What is Change in Mental Status?
Altered mental status is a broad medical term that covers changes in a person’s mental alertness or conscious awareness. Accurate diagnosis requires a thorough patient history and physical examination to rule out serious health emergencies.
Changes in mental status can involve arousal (wakefulness or alertness) and/or the content of consciousness, which includes aspects like self-awareness, expression, language, and emotions. Someone could be more or less alert (hyperactive or hypoactive), or experience changes in their self-awareness, expression, language, and emotions.
These changes could generally manifest in four different ways: delirium, depression, dementia, and coma. Delirium often represents an acute or sudden change, marked by confusion and attention or cognitive impairment over hours or days. A key characteristic of delirium is a disrupted sleep-wake cycle, which can lead to worsening of symptoms at night (a condition called “sundowning”).
Depression, on the other hand, is marked by personal withdrawal, slowed speech, or poor cognitive test results. People with depression rarely exhibit rapid symptom changes and are generally able to follow commands.
Dementia is a gradual and progressive loss of mental capacity, leading to cognitive and behavior deterioration. The most common types of dementia are idiopathic (commonly known as Alzheimer’s disease) and vascular dementia. Alzheimer’s disease is characterised by a slow erosion of recent memory and orientation, leaving distant memories, motor skills and speech abilities intact in the early stages. Progression of the disease leads to social difficulties, self-care problems, and personality changes. Vascular dementia shares many characteristics with Alzheimer’s but also includes motor abnormalities and a stepwise decline due to multiple vascular events.
Lastly, coma represents a complete dysfunction of the arousal system. Patients in a coma do not respond to basic stimuli but often retain some brain stem reflexes.
What Causes Change in Mental Status?
There are many possible diagnoses when it comes to brain-related conditions, and these can generally be grouped into four main categories. The first includes diseases that primarily affect the brain itself. The second category covers systemic diseases, which are issues affecting the whole body that also happen to impact the brain or central nervous system. The third category involves harmful substances from outside the body, like toxins and poisons. Finally, the fourth category encompasses cases where the symptoms are a result of stopping or withdrawing from a certain type of drug. For a more detailed breakdown of these potential diagnoses, please refer to the accompanying table.
Risk Factors and Frequency for Change in Mental Status
Changes in mental status in infants and children are usually due to infection, physical injury, changes in metabolism, or eating something toxic. Young adults often experience altered mental states due to consuming something toxic or suffering an injury. On the other hand, the elderly can experience changes in their mental state due to stroke, infection, interactions between different medications, or changes in their living conditions. Also, when hospitalised, between 10% to 25% of elderly patients will experience delirium on admission.
- In infants and children, altered mental states usually stem from infection, trauma, metabolic changes, and toxic ingestion.
- Youths often experience changes in mental state due to toxic ingestion or trauma.
- Elderly individuals typically have altered mental states due to stroke, infection, drug interactions, or changes in the living environment.
- Among the elderly population in the hospital, 10% to 25% of patients have delirium at the time of admission.
Signs and Symptoms of Change in Mental Status
When something seems to be wrong with a person’s mental state, getting information is key. This insight should come both from the individual and from others who are close to them, such as family members, friends, emergency services, onlookers, and their main doctor. This multi-source info can give a clear picture of how these changes unfolded, what may have caused them, factors that make them worse or better, and other recent or long-term health issues.
- A detailed list of all medications, including non-prescription and natural remedies, is needed to see if an unwanted drug reaction is causing the mental changes.
- Information about the use of any illicit substances like drugs and alcohol, as well as details about how often they’re used, in what amount, and the last use, can also help clarify the situation.
During the physical examination, the first step should be a quick check of vital functions. This includes assessing the patient’s airway, breathing, pulse and heart rate, and consciousness level. It’s also crucial to fully check the patient’s body, including their back and limbs, for any signs of injury or infection. After this, a more detailed examination should be carried out, paying careful attention to eye response and other neurological signs.
Doctors may use diagnostic tools to accurately assess a person’s mental state. These can include the Mini-Mental Status Exam (MMSE), the Quick Confusion Scale, or the Confusion Assessment Method (CAM).
Testing for Change in Mental Status
First, it’s crucial to check a patient’s airway, breathing, and circulation, providing necessary stabilization. If the person shows signs of being unable to protect their airway, such as scoring less than 8 on the Glasgow coma scale, having no gag reflex, you may need to help them breathe using a technique known as rapid sequence intubation. If they have a slow heart rate or low blood pressure, further methods like external pacing, defibrillation (restoring normal heartbeat), or vasopressors (drugs that increase blood pressure) might be necessary.
In addition, you need to regularly check the patient’s vital signs, heart rhythm, and blood sugar levels. In certain cases, you might give them a “coma cocktail”, which includes naloxone for potential opiate overdose, dextrose for low blood sugar, and thiamine for illnesses related to vitamin deficiencies like Wernicke-Korsakoff syndrome or beriberi.
If there’s any suspicion of physical trauma, extra precaution is needed to stabilize the neck. If the patient shows signs of developing serious conditions like brain herniation, either due to reflex reactions in response to increased brain pressure or a dilated pupil in one eye, you can raise the head of the bed slightly, increase their breathing rate, and consider treatments like mannitol and neurosurgical procedures. If there are no such signs, a head CT scan and consultation with a neurosurgery specialist might be warranted for any lesions seen on the CT.
If there’s evidence of possible infections, administering antibiotics, providing fluids based on the patient’s weight, and consulting about pulse dose steroids for patients dependent on them might be necessary. In case there are no signs of physical injuries or infection, think about potential causes linked to toxic substances or metabolic disorders, such as drug overdose, withdrawal symptoms, or harmful drug interactions.
Tests to check the levels of salts and minerals in the bloodstream as well as liver and kidney function should be considered, in addition to a urine test. It might also be helpful to do imaging like a chest x-ray to rule out lung infection as a cause of mental status changes, or a head CT scan to check for possible bleeding within the skull. If these examinations don’t reveal the cause of the patient’s altered mental status, consider checking thyroid function, vitamin B12 levels, and for any signs of syphilis. Additionally, a lumbar puncture – extracting and analyzing the fluid from the lower back – can be used to confirm or rule out conditions like meningitis or subarachnoid hemorrhage.
Treatment Options for Change in Mental Status
Treatment for a condition called ‘altered mental status’ aims to address the root cause of the issue. This could mean managing symptoms such as breathing problems or heart irregularities with treatments like intubation (inserting a tube into the airway) or external pacing (helping the heart keep a steady beat). If a serious infection is causing a severe reaction in the body (known as sepsis or septic shock), antibiotics and replenishing bodily fluids may be necessary. Low blood sugar would need to be treated with glucose, while a bleed within the brain might require a surgical procedure.
If a patient is disoriented or confused, which is known as being delirious, adjusting their environment can sometimes help. This could mean altering the lighting, reducing unnecessary noise, and offering psychological support. Encouraging movement can also be beneficial to prevent their confusion from worsening as the day progresses into evening, a phenomenon known as ‘sundowning’. If the patient needs to be calmed quickly, a medication called haloperidol could be administered orally, as an injection, or via an intravenous drip. Care should be taken with dosage, particularly in older adults. While a class of drugs called benzodiazepines is usually not recommended for long-term use in older people due to potential side effects, a dose of lorazepam may be helpful in managing acute symptoms.
For managing long-term symptoms of a patient with dementia who experiences sundowning, a drug called donepezil or atypical antipsychotics like risperidone, olanzapine, or quetiapine could be considered. These need a doctor’s prescription and should be used under medical supervision.
What else can Change in Mental Status be?
- Damage to the brain stem
- Blood clot within the brain’s outermost protective layer (epidural hematoma)
- An infection or swelling within the brain’s outermost protective layer (epidural abscess)
- Bleeding within the brain (intracerebral hemorrhage)
- Tumors within the brain (intracerebral tumors)
- An infection or swelling in the brain (intracerebral abscess)
- Large strokes affecting the major regions of the brain (large hemispheric strokes)
- Bleeding in the space surrounding your brain (subarachnoid hemorrhage)
- Blood clot beneath the outermost layer of brain’s covering (subdural hematoma)
