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

Dementia evaluation

Dementia evaluation

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

End

End

End

Evaluation and treatment as appropriate for each condition

Evaluation and treatment as appropriate for each condition

Evaluation and treatment as appropriate for each condition

Cognitive assessment (including delirium rating)

Cognitive assessment (including delirium rating)

Cognitive assessment (including delirium rating)

Delirium

Delirium

Delirium


Depression
Acute psychotic disorder
Other psychiatric disorder


Depression
Acute psychotic disorder
Other psychiatric disorder


Depression
Acute psychotic disorder
Other psychiatric disorder Depression

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

Identify and treat underlying causes

Delirium management

Identify and treat underlying causes

Delirium management

Delirium management

Identify and treat underlying causes

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

Identify and treat underlying causes

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

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

Identify and treat underlying causes


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

Identify and treat underlying causes


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, including alcohol use

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


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


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

Evaluation and treatment as appropriate for each contributor

Evaluation and treatment as appropriate for each contributor

Evaluation and treatment as appropriate for each contributor

Potential contributor identified

Potential contributor identified

Potential contributor identified

No potential contributor identified

No potential contributor identified

No potential contributor identified

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 IM/IV or PO
Repeat dose q30min until sedation achieved (maximum haloperidol 3-5 mg/24 hr)
Maintenance: 50% loading dose in divided doses over next 24 hours
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 IM/IV or PO
Repeat dose q30min until sedation achieved (maximum haloperidol 3-5 mg/24 hr)
Maintenance: 50% loading dose in divided doses over next 24 hours
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 IM/IV or PO
Repeat dose q30min until sedation achieved (maximum haloperidol 3-5 mg/24 hr)
Maintenance: 50% loading dose in divided doses over next 24 hours
Taper dose over next few days


Haloperidol 0.5-1.0 mg IM/IV or PO
Repeat dose q30min until sedation achieved (maximum haloperidol 3-5 mg/24 hr)
Maintenance: 50% loading dose in divided doses over next 24 hours
Taper dose over next few days

Nonpharmacologic approaches


Reorientation strategies and schedule of activities
Use of sitters or family members
Relaxation techniques, music, 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

Nonpharmacologic approaches


Reorientation strategies and schedule of activities
Use of sitters or family members
Relaxation techniques, music, 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

Nonpharmacologic approaches

Nonpharmacologic approaches


Reorientation strategies and schedule of activities
Use of sitters or family members
Relaxation techniques, music, 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


Reorientation strategies and schedule of activities
Use of sitters or family members
Relaxation techniques, music, 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

Manage delirium symptoms

All patients

Manage delirium symptoms

All patients

All patients

Manage delirium symptoms

Subgroup with severe agitation

Manage delirium symptoms

Subgroup with severe agitation

Subgroup with severe agitation