Can steroids cause altered mental status?

Can Steroids Cause Altered Mental Status?

Yes, steroids definitively cause altered mental status, ranging from mild cognitive changes to severe psychiatric disturbances including delirium and psychosis, occurring in approximately 28-34% of patients receiving corticosteroid therapy. 1, 2

Incidence and Clinical Presentation

The psychiatric effects of corticosteroids are well-established and common:

• Severe psychiatric reactions occur in approximately 5-6% of steroid-treated patients, while mild to moderate neuropsychiatric reactions affect about 28-34% 2, 3
• Altered mental status from steroids presents as a spectrum of symptoms including emotional lability, anxiety, distractibility, pressured speech, insomnia, depression, perplexity, agitation, auditory and visual hallucinations, intermittent memory impairment, mutism, delusions, apathy, and hypomania 4
• The most common manifestations with short-term therapy are euphoria and hypomania, while long-term therapy tends to induce depressive symptoms 2

Critical Diagnostic Considerations

When evaluating altered mental status in patients on steroids, recognize that:

• Steroid-induced mental status changes are a diagnosis of exclusion - you must rule out other causes including infections, metabolic derangements, intracranial pathology, and substance withdrawal 1
• Traditional hypercalcemia symptoms (fatigue, weakness, altered mental status, irritability, coma) can occur with vitamin D toxicity at levels >150 ng/ml, which has cross-talk with steroid hormone receptors 1
• Psychiatric disturbances usually occur early in the course of steroid therapy - psychotic reactions are twice as likely to occur during the first 5 days of treatment 4, 3

Dose-Response Relationship

Dosage is directly related to the incidence of adverse psychiatric effects:

• Patients receiving daily doses of 40 mg prednisone or equivalent are at significantly greater risk for developing steroid psychosis 4
• Higher doses and longer duration increase risk, though dosage is not related to the timing, severity, or duration of psychiatric effects once they occur 2
• Even short courses (<21 days) can cause insomnia and mental status changes 5

Risk Factors

Key risk factors to identify include:

• Female sex, systemic lupus erythematosus, and high-dose prednisone are established risk factors 3
• Neither the presence nor absence of previous psychiatric reactions predicts adverse responses to subsequent steroid courses 2
• Premorbid personality and history of previous psychiatric disorder do not clearly increase risk during any given treatment course 4

Management Algorithm

Immediate Actions:

1. Reduce or discontinue corticosteroids if clinically feasible - symptoms typically resolve with dosage reduction 2, 3
2. Rule out other causes of altered mental status (infections, metabolic abnormalities, intracranial pathology) 1
3. Ensure airway protection if consciousness is significantly impaired 1

Pharmacologic Management:

• For severe cases requiring continued steroids: initiate antipsychotics or mood stabilizers 2
• Phenothiazines in average daily doses of 212 mg produce excellent response in steroid-induced psychosis 4
• Avoid tricyclic antidepressants - they produce exacerbation or worsening of steroid-induced psychiatric symptoms in all patients studied 4, 3

Monitoring:

• Use West Haven criteria or Glasgow Coma Scale to characterize severity of mental status changes 1
• Consider ICU admission for severe alterations (Grade 3-4 hepatic encephalopathy equivalent or GCS <8) 1
• Use short-acting sedatives (propofol, dexmedetomidine) if intubation required, avoiding benzodiazepines which can worsen confusion 1

Long-Term Neuropsychiatric Effects

Beyond acute altered mental status, be aware of:

• Memory impairment can occur, particularly with dexamethasone affecting hippocampal function 6
• Sleep disturbances occur in >30% of patients, which can compound cognitive dysfunction 5, 7
• Anxiety, depression, and other mental disorders develop in approximately 4.5% of patients on prolonged oral corticosteroids (>28 days) 8
• In pediatric populations, antenatal corticosteroid exposure has been associated with increased risk of mental and behavioral disorders, though confounding by underlying illness makes causality uncertain 1

Critical Pitfalls to Avoid

• Do not assume psychiatric history predicts steroid-induced reactions - previous tolerance does not guarantee future tolerance 2
• Do not use tricyclic antidepressants for depressive symptoms during steroid therapy - they worsen outcomes 4, 3
• Do not abruptly discontinue steroids without medical supervision due to adrenal insufficiency risk 6
• Do not overlook sleep disturbances as a contributor to altered mental status and quality of life impairment 5, 7

Prevention Strategies

• Use the lowest effective dose for the shortest duration possible to minimize neuropsychiatric complications 1, 5, 7
• Avoid nighttime dosing to reduce sleep disturbances 1
• Educate patients preemptively about potential psychiatric side effects 5, 7
• Monitor closely during the first week of therapy when risk is highest 4, 3

Most patients recover within several weeks of symptom onset with appropriate management 3.