Altered Mental Status

Altered mental status (AMS) is a symptom, not a diagnosis.

Causes range from rapidly reversible (hypoglycemia, opioid overdose) to immediately life-threatening (ICH, meningitis, encephalitis). A structured, systematic approach saves lives.

ABCs

• Airway: Is it protected?
• Breathing: RR, depth, SpO₂ → give O₂ if hypoxic.
• Circulation: BP, pulse, rhythm, skin (warm versus clammy).

D = Disability

• GCS or AVPU.
• Look for seizure clues: tongue trauma, incontinence, postictal state.
• Check pupils: pinpoint = opioids → give naloxone.
• Fingerstick glucose on every AMS patient.
• Hypoglycemia is common, deadly, and reversible.

Fully undress the patient. Look for:

• Trauma.
• Transdermal patches.
• Dialysis access.
• Infection sources.
• Temperature abnormalities.

Think AEIOU TIPS

Delirium, dementia, and psychosis

AMS patients cannot give reliable histories.

• Call family, the nursing facility, and EMS.
• Ask: “Is this baseline?”
• Acute change in dementia = delirium.

• Asterixis → hepatic or uremic encephalopathy.
• Fever + AMS → think infection (meningitis, sepsis).
• Nuchal rigidity → CNS infection or SAH.
• New murmur + AMS → endocarditis → embolic stroke.

Order tests based on history and physical examination, but err on liberal testing.

Core tests

• Glucose, BMP, Ca²⁺.
• BUN/Cr, ABG/VBG.
• LFTs, ammonia.
• CBC, lactate.
• UA, CXR.
• EKG.
• Drug levels/toxicology.
• Non-contrast head CT if trauma, stroke, or ↓ level of consciousness.

Most AMS patients require admission.

Safe discharge only if:

1. The cause is identified.
2. The cause is fully reversed.
3. The patient has returned to baseline.
4. Reliable social support is available.

Never clear for psychiatry without ruling out organic causes.

Frequently tested pearls and pitfalls

• Subtle behavioral changes matter.
• Delirium has high mortality if missed.
• Always check glucose.
• Do not allow AMA discharge without documented capacity.
• Elderly patients may have infection without fever or leukocytosis.