Algorithm for Evaluation of Suspected Mental Status Change in an Older Patient

Algorithm for Evaluation of Suspected Mental Status Change in an Older Patient - Flowchart Delirium Delirium

Flowchart

Establish mental status diagnosis

Suspected mental status change

Establish mental status diagnosis

Suspected mental status change

Establish mental status diagnosis

Suspected mental status change

Dementia evaluation

Evaluation

Treatment as appropriate for each condition

Evaluation
Treatment as appropriate for each condition

Evaluation

Treatment as appropriate for each condition

Nonpharmacologic approaches
Reorientation strategies and schedule of activities
Use of sitters or family members
Relaxation techniques: Music and massage
Avoid physical restraints and immobilizing devices (e.g., Foley catheters)
Maintain mobility and self-care
Use eyeglasses, hearing aids, interpreters
At night, keep room quiet with low-level lighting
Allow uninterrupted period of sleep at night
Encorage fluids, prevent dehydration

Nonpharmacologic approaches
Reorientation strategies and schedule of activities
Use of sitters or family members
Relaxation techniques: Music and massage
Avoid physical restraints and immobilizing devices (e.g., Foley catheters)
Maintain mobility and self-care
Use eyeglasses, hearing aids, interpreters
At night, keep room quiet with low-level lighting
Allow uninterrupted period of sleep at night
Encorage fluids, prevent dehydration

Nonpharmacologic approaches
Nonpharmacologic approaches
Reorientation strategies and schedule of activities
Use of sitters or family members
Relaxation techniques: Music and massage
Avoid physical restraints and immobilizing devices (e.g., Foley catheters)
Maintain mobility and self-care
Use eyeglasses, hearing aids, interpreters
At night, keep room quiet with low-level lighting
Allow uninterrupted period of sleep at night
Encorage fluids, prevent dehydration

Pharmacologic approaches
Indications: Reserved for patients with severe agitation that will

cause interruption of needed medical therapies (e.g., intubation)
pose safety hazard to patient or staff
Treatment:

Haloperidol 0.5–1.0 mg PO or IM
Repeat dose q 30 min until sedation achieved (maximum haloperidol 3–5 mg/24 hr)
Maintenance: 50% loading dose in divided doses over next 24 hr
Taper dose over next few days

Pharmacologic approaches
Indications: Reserved for patients with severe agitation that will

cause interruption of needed medical therapies (e.g., intubation)
pose safety hazard to patient or staff
Treatment:

Haloperidol 0.5–1.0 mg PO or IM
Repeat dose q 30 min until sedation achieved (maximum haloperidol 3–5 mg/24 hr)
Maintenance: 50% loading dose in divided doses over next 24 hr
Taper dose over next few days

Pharmacologic approaches
Pharmacologic approaches
Indications: Reserved for patients with severe agitation that will

cause interruption of needed medical therapies (e.g., intubation)
pose safety hazard to patient or staff

cause interruption of needed medical therapies (e.g., intubation)
pose safety hazard to patient or staff
Treatment:

Haloperidol 0.5–1.0 mg PO or IM
Repeat dose q 30 min until sedation achieved (maximum haloperidol 3–5 mg/24 hr)
Maintenance: 50% loading dose in divided doses over next 24 hr
Taper dose over next few days

Haloperidol 0.5–1.0 mg PO or IM
Repeat dose q 30 min until sedation achieved (maximum haloperidol 3–5 mg/24 hr)
Maintenance: 50% loading dose in divided doses over next 24 hr
Taper dose over next few days
Remove or alter any potentially contributory medications or any with potentially harmful interactions

Remove or alter any potentially contributory medications or any with potentially harmful interactions

Remove or alter any potentially contributory medications or any with potentially harmful interactions

Evaluation
Treatment as appropriate for each contributor

Evaluation
Treatment as appropriate for each contributor

Evaluation

Treatment as appropriate for each contributor

Consider further options
Laboratory testing: TFTs, B₁₂, toxicology screen, ammonia level, cortisol, etc.
Arterial blood gas
Cerebrospinal fluid examination
Brain imaging
Electroencephalogram

Consider further options
Laboratory testing: TFTs, B₁₂, toxicology screen, ammonia level, cortisol, etc.
Arterial blood gas
Cerebrospinal fluid examination
Brain imaging
Electroencephalogram

Consider further options
Consider further options
Laboratory testing: TFTs, B₁₂, toxicology screen, ammonia level, cortisol, etc.
Arterial blood gas
Cerebrospinal fluid examination
Brain imaging
Electroencephalogram
₁₂

End

End

End

Establish patient's baseline cognitive functioning and clinical course of change

Establish patient's baseline cognitive functioning and clinical course of change

Establish patient's baseline cognitive functioning and clinical course of change

Chronic

Chronic
Chronic
Acute

Acute
Acute
Potential contributor identified

Potential contributor identified
Potential contributor identified
No potential contributor identified

No potential contributor identified
No potential contributor identified
Manage delirium symptoms

Manage delirium symptoms

Manage delirium symptoms

All patients

All patients
All patients
Subgroup with severe agitation

Subgroup with severe agitation
Subgroup with severe agitation
IM, Intramuscular; NG, nasogastric; PO, by mouth; PRN, as needed; TFTs, thyroid function tests.

IM, Intramuscular; NG, nasogastric; PO, by mouth; PRN, as needed; TFTs, thyroid function tests.

IM, Intramuscular; NG, nasogastric; PO, by mouth; PRN, as needed; TFTs, thyroid function tests.
IM NG PO PRN TFTs
Cognitive assessment (including delirium assessment)

Cognitive assessment (including delirium assessment)

Cognitive assessment (including delirium assessment)

Delirium

Delirium
Delirium
Depression
Acute psychotic disorder
Other psychiatric disorder

Depression
Acute psychotic disorder
Other psychiatric disorder

Depression
Identify and treat underlying causes

Identify and treat underlying causes

Identify and treat underlying causes

Delirium mangement

Delirium mangement
Delirium mangement
Review medication (including PRNs and over-the-counter medications)

Review medication (including PRNs and over-the-counter medications)
Review medication
History, including alcohol use
Vital signs
Physical examination, including neurologic examination
Targeted laboratory testing
Search for occult infection

History, including alcohol use
Vital signs
Physical examination, including neurologic examination
Targeted laboratory testing
Search for occult infection

History