Altered Mental Status in the Emergency Department

Austin T. Smith, MD; Jin H. Han, MD, MSc


Semin Neurol. 2019;39(1):5-19. 

In This Article


The disposition for patients with AMS depends on the cause, stability, and reversibility of the underlying condition. Stuporous or comatose patients likely require intensive care.

Patients with a stroke should be admitted to a stroke unit if possible, as this has been associated with improved mortality and outcomes.[143] Patients with large vessel occlusions may be best served at a comprehensive stroke center where thrombectomies are performed.[144]

If the cause of AMS is from a toxic etiology, disposition should be decided in conjunction with a poison center (1–800–222–1222). Many ingestions, particularly those involving delayed-release drug formulations, require 24-hour monitoring even with a reassuring evaluation.

For delirious patients, there is very little evidence-based literature regarding disposition. There is, however, evidence that delirious patients discharged from the ED have higher rates of mortality than those without delirium, particularly if the diagnosis is missed in the ED.[145]

If the cause of AMS, however, is determined and symptoms are rapidly reversed, observation or discharge home with close supervision can be considered. If a patient without a known neurologic disorder becomes delirious from a seemingly benign insult, outpatient follow-up with a neurologist should be arranged, as they have essentially failed a "stress test for the brain."[9]