What is the approach to managing altered mental status in hospitalized patients?

Approach to Altered Mental Status in Hospitalized Patients

The management of altered mental status in hospitalized patients requires a systematic four-pronged approach executed concurrently: (1) airway protection and transfer to monitored setting, (2) investigation of underlying causes, (3) identification and treatment of precipitating factors, and (4) empiric therapy when appropriate. 1

Initial Stabilization and Assessment

Immediate Airway Management

• Transfer patients with Grade 3-4 altered mental status (West Haven criteria) or Glasgow Coma Scale <8 to ICU-level monitoring immediately 1
• Consider intubation for: inability to maintain airway, massive GI bleeding, or respiratory distress 1
• If intubation is needed, discuss goals of care beforehand when possible 1
• Use short-acting sedatives (propofol or dexmedetomidine) rather than benzodiazepines to preserve cognitive function and reduce ventilation duration 1

Objective Mental Status Quantification

• Use validated scales: West Haven criteria for hepatic encephalopathy or Glasgow Coma Scale for general altered mental status 1, 2
• Document baseline mental status and serial assessments 2

Diagnostic Workup

Essential Laboratory Testing

• Obtain comprehensive metabolic panel including: complete blood count, electrolytes, glucose, renal function (BUN/creatinine), liver function tests, and urinalysis 1, 2
• Perform toxicology screens and obtain drug/alcohol levels based on history 1, 2
• Do NOT routinely measure ammonia levels—they are variable and unreliable for diagnosis; however, a normal ammonia level effectively excludes hepatic encephalopathy 1

Neuroimaging Indications

Obtain head CT without contrast for: 1, 2

• First episode of altered mental status
• Seizures or new focal neurological signs
• Unsatisfactory response to treatment of precipitating factors
• History of trauma, falls, anticoagulation, or malignancy

Do NOT routinely image patients with: 1

• Recurrent, nonfocal presentations with known etiology
• Typical hepatic encephalopathy pattern in cirrhotic patients

Systematic Etiologic Investigation

Most Common Causes (in order of frequency)

1. Neurological (30-35%): stroke, intracranial hemorrhage, seizures, encephalitis 2, 3, 4
2. Toxicologic/Pharmacologic (20-25%): medication effects, alcohol intoxication/withdrawal, illicit drugs 2, 4
3. Infectious (9-18%): sepsis, UTI, pneumonia, meningitis 2, 3, 4
4. Metabolic/Systemic (15-20%): hypoglycemia, electrolyte abnormalities, hepatic encephalopathy, uremia 2, 4

Special Population: Cirrhotic Patients

Hepatic encephalopathy is a diagnosis of exclusion—always investigate alternative causes: 1

• Alcohol intoxication and withdrawal (most common alternative)
• Infections (spontaneous bacterial peritonitis, pneumonia, UTI)
• Gastrointestinal bleeding
• Electrolyte disorders (hyponatremia, hypokalemia)
• Medications (benzodiazepines, opioids, gabapentin)
• Diabetic emergencies (DKA, hyperosmolar state)
• Intracranial bleeding
• Seizures

Treatment Approach

Precipitating Factor Management

Identifying and treating precipitating factors is paramount—approximately 90% of patients improve with correction of the precipitating factor alone 1

Empiric Therapy Guidelines

• For suspected hepatic encephalopathy: initiate lactulose (oral or rectal) or polyethylene glycol if ileus risk exists 1
• Rifaximin as add-on therapy requires further investigation in critically ill patients 1
• Avoid or minimize opioids, benzodiazepines, and gabapentin due to synergistic sedating effects 1
• For pain control in patients requiring opioids: use lowest effective doses with frequent reassessment and titration 1

Delirium Prevention

• Implement multicomponent nonpharmacological interventions as first-line approach 1
• Consider dexmedetomidine over benzodiazepines for sedation to reduce delirium incidence 1, 5

Critical Pitfalls to Avoid

• Never attribute altered mental status solely to psychiatric causes without completing medical workup 1, 2
• Do not rely on ammonia levels alone to diagnose hepatic encephalopathy in cirrhotic patients 1
• Always consider multiple concurrent etiologies, especially in elderly patients where delirium is often multifactorial 1, 2
• Do not delay empiric treatment while awaiting diagnostic results in potentially life-threatening conditions 2
• History and physical examination have 94% sensitivity for identifying medical conditions versus only 20% for laboratory studies alone—do not skip thorough clinical assessment 2

Documentation and Follow-up

• Document mental status assessments, precipitating factors identified, treatments initiated, and response to therapy in medical record 1
• Reassess mental status serially using objective scales 2
• Monitor for complications: aspiration pneumonia, falls, pressure ulcers 1

Prognosis

• Overall mortality in hospitalized patients with altered mental status is approximately 8.1%, significantly higher in elderly patients (10.8% vs 6.9% in younger patients) 3, 4
• Mortality doubles if delirium diagnosis is missed 1
• Mean hospital length of stay is 11.6 days, longer with abnormal neuroimaging (9 vs 6 days) 3