What is the diagnosis for a 76-year-old male (YOM) patient transported to Baptist Community Medical Hospital Emergency Department (BCMH ED) with altered mental status, who had no complaints, unremarkable assessments, and normal vitals?

From the Guidelines

The patient should be thoroughly evaluated at the receiving facility to determine the cause of altered mental status, with consideration of potential etiologies such as metabolic disorders, medication effects, infection, neurological events, or dehydration, as the patient's baseline mental status and medical history will be crucial in guiding the evaluation and management plan. The patient, a 76-year-old male, presented with altered mental status, but upon assessment, had no specific complaints, and all physical assessments were unremarkable, with vital signs obtained and documented within normal parameters. During transport to Baylor College of Medicine Hospital Emergency Department, the patient remained stable with no deterioration in condition. According to the most recent study 1, the yield of neuroimaging studies in patients with altered mental status (AMS) is low, with relevant abnormal findings in only 11% of cases. However, it is essential to identify patients with AMS or delirium secondary to acute intracranial pathology to guide management and ensure early appropriate triage. The study also highlights that the prevalence of delirium in the ED ranges from 7% to 35%, with four factors strongly associated with ED delirium: nursing home residence, cognitive impairment, hearing impairment, and a history of stroke.

Some key points to consider in the evaluation and management of this patient include:

• The patient's age and potential for underlying medical conditions that may contribute to altered mental status
• The importance of a thorough medical history and physical examination to guide the evaluation and management plan
• The potential for delirium, which is a medical emergency, and the need for early detection and accurate diagnosis to reduce mortality
• The consideration of potential etiologies such as metabolic disorders, medication effects, infection, neurological events, or dehydration, and the need for targeted evaluation and management.

As noted in the study 1, management of altered mental status is based on treatment of the underlying cause, control of symptoms with nonpharmacological approaches, medication when deemed appropriate, and effective aftercare planning. The economic impact of delirium in the United States is profound, with total costs estimated at $38 to $152 billion each year. Therefore, it is crucial to prioritize a comprehensive evaluation at the receiving facility to determine the cause of altered mental status and guide the management plan.

From the Research

Patient Information

• Patient: 76-year-old male
• Chief Complaint: Altered mental status
• Transported to: BCMH ED

Assessment and Vitals

• No complaints from the patient
• All assessments unremarkable
• All vitals charted

Possible Causes of Altered Mental Status

• Systemic infection or metabolic derangement 2
• Primary central nervous system insults, systemic infections, metabolic disturbances, toxin exposure, medications, chronic systemic diseases, and psychiatric conditions 3
• Ceftriaxone-induced neurotoxicity, although rare 4

Evaluation and Management

• History and physical examination guide diagnostic testing 3
• Laboratory testing, chest radiography, and electrocardiography help diagnose infections, metabolic disturbances, toxins, and systemic conditions 3
• Neuroimaging with computed tomography or magnetic resonance imaging should be performed when the initial evaluation does not identify a cause or raises concern for intracranial pathology 3
• Lumbar puncture and electroencephalography are also important diagnostic tests in the evaluation of altered mental status 3

Antibiotic Prescribing and Outcomes

• The Infectious Diseases Society of America recommends against antibiotic treatment of asymptomatic bacteriuria (ASB) for most patients, including those presenting with altered mental status (AMS) 5
• Inappropriate antibiotic use is common among hospitalized patients presenting with AMS and pyuria 5, 6
• Treatment of asymptomatic pyuria did not decrease rates of subsequent readmission for AMS or retreatment of symptomatic UTI 5