Clinical Characteristics, Aetiologies, and Disposition Outcomes of Patients Presenting with Altered Mental Status in an Academic Emergency Department.

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Learn more: PMC Disclaimer | PMC Copyright Notice Neurosciences (Riyadh) . 2026 Mar 27;31(1):67–74. doi: 10.17712/1658-3183.1009 Clinical Characteristics, Aetiologies, and Disposition Outcomes of Patients Presenting with Altered Mental Status in an Academic Emergency Department Zohair A Al Aseri a, b, c, a , Omar M Alotaibi a , Ibrahim M A Albarrak d , Saif A S Aljaghwani d , Ahmed M A Alkhars d , Marwan M Althubaiti d , Abdulaziz A Alkathami e , Abdullah R A Alanazi d , Fahad I Abuguyan a Author information Article notes Copyright and License information a Department Emergency Medicine and Critical Care, College of Medicine, King Saud University, Riyadh, Saudi Arabia b Department of Clinical Sciences, College of Medicine and Riyadh Hospital, Dar Al Uloom University, Riyadh, Saudi Arabia c Therapeutic Deputyship, Ministry of Health, Riyadh, Saudi Arabia d Medical Intern, College of Medicine, Dar Al Uloom University, Riyadh, Saudi Arabia e Second Health Cluster, Ministry of Health, Riyadh, Saudi Arabia a Address correspondence and reprint request to: Zohair Al Aseri, Department Emergency Medicine and Critical Care, College of Medicine, King Saud University, Riyadh, Saudi Arabia . Received 2025 Jun 23; Accepted 2025 Dec 8; Issue date 2026 Jan. Copyright: © Neurosciences Neurosciences is an Open Access journal and articles published are distributed under the terms of the Creative Commons Attribution-NonCommercial License (CC BY-NC). Readers may copy, distribute, and display the work for non-commercial purposes with the proper citation of the original work. PMC Copyright notice PMCID: PMC13169169  PMID: 42238832 Summary Objectives: To assess the clinical characteristics, aetiologies, and disposition outcomes of patients presenting with altered mental status (AMS) in an academic emergency department, as well as to explore factors associated with hospitalization, intubation, and mortality. Methods: This retrospective cross-sectional study included 142 AMS patients presenting to the Emergency Department of (Blinded for Review) between December 2019 and December 2022. Adults (≥18 years) with documented AMS were enrolled, excluding those who died upon arrival or with iatrogenic AMS. Demographic, clinical presentation, comorbidity, medication, aetiology, intervention, and disposition outcome data, were extracted from the electronic System for Integrated Health Information. Results: The cohort (N = 142, mean age of 44.7 ± 21.1 years) was predominantly male (58.5%), and 83.1% of patients developed symptoms within 1 hour. Chronic comorbidities included diabetes (28.9%) and hypertension (28.2%), with frequent use of antihypertensives (23.2%), insulin (17.6%), and anticonvulsants (18.3%). Aetiologies were neurological (24.6%), drug abuse (24.6%), cardiovascular (15.5%), and endocrine/metabolic (12.0%). Most patients were discharged (81.7%), but the mortality rate was 4.2%. Intubation rate was 5.6%, of which intubation was primarily for traumatic AMS patients (37.5%), and all the intubated patients were male (p = 0.021). Males accounted for 83.3% of fatalities. Conclusion: The present study identified key AMS patterns, including high-risk aetiologies (cardiovascular and traumatic) and male-dominated disparities (intubation and mortality). These findings advocate for aetiology-specific protocols and reassessment of potential sex biases in acute care. Keywords: Altered mental status, Emergency medicine, Aetiology, Disposition outcomes, Intubation, Mortality Altered mental status (AMS) is a common yet complex emergency presentation, representing a significant diagnostic challenge because of its broad differential diagnosis and potential life-threatening causes [ 1 , 2 ]. AMS presents as delirium, dementia, psychosis, or coma [ 3 , 4 , 5 ]. It accounts for 5–10% of adult emergency department (ED) visits and is more prevalent in elderly and comorbid patients [ 6 ]. Its clinical significance lies in poor outcomes among vulnerable groups, especially elderly individuals with multiple comorbidities [ 7 ]. Despite its frequency and clinical importance, AMS often lacks a definitive ED diagnosis, leading to suboptimal outcomes and higher health care costs from unnecessary testing or treatment delays [ 8 , 9 ]. The aetiological spectrum of AMS is broad and includes neurological, metabolic, infectious, toxicological, and psychiatric causes [ 1 , 4 ]. Emergency physicians understand that these causes vary by age, comorbidities, and environment [ 10 ]. For example, elderly patients more commonly present with metabolic or infectious causes, whereas younger adults may more frequently have toxicological or traumatic aetiologies. The core diagnostic challenge lies in AMS presentation variability and the frequent lack of clear history in emergency settings, necessitating assessments tailored to individual patient profiles [ 1 , 10 , 11 ]. Despite advances in emergency medicine, several gaps remain in the understanding and management of AMS. Current knowledge focuses on elderly populations, potentially overlooking unique characteristics and challenges in younger adult patients presenting with AMS. There is a limited understanding of how specific AMS aetiologies are related to acute interventions, such as intubation, particularly in academic emergency departments, which serve diverse patient populations. Furthermore, disposition outcomes remain poorly characterized for many clinical settings, and the variable performance of existing approaches across populations underscores the need for more tailored management strategies [ 12 ]. The present study aimed to assess the clinical characteristics, aetiologies, and disposition outcomes of patients presenting with AMS to the emergency department at (Blinded for Review) . Moreover, factors associated with hospitalization and critical outcomes, such as the need for intubation and in-hospital death, were explored. Methods Study design and participants This retrospective cross-sectional study was conducted to assess the clinical characteristics, aetiologies, disposition outcomes, and factors associated with hospitalization, intubation, and mortality among 142 patients presenting with AMS at the emergency department. The study was performed between December 2019 and December 2022, at (Blinded for Review) , a teaching hospital in (Blinded for Review) . Affiliated with (Blinded for Review) , the hospital serves as a centre for medical education, research, and health care services. Inclusion and exclusion criteria The participants included in this study were adults (≥18 years) with documented altered mental status changes upon emergency department presentation, provided that they had complete medical records detailing the aetiology, interventions, and disposition. Patients who died on arrival, those with iatrogenic AMS induced by medications administered in the ED (e.g., sedatives), or individuals who regained full consciousness prior to formal evaluation were excluded from the study. Sample size calculation The sample size was calculated on the basis of an estimated 10% prevalence of altered mental status among emergency department visits, aiming for a 95% confidence interval (CI) with a ±5% margin of error. The standard formula for estimating the sample size for proportions was as follows: n = ( z 2 × p × ( 1 - p ) ) / E 2 where: Z = 1.96 (95% CI) p = 0.10 (prevalence) E = 0.05 (precision). This calculation yielded a required sample size of approximately 138 participants. This represents the minimum target sample size for estimating a single proportion with the stated precision. To account for potential variability or missing data, a conservative upper estimate of 384 participants (based on a wider prevalence range or smaller margin of error) was also considered. However, as a retrospective study conducted over a defined period, the final cohort was constrained by the number of eligible patients presenting to the emergency department who met the strict inclusion and exclusion criteria. The final cohort size of 142 was determined by the total number of eligible cases identified during the study period (December 2019 - December 2022). While this is lower than the conservative estimate, the final cohort size of 142 met the minimum requirement for statistical validity. Procedure and data collection Data were collected through a review of patient files in the e-SiHi electronic medical record system of (Blinded for Review) . The e-SiHi system is a comprehensive hospital information platform that integrates patient registration, clinical documentation, laboratory results, medication records, and discharge summaries into a unified digital record for each encounter. We selected patient files meeting the inclusion and exclusion criteria through this system and then verified complete data availability. Anonymized data were extracted using medical record numbers (MRNs) from e-SiHi for all patients presenting to the emergency department with AMS. An Excel spreadsheet was designed to capture all variables systematically. The following data were collected: Baseline characteristics and emergency department presentation , such as age, sex, length of stay (LOS), time and day of visit, arrival mode, and onset of AMS. Clinical variables , such as comorbidities, current medications, and aetiology classification. Patient disposition outcomes , such as disposition (admission, discharge, and death) and intubation status. Ethical considerations This study followed the Declaration of Helsinki and was approved by the Research Ethics Committee at (Blinded for Review), under IRB log number (Blinded for Review). Patient records were anonymized at extraction from e-SiHi, with identifiers replaced by study codes. Statistical analysis Statistical analysis was performed with SPSS version 28 (IBM Co., Armonk, NY, USA). Numerical data are presented as the means and standard deviations (SDs) or medians and interquartile ranges (IQRs). Independent t tests were used for two-group comparisons, and one-way ANOVA was used for comparisons across more than two groups. Categorical data are presented as frequencies and percentages, and they were analysed by the chi-square test or exact test, as appropriate. A two-tailed P value <0.05 was considered statistically significant. Results The baseline characteristics, emergency department presentation, and aetiological classification of patients with AMS are presented in Table 1 . The cohort included 142 patients with a mean age of 44.71 years (±21.05 SD), ranging from 19–92 years. Males comprised 58.5% (83 patients), whereas females accounted for 41.5% (59 patients). Most patients (87.3%) were discharged on the same day, and only one patient required hospitalization for up to one month. The median length of stay was 2 days (IQR 1, 2.25). AMS presentations were most common during evening (38.0%) and night shifts (38.7%), with fewer during morning hours (23.2%). Weekday visits (74.6%) exceeded weekend visits (25.4%). Arrival by private vehicles was most common (56.3%), followed by ambulatory presentations (22.5%) and ambulance transport (21.1%). Notably, 83.1% of patients experienced symptom onset within 1 hour prior to presentation, whereas only 1.4% of patients presented symptoms after more than 1 week. Neurological causes and drug abuse-related aetiologies represented the most common categories (24.6%) for each. Cardiovascular causes accounted for 22 cases (15.5%), while endocrine/metabolic disorders were identified in 17 patients (12.0%). Traumatic causes were documented in 8 patients (5.6%), and psychiatric aetiologies in 7 patients (4.9%). Less frequent etiological categories included gastrointestinal causes (2.8%), respiratory factors (1.4%), and infectious origins (1, 0.7%). A residual category of other unspecified causes accounted for 11 cases (7.7%). Table 1. Baseline characteristics, emergency department presentation, and aetiological classification of patients with altered mental status (N = 142). Item N % Age (years) Mean ± SD 44.71 ± 21.05 Range 19–92 Sex Male 83 58.5 Female 59 41.5 Length of stay (LOS) 0 days 124 87.3 1 day 7 4.9 2 days 7 4.9 3 days 1 0.7 5 days 1 0.7 1 week 1 0.7 1 month 1 0.7 Median (IQR) 2 (1, 2.25) Time of visit Morning shift (07:01–15:00) 33 23.2 Evening shift (15:01–23:00) 54 38.0 Night shift (23:01–7:00) 55 38.7 Day of visit Weekday 106 74.6 Weekend 36 25.4 Mode of arrival Ambulance 30 21.1 Private car 80 56.3 Ambulatory 32 22.5 Onset of altered mental status <1 hour 118 83.1 <12 hours 11 7.7 <24 hours 6 4.2 <1 week 5 3.5 >1 week 2 1.4 Aetiology Neurological 35 24.6 Cardiovascular 22 15.5 Respiratory 2 1.4 Gastrointestinal 4 2.8 Endocrine/Metabolic 17 12.0 Infection 1 0.7 Psychiatric 7 4.9 Traumatic 8 5.6 Drug abuse 35 24.6 Other 11 7.7 Open in a new tab IQR = Interquartile Range. The prevalence of comorbidities among patients presenting with AMS is presented in Supplementary Table 1 . Among the 142 patients, diabetes mellitus and hypertension were the most common (28.9% each). Metabolic disorders (dyslipidemia: 9.2%), neurological comorbidities (seizure disorders: 10.6%; epilepsy: 9.2%), and mental illness (4.9%) were also documented. Cardiovascular conditions (ischemic heart disease/heart failure: 2.8% each), asthma (2.8%), stroke (2.1%), and liver cirrhosis (1.4%) were less frequent. Rare conditions (end-stage renal disease/hearing loss: 0.7% each), pre-existing AMS (1.4%), and other unspecified comorbidities (23.9%) were also observed. The current medication use among patients presenting with AMS is presented in Supplementary Table 2 . Of the 142 patients, 38.0% were medication-free at presentation. The most commonly reported medications were antihypertensives (23.2%), insulin (17.6%), and anticonvulsants (18.3%), followed by oral hypoglycemics (4.2%), anticoagulants (3.5%), anti-lipid agents (4.9%), antipsychotics (4.2%), and antidepressants (3.5%). Pain and inflammation management medications were reported, with anti-inflammatories (7.0%) and analgesics (4.9%) being most notable. Less common medications included antineoplastics (2.8%), diuretics (1.4%), and single cases (0.7%) of antibacterial, antiviral, antifungal, antiemetic, and bronchodilator use. One patient (0.7%) had unknown medication status, while 12 patients (8.5%) reported unspecified medications. Table 2. Disposition outcomes and interventions for patients presenting with altered mental status (N = 142). Item N % 95% CI Patient disposition Admitted to hospital 20 14.1 8.6–21.75 • Regular ward 17 12.0 6.97–19.17 • Intensive care unit (ICU) 3 2.1 0.44–6.17 Discharge from emergency department (ED) 116 81.7 67.5–97.98 Died in emergency department (ED) 6 4.2 1.55–9.2 Intubation No 134 94.4 Yes 8 5.6 2.43–11.1 Open in a new tab CI: Confidence interval. The disposition outcomes and interventions for patients presenting with AMS are presented in Table 2 . Most patients (81.7%; 95% CI: 67.5–97.98) were discharged directly from the emergency department. Twenty patients (14.1%; 95% CI: 8.6–21.75) were admitted to the hospital, with most admissions to regular wards (12.0%; 95% CI: 6.97–19.17) rather than intensive care units (2.1%; 95% CI: 0.44–6.17). Mortality in the emergency department was documented in 6 patients (4.2%; 95% CI: 1.55–9.2). Regarding critical interventions, the vast majority of patients (94.4%) did not require intubation, whereas 8 patients (5.6%; 95% CI: 2.43–11.1) received intubation during their emergency department management. The association between baseline characteristics and disposition outcomes in patients presenting with AMS is presented in Table 3 . Age showed no significant differences across disposition groups (admitted: 47.45 ± 21.2 years, discharged: 44.12 ± 20.98 years, died: 47 ± 24.71 years; p = 0.781). Gender distribution was similar between admitted (55% male) and discharged groups (57.8%), though males represented 83.3% of deaths (p = 0.505). AMS onset was predominantly acute (<1 hour) across all groups (admitted: 80%, discharged: 83.6%, died: 83.3%; p = 0.298). Comorbidities (p = 0.933) and medications (p = 0.453) showed no significant association with disposition. Aetiologies varied significantly (p = 0.016): cardiovascular causes accounted for 50% of deaths (vs 5% admissions, 15.5% discharges), traumatic causes represented 33.3% of deaths (vs 15% admissions, 2.6% discharges), and neurological aetiologies were absent in deaths (0% vs 20% admissions, 26.7% discharges). Drug abuse-related cases showed similar proportions across all groups (admitted: 25%, discharged: 25%, died: 16.7%). Table 3. Association between baseline characteristics and disposition outcomes in patients presenting with altered mental status (N = 142). Patient disposition Item Admitted (n = 20) Discharged (n = 116) Died (n = 6) P value Age (years) 47.45 ± 21.2 44.12 ± 20.98 47 ± 24.71 0.781 Sex Male 11 (55%) 67 (57.8%) 5 (83.3%) 0.505 Female 9 (45%) 49 (42.2%) 1 (16.7%) Onset of AMS <1 hour 16 (80%) 97 (83.6%) 5 (83.3%) 0.298 <12 hours 2 (10%) 9 (7.8%) 0 (0%) <24 hours 0 (0%) 6 (5.2%) 0 (0%) <1 week 2 (10%) 2 (1.7%) 1 (16.7%) >1 week 0 (0%) 2 (1.7%) 0 (0%) Comorbidities No 5 (25%) 34 (29.3%) 2 (33.3%) 0.933 Yes 15 (75%) 82 (70.7%) 4 (66.7%) Medications No 5 (25%) 47 (40.5%) 2 (33.3%) 0.453 Yes 15 (75%) 69 (59.5%) 4 (66.7%) Aetiology Neurological 4 (20%) 31 (26.7%) 0 (0%) 0.016 Cardiovascular 1 (5%) 18 (15.5%) 3 (50%) Endocrine/metabolic 1 (5%) 16 (13.8%) 0 (0%) Psychiatric 2 (10%) 5 (4.3%) 0 (0%) Traumatic 3 (15%) 3 (2.6%) 2 (33.3%) Drug abuse 5 (25%) 29 (25%) 1 (16.7%) Other 4 (20%) 14 (12.1%) 0 (0%) Open in a new tab Numerical data are presented as the mean ± SD and compared using one-way ANOVA, while categorical data are presented as the frequency (%) and compared using Chi-square test or the Fisher–Freeman–Halton Exact Test if there are expected cell count <5, with a P value < 0.05 indicating statistical significance. The association between baseline characteristics and intubation status in patients presenting with AMS is presented in Table 4 . Age showed no significant difference between nonintubated (44.5 ± 21.18 years) and intubated patients (48.25 ± 19.64 years); p = 0.626. All intubated patients were male compared to 56% males in the nonintubated group (p = 0.021). Most cases in both groups presented within 1 hour of symptom onset (nonintubated: 83.6%, intubated: 75%; p = 0.246). Comorbidity status (p = 0.175) and medication use (p = 0.710) showed no significant association with intubation need. Etiological classification varied significantly (p = 0.014): intubated patients had no neurological (0% vs 26.1%) or psychiatric causes, more traumatic causes (37.5% vs 3.7%), higher cardiovascular representation (25% vs 14.9%), and less drug abuse-related aetiologies (12.5% vs 25.4%) compared to non-intubated patients. Table 4. Association between baseline characteristics and intubation status in patients presenting with altered mental status (N = 142). Intubation Item No (n = 134) Yes (n = 8) P value Age (years) 44.5 ± 21.18 48.25 ± 19.64 0.626 Sex Male 75 (56%) 8 (100%) 0.021 Female 59 (44%) 0 (0%) Onset of AMS <1 hour 112 (83.6%) 6 (75%) 0.246 <12 hours 11 (8.2%) 0 (0%) <24 hours 5 (3.7%) 1 (12.5%) <1 week 4 (3%) 1 (12.5%) >1 week 2 (1.5%) 0 (0%) Comorbidities No 37 (27.6%) 4 (50%) 0.175 Yes 97 (72.4%) 4 (50%) Medications No 50 (37.3%) 4 (50%) 0.710 Yes 84 (62.7%) 4 (50%) Aetiology Neurological 35 (26.1%) 0 (0%) 0.014 Cardiovascular 20 (14.9%) 2 (25%) Endocrine/metabolic 16 (11.9%) 1 (12.5%) Psychiatric 7 (5.2%) 0 (0%) Traumatic 5 (3.7%) 3 (37.5%) Drug abuse 34 (25.4%) 1 (12.5%) Other 17 (12.7%) 1 (12.5%) Open in a new tab Numerical data are presented as the mean ± SD and compared using independent t test, while categorical data are presented as the frequency (%) and compared using Chi-Square test, Fisher's exact test, or the Fisher–Freeman–Halton Exact Test if there are expected cell count <5, with a P value < 0.05 indicating statistical significance. Discussion AMS represents a critical diagnostic challenge in emergency medicine, significantly impacting patient outcomes and resource utilization. Understanding the demographic patterns, clinical characteristics, and aetiological distributions of AMS is essential for optimizing emergency care pathways. The demographic patterns observed in this cohort have significant implications for AMS triage and management. The wide age range (19–92 years, mean 44.7) and male predominance (58.5%) mirrored global AMS trends but revealed contextual variations. While these findings align with those of Manji et al. (2022), who reported a median age of 56 years and 56.2% male representation in Tanzania [ 13 ], the younger mean age in this cohort may reflect regional differences in disease burden or health care access. The male predominance parallels Xiao et al. (2012) findings, reporting 53.1% of AMS patients are male [ 14 ], and Lai et al. (2009), reporting that trauma, a condition with established male predominance, is a leading aetiology [ 15 ]. This consistency in male predominance across diverse settings suggests biological (e.g., higher rates of substance use or trauma) and sociobehavioural factors (e.g., risk-taking behaviours) as plausible drivers. The predominance of abrupt-onset AMS (<1 hour, 83.1%) in this cohort suggested acute aetiologies such as intoxication, trauma, or cerebrovascular events. This contrasts with Leong et al. (2008), where only 67% of patients presented within 24 hours of symptom onset [ 16 ], potentially reflecting population or healthcare-seeking differences. The higher rate in this study may stem from the urban academic setting's role in acute referrals and the cohort's younger mean age (44.7 years) versus Leong et al.'s elderly group (60% ≥ 65 years). The predominance of acute presentations may also reflect triage patterns that miss subacute AMS or redirect it to outpatient care. These findings highlight the need for standardized documentation to improve onset accuracy in diverse populations. The contrast with Leong et al. suggests symptom onset timing may vary by context, meriting further study of demographic and institutional influences on AMS patterns. The comorbidity profile in this study revealed critical considerations for AMS assessment, with diabetes (28.9%) and hypertension (28.2%) being the most common. This aligns with Manji et al. (2022), where 53.5% had hypertension, supporting cardiovascular-metabolic comorbidities as universal AMS risks [ 13 ]. Pathophysiology likely involves both acute (e.g., hypertensive encephalopathy) and chronic (e.g., cerebrovascular damage) mechanisms. The lower hypertension rate in this study may reflect age or regional differences (mean age 44.7 vs. 56 years). Moreover, the substantial seizure disorder prevalence (10.6%) in this study supports the findings reported by LaHue et al. (2022), who suggested that epilepsy, especially nonconvulsive status epilepticus, is a subtle but critical cause of AMS [ 10 ]. However, the low mental illness rate (4.9%) in this study contrasts with the literature noting frequent psychiatric contributions, possibly due to underrecognition in EDs prioritizing organic causes [ 17 ]. This gap highlights the need for better screening, in line with the suggestion of LaHue et al. to assess immune status and medications [ 10 ]. Overall, these findings support comorbidity-driven AMS evaluations addressing both acute derangements and occult neuropsychiatric contributors, especially in resource-variable settings. The medication profiles in this cohort revealed critical iatrogenic and disease-related AMS risk factors, with antihypertensives (23.2%) and insulin (17.6%) demonstrating the dual role of medications as both therapeutic agents and potential AMS contributors through mechanisms ranging from intended effects (e.g., insulin-induced hypoglycaemia) to toxicity (e.g., beta-blocker overdose). These findings provide additional context when considering the report by Boerckel et al. (2024), which suggested that AMS frequently leads to diagnostic uncertainty in medication decisions, in which 66% of AMS patients receiving antibiotics for pyuria ultimately have alternative AMS diagnoses [ 18 ]. The anticonvulsant use (18.3%) in this study underscores how both underlying neurological conditions and medication side effects (e.g., sedation and metabolic disturbances) can precipitate AMS, a complexity mirrored by Boerckel et al., who reported that bacterial markers often prompt treatment despite frequent noninfectious AMS aetiologies. While psychotropic medications were less prevalent (4.2% antipsychotics and 3.5% antidepressants), their clinical significance persists given their established delirium risk [ 19 ], with the documented low rates potentially reflecting either regional prescribing patterns or diagnostic overshadowing where medication effects were attributed to primary conditions. These findings parallel those of Boerckel et al., who reported that AMS presentation can obscure underlying causes, as untreated AMS patients have higher alternative diagnosis rates (86.8%) [ 18 ]. These findings support the use of medication reconciliation protocols that assess both therapeutic and adverse effects while guarding against attribution bias in AMS diagnosis. The aetiological distribution in this cohort challenges conventional AMS assumptions, showing both alignment and divergence from literature. The neurological causes (24.6%) and drug abuse causes (24.6%) match the CNS (35.0%) and toxicological (23.0%) dominance reported by Xiao et al. (2012) [ 14 ], indicating their consistent prominence across settings. In contrast, our lower infection rate (0.7%) compared to Dhar et al [ 20 ] (30.23%) and Xiao et al. [ 14 ] (9.1%), is likely due to our younger cohort (mean age of 44.7 vs. 67.82 years) or reduced transmission during the pandemic. Compared with percentages reported by Dhar et al. [ 20 ] and Xiao et al. [ 14 ] (16.27% and 7.9%, respectively), the endocrine/metabolic representation (12.0%) in this study suggests possible diagnostic overshadowing, particularly given that Martel et al. (2018) suggested that presumptive diagnoses (e.g., intoxication) can obscure medical aetiologies [ 21 ]. Moreover, the present cardiovascular representation (15.5%) reinforces the systemic/organic causes (14.5%) reported by Xiao et al., highlighting that AMS may be the sole manifestation of life-threatening cardiac conditions [ 14 ]. The consistent neurological predominance (24.6% vs. 47.09% in Dhar et al. and 35.0% in Xiao et al.) underscores the need for standardized neurodiagnostic protocols. Overall, these findings support aetiology-specific frameworks, especially for younger populations where traditional assumptions may not hold. The results of this study highlight key patterns in AMS severity and management. The high discharge rate (81.7%) suggests that most cases were transient and reversible, which contrasts sharply with the Tanzanian cohort reported by Manji et al. (2022) [ 13 ], which had a 9.8% discharge rate but a much higher mortality rate (35.4% vs. our 4.2%) [ 13 ]. The 50% mortality rate among cardiovascular cases indicates that this high-risk group needs closer evaluation. The exclusive male predominance (100%) of the 5.6% intubation rate in this study raises questions about biological risks (e.g., higher substance-related respiratory depression) versus potential clinical decision biases, a concern amplified by Manji et al., who reported ICU admissions predominantly involving infectious aetiologies (20.4% of patients with 43.5% mortality) [ 13 ]. These disparities support the need for standardized risk stratification protocols that address both clinical and demographic variables, particularly in resource-limited settings where disposition may reflect system constraints as much as patient status. Disposition predictors reveal critical AMS outcome patterns that both confirm and challenge existing paradigms. The strong aetiology–outcome association (p = 0.016), particularly the disproportionate mortality of cardiovascular causes (50% of deaths despite 15.5% prevalence), aligns with study by Stanich et al. (2022), who reported that AMS is associated with higher short-term mortality than other complaints, with a hazard ratio of 3.72 compared with chest pain [ 22 ]. Similarly, the mortality pattern of traumatic AMS (33.3% of deaths vs. 5.6% prevalence) mirrors the observation of low admission rates despite the significance of trauma reported by Lai et al. (2009) [ 15 ], suggesting that current triage protocols may underestimate trauma-related AMS severity. The complete absence of neurological fatalities in this study (0% vs. 24.6% prevalence) may reflect either postictal reversibility or effective neuroprotocols, which contrasts the 12.4% prevalence of neurological fatalities, including strokes, reported by Lai et al. [ 15 ]. These patterns advocate aetiology-driven disposition protocols prioritizing cardiovascular and traumatic AMS while maintaining low hospitalization thresholds. The intubation analysis revealed notable demographic and aetiological patterns that challenge conventional airway management assumptions in AMS patients. The complete sex disparity (100% of intubated patients were males vs. 56% of nonintubated patients were males, p = 0.021) exceeds what traditional risk factors explain, particularly given the study by Viarasilpa et al. (2020) reported that intubation decisions often correlate with clinical presentation severity rather than with demographic factors alone [ 23 ]. While a higher male prevalence of trauma (37.5%) and drug abuse (12.5%), conditions frequently requiring airway intervention, may partially account for this discrepancy, the absolute absence of female intubations suggests either unmeasured biological protective factors or potential clinical bias in airway decision-making—a concern amplified by Viarasilpa et al., who suggested that treatment aggressiveness independently predicts intubation [ 23 ]. The neurological paradox (24.6% of AMS patients with 0% intubation rate) aligns with expectations for conditions such as syncope but contrasts with the study by Viarasilpa et al., which reported that altered consciousness frequently drives intubation in seizure-like presentations [ 23 ], highlighting how aetiology-specific airway risks may vary across patient populations. The dramatic overrepresentation of traumatic AMS among intubations (37.5% vs. 3.7%, p = 0.014) underscores the delayed respiratory risk of head injury, which is consistent with the study by Viarasilpa et al., which suggested that prolonged symptom duration is an intubation predictor [ 23 ]. The absence of age or onset timing associations (p = 0.626 and p = 0.246, respectively) reinforces that acute physiological insults rather than baseline characteristics determine airway outcomes, although this contradicts the study by Viarasilpa et al., which suggested that a depressed consciousness level impacts intubation decisions [ 23 ]. These findings call for vigilant airway assessment in trauma patients and standardized protocols that address aetiology-specific risks while reducing sex bias. Strengths and limitations The present findings add to the AMS literature through a systematic assessment, focusing on outcomes and management in an academic ED. The e-SiHi system enables detailed documentation, and the inclusion of diverse aetiologies with intervention analysis offers valuable insights. The tertiary setting provides a benchmark, and the disposition analysis addresses a research gap. Limitations of this study include a retrospective design, potential documentation bias, and limited power for rare outcomes. Furthermore, the single-centre design may limit the generalizability of our findings to other settings with different patient demographics and clinical practices. To address this and build upon our results, future multicenter and prospective studies are recommended to validate these findings across broader populations and enhance their generalizability. In conclusion, The present study reveals that AMS in our academic emergency department follows distinct patterns diverging from Western models. In the present younger, male-predominant cohort, most cases were driven by neurological and drug-related aetiologies, while trauma and cardiovascular causes disproportionately impacted outcomes. The near absence of infectious AMS and universal male intubations challenge conventional diagnostic and management paradigms. These findings underscore that AMS is not a monolithic entity but rather a syndrome shaped by regional epidemiology, cultural factors, and health care access patterns. The significant sex disparities observed in critical outcomes like intubation and mortality warrant further investigation into the underlying causes, which may include sociocultural factors, differences in healthcare-seeking behavior, or potential clinical biases in acute care management. Ethical approval This study was performed in accordance with the principles of the Declaration of Helsinki. Ethical approval was obtained under IRB log number E-22-7390 from the Research Ethics Committee at King Saud University Medical City. Disclosure Authors have no conflict of interests and the work was not supported or funded by any drug company Disclosure of AI-assisted tools The authors utilized the following AI-based tools during the preparation of this manuscript: QuillBot for paraphrasing certain sections of the text to improve clarity and Grammarly for grammar and spelling checks. No AI tools were used for data collection, analysis, or image generation. Acknowledgment Supplementary materials Supplementary materials is available at 10.17712/nsj.2026.1.20250073 . References [1]. Patti L, Gupta M. Change in mental status. StatPearls. Treasure Island (FL): StatPearls Publishing LLC. 2025. [ PubMed ] [ Google Scholar ] [2]. Simkins TJ, Bissig D, Moreno G, Kahlon NPK, Gorin F, Duffy A. 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