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Altered Level of Consciousness
in the Community Dwelling Elderly Patient
June 2006
Authors: Gordon Margolin, MD and John Kasckow, MD
Core competencies:
1. Patient care
2. Medical knowledge
3. Interpersonal and communication skills
4. Systems based practice
Learning Objectives:
1. List 8 possible causes of confusion and other acute changes of
consciousness.
2. Describe three specific elements each of history, physical and laboratory
studies needed to identify the causes of such changes.
3. Justify your choices for in-patient vs out-patient care of patients with
confusional state.
Key Points:
1. Acute behavioral changes, including confusion, paranoia, grandiosity,
aggressiveness, withdrawal, unresponsiveness, etc, can occur in
individuals of all ages, but are more frequently seen in the elderly.
2. Sudden changes of consciousness and acute states of confusion require
urgent attention.
3. Differential diagnosis of these changes can be quite extensive but highly
relevant to determine treatment and management.
Introduction:
Your daily workload is often interrupted by a call from a distracted relative or
caregiver indicating an acute change in behavioral activity by one of your regular
patients. Your knowledge of the patient’s history and background may quickly lead you
to an analysis and solution of the problem, but, more likely, the potential complexities of
the acute situation will require a full and directed inquiry with history, physical
examination and laboratory tests. Management of this emergency problem will be
dependent on your diagnosis.
Main Description:
The potential causes for sudden, unexpected changes in mentation and associated
altered behavioral pattern are numerous. The changes may be recognized as:
a) anxiety-depressive (agitation, withdrawal, lethargy, lack of response, stupor, etc)
b) psychotic: delusions (stealing, infidelity and belief than an important person is
replaced by an identical imposter) and hallucinations.
c) physically aggressive (pushing, hitting, scratching, kicking, sexual harassment,
screaming, cursing, having temper outbursts),
d) physically nonaggressive (wandering, pacing, disrobing, searching, refusing,
displaying apathy or unresponsiveness, requesting attention, whining, negativism,
rambling).
Causes:
Many of the potential etiologic factors are obvious and self-explanatory. The problem is
to identify the precise cause in the given patient. Oftentimes, however, in the elderly
individual a combination of factors may be responsible for alteration in level of
consciousness. A representative list of possibilities follows:
1. Neurologic
a. Vascular disorders, such as TIAs, infarcts, bleeds, hypertensives
encephalopathy
b. Seizure disorders and postictal states
c. Delirium or other functional disorders
d. Infections, such as meningitis and encephalitis and HIV
e. Neoplasms
f. Brain trauma (concussion)
g. Migraines
2. Psychiatric
a. Pre existing psychiatric illness—dementia, bipolar, schizophrenia, agitated
depression
b. Current psychosocial problem
c. Sensory deprivation—visual or hearing
d. Environmental problem
3. Drugs and Poisons
a. Drugs (ingestion or withdrawal)
i. Alcohol
ii. Amphetamines
iii. Anticholinergics
iv. Anticonvulsants
v. Antihypertensives
vi. Antipsychotics
vii. Antiparkinsonian agents
viii. Cardiac glycosides
ix. Cimetidine
x. Clonidine
xi. Disulfiram
xii.
xiii.
xiv.
xv.
xvi.
xvii.
xviii.
Insulin
Opiates
Phenytoin
Ritalin
Salicylates
Sedatives
Steroids—cortico- and anabolic
b.
Poisons
i. Carbon monoxide
ii. Cocaine
iii. Hallucinogens
iv. Heavy metals
3. Other medical causes
a. Endocrine dysfunctions (hypo or hyper)
i. Thyroid—hypo or hyper
ii. Pancreas—insulinoma
iii. Adrenal—Cushing’s
iv. Parathyroid
v. Pituitary
vi. Parathyroid
b. Diseases of non-endocrine organs
i. Liver—encephalopathy
ii. Kidney—uremia
iii. Lung—Carbon dioxide narcosis, hypoxia
iv. Cardiovascular—arrhythmias, cardiac failure, hypotension, PE
v. General diseases—lupus
c. Deficiency diseases, such as thiamine, nicotinic, B12 or folic acid
d. Systemic infections with sepsis
e. Electrolyte imbalance of any sort
f. Unexpressed pain (often when there is also underlying dementia)
Workup
A careful systematic search for possible offending agents and underlying disorders
should be undertaken with the same urgency as is warranted in other potentially lifethreatening emergencies.
History. Simply knowing the above list leads to appropriate questioning. It is
important to know the individual’s mental and psychiatric background, his medical
conditions, use of drugs (prescribed or self-selected), habits (drinking, eating),
occupational exposures. One would inquire about the nature and timing of the current
episode, whether new or recurrent, exact manifestations, duration, antecedent events,
environmental stressors. The medical background of the patient would be essential.
Physical exam. Vital signs. General appearance and color. Awareness and ability to
relate history. Eyes and pupillary responses; fundi for papilledema. Neck stiffness. Status
of neck veins. Cardiac auscultation. Pulmonary evaluation. Abdominal palpation. Careful
neurological assessment (which may be limited, eg sensory exam) by patients status.
Laboratory. CBC, urinalysis, renal and hepatic panels, TSH, drug screen (if
indicated), appropriate xrays, brain imaging, blood cultures (if indicated), blood gases,
lumbar tap (if justified).
Management:
As in all acute medical conditions, the precise evaluation and testing requires the
judgment of the physician in charge of the case. Is this purely an acute condition, or is
acute engrafted on an underlying chronic state (such as, delirium on dementia).
Many etiologies arise outside the CNS, though the focus on clinical manifestations point
to cerebral disruption. Thus, all such patients do not require directed tests of the CNS,
such as, brain imaging, lumbar taps or Doppler studies.
Are there legal or privacy implications? Can patient give voluntary consent? Collateral
information from family or caregiver may be crucial. Has there been a Power of Attorney
or Guardian assigned?
Can simple environmental and behavioral strategies be applied while the workup is
proceeding? If so, office or outpatient interventions may suffice.
Is the patient of harm to himself or to others, can he not be controlled by simple methods,
or is he expressing suicidal ideation? In such instances, patient may need to be placed in a
protective environment while testing proceeds.
Will medications be useful in control of the situation? Selection of drugs may be critical,
especially if there is any suspicion that the problem is caused by drugs or poisons.
Will the help of other specialists, such as a psychiatrist or neurologist, be required?
The key is to determine as rapidly as possible the suspected mechanism.
Goals of Treatment:
 Acute stabilization
 Symptom attenuation
 Restoration of function
 Prevention of future episodes
Proposed Interventions:
 Treat underlying medical precipitants
 Identify new medical conditions
 Remove offending medications
 Assure safety of the patient during workup
 Educate the caregiver
 Utilize appropriate drugs with care
 Plan close follow up
 Admit to hospital or other facility if diagnosis is uncertain or if patient is
unsafe in the community
 Involve consultative assistance when required
QUESTIONS
1. The daughter of your 82 year old patient calls you urgently to tell you that she is
unable to awaken her mother this morning and that she seems to be in deep sleep,
though she pushes the daughter away when she approaches. Patient was her usual
self when she went to bed last night. She has been complaining of getting “older”,
easily fatigued, slowing of responses, wanting to nap more during daytimes
despite no problem with sleep at night, and weight increase despite a poor
appetite. You have been following this woman, so you know her only medications
are furosemide for peripheral edema and laxatives for severe constipation. Recent
renal panel was normal.
You see the patient in the ER where she is brought by paramedics. She is
minimally responsive. T. 95.6 degrees BP 138/72 P 62 regular R 12 Face is
puffy. Hair is sparse. Skin is dry and rough. Eyes and pupils are normal. No neck
stiffness.. Heart and lungs negative. Abdomen is distended and silent.
Neurological exam reveals no localized findings, though deep tendon reflexes
respond slowly. There is doughy 2 plus edema of her ankles. The rectum is
impacted with hard stool. What is the next most important measure?
a.
b.
c.
d.
e.
Inquire as to noncompliance with her medications
Order serum sodium and osmolality
Check TSH and T4 levels
Obtain a head CT
Order a blood culture
2. You have been caring for Mr. G. for several years. He is a vigorous 78 year old,
retired engineer who has complained of memory problems for the last 6 months.
Folstein minimental has scored 27/30, as he could remember only 2 of 3 objects
and stumbled over 2 orientation questions. He is fully functional in all ADLs and
continues with usual luncheon meetings with old friends and with his evening
bridge group. Wife says she that he often repeatedly questions her about times and
places of appointments.
Wife has called you urgently at home telling you that something has happened to
her husband. Last night he had had a low grade fever, was going to the bathroom
frequently and felt tired, but this morning he does not seem to know where he is
and cannot carry on a conversation.
You see him in the ER and confirm the wife’s concerns. He is confused and
distractable. He is afebrile. Examination including neurological is normal.
Urinalysis reveals >100 wbcs, a few rbcs and many bacteria.
You suspect the patient has:
a. A vascular accident involving the posterior circulation
b. Overdose of ativan, which you have given him prn for periods of
agitation
c. Accelerated dementia for reason to be evaluated
d. Delirium
e. Overwhelming infection
What is your initial workup of this patient?:
a. Head CT
b. Toxic screen
c. Blood cultures
d. Urine culture
e. Lumbar puncture
Case 3. Your hypertensive, diabetic and hypercholesterolemic patient, age 75, who is not
always compliant with medications suddenly develops an acute confusional state. He has
had a recent history of recurrent falls. You suspect he has had a stroke, but on
examination there are no localizing symptoms, such as hemiplegia or hemianopsia. You
order an MRI of his head. What intracranial lesion are you expecting to find?
a. Infarction in the medial frontal lobe area
b. Glioblastoma of the temporal area
c. Infarction in distribution of middle cerebral artery
d. Infarction in the distribution of the posterior circulation
e. Bilateral subdural hematoma
ANSWERS
Case 1. c. Patient has hypothyroidism which has developed insidiously and therefore not
recognized. It explains her complaints, her physical findings and the problems for which
she is being treated medically. She has slipped into myxedema coma. The history has not
revealed that she ingested an over the counter sleeping pill the night before, enough to
overwhelm her slim metabolic balance. Though hyponatremia may be associated with
this condition, the primary problem is that of thyroid deficiency. She will require
hospitalization for cautious replacement of thyroid hormone, while her cardiac status is
being carefully monitored. Triiodothyronine may be necessary in addition to thyroxine,
as conversion of T4 to T3 may be reduced. Some would also add steroids, recognizing
the associated decline in adrenal function when thyroid is deficient. She need not be fully
recovered by the time of discharge but should be alert enough to continue to care for
herself. She should not be discharged to home unless someone is with her at all times.
Case 2. d. Patient has a background of early dementia and seemingly has acquired a
urinary infection, with no good evidence of systemic involvement. Delirium is a frequent
hallmark of this setting when even a minor disruption is added to the underlying state of
dementia. Very often, an episode of delirium (associated with infection, displacement,
disruption of routines, medical interventions, surgical procedures, medications, etc) is the
first recognized historical event in a dementing patient. Reviewing the prior history may
uncover the background disease. Prognosis regarding further dementia in this patient is
very concerning. The episode of delirium may respond quickly to treatment of his UTI
and reorientation in a familiar environment. After counseling with the family, this patient
will probably do better if returned to his home. Ativan should no longer be available to
him, even though there is no evidence that this drug was involved in this current episode.
Case 2. d. Urine culture to determine organisms and treatment choices is most
important. If you are considering systemic sepsis, blood cultures would be important.
Unless you think that this confused elderly patient is manifesting organic changes in his
brain, only then would LP and head CT be appropriate interventions at this time.
Otherwise, these tests are not necessary. There is no good history of drug overdose,
though you might ask the family to check the bottle of ativan to see if they can determine
the frequency of its use.
Case 3. a. Patient has a high propensity for vascular disease and is at risk for stroke of
some sort. Infarction in the frontal lobe area may result in change in mentation and
personality, in the absence of peripheral neurologic findings. Obviously, the MRI will
determine the location and type of problem, and will direct you to appropriate care or
referral. Rapid diagnosis may be important, if antithrombic therapy is to be offered.
Infarction of the infero-temporal occipital region may also lack peripheral neuropathic
signs. Lesions in the right parietal area may be recognized by syndrome of left hemispatial neglect, not always easily identified on neurologic exam.
The acute nature of this problem probably is not consistent with subdural hematoma. The
other diagnoses listed ordinarily would be identified by peripheral neurologic changes.