Altered mental status: documentation that holds up
Altered mental status is a chief complaint that hides killers behind "baseline dementia," "intoxication," or "psych." Delirium is missed in most elderly ED patients and independently predicts death — the defensible chart establishes the baseline, screens for it, and excludes the reversible causes first.
01What's at stake
Delirium goes unrecognized in roughly 54%–89% of cases, and discharged delirious elders have a 2–3× higher mortality over the following months. The danger is anchoring: assuming the confused elder is "just demented," the agitated patient is "just psych," or the obtunded patient is "just intoxicated" — when a reversible, time-critical cause is driving it.
02Can't-miss reversible causes
- Hypoglycemia & hypoxia / hypercarbia — the first two things to fix.
- Opioid / toxic ingestion & withdrawal — naloxone; anticholinergic, sympathomimetic, alcohol.
- Sepsis / infection — the most common driver in elders (UTI, pneumonia), often hypoactive.
- Intracranial — stroke, ICH, SAH, mass; AMS can be the only sign of STEMI in some elders.
- CNS infection / non-convulsive status epilepticus — lower threshold for LP and EEG.
- Metabolic — sodium, calcium, hepatic, thyroid; Wernicke; hypertensive emergency.
03Approach — baseline, then the reversibles
- Establish the baseline and confirm an acute change — this almost always needs a proxy (family, caregiver, EMS, prior notes). Don't accept the patient's "I'm fine."
- Check glucose and pulse oximetry with the vitals — the pathway starts here.
- Screen for delirium — the CAM (short form ~2 min) or the DTS→bCAM 2-step is the validated ED approach; document the result.
- Targeted workup — CBC, electrolytes/BUN:Cr, urinalysis, ECG (QT, ischemia, nodal/TCA patterns), CXR; broaden to LFTs/ammonia, TSH, tox, CT head, LP, EEG as the picture directs.
- Head CT is low-yield (~5%) in undifferentiated delirium without focal findings or fall/trauma — image for those, but don't let a normal CT end the search.
Skip the typing
Work the case in the Altered Mental Status Workup — it records glucose, the GCS and neuro exam, and the can't-miss reversibles, and assembles an MDM that documents the baseline, the screen, and the causes excluded.
04Delirium & agitation — do less harm
- Nonpharmacologic first — reorientation, family at bedside, hearing/visual aids, remove tethers (Foley), verbal de-escalation; treat the cause.
- Medications and restraints are a last resort — benzodiazepines are an independent risk factor for delirium (reserve for alcohol/benzo withdrawal); antipsychotics carry QT/mortality warnings and are contraindicated in Parkinson/Lewy body disease.
- Excited delirium is a medical emergency — monitor for hyperthermia, acidosis, rhabdomyolysis, and arrhythmia after sedation; use capnography.
- Review the medication list — even dose changes and OTC interactions cause delirium (Beers list).
05What to document
06Where charts fail
- Attributing the change to "baseline dementia," "psych," or "intoxication" without confirming the baseline by proxy.
- Not documenting a glucose and a delirium screen.
- Letting a normal head CT close an undifferentiated workup (consider NCSE, encephalitis, metabolic).
- Reaching for restraints/benzodiazepines before nonpharmacologic measures.
- Discharging a delirious elder without recognizing the elevated mortality and arranging support.
07Sources
- Wong N, Abraham G. Managing delirium in the emergency department: tools for targeting underlying etiology. Emergency Medicine Practice (EB Medicine). 2015;17(10).
- Han JH, Wilson A, Vasilevskis EE, et al. Diagnosing delirium in older ED patients: the delirium triage screen and brief CAM. Ann Emerg Med. 2013;62(5):457-465.
- American College of Emergency Physicians, American Geriatrics Society, et al. Geriatric emergency department guidelines. Ann Emerg Med. 2014;63(5):e7-e25.
- Inouye SK. Delirium in older persons. N Engl J Med. 2006;354(11):1157-1165.
- Witlox J, Eurelings LS, de Jonghe JF, et al. Delirium in elderly patients and the risk of postdischarge mortality. JAMA. 2010;304(4):443-451.
© 2026 Kim Trinh, MD. All rights reserved. Educational only — synthesized from EB Medicine and primary literature. Synthetic examples. Not medical advice — apply local protocol and judgment.