Thiamine for altered mental status: a high-value strategy beyond alcohol

Altered mental status (AMS) prompts rapid diagnostic evaluation in hospitalized patients, yet a low-cost, reversible cause - thiamine deficiency - often receives inconsistent attention outside alcohol-associated contexts. Although classically linked to alcohol misuse, contemporary evidence links thiamine depletion to a broad range of medical, surgical, oncologic, obstetric, and critically ill populations.

In these settings, AMS may be the earliest clinical manifestation, while standard diagnostic tools such as MRI and serum thiamine levels frequently lack sensitivity early in the disease course. Delayed recognition leads to persistent cognitive and neurologic deficits, despite the safety, low cost, and ready availability of parenteral thiamine. This Perspective highlights why relying on alcohol history alone risks missing high-risk patients, outlines a pragmatic risk-based framework for hospitalists, and identifies key areas for future investigation.

Early empiric thiamine aligns with principles of high-value care and represents a simple, underutilized intervention that may prevent irreversible neurologic injury in hospitalized patients with AMS. Broader adoption of a more inclusive, clinically grounded approach is warranted until higher-quality evidence clarifies optimal screening and treatment strategies.