Do all AMS patients need to be admitted?

[prolene60]

During residency we admitted almost all altered mental status patients without an etiology especially the elderly. If you have a patient brought in by the family confused but not lethargic, afebrile, other vitals are stable, head CT, CXR, urine, ekg, basic labs are normal, and you find no focal neurological deficits is it still necessary to admit? If you do admit do you tell the hospitalist "it might be a subtle cva and he/she needs an mri and further work-up or maybe early sepsis and I'll order blood cultures etc.." or do you just say "Im admitting someone for AMS, don't have a definite cause here in the ED, please take the pt."

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[NinerNiner999]

In my shop we say "I'm admitting someone for AMS, don't have a definite cause here in the ED, please take the patient." Seriously, altered mental status in the absence of trauma - especially in the elderly - needs a workup. There are no exceptions. This includes transient global amnesia and the "stroke like spectrum" of other illnesses that are a diagnosis by exclusion.

 

[neusu]

Is this the typical Thanksgiving we haven't seen the patient in months or the patient lives with us and is altered today? The former can be evaluated as an outpatient, the latter inpatient.

 

[dotcb]

The AMS cases that can be discharged are those who have returned to baseline with a clear benign explanation for the cause of AMS - which is basically no one except for intoxication, post-ictal, etc.

 

[Birdstrike]

Altered mental status of unknown cause?

Yes, always admit.

There's nothing good, that isn't immediately obvious, that causes unexplained altered mental status.

AMS of known cause?

That's a whole different entity and dispo becomes obvious if the cause is known, whether it's admit or discharge.

Key point: Is the cause of AMS, known or unknown?


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[gman33]

What about the dementia patient who was been brought in 10 times for AMS with a negative workup?

When they come in you just order every test in the book.
If they are all negative, do you still admit?
I do. Just diagnose, AMS, unknown etiology.
I'm sure the inpatient team hates these admits.
I wish I had a way to send them home.

 

[neusu]

You guys realize that old people do die, right?

 

[Rendar5]

You guys realize that old people do die, right?

and you realize that their families sue after, right? It's not us who need convincing that old people die =p

I actually had a patient who denied the concept that people even die, this was an old guy with pna who had been refusing treatment thankfully the nursing home had papers stating his lack of capacity, and this was further helped by my being able to document him having conversations with multiple invisible people when left in the room alone...

 

[Birdstrike]

You guys realize that old people do die, right?

Yes, more often than anyone else, which is why no one (that's smart) wants to be the last guy to touch the hot potato (or "potaoe" if you are Dan Quayle.)

 

[Birdstrike]

What about the dementia patient who was been brought in 10 times for AMS with a negative workup?

When they come in you just order every test in the book.
If they are all negative, do you still admit?
I do. Just diagnose, AMS, unknown etiology.
I'm sure the inpatient team hates these admits.
I wish I had a way to send them home.

Elderly demented patients also get septic with no fever, no elevated WBC and no symptoms other than, "brought in 10 times for AMS with a negative workup."

You'll only know it two days later when their culture turns + or when their a BP crashes.

You do have a way to send them home: consult Medicine so they can send them home in 2 days, or now if they're feeling lucky. (And when they actually come to see the patient, often they have a different view compared to the grumbling on the phone.)

 

[edgesofsanity]

I can't say it's a regular occurrence, but I've sent a few elderly AMS of unknown etiology home. The real key is - what does the POA/family want to do? If they want to take the patient home, and understand that medically you can't clear them, just document the conversation, make it explicit they can return for any reason, and there ya go.

Now, if they want the patient to stay, roll out the carpet.

 

[Spinach Dip]

You guys realize that old people do die, right?

"But we brought gramps to the hospital so he WOULDN'T die!"


(said the family who doesnt care that gramps has COPD, diabetes, alzheimers, CHF, and terminal cancer. This is a hospital, so you're going to save him, right?)

 

[Old_Mil]

You guys realize that old people do die, right?

We do. Most old people do. Lawyers, and the families of old people who die don't. Many of these admissions are driven by lawsuits and demanding a 0 percent miss rate while simultaneosuly being unwilling to pay for it.

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