Acute changes in mental status are common in the hospital, and the best approach to their evaluation is described in the "DO'S" section of this chapter of GQC.
Please refer to those for more detail.
It is unusual for acute changes in mental status to be caused by major structural intracerebral processes, such as hemorrhage or ischemic stroke.
Unfortunately, we have developed a tendency to get head CT scans early in the evaluation. This wastes resources and removes patients from the floor. They miss meals and miss meds. We miss finding the real cause of their delirium.
You SHOULD move quickly to brain imaging if there is a specific reason to suspect a CNS hemorrhage or a major new stroke, such as a severe headache, a new focal neurologic deficit, or a condition known to cause CNS bleeding (severe thrombocytopenia, <10,000/mm3).
Otherwise, start with basic studies for delirium, as follows (see the "DO'S for Delirium).
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Review medications given in past several days
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Physical exam
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Fingerstick glucose
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Pulse oximetry
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Urinalysis
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Basic metabolic panel
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CBC
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Calcium
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Defer ordering a head CT for delirium until after looking for the usual causes.
Get an early head CT if there are high risks:
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new focal neurologic deficit
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new seizure
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low platelet count or coagulopathy
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head trauma
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