Physical Address

304 North Cardinal St.
Dorchester Center, MA 02124

Mental Status Changes


The patient’s cognitive functioning is the most complex of all physiologic processes, and it is therefore affected by derangements in many organ systems. Appropriate assessment of mental status changes requires a knowledge of a prior mental status examination. This information may be available from the chart or from the bedside caregiver. It is useful to organize your thinking according to that baseline and how the patient appears. The etiologies of confusion fall into two major categories: delirium and dementia.

Delirium: Delirium is an acute or subacute change and is characterized by clouded sensorium, agitation, confusion, and misinterpretations of the environment (hallucinations, illusions, and delusions). A hallmark of delirium is that it waxes and wanes. Take delirium seriously, as mortality increases in patients with delirium. Delirium is potentially reversible and may be recurrent. For example, a common cause of a confusion in a postoperative patient is hypoperfusion.

Remember that mental status is one of the three readily identifiable end-organ functions that are acutely affected by shock (the others being skin perfusion and urine output). Correction of the hypoperfusion will, in many cases, also reverse the confusion. Untreated, delirium increases morbidity and mortality.

Dementia: Dementia is an irreversible state of loss of memory, loss of cognitive function, and recognition. This is a baseline finding and should be well documented in the chart. A patient who has elements of dementia may still become delirious. It is necessary to compare the current state with how the patient was described at the time of his or her best recent cognitive functioning.

Most concerning acute are mental status changes in patients after head trauma or recent neurosurgical procedures or in patients at risk for sepsis.

Phone Call

Questions

  • 1.

    What symptoms is the patient exhibiting?

    • Clarify whether the patient is a risk to him- or herself or to others.

  • 2.

    Is this level of consciousness a change?

    • What was the baseline level of consciousness? Has the patient exhibited this sort of behavior before? When was the last time the patient appeared at the baseline or “normal” level of consciousness? It is often helpful to learn from the patient’s family regarding baseline mental status.

  • 3.

    Are there other medical problems?

    • This may include metabolic derangements such as diabetes, hypocalcemia, hypomagnesemia, or thyroid malfunction; primary central nervous system (CNS) disease such as seizure disorder, stroke, or organic brain syndrome; or infectious disease such as meningitis or sepsis.

  • 4.

    What medications is the patient currently taking?

    • Many will cause a change in mental status.

  • 5.

    Has the patient undergone a surgical procedure, and if so, how long ago?

    • If this was a neurosurgical procedure, consider ordering a noncontrast computed tomography (CT) of the head immediately. If the patient is taking narcotic medication, depressed cognitive functioning may result.

  • 6.

    Does the patient drink alcohol on a regular basis? If so, how much, how often, and does the patient have a history of withdrawal?

  • 7.

    Did the patient fall?

  • 8.

    Are there any other symptoms?

  • 9.

    Are there any changes in vital signs?

Orders

  • 1.

    Make sure the patient and the bedside caregivers are safe. Often delirious patients exhibit combative behavior.

  • 2.

    Order quick reversible tests immediately: a bedside finger-stick glucose level check, complete blood count (CBC), and electrolyte level.

  • 3.

    Check oxygen saturation of arterial blood (SaO 2 ) with pulse oximetry.

    • Supply O 2 if necessary. Be careful when delivering O 2 to patients with chronic obstructive pulmonary disease (COPD).

  • 4.

    Hold all medications that could further alter the patient’s sensorium.

  • 5.

    If the patient is currently taking narcotic medication, have naloxone hydrochloride (Narcan) 0.4–2 mg for intravenous (IV) administration at the bedside.

Degree of Urgency

The patient must be evaluated immediately. A recurrent benign problem that is well documented in the chart, or that is expected, may wait if there is more urgent work to do. If there is any uncertainty in your mind, see the patient immediately.

Elevator Thoughts

What causes a change in mental status?

  • 1.

    Central nervous system

    • a.

      Infection (meningitis, abscess, infected appliance, human immunodeficiency virus [HIV], and encephalitis)

    • b.

      Cerebral vascular accident (CVA) and transient ischemic attack (TIA)

    • c.

      Head trauma

    • d.

      Tumor

    • e.

      Primary dementia (Alzheimer’s, multi-infarct dementia, and Parkinson’s disease)

    • f.

      Encephalopathies (Wernicke’s and alcoholic)

    • g.

      Seizures (petit mal and postictal state)

    • h.

      CNS vasculitis

  • 2.

    Medications

    • a.

      Narcotics

    • b.

      Sedatives

    • c.

      Hypnotics

    • d.

      Anesthetic agents

    • e.

      Antidepressants

    • f.

      Anticonvulsants

    • g.

      Nonsteroidal antiinflammatory drugs (NSAIDs)

    • h.

      Steroids

    • i.

      Other medications (e.g., histamine H 2 receptor antagonists, other antihistamines, lidocaine, and digoxin)

  • 3.

    Medication withdrawal

    • a.

      Alcohol

    • b.

      Anxiolytics

  • 4.

    Metabolic derangements

    • a.

      Hypoglycemia and hyperglycemia

    • b.

      Hyponatremia and hypernatremia

    • c.

      Hypercalcemia

    • d.

      Acid–base disorders

    • e.

      Endocrinopathies (e.g., hypothyroidism, hyperthyroidism, and adrenal malfunction)

  • 5.

    Organ failure

    • a.

      Renal

    • b.

      Liver (encephalopathy)

    • c.

      Respiratory system (hypoxia and hypercapnia)

    • d.

      Circulatory system (hypoperfusion)

    • e.

      Multiorgan failure

  • 6.

    Other global infection or serious illness

    • a.

      Sepsis

    • b.

      Polytrauma

Major Threat to Life

  • Alcohol withdrawal

  • CNS mass lesion (herniation, tumor, and epidural or subdural fluid collections)

  • Hypoxia

  • Medication overdose

  • CNS infection

  • Sepsis

  • Injury to self or staff

Surgical Chart Biopsy

  • Check for fever curve (trend over time), tachycardia, O 2 saturation, and hypotension.

  • What is the trend in white blood cell (WBC) on CBC?

  • What medications have recently been started or stopped?

  • What hospital day is this? (Important for withdrawal assessment.)

Bedside

Quick Look Test

The degree of change in a patient’s mental status is an indication of the severity of the underlying condition. A patient may be described as:

  • Awake and alert

  • Agitated or uncontrollable

  • Lethargic

  • Stuporous

  • Comatose

Patients who need emergent treatment include those for whom lethargy, stupor, or coma is an acute change.

A Glasgow Coma Scale (GCS) is often used ( Table 21.1 ).

TABLE 21.1
Glasgow Coma Scale
Function Response Score
Eye opening (E) Spontaneously 4
To voice 3
To pain 2
None 1
Eyes swollen closed C
Best motor response (M) Obeys commands 6
Localizes pain 5
Withdraws from pain 4
Decorticate to pain 3
Decerebrate to pain 2
None 1
Best verbal response (V) Oriented, appropriate 5
Confused 4
Inappropriate words 3
Incomprehensible sounds 2
None 1
Intubated/trach T

You're Reading a Preview

Become a Clinical Tree membership for Full access and enjoy Unlimited articles

Become membership

If you are a member. Log in here

Related Posts