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ORIGINAL ARTICLE
Year : 2023 | Volume
: 22
| Issue : 2 | Page : 213-218
Clinico-etiological profile of the elderly population with altered mental status in a teaching hospital
Minakshi Dhar1, Birata Debbarma1, Anirudh Mukherjee1, Senkadhir Dasan2
1 Department of Medicine, AIIMS, Rishikesh, Uttarakhand, India
2 Department of Community and Family Medicine, AIIMS Rishikesh, Utarakhand, India
Correspondence Address:
Birata Debbarma
6th Floor, Medical College Building, Department of Medicine, AIIMS, Rishikesh - 243 203, Uttarakhand
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/aam.aam_92_22
Abstract
Background: This study aimed at evaluating the clinico-etiological profile of altered mental status (AMS) among elderly patients and making recommendations regarding management based on etiologies, thereby improving both morbidity and mortality outcomes. Materials and Methods: This retrospective observational study was conducted in a teaching cum tertiary care hospital. Two years data (from July 2017 to June 2019) were extracted from the medical records section, and 172 eligible participants were analyzed using descriptive statistics for clinical outcomes, demographic profiles, and various etiological factors. Results: A total of 1784 elderly inpatients (age >60 years) were screened from the records, and 172 eligible elderly AMS patients were found eligible for the study. The male elderly population consisted of 110 (63.95%), and the female elderly was 62 (36.04%). The mean age of the study population was 67.82 years. The etiological factors of AMS in the study population were neurological – 47.09% (n = 81), infection – 30.23% (n = 52), metabolic/endocrine – 16.27% (n = 28), pulmonary – 2.32% (n = 4), fall – 1.74% (n = 3), toxic cause – 1.16% (n = 2), and psychiatric illness – 1.16% (n = 2). The total mortality rate was 9.30% (n = 16). Conclusion: The main etiological factors of AMS in the elderly population were predominantly of neurological, septic, and metabolic causes. These factors were preventable and treatable by training physicians, staff (as most of the physicians in the developing countries are not trained in managing this fragile group of population with multiple comorbidities), and by decentralizing geriatrics health-care setups.
Keywords: Altered mental status, elderly, etiological profile
Introduction 
The elderly population presenting with altered mental status (AMS) is very common, consisting of up to 60% of inpatients.[1] The term “altered mental sensorium (AMS)” is a vague term which denotes a varied clinical spectrum, which can be simply defined as altered attention, awareness, and impaired cognition precipitated by underlying condition(s) with variable management modalities and clinical outcomes.[2] In some of the hospital settings, the elderly AMS population consists of 60% of inpatients, and they need a prolonged hospital stay, which not only have effects on morbidity and mortality outcome but also affects the economy of caregivers and require trained staff too.[2],[3],[4]
It is also one of the most common reasons for hospitalization, intensive care unit admissions, and referrals to a tertiary care hospital from the peripheral hospitals/health-care setups. The etiological factors of AMS in the elderly population are very variable and different from younger patients. As this group of patients often has multiple comorbidities with polypharmacy, it requires both time and resources to evaluate and manage them. In fact, many drugs have to be used cautiously with limitations, and at the same time, they need an early initiation of proper treatment for a better morbidity and mortality outcome.[5],[6],[7],[8]
Hence, it is indeed challenging for physicians to determine the etiological factors of AMS, thereby leading to difficulty in adopting an early precise management plan. The current elderly populations are nearly 104 million (aged 60 years or above) in India, and it is expected to grow exponentially to 173 million by 2026, as reported by the United Nations Population Fund and HelpAge India, 2017.[9]
It is also estimated that by 2050, India will have approximately one-fifth of its total population aged 60 years and above.[10] Not only in India, at present, the most rapidly growing population worldwide is also the elderly population.[11]
In India, there are no adequate data and guidelines available to assess and manage these elderly populations who are admitted with AMS. Therefore, assessment of the etiological factors, demographic, and clinical outcomes of AMS in the elderly population is necessary.
Materials and Methods This retrospective observational cohort study was conducted in a teaching hospital. The ethical clearance of the study was approved by the Ethical Committee of the institute.
A total of 1784 elderly populations above 60 years who were admitted with the complaints of AMS were screened at the time of admission with the objective of determining their clinical outcomes, demographic variables, and etiological factors.
Those elderly patients with a history of altered sensorium but recovered at the time of admission and those who had cardiac arrest within 8 h of admission were excluded from the study.
Of 1784 elderly patients, 172 AMS patients were found to be eligible and included in the study. Their detailed hospital records were collected as per the inclusion and exclusion criteria.
The duration of the study was from July 1, 2017 to June 30, 2019. The AMS of the elderly population was assessed by the Glasgow Coma Scale (GCS) at the time of presentation.[11],[12]
The diagnosis of AMS was based on the GCS scale. The GCS scale lesser than 15, who were aggressive in behavior, disoriented to time, place, person, and reduced verbal response, were considered AMS in the study population.[12],[13],[14]
The etiological factors of the AMS in the study population were broadly grouped into five (five) major categories based on the underlying causes. They were namely, (1) neurologic; (2) infective; (3) metabolic; (4) pulmonary; and (5) miscellaneous (toxin, psychiatrists, and fall).
Statistical analysis of the collected data was performed using IBM SPSS Statistics for Macintosh, Version 25.0. (Armonk, NY: IBM Corp.). Continuous variables were denoted in the form of mean, median (minimum–maximum) or standard deviation (SD) and number (percentage) for categorical variables. Ninety-five percent confidence interval and odds ratio were applied to measure the strength of the association. The Chi-squared test or Fischer's test was used where applicable, and P < 0.05 was considered statistically significant.
Results In this retrospective study, a total of 172 AMS elderly patients were included after the screening of 1784 elderly inpatients' hospital records. In the study population, 110 (63.95%) were male and 62 (36.04%) were female. The age of the elderly AMS in the study population ranged from 60 to 96 years. The average mean age was 67.82 years (67.82±7.71SD). The average hospital stay was maximum (6.39±1.36SD) in the elderly AMS populations of neurological cause. Elderly AMS patients caused by toxins and fall need a lesser average hospital stay (4 days, 4.00±1.84SD) [Table 1].
The level of altered sensorium was grouped according to the GCS Score among the study population.
The GCS score of 13 to <15 was seen in 70.34% (n = 121) of elderly AMS patients, and 3 GCS score was seen in 4% (n = 7) of AMS patients. Of these seven AMS patients, four cases were seen in metabolic cause, two cases in neurological, and one case in the infective cause of AMS, respectively [Table 1].
Among the elderly AMS patients, hypertension (HTN) (n = 97, 56.39%) was the most commonly associated comorbidities, and the second-most common was diabetes mellitus (n = 47, 27.32%), which was found in 27.32% of cases. Coexistence of diabetes, cerebrovascular accident (CVA), and HTN was most commonly found among the cases of multiple comorbidities (n = 33, 19.18%). Only 9 (5.23%) elderly AMS were without any comorbidity among the studied population [Table 1].
The overall mortality rate was 9.30% (n = 16) in the study population. Most of the mortality (n = 7, 43.75%) was seen in AMS of neurological etiology. This includes four cases (57.14%) of CVA (three hemorrhagic and one ischemic CVA), two cases (28.57%) of meningitis, and one case (14.28%) of glioblastoma. Among the infective etiology (n = 5, 31.25%), mortality was seen in three cases of pneumonia (60%), one case each in urosepsis (20%) and mucormycosis (20%) of the total mortality. The lowest mortality was seen in AMS of metabolic cause (n = 4, 25%). There was no mortality observed in the pulmonary and miscellaneous groups [Table 1].
In our study, the most common etiological factor responsible for AMS in the elderly population was neurological cause (47.09%, n = 81). Of these, 70.37% was CVA (n = 57), becoming the most common cause of AMS in the study population of neurological etiology. AMS was seen more in hemorrhagic CVA (n = 32, 56.14%) than ischemic CVA (n = 25, 43.85%). The next common neurological cause of AMS was meningitis (16.04%, n = 13). Of these, 30.76% (n = 4) of patients were having tubercular meningitis. In rest of the patients (n = 9, 69.23), the definite cause of meningitis could not be ascertained [Table 2].
Table 2: Etiological factors of altered mental status in elderly populationChronic neurological disease like Parkinson's disease (n = 4) and malignancy (glioblastoma, n = 2) comprised 4.93% and 2.93% of AMS, respectively, in the study population.
Following neurological disorder, the second-most common etiological factor of AMS in the elderly population was infective etiology (n = 52, 30.23%). In this group of AMS patients with infective etiology, pneumonia (n = 21, 40.38%) predominated the etiology of AMS among the elderly population, followed by urosepsis which was seen in 21.15% of patients (n = 11). Community-acquired pneumonia was seen in 76.19% (n = 16) of AMS cases. Rest five AMS (23.80%) patients were cases of hospital-acquired pneumonia, which were referred from peripheral hospitals [Table 2].
The other etiologies of AMS of infective etiology include pulmonary tuberculosis (n = 8, 15.38%), viral hepatitis (n = 5, 9.61%), and gastrointestinal infections (GIT) infections (n = 4, 7.69%). In GIT infections, one case of acute necrotizing pancreatitis and three cases of acute diarrhea were seen, respectively. Fungal infections (n = 2, 3.84%) consisted of a single case of both mucormycosis and aspergillosis [Table 2]. AMS of metabolic etiology was seen in 16.27% (n = 28) of AMS patients. Uremic encephalopathy topped among the metabolic etiology and was found in 39.28% (n = 11) of patients [Table 2].
The mortality rate was correlated with the severity of the GCS score. The higher mortality rate was seen as the GCS score lowers or tends toward more severity as described in [Table 3].
Table 3: Altered mental sensorium based on the Glasgow Coma Scale score and mortality association in the study groupThe overall mortality rate ranged from 6.73% to 50% in different age groups and found to be proportional to the age of the study population. Older the AMS population, higher the mortality rate. There was 50% mortality in the age group above >90 years (n = 2). The cause of mortality in >90 years' age group was infective etiology in both the cases. The least mortality was seen in 60–69 years' age group (n = 103) in the studied AMS population (6.73%, n = 7) [Table 2].
Discussion This study was conducted in a multispecialty teaching hospital to assess the etiological profile of AMS in the elderly population. A total of 1784 elderly were admitted during the study. Of these, 172 elderly AMS were found eligible and included in the study. Elderly patients who presented in the emergency department (ED) with altered mental status require urgent attention and appropriate diagnosis for providing a better management. To provide empirical treatment on these population, determining local clinical and etiological factors plays a role for a better clinical outcome.[15],[16] This study had attempted to find the common etiologies of AMS in the elderly population and thereby initiating early treatment to reduce both morbidity and mortality.
Several worldwide studies on etiologic factors of AMS showed that elderly with AMS constitutes around 4%–10% of the total hospital admission.[17]
In our study, elderly AMS comprised 9.64% (n = 172) of the total elderly inpatients (n = 1,784). This hospital admission rate of elderly AMS was similar to other studies done by Erkinjuntti, et al.[18]
It was found that AMS was more commonly seen in 60–70 years' age group patients, which consisted of 60% (n = 103) of the total AMS cases. The gender-wise distribution of elderly AMS was almost similar in our study compared to the study by Kanich et al.[19] HTN (n = 97, 56.39%) was seen as the most common associated comorbidity among the AMS population, followed by diabetes (n = 47, 27.32%).
In our study, the most common etiology of AMS was neurological cause which comprised 47.09% (n = 81) of the total study population. Out of all neurological cases, CVA alone constituted 70.37% (n = 57) of all neurological causes (n = 81). Hemorrhagic CVA (n = 32, 56.14%) was more associated with AMS than ischemic CVA (n = 25, 43.85%). In a retrospective study, Kanich, et al.[19] found that neurological etiology (28%) was the most common followed by toxic etiology (21%), whereas a study in China, by Xiao, et al.[20] showed that neurological causes (stroke, head trauma, or mass lesion) accounted for 35.0% (n = 641) and 65.0% (n = 1190) of cases were of nonneurological factors. The higher percentage of CVA in our study might be due to exclusion of head trauma cases.
A study conducted by Xiao et al.[20] had found the metabolic causes of AMS in elderly being 6.3% of cases.
Xiao et al.[20] found in their prospective cohort study that the mortality rate was higher in elderly AMS of >60 years than younger patients (10.8%) [Figure 2].
Kanich et al.[19],[21] found that metabolic/endocrine causes constituted 5%, whereas a recent study by Rai et al.[22] had found metabolic causes comprised 36% of elderly AMS.
In their study (Rai et al[22]),the increased number of metabolic causes was contributed by the increased number of dyselectrolytemia, which consisted mostly cases of hyponatremia. The mortality rate was the highest in the age group of >90 years (50%, n = 2) and the lowest (6.73%, n = 7) in the age group of between 60 and 69 years. In relation to the GCS score, mortality rate was maximum in AMS with the GCS score 3 (28.57%, n = 2) [Figure 1] and least (6.61%, n = 8) with the GCS score between 13 and 15 [Table 4].
Table 4: Age group and mortality association in elderly altered mental status populationThe top three AMS etiology in the elderly found by Xiao was cerebrovascular disease (36.2%), organ dysfunction (19.4%), and infection (10.4%).[20] The second-most common was infection-induced AMS (n = 52, 32.23%), followed by metabolic etiology (n = 28, 16.27%). Infective etiology in the elderly population was lower in a study done by Xiao (9.1%), whereas a multicenter prospective study by Aslaner et al.[21] showed that 39.5% of elderly AMS were of infective etiology. In their study (Aslaner et al.[21]) among the infective etiology, pneumonia was found to be the most common cause of AMS.
In a study from North India, Rai et al.[22] had found that bronchopneumonia (70%) was the most common cause of AMS among the infective etiology. In our study, community-acquired pneumonia (40.8%, n = 21) predominated among the infective etiology. The etiology AMS differs from region to region and population throughout the world. In Zambia and Ethiopia, the most common cause of nontraumatic AMS was infection. The cerebral malaria topped the infectious cause of AMS in those countries.[23]
A study conducted by Tintinalli et al.[24] found that around 4% of patients admitted in psychiatry ward with AMS had infective etiology and needed to transfer back them to the medicine ward.[24] The ED is a busy and hectic department; some patients with AMS might miss during evaluation in ED. As our study found that infection-induced AMS was the second-most common cause, physicians may emphasize on clinical evaluation of occult septic focus in patients with AMS like osteomyelitis, perineal abscess, gluteal abscess, pyelonephritis, etc., as early as possible and start empirical treatment after rolling out any underlying neurological cause of AMS.
AMS of the metabolic origin was seen in 16.27% (n = 28) of cases in our study. Uremic encephalopathy (39.28%, n = 11) predominated among the metabolic cases.
Elderly AMS is not only potentially life-threatening but also the management of these patients as most of the time eliciting a proper relevant history of these patients was not possible and have to rely on the attendants and caregivers.[2] In developing countries, blood laboratory and imaging reports used to get delayed due to the high number of patients, thereby compromising demand and supply ratio.
Therefore, before starting an early empirical therapy, physicians must emphasize on the clinical history and physical examinations before starting the treatment of AMS and its underlying cause.
As the elderly population is growing rapidly both in developed and developing countries,[24] US medical schools have adopted to develop competencies in geriatrics for all medical students and also in residency training programs. These were endorsed by the American Geriatrics Society and American Medical Association.[24],[25] Similar programs also could be adopted by the Indian medical colleges and institutes to provide a quality care to elderly AMS patients.
From the study findings, it is obvious that the etiology of AMS in the study population in this part of the world differs from others. The top three etiological factors of AMS in the elderly are treatable and preventable as well. They can be achieved by training the health-care professionals, lifestyle modifications, antibiotic stewardship, public awareness, and decentralizing the geriatric health-care facilities.
Conclusion The AMS in elderly population has wide etiological factors and outcome. The outcome depends on initial diagnosis and management by trained physicians and staff.[16],[17] This study reveals that the etiological factors for AMS in the elderly population in this part of the world are different from others. All of these three common etiological factors, namely, neurological, infective, and metabolic causes of AMS in the elderly are preventable and treatable by adopting appropriate training policy to physicians and staff by enhancing geriatric health-care competences like that of the USA.
At the same time, while giving an early empirical therapy of AMS with infective etiology, the rational use of drugs and antibiotic stewardship also to be considered. Formulation of the local guidelines/protocols will help physicians to execute a timely and better management plan as these populations were mostly with multiple comorbidities.
Limitation
This is a hospital-based single-center study which may not represent the same etiology of AMS in the elderly population in other health-care setups of the country. Therefore, further studies are needed (preferably multicenter) to determine the etiological factors and their clinical outcome of AMS in the elderly population.
Acknowledgments
We would like to thank to the Ethical Committee of the institute for timely clearance and considering this study with due importance.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References 
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