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]

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

Altered mental status is a life-threatening condition and must be treated as such irrespective of the causes.

Common Causes

• Acute systemic infection
• Acute psychosis
• Alcohol withdrawal
• Alcohol toxicity
• Congestive heart failure
• CVA
• Dehydration (volume depletion)
• Dementia
• Delirium
• Depression
• Drug toxicity
• Drug withdrawal
• Head injury

• Hepatic encephalopathy
• Hip fracture
• Hypercarbia
• Hyperglycemia
• Hypoglycemia
• Hypernatremia
• Hyponatremia
• Hypothermia
• Hypoxia
• Myocardial infarction
• Pulmonary embolism
• Seizures
• Uremia
• Ventricular arrhythmia

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	Muscle relaxants, Serotonin syndrome, Quinolones, Lithium, Drug withdrawal, Drug overdose,Cabergoline, Antihistamines ], Antidepressants: for instance sedating tricyclic antidepressants, Analgesics: mostly prescribed or illicit opiates such as oxycontin, Antiepileptics such as phenytoin, carbamazepine, gabapentin, Antihistamines: diphenhydramine and doxylamine, Antipsychotics: thioridazine, quetiapine, olanzapine, risperidone, and ziprasidone but not haloperidol, HIV medications for example, efavirenz, Antihypertensive medications like amlodipine, Hypnotics like zopiclone, or the benzodiazepine such as diazepam or nitrazepam and the barbiturate, such as amobarbital or secobarbital, Benzodiazepine receptor agonists: Eszopiclone, Zolpidem, Zaleplon, Dopamine agonists used in the treatment of parkinson's disease e.g. pergolide, ropinirole and pramipexole, Antiepileptics such as phenytoin, carbamazepine, gabapentin
Ear Nose Throat	No underlying causes
Endocrine	Pituitary apoplexy, Phaeochromocytoma, Hypothyroidism, Hypopituitarism, Hypoglycemia, Hyperthyroidism,Hyperosmolar non-ketotic diabetic coma, Hyperglycemia, Hyperthyroidism, Elevated or depressed pituitary function ,Elevated or depressed adrenal function, Diabetic ketoacidosis, Diabetic hypoglycemia, Cushing syndrome, Adrenal cortex insufficiency , Thyrotoxicosis, Myxedema coma, Pituitary apoplexy
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
Musculoskeletal/Orthopedic	No underlying causes
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
Nutritional/Metabolic	Wilson's disease, Wernicke's encephalopathy, Vitamin B12 deficiency, Thiamine (Vitamin B1) deficiency, Niacin deficiencies, Folate deficiency, Acute intermittent porphyria
Obstetric/Gynecologic	No underlying causes
Oncologic	No underlying causes
Ophthalmologic	No underlying causes
Overdose/Toxicity	No underlying causes
Psychiatric	Schizoaffective disorder , Advanced sleep phase disorder
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
Rheumatology/Immunology/Allergy	Vasculitis
Sexual	No underlying causes
Trauma	Trauma, Skull fracture, Head injury
Urologic	Urinary Track Infection
Miscellaneous	Coproporphyria, Burns

Causes in Alphabetical Order

Acute diverticulitis Acute intermittent porphyria Advanced sleep phase disorder Analgesics: mostly prescribed or illicit opiates such as oxycontin Antiepileptics such as phenytoin, carbamazepine, gabapentin Antidepressants: for instance sedating tricyclic antidepressants Antihistamines: diphenhydramine and doxylamine Antihypertensive medications like amlodipine Antipsychotics: thioridazine, quetiapine, olanzapine, risperidone, and ziprasidone but not haloperidol Appendicitis Acute Liver failure Acute Renal failure Adrenal cortex insufficiency Alcohol withdrawal Acute altitude sickness Antihistamines Antipsychotics Benzodiazepine receptor agonists: Eszopiclone, Zolpidem, Zaleplon Brain abscess Brain edema Brain infection Brain or epidural abscess Cerebral hypoxia Chronic fatigue syndrome Dopamine agonists used in the treatment of parkinson's disease e.g. pergolide, ropinirole and pramipexole. Brain tumor Burns Cabergoline Carbon monoxide toxicity Carbon tetrachloride Cardiac failure Cerebral infarction Cerebral malaria Cerebral oedema Cerebrovascular accident Congestive heart failure Constipation Dehydration Delayed sleep phase syndrome Depression Dopamine agonists used in the treatment of parkinson's disease e.g. pergolide, ropinirole and pramipexole. Chest infection Chronic Liver failure Chronic Renal failure Coproporphyria, hereditary Cushing syndrome Cyanide Daphne poisoning Decompression sickness Diabetic hypoglycemia Diabetic ketoacidosis Drug overdose Drug withdrawal Electric shock Elevated or depressed adrenal function Elevated or depressed pancreas function

Elevated or depressed pituitary function Encephalitis Encephalitis Epidural hematoma Epidural haemorrhage Epileptic seizures Ethanol Ethylene glycol Fat embolism Folate deficiency Gangrene Hallucinogens Head injury Heart failure Heat stroke Heroin HIV medications for example, efavirenz Hypnotics like zopiclone, or the benzodiazepine such as diazepam or nitrazepam and the barbiturate, such as amobarbital or secobarbital Hperthyroidism Hpherphosphatemia Hydrogen sulfide Hyomagnesemia Fibromyalgia Hydrocephalus Hyperbaric sickness Hypercalcemia Hypercarbia Hypereosinophilia Hyperglycemia Hypermagnesia Hypernatremia Hyperosmolar non-ketotic diabetic coma Hyperosmolar states Hypertensive encephalopathy Hyperthermia Hyperthyroid Hypocalcemia Hypoglycemia Hyponatremia hypoosmolar states Hypophosphatemia Hypopituitarism Hypothermia Hypothyroidism Hypoxemia Hypoxia Infections Infectious mononucleosis (glandular fever) Intracranial abscess / granuloma Intracranial bleeding Intraspinal abscess / granuloma Jimson weed Lead Leukemic blast cell crisis Lithium Liver failure Lyme disease Malaria Malignant hypertension Marijuana Melatonin receptor agonists: Ramelteon Meningitis Meningoencephalitis Mesenteric ischemia

Methanol Muscle relaxant Myocardial infarction Myxedema coma Neurocysticercosis Neurosyphilis Niacin deficiencies Nickel poisoning Nonconvulsive status epilepticus Organic solvent Pituitary apoplexy Phaeochromocytoma Phencyclidine Pituitary apoplexy Plague Poison hemlock Polycythemia Porphyria Postictal state Postoperative stress Pyelonephritis, acute Quinolones Rabies Raised intracranial pressure Renal failure, acute Renal failure, chronic Respiratory failure Rickettsiae Schizoaffective disorder Sepsis Serotonin syndrome Skull fracture Sleep apnea Sleeping sickness (East African) Sleeping sickness (West African) Starvation Subdural empyema Subdural hematoma Subarachnoid hemorrhage Wound#infectionSurgical wound infection Systemic infection systemic inflammatory response syndrome Systemic organ failure Texas Mescalbean poisoning Thiamine (Vitamin B1) deficiency Thallium Sulfate poisoning Thrombocytosis Thyrotoxicosis Toluene Toxic mushrooms -- Monomethylhydrazine Trauma Typhoid fever Uremia Urinary tract infection Valproic acid Vancomycin resistant enterococcal bacteremia Vasculitis Venous sinus thrombosis Ventricular arrhythmia Viral hemorrhagic fever Vitamin B12 deficiency Water hemlock poisoning Wernicke's encephalopathy Wilson's disease Withdrawal states e.g. ethanol, benzodiazepines

References