Scoring and Documentation

Each neurocritical care unit should adopt a special scoring and
documentation system, to be used to assess and document
baseline patient neurological status and status at time of
discharge. These include:
– Vital Signs: BP, temp, pulse, respiration, oximetry
– Pupils: size and reaction to light
– Eye movement: gaze, vergence, individual extraocular
movement and nystagmus
– Mental status: LOC, orientation and speech
– Motor functions: state, power, tone, deep reflexes and
pathological reflexes
– Coordination: gate, upper and lower limbs, if applicable
There are many scales used to assess these functions; each
critical care unit can adopt a set that can be used by its staff.
Tables 3.1, 3.2, and 3.3 show some of the commonly used scales
in clinical practice.
Documentation and Scores | 35
Table 3.1 – Neurological Scales used for assessment of level of
consciousness and mental status
Name and Source Strengths and Weaknesses
Level-of-consciousness scale
Glasgow Coma Scale
(Teasdale 1974, 1979)
Strength: Simple, valid, reliable, for assessment of
level-of-consciousness.
Weaknesses: none observed.
Full Outline
Unresponsiveness – FOUR
Score
(Wijdicks 2005)
Strength: The FOUR score is easy to apply and
provides more neurological details than the
Glasgow scale. This scale is able to detect
conditions such locked-in syndrome and the
vegetative state, which are not detected by the
GCS.
Weaknesses: none observed.
Delirium Scale
Confusion Assessment
Method (CAM)
(Inouye 1990)
Strength: CAM-ICU is an adaptation of the
Confusion Assessment Method (CAM), which was
adapted to be a delirium assessment tool for use in
ICU patients (e.g., critically ill patients on and off
the ventilator who are largely unable to talk).
Weaknesses: none observed.
Richmond Agitation
Sedation Scale (RASS)
(Sessler 2002)
Strength: RASS is logical, easy to administer, and
readily recalled. RASS has high reliability and
validity in medical and surgical, ventilated and
non-ventilated, and sedated and non-sedated
adult ICU patients.
Weaknesses: none observed
Mental status screening
Folstein Mini-Mental State
Examination (Folstein 1975)
Strength: Widely used for screening.
Weaknesses: Several functions with summed
score. May mis-classify patients with aphasia.
Neurobehavioral Cognition
Status Exam (NCSE)
(Kiernan 1987)
Strength: Predicts gain in Barthel Index scores.
Unrelated to age.
Weaknesses: Does not distinguish right from left
hemisphere. No reliability studies in stroke. No
studies of factorial structure. Correlates with
education.
36 | Critical Care in Neurology
Table 3.2 – Neurological Scales used for assessment of stroke deficits
Name and Source Strengths Weaknesses
Measures of disability/activities of daily living (ADL)
Barthel Index
(Mahoney 1965,
Wade 1988)
Widely used for stroke.
Excellent validity and
reliability.
Low sensitivity for high-level
functioning
Functional
Independence
Measure (FIM)
(Granger 1987)
Widely used for stroke.
Measures mobility, ADL,
cognition, functional
communication.
"Ceiling" and "floor" effects
Stroke deficit scales
NIH Stroke Scale
(Brott 1989)
Brief, reliable, can be
administered by nonneurologists
Low sensitivity
Canadian
Neurological Scale
(Cote 1986)
Brief, valid, reliable Some useful measures omitted
Assessment of motor function
Fugl-Meyer
(Fugl-Meyer 1975)
Extensively evaluated
measure. Good validity
and reliability for
assessing sensorimotor
function and balance
Considered too complex and timeconsuming
by many
Motor Assessment
Scale (Poole 1988)
Good, brief assessment of
movement and physical
mobility
Reliability assessed only in stable
patients. Sensitivity not tested
Motricity Index
(Collin 1990)
Brief assessment of motor
function of arm, leg, and
trunk
Sensitivity not tested
Balance assessment
Berg Balance
Assessment
(Berg 1992)
Simple, well established
with stroke patients,
sensitive to change
None observed
Mobility assessment
Rivermead
Mobility Index
(Collen 1991)
Valid, brief, reliable test of
physical mobility
Sensitivity not tested
Documentation and Scores | 37
Name and Source Strengths Weaknesses
Assessment of speech and language functions
Boston Diagnostic
Aphasia
Examination
(Goodglass 1983)
Widely used,
comprehensive, good
standardization data,
sound theoretical
rationale
Long time to administer; half of
patients cannot be classified
Porch Index of
Communicative
Ability (PICA)
(Porch 1981)
Widely used,
comprehensive, careful
test development and
standardization
Long time to administer. Special
training required to administer.
Inadequate sampling of language
other than one word and single
sentences
Western aphasia
Battery (Kertesz
1982)
Widely used,
comprehensive
Long time to administer. "Aphasia
quotients" and "taxonomy" of
aphasia not well validated
Table 3.3 – Neurological Scales used for assessment of health status and
global disabilities
Type Name and
Source
Strengths Weaknesses
Global
disability scale
Rankin Scale
(Rankin 1957,
Bonita 1988,
Van Swieten
1988)
Good for overall
assessment of
disability.
Walking is the only
explicit assessment
criterion. Low
sensitivity
Health status/
quality of life
measures
Medical
Outcomes Study
(MOS) 36 Item
Short-Form
Health Survey
(Ware 1992)
Generic health status
scale SF36 is improved
version of SF20. Brief,
can be self -
administered or
administered by phone
or interview. Widely
used in the US
Possible "floor" effect
in seriously ill patients
(especially for physical
functioning), suggests it
should be
supplemented by an
ADL scale in stroke
patients
Sickness Impact
Profile (SIP)
(Bergner 1981)
Comprehensive and
well-evaluated. Broad
range of items reduces
"floor" or "ceiling"
effects
Time to administer
somewhat long.
Evaluates behavior
rather than subjective
health; needs questions
on well-being,
happiness, and
satisfaction