From the Guidelines
The workup for an elderly patient presenting with altered mental status secondary to failure to thrive should be comprehensive and systematic, following the "Geriatric 5Ms" framework, which includes evaluating the mind, mobility, medications, what matters most to the patient, and multicomplexity. This approach is supported by the most recent and highest quality study, which emphasizes the importance of a comprehensive geriatric assessment in managing the care of older adults 1.
Initial Evaluation
Initial evaluation should include a complete history and physical examination, focusing on medication review, recent changes in health status, and assessment of vital signs including temperature, blood pressure, heart rate, respiratory rate, and oxygen saturation.
Laboratory Tests and Imaging
Laboratory tests should include complete blood count, comprehensive metabolic panel (including electrolytes, renal and liver function), urinalysis, thyroid function tests, vitamin B12 and folate levels, and inflammatory markers such as C-reactive protein or erythrocyte sedimentation rate. Blood glucose measurement is essential to rule out hypoglycemia or hyperglycemia. Additional tests should include chest X-ray, electrocardiogram, and blood cultures if infection is suspected. Neuroimaging with CT or MRI of the brain should be performed to rule out stroke, subdural hematoma, or other intracranial pathologies. Lumbar puncture may be indicated if meningitis or encephalitis is suspected.
Nutrition and Support
Nutritional screening and assessment are crucial, as malnutrition is common in elderly patients with dementia, and can be effectively managed with adequate support and interventions 1. The use of oral nutritional supplements (ONS) can improve nutritional status, but their use should be individualized and based on the patient's specific needs and preferences.
Medication Management
Medication review and reconciliation are essential to identify potential causes of altered mental status, such as medication non-adherence or overdose. The use of chemical and physical restraints should be limited to only those situations in which they are absolutely necessary, and alternative safety measures should be maximized to manage the agitated geriatric patient 1.
Comprehensive Approach
This comprehensive approach is necessary because altered mental status in elderly patients often has multiple contributing factors, including dehydration, infection, metabolic disturbances, medication effects, and neurological conditions, all of which can contribute to failure to thrive and require prompt identification and treatment. By following the "Geriatric 5Ms" framework and incorporating nutritional screening and assessment, medication management, and a comprehensive evaluation, healthcare providers can provide high-quality care that prioritizes morbidity, mortality, and quality of life outcomes for elderly patients with altered mental status secondary to failure to thrive.
From the Research
Initial Evaluation
- The workup for an elderly patient presenting with altered mental status secondary to failure to thrive should begin with a thorough medical history and physical examination 2, 3, 4, 5.
- It is essential to identify any potential underlying causes of altered mental status, such as infection, metabolic derangements, or other systemic conditions 3, 4, 5.
Diagnostic Approach
- A systematic approach to the patient is crucial, with an understanding of when to initiate a more advanced and potentially more resource-intense diagnostic workup 3.
- The evaluation should focus on searching for the underlying etiology of the altered mental status, including infection, which is one of the most common precipitants of delirium 4.
- The use of continuous electroencephalography may be helpful in identifying nonconvulsive seizures as a potential cause of altered mental status 3.
Considerations in Elderly Patients
- Acute changes in mental status are more concerning in elderly patients and are usually secondary to delirium, stupor, and coma 4.
- The clinical presentation of delirium can be subtle and is often missed without actively screening for it 4.
- A structured mental status examination can help identify the etiology of symptoms and distinguish cognitive changes caused by dementia, delirium, and depression 6.