Definitions

 Consciousness: It is defined as the state of

awareness of self and the environment.

 Confusion: it is lack of clarity and coherence of

thought , perception, understanding or
action. It is often the first feature of cognitive
impairment.

 Coma: It is a state of unconsciousness in

which the patient does not respond to any
type of external stimuli or inner need.
Cont….
 Stupor (or) Semiconsciousness It is a state of
disturbed consciousness from which only
vigorous external stimuli can produce
arousal.
• determine the degree to which an
individual is able to respond.
• Ascending reticular activating system:
includes
• core neurons in the brainstem, the
• locus coeruleus, and raphe nuclei
• Function- to arouse and awaken the
brain and control sleep– wake cycles.
• High levels of activity are associated
with extreme excitement (high arousal),
whereas lesions in the brainstem are
associated with sleep and coma.

• Descending reticular activating system

(DRAS) :
• pontine and medullary reticulospinal
tracts.
• Pontine (medial) reticulospinal tract
enhances spinal cord antigravity reflexes
and extensor tone of lower limbs.
• Medullary (lateral) reticulospinal tract has
the
opposite effect, reducing antigravity control.
1. Consciousness- a state of arousal accompanied
by awareness of one’s environment.
• A conscious patient is awake, alert, and oriented to his or
her surroundings.

2. Lethargy - altered consciousness in which a

person’s level of arousal is diminished.
• The lethargic patient appears drowsy but when
questioned can open the eyes and respond briefly.
• The patient easily falls asleep if not continually
stimulated and does not fully appreciate the environment.
• The therapist should speak in a loud voice while calling
the patient’s name. Questions should be simple and
directed toward the individual (e.g., How are you
feeling?).

3.Obtunded state - diminished arousal and awareness.

• The obtunded patient is difficult to arouse from
sleeping
and once aroused, appears confused.
• Attempts to interact with the patient are generally
nonproductive.
• The therapist should shake the patient gently as if
awakening someone from sleep and again use simple
questions.
4.Stupor - a state of altered mental status and
responsiveness to one’s environment.
• 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.
• The unconscious patient is said to be in a coma and
cannot be aroused.
• The eyes remain closed and there are no sleep–wake
cycles.
• The patient does not respond to repeated painful stimuli
and may be ventilator dependent.
• Reflex reactions may or may not be seen, depending on
the location of the lesion(s) within the CNS.
• Clinically the patient can progress from one level of
consciousness to another.
• 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 TBI and 3 months or more for anoxic brain
injury. This state is caused by severe brain injury.
• A gold standard instrument used to document level of
consciousness in acute brain injury.
• Total GCS scores range from a low of 3 to a high of 15.
• 8 or less- severe brain injury and coma,
• between 9 and 12 - moderate brain injury,
• 13 to 15 - mild brain injury
• Can also reveal important information about the
unconscious patient.
• Pupils that are bilaterally small - damage to the
sympathetic pathways in the hypothalamus or metabolic
encephalopathy.
• Pinpoint pupils - hemorrhagic pontine lesion or narcotic
overdose (e.g., morphine, heroin).
• large bilaterally fixed and dilated pupils -severe anoxia
or
drug toxicity (e.g., tricyclic antidepressants).
• If only one pupil is fixed and dilated, temporal lobe
herniation with compression of the oculomotor nerve and
midbrain is likely.
• A screening examination of cognitive abilities should
include
• orientation,
• attention,
• memory;
• communication;
• and executive or higher-order cognition
• (e.g., calculating abilities, abstract thinking, constructional
ability).
• Orientation is the ability to comprehend and to adjust oneself with
regard to time, location, and identity of persons. It is examined
with respect to
(1) Time
• (What day/month/season/year is it?
• What is the time of day?);
(2) Place
• (Where are you?
• What city/state are we in?
• What is the name of this place?); and
(3) 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, 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?).
• 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 long-term
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 therapist 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 is used to determine divided
attention.
• For example, the patient talks while walking
(Walkie–
Talkie Test).
• Memory is the process of registration, retention,
and
recall of past experience, knowledge, and ideas.
• Declarative (explicit) memory involves the
conscious recollection of facts, past events,
experiences, and
places.
• Motor memory (procedural memory) -recall of
movements or motor information and storage of motor
programs, subroutines, or schema as well as perceptual
and cognitive skills.
• Patients with brain injury and deficits in the medial
temporal lobe areas and hippocampus demonstrate
impaired explicit memory

• implicit memory, impaired in damge to the CNS motor

areas ( cerebellum, premotor cortex).
• Immediate memory (immediate recall) -the immediate
registration and recall of information after an interval of a
few seconds (e.g., repeat after me).
• Short-term memory (STM) (recent memory) -the
capability to remember current, day-to-day events (e.g.,
what was eaten for breakfast, date
• Long-term memory (LTM) (remote memory) - the recall
of facts or events that occurred years before (e.g.,
birthdays, anniversary, historic facts).
• A simple test for memory involves presenting the patient
with a short list of words of unrelated objects (e.g., pony,
coin, pencil) and asking the patient to repeat those words
immediately after presentation (immediate recall) and
again 5 minutes after presentation (STM).

• LTM can be determined by having the patient recall

events or persons from his or her past
• (Where were you born?
• Where did you go to school?
• Where do/ did you work?).
• The patient’s grasp of information and ability to
communicate should be ascertained.
Word comprehension :
• can be determined by varying the difficulty of commands,
from one- to two- or three-stage commands (Point to your
nose; Point to your right hand and lift your left hand).

Repetition and naming :

• Repeat after me: Name the parts of a watch.
• Problems with articulation (dysarthria) are evidenced by
speech errors, such as difficulties with timing, vocal
quality, pitch, volume, and breath control.

• FLUENCY
• word flow without pauses or breaks, should be noted.
• Speech that flows smoothly but contains errors,
• neologisms (nonsense words), misuse of words, and
circumlocutions
• (word substitution) is indicative of fluent
• aphasia (i.e., Wernicke’s aphasia)
• Speech that is slow and hesitant with limited vocabulary
and impaired syntax is indicative of nonfluent aphasia
(i.e., Broca’s aphasia).

• Articulation is labored and wordfinding difficulties are

apparent.
• Mini-Mental Status Examination (MMSE) provides a valid
and reliable quick screen of cognitive function.
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