currently exist, especially for those who are agitated. In general, nonpharmacologic interventions are favored as the initial management and

Disposition

Patients who are stuporous or comatose need a hospital admission and likely require an intensive care unit. With delirium, however, there is little evidence-based guidance regarding the appropriate disposition of older ED patients. Most delirious patients will require hospitalization, especially if they have severe symptoms, have poor social support at home, or poor access to follow-up care. There is also evidence to suggest that older ED patients with delirium who are discharged home are more

Communication during transitions of care

Regardless of the patient’s disposition, the patient's mental status in the ED should be communicated to the physician at the next level of care. The patient's delirium status and the delirium assessment used to make the diagnosis, the suspected underlying etiology, and treatments administered should be communicated. Communicating the patient's level of consciousness using an arousal scale such as the RASS may also be useful to provide information on the patient's psychomotor status (normal,

Improving delirium recognition in the emergency department: challenges and future research

Delirium is currently missed in the majority of older ED patients,10, 12, 13, 14, 15, 16, 17 because EDs do not screen for this form of acute brain dysfunction. Improving delirium recognition in the ED will be challenging. Emergency physicians are usually under huge time constraints and have a limited amount of time to spend with the patient. These clinicians often take care of large numbers of patients at once, and their patient evaluations are also frequently interrupted (ie, radiologic

The American Delirium Society

Delirium remains an underappreciated geriatric syndrome among clinicians outside of geriatrics and psychiatry. To increase delirium's awareness and recognition, and to advance its science, the American Delirium Society was recently created. The overall mission of this society is to “foster research, education, quality improvement, advocacy and implementation science to minimize the impact of delirium on short and long-term health and well being, and the effects of delirium on the health care

Summary

Altered mental status is a common complaint in older ED patients. Acute changes are more concerning because they are usually caused by an underlying medical illness and can be life-threatening. Delirium, stupor, and coma are common causes of altered mental status, and these forms of acute brain dysfunction are associated with a multitude of adverse outcomes including higher death rates. Their etiology is multifactorial and is a result of a complex interplay between patient vulnerability and

First page preview

First page preview
Click to open first page preview

References (176)

  • A. Adunsky et al.

    Meperidine analgesia and delirium in aged hip fracture patients

    Arch Gerontol Geriatr

    (2002)
  • B. Jennett et al.

    Assessment of outcome after severe brain damage

    Lancet

    (1975)
  • M. Gonzalez et al.

    Impact of delirium on short-term mortality in elderly inpatients: a prospective cohort study

    Psychosomatics

    (2009)
  • S. Grover et al.

    Distress due to delirium experience

    Gen Hosp Psychiatry

    (2011)
  • A. Morandi et al.

    Understanding international differences in terminology for delirium and other types of acute brain dysfunction in critically ill patients

    Intensive Care Med

    (2008)
  • A.M. Clarfield

    The decreasing prevalence of reversible dementias: an updated meta-analysis

    Arch Intern Med

    (2003)
  • J.D. Schuur et al.

    The growing role of emergency departments in hospital admissions

    N Engl J Med

    (2012)
  • R. Niska et al.

    National hospital ambulatory medical care survey: 2007 emergency department summary

    Natl Health Stat Report

    (2010)
  • W. He et al.

    U.S census bureau, current population reports, P23-209, 65+ in the United States: 2005

    (2005)
  • J.B. Posner et al.

    Plum and Posner's diagnosis of stupor and coma

    (2007)
  • C.N. Sessler et al.

    The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients

    Am J Respir Crit Care Med

    (2002)
  • E.W. Ely et al.

    Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS)

    JAMA

    (2003)
  • B.J. Naughton et al.

    Computed tomography scanning and delirium in elder patients

    Acad Emerg Med

    (1997)
  • American Psychiatric Association

    Task force on DSM-IV. Diagnostic and statistical manual of mental disorders: DSM-IV-TR

    (2000)
  • J.H. Han et al.

    Delirium in older emergency department patients: recognition, risk factors, and psychomotor subtypes

    Acad Emerg Med

    (2009)
  • M. Elie et al.

    Prevalence and detection of delirium in elderly emergency department patients

    CMAJ

    (2000)
  • R. Kakuma et al.

    Delirium in older emergency department patients discharged home: effect on survival

    J Am Geriatr Soc

    (2003)
  • D.J. Meagher et al.

    Phenomenology of delirium. Assessment of 100 adult cases using standardised measures

    Br J Psychiatry

    (2007)
  • D.J. Meagher et al.

    Motoric subtypes of delirium

    Semin Clin Neuropsychiatry

    (2000)
  • S.K. Inouye et al.

    Nurses' recognition of delirium and its symptoms: comparison of nurse and researcher ratings

    Arch Intern Med

    (2001)
  • K.R. Farrell et al.

    Misdiagnosing delirium as depression in medically ill elderly patients

    Arch Intern Med

    (1995)
  • J.F. Peterson et al.

    Delirium and its motoric subtypes: a study of 614 critically ill patients

    J Am Geriatr Soc

    (2006)
  • B. Liptzin et al.

    An empirical study of delirium subtypes

    Br J Psychiatry

    (1992)
  • S.T. O'Keeffe

    Clinical subtypes of delirium in the elderly

    Dement Geriatr Cogn Disord

    (1999)
  • E. Marcantonio et al.

    Delirium severity and psychomotor types: their relationship with outcomes after hip fracture repair

    J Am Geriatr Soc

    (2002)
  • P. Pandharipande et al.

    Motoric subtypes of delirium in mechanically ventilated surgical and trauma intensive care unit patients

    Intensive Care Med

    (2007)
  • C.A. Ross

    CNS arousal systems: possible role in delirium

    Int Psychogeriatr

    (1991)
  • C.A. Ross et al.

    Delirium: phenomenologic and etiologic subtypes

    Int Psychogeriatr

    (1991)
  • S.T. O'Keeffe et al.

    Clinical significance of delirium subtypes in older people

    Age Ageing

    (1999)
  • D.K. Kiely et al.

    Association between psychomotor activity delirium subtypes and mortality among newly admitted post-acute facility patients

    J Gerontol A Biol Sci Med Sci

    (2007)
  • F. Boller et al.

    Clinical features and assessment of severe dementia. A review

    Eur J Neurol

    (2002)
  • E.R. Marcantonio et al.

    Delirium symptoms in post-acute care: prevalent, persistent, and associated with poor functional recovery

    J Am Geriatr Soc

    (2003)
  • S.E. Levkoff et al.

    Delirium. The occurrence and persistence of symptoms among elderly hospitalized patients

    Arch Intern Med

    (1992)
  • I.G. McKeith et al.

    Consensus guidelines for the clinical and pathologic diagnosis of dementia with Lewy bodies (DLB): report of the consortium on DLB international workshop

    Neurology

    (1996)
  • E. Smith et al.

    Locked-in syndrome

    BMJ

    (2005)
  • S.K. Inouye et al.

    A predictive model for delirium in hospitalized elderly medical patients based on admission characteristics

    Ann Intern Med

    (1993)
  • S.K. Inouye et al.

    Precipitating factors for delirium in hospitalized elderly persons. Predictive model and interrelationship with baseline vulnerability

    JAMA

    (1996)
  • S.K. Inouye

    Predisposing and precipitating factors for delirium in hospitalized older patients

    Dement Geriatr Cogn Disord

    (1999)
  • J.H. Han et al.

    Delirium in the nursing home patients seen in the emergency department

    J Am Geriatr Soc

    (2009)
  • M. Elie et al.

    Delirium risk factors in elderly hospitalized patients

    J Gen Intern Med

    (1998)
  • Cited by (0)

    Jin H. Han is supported by a grant from the National Institute on Aging, K23AG032355.

    View full text