Stupor It is a state of partial or relative loss of response to the environment in which the patient’s

consciousness may be impaired to varying degrees.

The patient can be aroused only with vigorous or unpleasant stimuli (e.g. sharp pressure or

pinch, or rolling a pencil across the nail bed).

No significant voluntary verbal or motor responses.

Mass movement responses may be observed in response to painful stimuli or loud noises.

For example:

Bilateral cerebral hemisphere disease

Upper brainstem diseases

Lethargy/drowsiness Patient can usually be aroused or awakened and may then appear to be in complete possession of

their senses, but promptly falls asleep when left alone. It resembles normal sleepiness.

For example: High brainstem disturbances

Obtundation Refers to moderate reduction in the patient’s level of awareness such that stimuli of mild-to- moderate intensity fail to arouse; when arousal does occur, the patient is slow to respond.

Minimally conscious

(vegetative) state

Return of irregular sleep-wake cycles and normalization of the so-called vegetative functions—

respiration, digestion, and blood pressure control.

The patient may be aroused, but remains unaware of his or her environment.

There is no purposeful attention or cognitive responsiveness.

Persistent vegetative

state

Individuals who remain in a vegetative state 1 year or longer after traumatic brain injury (TBI) and 3 months or more after anoxic brain injury.

Confusional state Patients may appear alert, but are confused and disoriented.

It is usually tested in three dimensions:

Time

Place

Person.

Delirium It is an acute organic mental disorder characterized by confusion, restlessness, incoherence,

inattention, anxiety, or hallucinations which may be reversible with treatment.

For example:

Toxicity (alcohol)

Infections

Catatonia Symptom of psychotic state in which the patient is otherwise normal.

He does not follow movements, does not appear to pay attention to surroundings and will often

have aplastic rigidity of limbs which may remain in any position in which they are placed

(however bizarre the position may be).

It is preferable to describe the patient’s state of responsiveness or use an objective and welldefined scheme, such as the Glasgow Coma Scale (GCS).

Glascow Coma Scale (GCS)

Eye opening Best verbal response Best motor response

Obeys commands 6

Oriented and converses 5 Localizes pain 5

Open spontaneously 4 Converses, but disoriented, confused 4 Exhibits flexion withdrawal 4

Open only to verbal stimuli 3 Uses inappropriate words 3 Decorticate rigidity 3

Open only to pain 2 Makes incomprehensible sounds 2 Decerebrate rigidity 2

Never open 1 No verbal response 1 No motor response 1

Maximum score = 15

Minimum score = 3

Coma is equal to GCS of 8 or less.

■

■

■

■

•

•

•

•

•

•

Mnemonic (GCS → EVM = 4, 5, and 6)

Note: In intubated patients, verbal response is denoted as VT.

Glasgow coma scale–pupils score

The Glasgow coma scale-pupils score (GCS-P) was described in 2018 as a strategy to

combine the two key indicators of the severity of traumatic brain injury into a single simple

index

Calculation of the GCS-P is by subtracting the pupil reactivity score (PRS) from the

Glasgow coma scale (GCS) total score:

GCS-P = GCS – PRS

The pupil reactivity score is calculated as follows:

Pupils unreactive to light Pupil reactivity score

Both pupils 2

One pupil 1

Neither pupil 0

The GCS-P score can range from 1 and 15 and extends the range over which early

severity can be shown to relate to outcomes of either mortality or independent recovery.

ORIENTATION

Time Ask for year, season, month, date, and time

Place Ask for country, state, city, hospital name, and floor/ward

Person What is your name?

How old are you?

Where were you born?

What is the name of your wife/husband?

Findings are documented in the medical record as follows: Patient is alert and oriented × 3 (time,

person, and place) or × 2 (person, place) depending on the domains correctly identified.

An additional domain that can be examined is circumstance.

(What happened to you? What kind of a place is this? Why do people come here?)

APPEARANCE/BEHAVIOR

Mood and affect

Thought and perception

These have been discussed under Chapter 9—Approach to Psychiatric Illness.

MEMORY

Classification of Memory

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•

• •

•

•

•

•

Explicit memory (declarative memory) Implicit memory

Involves conscious recall and requires integrity of various

cortical regions

Does not require conscious recall. Involves basal ganglia

and cerebellum

Can be tested bedside Cannot be tested bedside

It includes:

Immediate (prefrontal cortex)

Recent (medial temporal structures)

Remote (widespread neocortical areas).

It includes:

Procedural memory (basal ganglia)—like riding a car

Classical conditioning (cerebellum)

Probabilistic classification learning (basal ganglia).

Examination of Explicit Memory

Types of memory

Description and testing Areas in brain

Immediate

(working memory)

Digit span is a test of immediate memory, a very short-term function in

which the material is not actually committed to memory

Ask patient to repeat series of random digits forward and backward

Normal digit span is 7 ± 2

Dorsolateral frontal lobe,

prefrontal cortex, and

perisylvian cortex

Recent

(short-term)

Recent, or short-term memory is tested by giving the patient items (pen,

phone, and bottle) to recall

After ensuring the patient has registered the items, proceed with other

testing. After approximately 5 minutes, ask the patient to recall the items

Mammillothalamic tract

Hippocampus

Parahippocamal cortex

(spatial memory)

Amygdala (emotional

aspects)

Perirhinal cortex (for visual)

Medial temporal structures

and connections

Remote

(long-term)

A patient’s fund of information reflects their remote memory. The fund of

information includes schooling details, famous personalities, major events

in history, etc.

Widespread

Neocortical areas

Episodic memory refers to the system involved in remembering particular episodes or experiences, such as the movie you

saw last weekend or the meeting you attended yesterday.

Semantic memory refers to the type of long-term memory concerned with factual details outside of personal details

Budson and Price concept of memory systems: The frontal lobe can be considered as filing clerk, deciding which

information has to be filed or retrieved. The medial temporal lobes are the actual filing cabinets for recent memories and the

neocortical regions are filing cabinets for remote memories

Wernicke’s encephalopathy—g lobal confusion, ophthalmoplegia and ataxia (mneumonic—goa).

Korsakoff’s psychosis: Recent memory loss + confabulation (anteromedial thalamus)

Amnesia

Anterograde amnesia Impaired registration and recall of new information

Retrograde amnesia Impaired recall of information registered within a certain interval before the disease onset

ATTENTION

Attention is the directing of consciousness to a person, thing, perception, or thought.

It depends on the capacity of the brain to process information from the environment or from longterm memory.

An individual with intact selective attention is able to screen and process relevant sensory

information about both the task and the environment while screening out irrelevant information.

•

•

•

•

•

•

•

•

•

–

–

–

•

•

•

•

•

•

Selective attention can be examined by asking the patient to attend to a particular task.

For example, the doctor asks the patient to repeat a short list of numbers forward or backward

(digit span test).

Normally, individuals can recall seven forward and five backward numbers.

Sustained attention (or vigilance) is examined by determining how long the patient is able to

maintain attention on a particular task (time on task).

Alternating attention (attention flexibility) is examined by requesting the patient to alternate

back and forth between two different tasks (e.g. add the first two pairs of numbers, then subtract

the next two pairs of numbers).

Requesting the patient to perform two tasks simultaneously determines divided attention.

For example, the patient talks while walking (Walkie–Talkie test).

INTELLIGENCE/CALCULATION

Serial sevens, or spelling of any word backward.

COGNITION ASSESSMENT TOOLS

Mini Mental Status Examination (MMSE)—Folstein’s

O Orientation Place

Time

10

R Registration Name 3 objects 3

A Attention and calculation Serial 7/word backward 5

R Registration recall Recall previously named 3 objects 3

L Language 3 stage command

Name two objects

Read and follow

Draw a pentagon

Repetition

Write a sentence

9

MMSE total score:

21–24: Mild cognitive dysfunction

10–20: Moderate

Less than 10: Severe.

Montreal cognitive assessment (MoCA)

Cognitive state test (COST)

Addenbrooke’s cognitive examination (ACE)

Cambridge cognitive examination (CAMCOG)

Brief cognitive assessment tool (BCAT), and

Short test of mental status (STMS).

SPEECH

Definitions

Phonation It is defined as the production of vocal sounds without word formation; it is entirely a function of the larynx

•

•

•

•

•

•

Vocalization It is the sound made by the vibration of the vocal folds, modified by working of the vocal tract

Speech It consists of words which are articulate vocal sounds that symbolize and communicate ideas

Articulation It is the enunciation of words and phrases; it is a function of organs and muscles innervated by the brainstem

Language

(Fig.

6D(ii).1)

It is a mechanism for expressing thoughts and ideas as follows:

By speech (auditory symbols)

By writing (graphic symbols), or

By gestures and pantomime (motor symbols)

Language may be regarded as any means of expressing or communicating feeling or thought using a

system of symbols.

It is a function of the cerebral cortex

Aphasia Aphasia is an acquired disorder with loss or defective language content of speech resulting from damage to

the speech centers within the dominant (usually left in 97%) hemisphere

Paraphasia Substitution in the components of speech, e.g. foon for spoon

Neologism Use of words which are nonexistent. Classically seen with Wernicke’s aphasia

Jargon Completely meaningless speech containing neologisms and paraphasias. Described in Wernicke’s aphasia

Echolalia Continuous repetition of heard words or sentences. Seen with transcortical sensory and transcortical mixed

aphasias.

Alexia It is the impairment of visual word recognition, in the context of intact auditory word recognition and writing

ability

Agraphia It is the inability to write, as a language disorder resulting from brain damage

Anomia In this, word approximates the correct answer but it phonetically inaccurate (plentil for pencil)—phonemic

paraphasia. When the patient cannot say the appropriate name when an object is shown but can point the

object when the name is provided, it is known as one way or retrieval-based naming deficit

Mutism Unable to speak or make sound

Aphonia Unable to produce sound

Aphemia Loss of speech

Slurred speech can be because of aphasia or dysarthria.

Aphasia Dysarthria

Aphasia is a disorder of language Dysarthria is a disorder of the motor production or articulation of

speech

Usually due to cerebral dysfunction/lesions Dysarthria is defective articulation of sounds or words of

neurologic origin (usually brainstem)

Aphasia usually affects other language functions, such

as reading and writing

In dysarthria, there are often other accompanying bulbar

abnormalities, such as dysphagia

Fig. 6D(ii).1: Language and the brain.

Wernicke’s area (area 22) Arcuate fasciculus Broca’s area (area 44)

Decoding of sounds into

language information

(comprehension)

Communication between the Broca’s and

Wernicke’s area. Needed for speech

repetition

Responsible for spontaneous speech output

(i.e.) fluency.

Approximate number words produced per minute is 100/min for males and 150/min for

females

•

•

•

•

–

–

•

•

1.

2.

3.

Fig. 6D(ii).2: Genesis of speech.

APHASIAS

Aphasia is an acquired disorder with loss or defective language content of speech resulting from

damage to the speech centers within the dominant (usually left in 97%) hemisphere.

A language disturbance occurring after a right hemisphere lesion in a right hander is known as

crossed aphasia.

It includes defect in or loss of the power of expression by speech, writing, or gestures or a defect

in or loss of the ability to comprehend spoken or written language or to interpret gestures.

Aphasia may be categorized according to whether the speech output is fluent or nonfluent.

Fluent aphasias (receptive aphasias) are impairments mostly due to the input or reception

of language with difficulties either in auditory verbal comprehension or in the repetition of

words, phrases, or sentences spoken by others. For example, Wernicke’s aphasia.

Nonfluent aphasias (expressive aphasias) are difficulties in articulating with relatively good

auditory, verbal comprehension. For example, Broca’s aphasia [Fig. 6D(ii).3].

Normal fluency 100–150 words/min, sentence length >7 words.

Reduced fluency in Broca’s aphasia, transcortical motor, global aphasia, and primary progressive

aphasia.

Domains of Language

Spontaneous speech/fluency

Comprehension

Repetition

4.

5.

6.

Reading

Writing

Naming.

C—Comprehension (requires intact Wernicke’s and transcortical sensory area)

R—Repetition (requires intact Wernicke’s, arcuate fibers, and Broca’s area)

F—Fluency (requires intact Broca’s and transcortical motor area) [Flowchart 6D(ii).1].

Aphasia Site of lesion C R F

1 Wernicke’s—sensory/receptive/posterior Infarction of inferior division of middle cerebral artery – – +

2 Broca’s—motor/expressive/anterior Infarction of superior frontal branch of middle cerebral

artery

+ – –

3 Conduction/arcuate Arcuate fasciculus + – +

4 Transcortical sensory Posterior watershed zone – + +

5 Transcortical motor Anterior watershed zone + + –

6 Isolation aphasia (mixed transcortical

aphasia)

Both anterior and posterior watershed areas - + –

7 Global aphasia Dominant frontal, parietal and superior temporal lobe - – –

Note:

C—Comprehension

R—Repetition

F—Fluency

Once the comprehension, repetition, and fluency are intact, we look for reading, writing, and

naming disorders associated with reading, writing, and naming.

Fig. 6D(ii).3: Schematic representation of aphasias and associated lesions.

Flowchart 6D(ii).1: Approach for aphasias.

•

•

•

•

1.

2.

3.

4.