Common Causes of Altered Mental Status in Elderly patients

 The most common causes of altered mental status in elderly patients include:

1. Infections: Urinary tract infections, pneumonia, and sepsis are frequent culprits[1][2][3]. Even COVID-19 can cause altered mental status in older adults[5].

2. Metabolic disturbances: Electrolyte imbalances, dehydration, and organ dysfunction (e.g., hepatic encephalopathy) can lead to mental status changes[2][3][6].

3. Medications and drugs: Polypharmacy, drug interactions, overdose, or withdrawal from substances like benzodiazepines and opioids can cause altered mental status[1][2][3].

4. Neurological conditions: Stroke, brain hemorrhage, brain tumors, and seizures can affect mental status[2][3][5].

5. Delirium: This is a common presentation of altered mental status in the elderly, occurring in 7%-10% of geriatric patients in the emergency department[8]. It can be caused by various underlying factors, including those mentioned above.

6. Chronic conditions: Dementia, Parkinson's disease, and other neurodegenerative disorders can contribute to altered mental status[1][5].

7. Toxin exposure: Exposure to substances like carbon monoxide or cyanide can affect mental status[5].

8. Metabolic disorders: Thyroid imbalances and vitamin deficiencies can lead to altered mental function[3].

It's important to note that in elderly patients, the cause of altered mental status is often multifactorial, with several contributing factors present simultaneously[1][2].

Citations:

[1] https://pmc.ncbi.nlm.nih.gov/articles/PMC3614410/

[2] https://www.aafp.org/pubs/afp/issues/2021/1100/p461.html

[3] https://www.webmd.com/mental-health/what-is-altered-mental-status

[4] https://hign.org/consultgeri/resources/symptoms/abrupt-change-mental-status

[5] https://www.mayoclinic.org/diseases-conditions/delirium/symptoms-causes/syc-20371386

[6] https://my.clevelandclinic.org/health/diseases/23159-altered-mental-status-ams

[7] https://www.hmpgloballearningnetwork.com/site/emsworld/article/10850982/acute-altered-mental-status-elderly-patients

[8] https://reference.medscape.com/slideshow/altered-mental-status-elderly-6010546

Pulmonary artery pressures by echocardiography

 Measurement of pulmonary artery pressure and  grading by echocardiography with emphasis on new guidelines  

1. Estimation method:

The pulmonary artery systolic pressure (PASP) is typically estimated using the peak tricuspid regurgitation velocity (TRV) and adding an estimate of right atrial pressure[1][2]. This is done using the simplified Bernoulli equation: PASP = 4(TRV)^2 + estimated right atrial pressure.

2. Grading scale:

The severity of pulmonary hypertension based on mean pulmonary artery pressure (mPAP) is generally graded as[4]:

- Mild: 20-40 mmHg

- Moderate: 41-55 mmHg

- Severe: > 55 mmHg

3. Probability assessment:

Recent guidelines recommend assessing the probability of pulmonary hypertension rather than providing a specific pressure estimate[1][3]. The echocardiographic probability of pulmonary hypertension is categorized as:

- Low probability: TRV ≤ 2.8 m/s or not measurable, with no other echocardiographic signs of PH

- Intermediate probability: TRV ≤ 2.8 m/s with other signs of PH, or TRV 2.9-3.4 m/s without other signs

- High probability: TRV 2.9-3.4 m/s with other signs of PH, or TRV > 3.4 m/s

4. Additional echocardiographic signs:

Other echocardiographic parameters are considered when assessing the probability of pulmonary hypertension, including right ventricular size and function, pulmonary artery characteristics, and inferior vena cava and right atrium measurements[1][3].

5. Limitations:

It's important to note that numerical echocardiographic estimates of pulmonary artery pressure often are inaccurate compared to invasive measurements, with both overestimation and underestimation possible[1][2]. Right heart catheterization remains the gold standard for diagnosing pulmonary hypertension[4].

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In summary, while specific pressure values can be estimated, current guidelines emphasize assessing the probability of pulmonary hypertension using a combination of tricuspid regurgitation velocity and other echocardiographic signs, rather than relying solely on pressure estimates.

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Citations:

[1] https://pmc.ncbi.nlm.nih.gov/articles/PMC6055509/

[2] https://www.ccjm.org/content/83/4/256

[3] https://echo.biomedcentral.com/articles/10.1530/ERP-17-0071

[4] https://litfl.com/pulmonary-hypertension-echocardiography/

[5] https://www.sciencedirect.com/science/article/abs/pii/S2213260021000722

[6] https://www.ahajournals.org/doi/10.1161/jaha.113.000363

[7] https://www.ahajournals.org/doi/10.1161/circimaging.116.005711