Approach to the hospitalized patient with altered mental status

These are a few pearls from a talk by S. Andrew Josephson MD at UCSF's 17th annual hospital medicine conference.


Dementia with Lewy bodies (DLB)

Associated with parkinsonism.

Visual hallucinations.

Has a fluctuating course so may present as delirium.

Antipsychotics contraindicated. Cholinergics help.

Here are some links [1] [2]


HSV-1 meningoencephalitis

Tests may be negative initially. Speaker's comment: “We start a lot of confused patients on acyclovir.” (IV).


Wernike's

Triad: confusion, ataxia, occulomotor.

Alcoholism no longer the leading risk factor!

Low threshold to give IV thiamine in confused patient.


Agitated delirium

Non pharmacologic modalities are the treatment of choice. Drugs as a last resort (exception: ETOH withdrawal).

Benzos make it worse (exception: ETOH).

Antipsychotics may be necessary but contraindicated in some patients (e.g. Lewy body).