Altered mental status causes

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Pratik Bahekar, MBBS [2] Kiran Singh, M.D. [3]

Overview

Altered mental status has varying time courses and degrees of severity. Acute changes in mental status are usually secondary to delirium, stupor, and coma, which are forms of acute brain dysfunction. These changes occur over a period of hours or days and are usually precipitated by an underlying medical illness that is potentially life threatening. Chronic alterations in mental status (e.g. dementia) occur over a period of months and years and are less likely to be precipitated by a life-threatening illness. For these reasons, acute changes in mental status will be the focus of this review. Altered mental status is rarely caused by psychiatric illnesses such as depression or schizophrenia, and in elder patients, these should be diagnoses of exclusion. Acute brain dysfunction (delirium, stupor, and coma) and their underlying etiology should be ruled out prior to considering any psychiatric diagnoses, especially in patients without a previous history of psychiatric illness.

Causes

Life Threatening Causes

• Malignant hypertension
• Myocardial infarction
• Rabies
• Sepsis

Common Causes

• Alcohol withdrawal
• Drug withdrawal
• Dehydration
• Electrolyte disturbance
• Encephalitis
• Epileptic seizures
• Hyperglycemia
• Hypoglycemia
• Meningitis
• Sepsis

Causes by Organ System

Cardiovascular	Malignant hypertension, Heart failure, Myocardial infarction, Congestive heart failure, Ventricular arrhythmia
Chemical/Poisoning	Withdrawal states from ethanol, benzodiazepines,Water hemlock poisoning, Toxic mushrooms -- Monomethylhydrazine ,Toluene, Texas Mescalbean poisoning,Poison hemlock, Organic solvent, Methanol , Marijuana, Lead, Jimson weed, Hyperbaric sickness, Hydrogen sulfide , Heroin ,Hallucinogens, Ethylene glycol, Ethanol, Daphne poisoning, Cyanide, Carbon tetrachloride, Carbon monoxide toxicity, Alcohol withdrawal, Thallium Sulfate poisoning,Phencyclidine poisoning, Nickel, Carbonyl poisoning
Dental	No underlying causes
Dermatologic	No underlying causes
Drug Side Effect	Acyclovir, Alfentanil, Alphaprodine, Amantadine, Amiloride, Aminoglycosides, Aminophylline, Amitriptyline, AmlodipineAmobarbitalAmphetamine, Amphotericin B, AnalgesicsAntiarrhythmics, Anticholinergics, Antidepressants Antiemetics, Antihistamines Antimalarials, Antipsychotic agents, Antispasmodics, Apomorphine, Aripiprazole, Armodafinil, Amobarbital, Asparaginase, Aspirin, Atropine, Baclofen, Barbiturates, Benzodiazepines, Beta blockers, Blinatumomab, Bromocriptine, Bupivacaine, Buprenorphine, Butorphanol, Cabergoline, Camphorated opium tincture, carbamazepine, Carbamazepine, Cephalosporins, Chlophedianol, Chloroquine, Chlorpheniramine, Chlorpromazine,Cholinesterase inhibitors, Cinnarizine, Ciprofloxacin, Clomethiazole, Clonazepam, Clonidine, Clozapine, Cocaine, Codeine, Corticosteroids, Cyclazocine, Cyclobenzaprine, Cycloserine, Deserpidine, Desipramine, Dexamfetamine, Dextromoramide, Dezocine, Diamorphine, Diazepam, Digoxin, Dihydrocodeine, Diphenhydramine, Dipipanone, Disulfiram, Diuretics, Domperidone, Donepezil, Dopamine agonists Dothiepin, doxylamine, Drug overdose,drug withdrawal, Efavirenz, EszopicloneEthosuximide, Ethotoin, Ethylmorphine, Fentanyl, Fludarabine, Fluoroquinolones, gabapentinGeneral anaesthesia, Glutethimide, Guanethidine, Hallucinogens, Histamine-2 receptor blocker, Hydromorphone, Hydroxyzine, Ifosfamide, Interferon, Interleukin, Isoniazid, Ketobemidone, L-dopa, Lanatoside C, Lenalidomide, Levetiracetam, Levodopa, Levomepromazine, Levorphanol, Lidocaine, Linezolid, lithium, Loperamide, Lorazepam, Lysergic acid diethylamide, Lysuride, Macrolides, Marijuana, Memantine, Meptazinol, Mescaline, Methadone, Methadyl acetate, Methcathinone, Methyldopa, Methyldopate, Methylenedioxymethamphetamine, Methylphenidate, Metronidazole, Mirtazapine, Monoamine oxidase inhibitors, Monomethylhydrazine, Morphine, Muscle relaxant, Mushrooms, Nabilone, Nalbuphine, Nalidixic acid, Nelarabine, Nonsteroidal anti-inflammatory drugs, Norfloxacin, Norpropoxyphene, Nortriptyline, Noscapine, olanzapine, Opiates, Opium, Nitrazepam, Oxazepam, Oxycodone, Oxycontin, Oxymorphone, Papaveretum, Penicillins, Pentazocine, Perampanel, Pergolide, Pethidine, Phenazocine, Phencyclidine, Phenelzine, Phenobarbital, Phenoperidine, Phenothiazines, Phentermine, Phenytoin, Pholcodine, Piribedil, Piritramide, Pizotifen, Pomalidomide, Pramipexole, Prednisolone, Primidone, Prochlorperazine, Propoxyphene, Propranolol, Psychotropics, quetiapine, Quinine, Quinolones, Ramelteon, Rasagiline, Remifentanil, Reserpine, Retigabine, Rifampin, Risperidone, Rivastigmine, Ropinirole, Salicylate, secobarbital, Sedative hypnotics, Sedatives, Selective serotonin reuptake inhibitors, Selegiline, Skeletal muscle relaxant, St John's wort, Steroid abuse, Sufentanil, Sulfonamidesthioridazine, tricyclic antidepressants,Zaleplon, ziprasidone zolpidem, zopiclone
Ear Nose Throat	Burns, chester porphyria, decompression sickness, porphyria
Endocrine	Addisonian crisis, Adrenal cortex insufficiency , Carcinoid crisis, Cushing syndrome, Diabetic coma, Diabetic hypoglycemia, Diabetic ketoacidosis, Elevated or depressed adrenal function, Elevated or depressed pancreas function, Elevated or depressed pituitary function Hyperglycemia, Hyperosmolar non-ketotic diabetic coma, Hyperosmolar states, Hyperthyroidism, Hypoglycemia, Hypopituitarism, Hypothyroidism, Myxedema coma, Phaeochromocytoma, Pituitary apoplexy Thyrotoxicosis
Environmental	Hypothermia, hyperthermia, heat stroke, electric shock, decompression sickness, acute Altitude sickness
Gastroenterologic	Elevated or depressed pancreas function, Chronic Liver failure, Acute Liver failure, Mesenteric ischemia, Appendicitis, Acute diverticulitis, Constipation
Genetic	No underlying causes
Hematologic	Thrombocytosis, Polycythemia, Leukemic blast cell crisis, Hypereosinophilia
Iatrogenic	Postoperative stress
Infectious Disease	Viral hemorrhagic fever, Vancomycin resistant enterococcal bacteremia, Urinary tract infection, Typhoid fever, systemic inflammatory response syndrome, Systemic infection, Wound#infectionSurgical wound infection, Subdural empyema, Sleeping sickness (West African), Sleeping sickness (East African), Sepsis, Rickettsiae, Rabies , Pyelonephritis, acute, Plague , Neurocysticercosis,Malaria, Intraspinal abscess / granuloma, Intracranial abscess / granuloma, Gangrene , Chest infection, Cerebral malaria,Brain or epidural abscess, Brain infection, Infectious mononucleosis (glandular fever), Lyme disease
Musculoskeletal/Orthopedic	Fibromyalgia
Neurologic	Venous sinus thrombosis, Raised intracranial pressure, Postictal state, Nonconvulsive status epilepticus,Meningoencephalitis, Meningitis, Intracranial bleeding, Hypertensive encephalopathy, Epileptic seizures, Epidural haemorrhage,Encephalitis, Encephalitis, Cerebrovascular accident, Cerebral oedema, Cerebral infarction, Brain tumor, Brain abscess, Subdural hematoma, Epidural hematoma, Subarachnoid hemorrhage, Brain tumor, Neurosyphilis, Sleep apnea, Brain edema, Cerebral hypoxia, Hydrocephalus
Nutritional/Metabolic	Wilson's disease, Wernicke's encephalopathy, Vitamin B12 deficiency, Thiamine (Vitamin B1) deficiency, Niacin deficiencies, Folate deficiency, Acute intermittent porphyria, Starvation
Obstetric/Gynecologic	Eclampsia, hyperoestrogenic states, preeclampsia
Oncologic	No underlying causes
Ophthalmologic	No underlying causes
Overdose/Toxicity	No underlying causes
Psychiatric	Schizoaffective disorder , Advanced sleep phase disorder, Delayed sleep phase syndrome
Pulmonary	Respiratory failure, Hypoxemia, Hypercarbia
Renal/Electrolyte	Hypophosphatemia, hypoosmolar states, Hyponatremia, Hypocalcemia, Hyperosmolar states, Hypernatremia, Hypermagnesemia, Hypercalcemia, Hypomagnesemia, Hyperphosphatemia, Chronic Renal failure, Acute Renal failure, Uremia, Dehydration
Rheumatology/Immunology/Allergy	Vasculitis
Sexual	No underlying causes
Trauma	Trauma, Skull fracture, Head injury
Urologic	Urinary Track Infection
Miscellaneous	Coproporphyria, Burns, Chronic fatigue syndrome

Causes in Alphabetical Order

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