What initial workup and management should be ordered for a 73-year-old patient presenting to the Emergency Department (ED) with Altered Mental Status (AMS) and signs of cachexia and failure to thrive?

From the Guidelines

For a 73-year-old patient presenting to the ED with altered mental status, cachexia, and failure to thrive, the initial workup and management should prioritize stabilizing vital signs, identifying potential infections or metabolic derangements, and addressing the underlying causes of cachexia and failure to thrive. The initial workup should include a comprehensive metabolic panel, complete blood count, urinalysis, chest X-ray, ECG, and blood cultures to identify potential infections, metabolic derangements, or organ dysfunction 1. Immediate management should focus on ensuring adequate oxygenation with supplemental oxygen if needed, and establishing IV access for fluid resuscitation with normal saline at 1-2 L over the first 1-2 hours, titrated based on clinical response. Empiric antibiotics such as ceftriaxone 2g IV once daily plus vancomycin 15-20 mg/kg IV should be administered if infection is suspected 1. Thiamine 100mg IV should be given before glucose administration to prevent Wernicke's encephalopathy, followed by dextrose (D50W) if hypoglycemia is present. A head CT without contrast is essential to rule out intracranial pathology, as the yield of neuroimaging studies in patients with AMS is low, but critical findings can be present in up to 11% of cases 1. Additional workup should include thyroid function tests, vitamin B12 and folate levels, ammonia level, toxicology screen, and arterial blood gases if respiratory compromise is evident. Nutritional assessment and early consultation with geriatrics, neurology, and social services are important to address the underlying causes of cachexia and failure to thrive, which may include depression, dementia, malignancy, or social factors affecting the patient's ability to maintain adequate nutrition and self-care 1. It is also crucial to consider the patient's estimated life expectancy and tailor interventions accordingly, focusing on symptom management, patient goals, and preferences, as well as providing emotional support and education to the patient and family 1.

From the Research

Initial Workup and Management

For a 73-year-old patient presenting to the Emergency Department (ED) with Altered Mental Status (AMS) and signs of cachexia and failure to thrive, the following initial workup and management should be considered:

• A primary survey to identify immediate life-threatening conditions, followed by a secondary survey to gather more information about the patient's condition 2
• A comprehensive history and physical examination to guide diagnostic testing 2, 3
• Laboratory testing, including:
  • Complete blood count (CBC) to check for signs of infection or inflammation
  • Basic metabolic panel (BMP) to evaluate electrolyte levels and kidney function
  • Liver function tests (LFTs) to assess liver function
  • Thyroid function tests (TFTs) to evaluate thyroid function
• Chest radiography to diagnose infections or other respiratory conditions 3
• Electrocardiography (ECG) to evaluate cardiac function 3
• Neuroimaging with computed tomography (CT) or magnetic resonance imaging (MRI) if the initial evaluation does not identify a cause or raises concern for intracranial pathology 3

Additional Diagnostic Tests

Additional diagnostic tests that may be considered include:

• Lumbar puncture to evaluate for meningitis or encephalitis 3
• Electroencephalography (EEG) to evaluate for seizures or other abnormal brain activity 4, 3
• Toxicology screening to evaluate for substance use or overdose

Management

Management of the patient should focus on identifying and treating reversible causes of AMS, as well as providing supportive care to prevent further decline 5, 3. This may include:

• Fluid resuscitation and electrolyte replacement to address dehydration and electrolyte imbalances
• Antibiotics or other medications to treat underlying infections or conditions
• Nonpharmacologic interventions to control patient behaviors that threaten themselves or others, such as reorientation and reassurance 3
• Medications to manage symptoms such as agitation or aggression, if necessary 3