Altered Mental Status: Signs and What to Do

Signs and symptoms of altered level of consciousness

Altered mental status is not one symptom but a change in one or more of these areas:

1. Level of alertness: drowsy, hard to keep awake, slow to respond, or at the other end, hyperalert and agitated.
2. Orientation: not knowing where they are, what day it is, or who people are.
3. Attention: easily distracted, unable to follow a conversation or simple instructions, losing track mid-sentence.
4. Speech and thinking: muddled, rambling or slurred speech, illogical ideas.
5. Perception: seeing or hearing things that are not there, or misinterpreting what is.
6. Behavior and mood: new aggression, fearfulness, withdrawal, or behavior that is out of character.
7. Memory: not remembering recent events or repeating questions.

If you are asked to list three signs of an altered level of consciousness, the most commonly cited are confusion or disorientation, drowsiness or reduced responsiveness, and slurred or incoherent speech. Agitation and inability to follow commands are others.

Levels of consciousness, from mild to severe

Common causes

Doctors often use the memory aid AEIOU TIPS to cover the main causes:

• Alcohol and drugs: intoxication, withdrawal, overdose
• Epilepsy, electrolytes, encephalopathy: after a seizure, sodium or calcium imbalance, liver or kidney failure
• Insulin: low blood sugar or very high blood sugar
• Oxygen and opioids: low oxygen from lung or heart problems, carbon monoxide, opioid overdose
• Uremia: kidney failure
• Trauma and temperature: head injury, hypothermia, heat stroke
• Infection: sepsis, meningitis, pneumonia, urinary tract infection in older adults
• Psychiatric and poisoning: severe mental illness, toxic ingestion
• Stroke and shock: stroke, bleeding in the brain, very low blood pressure

Causes in older adults

In older people, especially those with dementia, sudden confusion is often delirium triggered by infection, dehydration, constipation, urinary retention, pain, poor sleep in hospital, or medicines such as sleeping tablets, strong painkillers and bladder medicines. Delirium can look like sleepiness and withdrawal rather than agitation, so it is easily missed. See delirium.

Causes in children

Febrile illness, dehydration, head injury, accidental ingestion of medicines or household products, seizures, diabetic ketoacidosis and meningitis are the main concerns.

What to do if someone suddenly becomes confused

1. Call 911 or your local emergency number if the change is sudden, the person is hard to wake, or there are stroke signs, a head injury, fever with a stiff neck, or trouble breathing.
2. Check for stroke using BE FAST: Balance loss, Eyes (vision loss), Face drooping, Arm weakness, Speech difficulty, Time to call. Note the time they were last normal.
3. If they have diabetes and can swallow safely, give fast-acting sugar such as juice, regular soda or glucose tablets, then recheck in 15 minutes.
4. If they are unresponsive but breathing, place them on their side in the recovery position. If they are not breathing normally, start CPR.
5. Do not give food, drink or medicines to someone who is very drowsy, because they may choke.
6. Collect information for the paramedics: medicines, recent illness, alcohol or drug use, falls, and how they were before.

How doctors assess altered mental status

Emergency teams check airway, breathing and circulation, measure blood sugar immediately, and use scales such as the Glasgow Coma Scale to grade responsiveness. Tests usually include blood tests (electrolytes, kidney and liver function, blood count, alcohol and drug levels), a urine test, oxygen levels, an ECG and a CT scan of the head. A lumbar puncture or EEG may follow. The full clinical approach is covered on the altered mental status condition page.

Preventing confusion in at-risk people

• Keep a current medicine list and review it with a pharmacist, especially for older adults.
• Make sure glasses and hearing aids are used and the person drinks enough.
• Watch for early signs of infection.
• During hospital stays, keep a clock, calendar and familiar objects nearby and encourage normal sleep times.

Frequently asked questions

What are three signs of altered level of consciousness?

Three common signs are confusion or disorientation (not knowing where they are or what day it is), drowsiness or reduced responsiveness, and slurred or incoherent speech. Others include agitation, inability to follow instructions and not recognizing familiar people.

What is the most common cause of altered mental status?

It depends on age and setting. In older adults, infections, dehydration and medicines causing delirium are very common. In younger people, alcohol, drugs, low blood sugar and head injury lead the list. Stroke is an important cause at any adult age.

Is altered mental status an emergency?

A sudden change in alertness or thinking should be treated as an emergency, because many causes, such as low blood sugar, stroke, meningitis and sepsis, need treatment within minutes to hours. Call 911 or your local emergency number.

Can a UTI cause altered mental status?

Yes, especially in older adults and people with dementia. A urinary tract infection can trigger delirium, with confusion, agitation or sleepiness, sometimes before any urinary symptoms. However, confusion should not be blamed on a UTI without checking for other causes.

What is the difference between confusion and altered mental status?

Confusion is one type of altered mental status. Altered mental status is the broader term, covering any change in alertness, awareness or behavior, from mild confusion and agitation to drowsiness, stupor and coma.