DiagnosticApproachtoAlteredMentalStatus

MichelStatler,MLA,PAC
Tuesday,May26,2009

I. LearningObjectives
a. Interprettheabnormalitiesonphysicalexamfoundinapatientwithalteredmental
status.
b. Recognizethesignsandsymptomsassociatedwithimpendingherniation.
c. Selecttheappropriatediagnosticstudiestoevaluateapatientwithalteredmental
status.

II. Introduction
a. Consciousnessisthestateofawarenessofselfandtheenvironment
i. Normalconsciousnessdependentupon:
1. Intactcerebralhemispheresforcognition
2. Reticularformationforalertness
b. Alteredmentalstatusresultsfromanimpairmentofarousalorcognition
c. Disordersofconsciousnesscanseeacuteconfusionalstatesordelirium
d. Disordersofcognitionleadtoimpairmentofmemoryorothercognitivefunction(i.e.
judgmentorabstractthinking)
i. Dementiaaffectscognitionwithoutaffectingconsciousness
ii. Focalneurologicdiseasecanaffectcognitionifcriticalcorticalareasofcognition
areinvolved.
e. Comaduetodysfunctionofbothcerebralhemispheresand/ortheupperbrainstem

III. Etiologies
a. Metaboliccauses
i. Hypoxia
ii. Electrolyteand/orglucosedisturbances
iii. Uremia
iv. Hepaticfailure
v. Drugssedatives,opiates,antidepressants,anticonvulsants
vi. Toxinsalcohol,carbonmonoxide,heavymetals
vii. Psychiatricdisorders
b. Intracranial/structuralcauses
i. Traumadiffuseaxonalinjury,epiduralorsubduralhematoma
ii. Vascularischemicstrokewithmasseffect,brainstemstroke,hemorrhagic
stroke
iii. Infectionmeningitis,encephalitis,abscess
iv. Otherepilepsy,hydrocephalus

IV. ImportantHistoricalDetails
a. Dependentupontheobservationsofothers
i. Onset/timelineofsymptoms
ii. Historyofrecentsystemicorneurologicsymptoms
iii. Historyofheadtrauma
iv. Pastmedicalhistoryrenalorhepaticdisease,diabetes
v. Medications

vi. Druguse,includingalcohol
vii. Associatedsymptoms:fever,HA,stiffneck,seizureactivity
b. Historywithpossibleetiologies
i. Hxofheadachemeningitis,encephalitis,subarachnoidhemorrhage,
intracerebralhemorrhage
ii. Hxofpriorheadinjurychronicsubduralhematoma
iii. Acuteonsetofsymptomsischemicorhemorrhagestroke
iv. Gradualonsetofsymptomsmasslesionormetaboliccause
v. Hxoflimbtwitchingand/orincontinenceseizurewithpostictalconfusion
vi. Hxofdiabeteshypoglycemia
vii. Hxofmalignancyintracranialmetastasis

Case#1
A73yearoldrighthandedmanisbroughtinbyhissonforincreasingforgetfulness.Hisson
saysthatheoftenlosesthingsandishavingahardtimerememberingdatesandfindingthe
rightwordsforthings.Recentlyhehasbeendroppinghiscoffeecupandhastrouble
feedinghimselfandwriting.
Alertandorientedx2;unabletorecalldate.Wordfindingdifficulty;abletoname3/5
objects.Poorrecallatoneminute(1/3);cannotrecallnamesofpresidents;knows
date/placeofbirth.Unabletodoserial7sorrepeatdigitspan.
Abletowrinkleforeheadbilaterally,mildflatteningofthenasolabialfoldontheleft
Decreasedhandgriponleft,4/5weaknessleftUE.

V. PhysicalExam
a. Vitalsigns
i. Signsofinfectionorsepsis
ii. Respiratorypatterns
1. CheyneStokesrespirationsseenwithbihemisphericlesionsor
metabolicencephalopathy
2. Centralneurogenichyperventilation(Kussmauls)seenwithmetabolic
acidosisorherniation
3. Apneusticrespirationsseenwithpontinedamage
4. Clusterbreathingseenwithpontineorcerebellardamage
5. Ataxic(Biots)respirationsseenwithmedullarydamage
iii. Hypertensionwithbradycardiaassociatedwithhighintracranialpressure
b. HEENTlookforsignsoftrauma
i. BattlesorRaccoonsign
ii. CSFotorrheaorrhinorrhea
iii. Hemotympanum
c. Skinexamcherryredskinconsistentwithcarbonmonoxidepoisoning
d. Neurologicexam
i. Levelofconsciousness
1. Lethargicpatientmaybeconversantbutinattentiveandslowto
respond;cantperformsimpletaskslikecounting.
2. Stuporincompletearousaltopainfulstimuli;little,ifanyresponseto
verbalcommands
3. Comatoseunresponsivetoallstimuli

ii.

iii.

iv.

v.

vi.

vii.

4. Ifpatientresponsive,attempttoevaluatelanguage,memoryand
concentration
5. Folsteinminimentalstatusexamcanbeused
GlasgowComaScale15pointscaleusedtopredictmortality
1. Basedoneyeopening,motor,andverbalresponses
a. Decorticateposturingflexionandadductionofarmsand
extensionoflegs(flexorresponse)
i. Reflectslesionincorticospinaltractfromcortexto
uppermidbrain
b. Decerebrateposturingextension,adduction,andinternal
rotationofthearmsandextensionofthelegs(extensor
response)
i. Reflectsdamagetocorticospinaltractatlevelofpoons
oruppermedulla
AVPUalternateassessmenttool;usedprimarilybyEMS
1. Alertness
2. Verbalresponse
3. Painfulstimulus
4. Unresponsive
RestingeyepositionGazepreference
1. GazepreferenceAWAYfromthesideofthehemiparesisisconsistent
withalargecerebralhemisphericlesion
a. Frontaleyefieldsnormallymoveeyestocontralateralside
b. Iflesionpresenteyeslookatthelesionandawayfrom
hemiparesis
2. GazepreferenceTOWARDthesideofthehemiparesisisconsistentwith
alesioninthebrainstem(pons)
a. Lateralgazemechanismintheponsmovestheeyestothe
ipsilateralside
b. Iflesionpresent,eyesdeviateawayfromthedamagedsideand
towardthehemiparesis
Spontaneouseyemovement
1. Rovingeyemovements
a. Slow,conjugatehorizontalmovements
b. Indicatesbrainstemcontrolofeyemovementsisintact
c. Seenwithbilateralhemisphericdysfunction(ieanoxia)
2. Ocularbobbing
a. Downwardjerkingofbotheyesfollowedbyslowreturntomid
position
b. Seenwithpontinelesions;needtoruleoutlockedinstate
Reflexeyemovements
1. Oculocephalic(DollsEyes)
2. Oculovestibular(Calorics)
LockedInSyndrome
1. Patientawakebutquadriplegicwithparalysisofhorizontaleye
movements
2. Verticaleyemovementpreserved
3. Abletocommunicatebylookingdownorblinking

4. Associatedwithlargepontinelesion,ieaninfarctorhemorrhage
5. Prognosisfavorable;recoverypossible
viii. Pupillaryresponses
1. Midposition(25mm)andnonreactiveseenwithmidbrainlesions
2. Pinpoint&reactiveseenwithpontinelesions
3. Unilateraldilated&fixedseenwithaCNIIIlesion/uncalherniation
4. Bilateraldilated&fixedseenwithcentralherniation,hypoxia
ix. Fundoscopicexamlookforpapilledema
1. Usuallytakes12hoursbeforepapilledemapresent
x. MotorExamlookforspontaneousmovementsandpresenceoffocaldeficits
(leftvs.right;uppervs.lowerextremity)
1. Usepronatordrifttoassessforsubtleweaknesses
xi. CheckDTRs.corticallesionswillproducehyperactivereflexes,clonus,anda
positiveBabinski
xii. Foradditionalcomponentsoftheneurologicexamtobereliable,youneedan
alertandcooperativepatient(i.e.sensoryandcerebellarexams,meningeal
signs)
e. PsychogenicComadiagnosisofexclusion
i. Patientsarephysiologicallyawakebutunresponsive
ii. Suspectwheninconsistentexamfindings
iii. Pupillaryandoculovestibularreflexesareintact
iv. EEGisnormal

Case#2
A24yearoldWMsustainedaclosedheadinjuryinaMVC.TherewasabriefLOCatthe
scene,butthepatientwasawakeuponarrivaltotheED.Hewasorientedtonamebutnot
toplaceortime.Hecouldmoveallfourextremitiesuponcommand.Pupilswereequal,
roundandreactivetolight.12hourslater,hewasunresponsivetoverbalcommandsand
withdrewtopainfulstimuli.Therightpupilwas6mmandsluggishlyreactive;leftpupilwas
3mmandbrisklyreactive.

VI. ImpendingHerniation
a. Potentiallylifethreateningcomplicationthatcanbeenseenwithamasslesion,
traumaticinjury,orCNSinfection
b. Increasingunresponsivenesstostimuli
c. Changesinpupillaryresponses
d. Unilateralfixedanddilatedpupilsareconsistentwithuncalherniation
e. Changesinrespiratorypatterns
i. CheyneStokes,apneustic,orclusterrespirations
f. Changesinmotorexam(withdrawingtopain,posturing)

VII. DiagnosticEvaluation
a. ThebasicsABCs
b. Intubateifpatienthasrespiratorycompromiseordeeplycomatose
c. StartanIV
d. Insertfoleycatheter
e. Checklabs:CBC,comprehensivemetabolicpanel,arterialbloodgas,PT/PTT,urinalysis,
fingerstickglucose,toxicologyscreen/bloodalcohollevel

f. Mayalsogetthyroidfunctiontests,serumcortisol,andammonialevel
g. NeuroimagingCT/MRI
i. NoncontrastCTgeneralfirstline
ii. Includecontrastiftumororabscesssuspected
h. LumbarpuncturewithCSFanalysisruleoutCNSinfectionorsubarachnoid
hemorrhage
i. EEGifdiagnosisunclear,EEGcanruleoutpostictalstate,nonconvulsivestatus
epilepticus,ormetaboliccause

VIII.
Puttingitalltogether
a. Patientwithnonfocalexamandintactbrainstemreflexes:
i. Characterizedbyreactivepupils,fulleyemovementsandsymmetricmotor
responses
ii. Mostlikelyetiologytoxic/metaboliccause,CNSinfectionorhydrocephalus
b. Patientwithfocalhemisphericsigns
i. Characterizedbycontralateralhemiparesis,gazeparesis
ii. Mostlikelyetiologystructurallesion
1. Forexamplestroke,tumor,orsubduralhematoma
c. Patientwithfocalbrainstemsigns
i. Characterizedbyabnormalpupillaryresponses,cranialnervepalsies,or
posturingonmotorexam
ii. Mostlikelycausebrainstemlesion(strokeortumor)oramasslesionwith
herniation

IX. PearlsofPractice
a. StructuralcausesofAMSareassociatedwithfocaldeficitsonexam
b. Focalfindingsonexamareanindicationforneuroimaging
i. CTgoodfortrauma&acutecerebralischemia
ii. MRIgoodfortumorsorotherstructuralabnormalities
c. Bemindfulofchangesconsistentwithimpendingherniationobtainanemergent
neurosurgicalconsultation

X. References
a. Gabriely,H,Leu,JP,andBarzel,US.BacktoBasics.TheNewEnglandJournalof
Medicine2008;358:19521956.
b. Kanich,W.etal.AlteredMentalStatus:EvaluationandEtiologyintheED.American
JournalofEmergencyMedicine2002;20(7):613617.
c. Lehman,RK,andMink,J.AlteredMentalStatus.ClinicalPediatricEmergencyMedicine
2008;9:6875.
d. Mistovich,JJ,Krost,WS,andLimmer,DD.BeyondtheBasics:InterpretingAlteredStatus
Assessment.EMSAugust2008:9097.
e. Washburn,LA.AlteredMentalStatus:CauseDeterminesTreatment.JAAPA2005;18
(2):1622.
f. Wilber,ST.AlteredMentalStatusinOlderEmergencyDepartmentPatients.Emergency
MedicineClinicsofNorthAmerica2006;24:299316.
g. Wong,J,Traub,SJ,Macnow,L,andKullchycki,LK.CasePresentationsoftheHarvard
AffiliatedEmergencyMedicineResidencies.JournalofEmergencyMedicine2008;35
(4);445448.