Assessment of Altered Mental Status and Tools
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Introduction
Because of the physiological changes that occur with age, the care of the geriatric patient often demands specialized knowledge and skills. Some examples of these physiological changes include decreased skin elasticity, decreased kidney, lung and liver function. The growing number of persons age 65 or older is another reason for nurses to better understand the needs of this population.
At the Scientific Assembly for the American College of Emergency Physicians, one of the speakers, Dr. Bradshaw Bunney, noted:
The number of people over the age of 65 will double in the United States in the next 30 years. As the population ages, the elderly will comprise a higher proportion of patients overall. This is especially true in the emergency department (ED). Persons age 65 and older account for 17.5 million ED visits in the U.S. annually and 15.4% of total ED visits. In 30 years, ED visits for elderly patients are predicted to increase to 25% to 30%. At least 25% of all ED patients over age 65 years have some form of altered mental status. The emergency department and acute hospital wards have the highest rates of patients presenting with delirium (2008).
It is further noted that “elderly patients who develop delirium during hospitalization have a 22-76% chance of dying during that hospitalization” (Bunney, 2008).
Definitions
The altered mental status symptom category has two main components
(1) level of consciousness
(2) context of consciousness or cognition (Bunney,2008).
The etiologies for altered mental status are many. Some authors have reported as many as 149 different causes of AMS. The focus of this discussion centers on the most common causes associated with the geriatric population while keeping the history and physical assessment of the patient at the forefront. In the geriatric population, mental status changes may be due to:
A. Infection (e.g. UTI)
B. Dementia
C. Delirium
D. Respiratory compromise
1. Hypercapnea
2. Hypoxia
E. Metabolic/Endocrine dysfunction
1. Hypoglycemia
2. Hyperglycemia
3. Hypernatremia as in dehydration
F. Cardiovascular dysfunction
1. Decreased cardiac output manifested by hypotension
2. Arrhythmias
Jarvis (p. 108), describes delirium as a “clouding of consciousness (dulled cognition, impaired alertness); inattentive, incoherent conversation; impaired recent memory and confabulatory for recent events; often agitated and visual hallucinations; disoriented, with confusion worse at night when environmental stimuli are decreased.” The author further states that delirium may be related to a medical condition, such as an infection, metabolic disorder, dehydration or drug induced. Delirium is further defined by an acute process that occurs in days or hours.
Dementias have common symptoms that form a syndrome, not a disease. It is an irreversible state that develops over years. According to Ebersole et. al, “dementia has over 70 causes, and any person with symptoms of dementia should have a thorough workup to determine the etiology” (2008, p. 560).
o Primary dementia – progressive disorder caused by pathological conditions of the brain such as Alzheimer’s disease (most common).
o Secondary dementia – pathological conditions of the brain that results from other causes such as alcohol abuse.
As you can see from the definitions of dementia and delirium, the rate of behavioral change is a defining characteristic. This applies to many other etiologies of AMS. When performing an assessment on a patient with altered mental status, it is important to note the time over which the changes are taking place.
The following table provides examples of conditions that may cause altered mental status and the rates at which mental status changes.
Very Rapid Onset (seconds to minutes)
Rapid Onset (hours to days)
To help you apply this knowledge, read this case study and more information about differentiating dementia and delirium in the geriatric population, then answer the questions that follow the case study. http://faculty.washington.edu/dgruen/cognition.htm
Assessment of Altered Mental Status
In order to identify a patient with altered mental status you may use several assessment tools. Two of the most often used tools are presented here.
Glascow Coma Scale
The Glasgow Coma Scale (GCS) is a tool used to objectively evaluate the degree to which a person is conscious or comatose. Scores on the GCS range from 3 to 15; the higher the score, the higher the patient’s level of consciousness.
Scores are determined by assigning points to the patient’s various physical responses. Visual ability, verbal responsiveness and motor skills are all examined and evaluated in the GCS. Because these responses are not always easily assessed (example: eyes swollen shut due to head trauma prevent the assessment of visual response), it's not always easy to assess in which category a patient falls. For this reason, the GCS is used regularly and multiple times on individual patients to determine their changing needs and assess whether the patient’s condition is improving or worsening.
You might also use the Mini-Mental Status exam, which tests an individual’s orientation, registration, attention, calculation, recall, language, and motor skills. The patient is given points for correct answers, and the score is calculated and interpreted as below.
Here is another Mini-Mental Status Exam written in checklist form: http://www.nmaging.state.nm.us/pdf_files/Mini_Mental_Status_Exam.pdf
Care of the Geriatric Patient Experiencing Altered Mental Status
Review the case study from earlier in the assessment guide. Think about what plan you would implement to care for the geriatric patient who was experiencing altered mental status changes.
Nursing Process and Collaborative Plan
Assessment
Analysis/Diagnosis: Collaborate with medical staff to identify the underlying cause
Planning: Decrease risk of injury/ complications i.e. fall prevention
Implementation: e.g. collaborate with medical staff to treat the cause; monitor labs and if
necessary report abnormal values
Evaluation of treatment/ specific interventions
Because of the physiological changes that occur with age, the care of the geriatric patient often demands specialized knowledge and skills. Some examples of these physiological changes include decreased skin elasticity, decreased kidney, lung and liver function. The growing number of persons age 65 or older is another reason for nurses to better understand the needs of this population.
At the Scientific Assembly for the American College of Emergency Physicians, one of the speakers, Dr. Bradshaw Bunney, noted:
The number of people over the age of 65 will double in the United States in the next 30 years. As the population ages, the elderly will comprise a higher proportion of patients overall. This is especially true in the emergency department (ED). Persons age 65 and older account for 17.5 million ED visits in the U.S. annually and 15.4% of total ED visits. In 30 years, ED visits for elderly patients are predicted to increase to 25% to 30%. At least 25% of all ED patients over age 65 years have some form of altered mental status. The emergency department and acute hospital wards have the highest rates of patients presenting with delirium (2008).
It is further noted that “elderly patients who develop delirium during hospitalization have a 22-76% chance of dying during that hospitalization” (Bunney, 2008).
Definitions
The altered mental status symptom category has two main components
(1) level of consciousness
(2) context of consciousness or cognition (Bunney,2008).
The etiologies for altered mental status are many. Some authors have reported as many as 149 different causes of AMS. The focus of this discussion centers on the most common causes associated with the geriatric population while keeping the history and physical assessment of the patient at the forefront. In the geriatric population, mental status changes may be due to:
A. Infection (e.g. UTI)
B. Dementia
C. Delirium
D. Respiratory compromise
1. Hypercapnea
2. Hypoxia
E. Metabolic/Endocrine dysfunction
1. Hypoglycemia
2. Hyperglycemia
3. Hypernatremia as in dehydration
F. Cardiovascular dysfunction
1. Decreased cardiac output manifested by hypotension
2. Arrhythmias
Jarvis (p. 108), describes delirium as a “clouding of consciousness (dulled cognition, impaired alertness); inattentive, incoherent conversation; impaired recent memory and confabulatory for recent events; often agitated and visual hallucinations; disoriented, with confusion worse at night when environmental stimuli are decreased.” The author further states that delirium may be related to a medical condition, such as an infection, metabolic disorder, dehydration or drug induced. Delirium is further defined by an acute process that occurs in days or hours.
Dementias have common symptoms that form a syndrome, not a disease. It is an irreversible state that develops over years. According to Ebersole et. al, “dementia has over 70 causes, and any person with symptoms of dementia should have a thorough workup to determine the etiology” (2008, p. 560).
o Primary dementia – progressive disorder caused by pathological conditions of the brain such as Alzheimer’s disease (most common).
o Secondary dementia – pathological conditions of the brain that results from other causes such as alcohol abuse.
As you can see from the definitions of dementia and delirium, the rate of behavioral change is a defining characteristic. This applies to many other etiologies of AMS. When performing an assessment on a patient with altered mental status, it is important to note the time over which the changes are taking place.
The following table provides examples of conditions that may cause altered mental status and the rates at which mental status changes.
Very Rapid Onset (seconds to minutes)
- Acute intoxication
- TIA, Stroke
- Syncope
- Seizure
- Subarachnoid Hemorrhage
- Epidural Hematoma
- Critical Decompensation of Mass (herniation, hemorrhage)
- Panic Attack
- Intermittent Explosive Disorder
Rapid Onset (hours to days)
- Toxic/Metabolic encephalopathies, including withdrawals
- Bacterial or Viral Infections
- Stroke
- Subdural Hematoma
- Increased Intracranial Pressure
- Subacute Onset (days to one month)
- Toxic/Metabolic Encephalopathies
- Brain Tumor
- Fungal meningitis
- Major Depressive Episode
- Post-partum Depression
- Stroke
- Insidious Onset
- Neurodegenerative Disease (Alzheimer’s, Parkinson’s)
- Cerebrovascular Dementia
- Toxic/Metabolic Encephalopathies
- Brain Tumor
- HIV Associated Syndromes
- Neurosyphilis
- Normal Pressure Hydrocephalus
- Subdural Hematoma
- Major Depressive Episode, Dysthymia
- Fluctuating Course
- TIAs
- Seizures
- Syncope
- Cardiac Arrythmias, especially intermittent atrial fibrillation
- Dementia with Lewy Bodies
- Neurocyticercosis
To help you apply this knowledge, read this case study and more information about differentiating dementia and delirium in the geriatric population, then answer the questions that follow the case study. http://faculty.washington.edu/dgruen/cognition.htm
Assessment of Altered Mental Status
In order to identify a patient with altered mental status you may use several assessment tools. Two of the most often used tools are presented here.
Glascow Coma Scale
The Glasgow Coma Scale (GCS) is a tool used to objectively evaluate the degree to which a person is conscious or comatose. Scores on the GCS range from 3 to 15; the higher the score, the higher the patient’s level of consciousness.
Scores are determined by assigning points to the patient’s various physical responses. Visual ability, verbal responsiveness and motor skills are all examined and evaluated in the GCS. Because these responses are not always easily assessed (example: eyes swollen shut due to head trauma prevent the assessment of visual response), it's not always easy to assess in which category a patient falls. For this reason, the GCS is used regularly and multiple times on individual patients to determine their changing needs and assess whether the patient’s condition is improving or worsening.
You might also use the Mini-Mental Status exam, which tests an individual’s orientation, registration, attention, calculation, recall, language, and motor skills. The patient is given points for correct answers, and the score is calculated and interpreted as below.
Here is another Mini-Mental Status Exam written in checklist form: http://www.nmaging.state.nm.us/pdf_files/Mini_Mental_Status_Exam.pdf
Care of the Geriatric Patient Experiencing Altered Mental Status
Review the case study from earlier in the assessment guide. Think about what plan you would implement to care for the geriatric patient who was experiencing altered mental status changes.
Nursing Process and Collaborative Plan
Assessment
Analysis/Diagnosis: Collaborate with medical staff to identify the underlying cause
Planning: Decrease risk of injury/ complications i.e. fall prevention
Implementation: e.g. collaborate with medical staff to treat the cause; monitor labs and if
necessary report abnormal values
Evaluation of treatment/ specific interventions