Change in Mental Status

Excerpt

The evaluation and management of altered mental status are broad and require careful history and physical examination to eliminate life-threatening situations. Changes in consciousness can be categorized into changes of arousal, the content of consciousness, or a combination of both. Arousal includes wakefulness and/or alertness and can be described as hypoactivity or hyperactivity, while changes in the content of consciousness can lead to changes in self-awareness, expression, language, and emotions .

Changes in mental status can be described as delirium (acute change in arousal and content), depression (chronic change in arousal), dementia (chronic change in arousal and content), and coma (dysfunction of arousal and content) .

Delirium is typically an acute confusional state, defined by impairment of attention or cognition that usually develops over hours to days. Some patients may experience rapid fluctuations between hypoactive and hyperactive states, that may be interjected with periods of intermittent lucidity. A nearly pathognomonic characteristic of delirium is sleep-wake cycle disruption, which leads to “sundowning,” a phenomenon in which delirium becomes worse or more persistent at night .

Depression is characterized by personal withdrawal, slowed speech, or poor results of a cognitive test. Patients rarely have a rapid fluctuation of symptoms and are usually oriented and able to follow commands .

Dementia is a slow, progressive loss of mental capacity, leading to deterioration of cognitive abilities and behavior. There are multiple types of dementia, but the most common are idiopathic (also referred to as Alzheimer disease) and vascular dementia. Idiopathic dementia is defined by the slow impairment of recent memory and orientation with remote memories and motor and speech abilities preserved. As the disease progresses, patients exhibit decreased performance in social situations, the inability to self-care, and changes in personality. Vascular dementia is similar to Alzheimer disease, although patients may have signs of motor abnormalities in addition to cognitive changes, and may exhibit a fluctuating step-wise decline, as multiple vascular events have an additive effect on the patient’s function .

Coma is a complete dysfunction of the arousal system, in which patients do not respond to basic stimuli but often retain brain stem reflexes .