I'm certain that I am not the only neurologist who cringes when asked to do a consult on a patient in the hospital or the emergency department who has “altered mental status.” Nor do I appreciate the term “change in mental status.” These phrases raise more questions than they answer. Altered in what way? Changed from what? Can you give me some more details? Did you do a previous mental status examination? Or, have you done one now?
Would a cardiologist want to see a patient after being told only that there is an “altered cardiac output?” What pulmonologist would be satisfied with the warning that his intensive care unit patient has a “change in tidal volume?” What general surgeon would immediately take a patient to the operating room knowing only that there is “altered abdominal function?”
Is altered mental status a useful or accurate diagnosis? I have never submitted this diagnosis to an insurance company. It is too vague, and leaves too much more information to be obtained. Yet all over America, there are patients at this moment lying in hospital beds with the sole diagnosis of altered mental status, or simply AMS.
Furthermore, altered mental status is an unlikely chief complaint. I was taught to use the patient's own words as a chief complaint, or the observations of a witness. Never in my 26 years of neurology has a patient come to me, pleading for help, tears rolling down his cheeks, saying, “Doctor, I am so worried; my mental status is altered!” Nor has a loved one informed me, “We've all been talking about how altered his mental status has been lately!”
I suspect, to paraphrase George Kennedy's character in the movie, Cool Hand Luke, this is more than “a failure to communicate.” No, this is a failure to examine.
Most physicians do feel limited in their ability to perform a mental status examination. Unlike neurologists and psychiatrists, who improve with experience, physicians in other specialties are uncomfortable in their powers to gauge their patient's mental status. Sure, they were taught to do this kind of examination, as second year students, maybe again during a psychiatry rotation in their third year, or a neurology rotation during the fourth year, but it's been a while. One of the biggest reasons for this timidity is the sheer number of things that can be tested if one has the time to do a full mental status examination. Presumed shortcuts, such as the Mini Mental State Examination, and the Short Test of Mental Status, are not so simple, and are more suited as a screen for dementia than for the acutely ill patient seen in the hospital.
Rather than continuing my complaint, I offer a suggestion. For the past two years I have been teaching students at Rocky Vista University College of Osteopathic Medicine my simplified version of a mental status examination for hospital patients. To make it simple, and hopefully memorable to these young students, I call it LOL AMEN.
LOL AMEN? Today's cell phone texters know that LOL stands for laugh out loud, and thank God, most medical students are still familiar with the traditional “amen” at the end of a prayer. They can recall my silly acronym: Laugh Out Loud, Amen.
It stands for the mental status examination in roughly the order in which it should be done:
- Level of consciousness: alert, lethargic, stuporous, comatose?
- Orientation: person, place, date, and perhaps reason for being in the hospital.
- Language: speech, reading, repeating, writing, naming objects.
- Attention: serial sevens, repeating numbers forwards and backwards.
- Memory: short term (three words), old memories
- Executive function: calculations, judgement, proverbs, verbal fluency.
- Nondominant hemisphere: spatial and construction skills, neglect?
Certainly one can argue with this order of testing. One could test attention earlier than language. There are advantages in using this order, however. First of all, one can remember laugh out loud, amen. And, one can simply check the first three categories, level of consciousness, orientation and language in a patient who appears to have no central nervous disorder at all, and be done with it. We often do the first two tests, anyway, and dictate in our notes that the patient is alert and oriented times three, or AOX3. However, language testing is extremely important, especially for physicians doing invasive procedures and operations. Aphasic patients cannot give full informed consent. So we could now say, “Alert, oriented times three, and comprehending fully,” in a patient without neurological disease, and proceed with some confidence. For the patient who clearly does have brain disease, we could then uses the last four areas of testing. That is why there is a pause between LOL and AMEN.
Using this simplified mental status examination, if the level of consciousness is clearly off, one can diagnose lethargy, stupor or coma. A lesion of the brain stem's reticular activating system and/or both cerebral hemispheres, or metabolic or infectious causes can be sought.
Loss of orientation isn't always diagnostic, but if it occurs with poor attention and impaired short term memory, one can label the patient as encephalopathic, or delirious, if there is a motor component to the acute confusion.
Aphasia is extremely helpful and helps localize the problem. The patient with Broca's or Wenicke's aphasia, or inability to name objects, certainly has a lesion of the dominant hemisphere, and deserves a head CT or brain MRI. Consider a stroke or trauma, if a recent aphasia, or a tumor, if more chronic.
Patients who do well with the first four categories, but have had longstanding problems with memory, executive function and the nondominant hemisphere are likely to have dementia. They may be in the hospital for another disorder, but knowing there is underlying dementia will be very helpful in patient management.
So these are the terms one can use confidently when assessing a hospital patient's mental status: lethargy, stupor, coma, encephalopathy, delirium, aphasia, and dementia. These are real diagnoses, which we can evaluate and treat. Using LOL AMEN might lead to much happier neurologists, and better patient outcomes.
Amen to that.
Disclosure: Dr. Cohen has no financial or research disclosures to make.
Gary L. Cohen, MD is a neurologist at Parkview Neurology Services in Pueblo, CO.