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Mental status is the clinical state of emotional and intellectual functioning of the individual. Presentations of altered mental status in the ED include delirium, dementia, and coma.

Clinical Features

Delirium is a transient disorder characterized by impaired attention, perception, memory, and cognition. Sleep-wake cycles may be disrupted, with increased somnolence during the day and agitation at night (“sundowning”). Alertness is reduced. Activity levels may fluctuate rapidly. Different caregivers may witness completely different behaviors within a brief time span. Tremor, asterixis, tachycardia, sweating, hypertension, emotional outbursts, and hallucinations may be present. Features of delirium, dementia, and psychiatric causes are listed in Table 142-1.

Table 142-1 Features of Delirium, Dementia, and Psychiatric Disorder

Diagnosis and Differential

The acute onset of attention deficits and cognitive abnormalities fluctuating throughout the day and worsening at night is virtually diagnostic. A detailed medication history should be obtained. ED evaluation is directed at identifying an underlying process, such as infection. Ancillary tests include basic metabolic panel, hepatic studies, urinalysis, complete blood count, and chest radiograph. Cranial CT should be performed if a mass lesion is suspected, followed by lumbar puncture if meningitis or subarachnoid hemorrhage is a consideration. The possible causes of delirium in the elderly are listed in Table 142-2.

Table 142-2 Important Medical Causes of Delirium in Elderly Patients

Emergency Department Care and Disposition

  1. Direct treatment at the underlying cause. Protect the patient while the workup proceeds. Consider restraining the patient, as needed. Environmental manipulation such as adequate lighting and emotional support may put the patient at ease.

  2. Treat agitation with haloperidol, 5 to 10 milligrams po, IM, or IV, with reduced dosing of 1 to 2 milligrams in the elderly. Lorazepam, 0.5 to 2 milligrams po, IM, or IV, may be used in combination with haloperidol ...

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