Kraepelin was fascinated by the spontaneous recovery of brain function

I think that psychiatric wards need to be transformed into wards for the study of altered mental status or altered state of consciousness.

The state of consciousness is a sum of arousal and cognition.

Arousal refers to awareness of the self and the environment. The Ascending Reticular Activating System in the brainstem modulates arousal.

The Cognition is the combination of orientation, reasoning, and memory. The cerebral cortex houses the cognition centers.

In sum, the normal state of consciousness requires a properly functioning brain stem and cerebral cortex.

Altered mental status may result from any changes in;

  • Arousal,
  • Cognition,
  • A combination of these two functions.

The altered mental state may mean coma, difficulty in awakening, confusion, aggression, or personality alteration. . Right now patients who lose their mind are seen in emergency, along with life threatening illness and injuries. The emergency ward is not the right place for a systematic exploration of the many problems that could lead to different patterns of altered mental status. The majority of the patients will require admission, either to the ward or intensive care unit. In the 21st century, the psychiatric ward should be changed into a ward which investigates and studies the many physiological and metabolic causes of altered mental status. Every adult who suffers a slow or sudden change in mental status should be investigated medically until we understand more about this physical problem.

The Differential diagnosis of altered mental status is very broad and people interested in these physiological syndromes should begin to sift through the various pathologies; to learn how these pathologies cause secondary effects to the brain and to function of mind. Diagnostic tests should be targeted to suspected underlying physiological problems. and information should be gathered and a lot of thought should go into the many secondary physiological conditions that could be disrupting the mind. Rather than a single specific algorithm, a ruling in and out approach should be followed…and should be repeated from time to time if normal mental status cannot be restored the first time or the 12th time.

Life as a terrified semi- zombie is not a life at all. Sustained abnormal internal arousal will most likely be a product of abnormal vital signs and sustained abnormal vital signs will most likely be due to mechanical failure of one or more of the systems of the body and it may not originate in the brain at all. PCO2 of the blood and 02 of the mitochondria will most likely need correction.

We need to THINK!

And thinking takes medical detective work and time and determination and knowledge of physiology and anatomy.

Altered mental status involves abnormal arousal and abnormal cognition. Arousal is a complex issue. If arousal is too low, a person may be in a coma, or they can be awake but unresponsive to their external environment but they can also be fully alert and hyper-aroused internally, but too confused and overstimulated physically to be able to think or speak in a purposeful way, if at all. .

I imagine that the measurement of their vital signs, especially breathing rate and volume and use of accessory muscles, will begin to suggest the circulatory problems that are affecting the brain. The more we understand how the autonomic nervous system works during mechanical failure of one system or another, the more we can hope to restore normal mental status [which will restore mood and maybe normal locomotor activity]. These are all intertwined and we need to study these patients more carefully. Unless there is great damage to the brain-such as a brain tumour, or a parasite or uncontrolled results of swelling or blunt injury or effects of a large stroke or period of anoxia with disruption of tissue, then it should be assumed that peripheral organ failure can be treated and the mental status restored. There is no quality of life with altered mental status. We must learn more about how to restore it.

Jerry’s mom did not recover her physical health, but at the age of 85 with the help of machines, her peak mental status returned and that was amazing! Her children had forgotten how smart she was. She enjoyed her last 5 years of life, difficult as they were physically. Jerry’s mom had suffered all her life from neuromuscular problems and gradual kidney failure. Seeing Jerry’s mom regain her peak higher intellect, at age 85 to 90, with medication for the blood and with dialysis to to replace her kidneys was a happy surprise. Unknown to everyone, her brain had been slightly muted but not permanently damaged.

Watching Jerry regain normal mood, normal intellectual function and normal personality for 6 weeks or more every summer [when he went off his over-tranquillizing medications] was miraculous, every time it happened. They did not even try to figure out how to keep him at his baseline. The medications the doctor put him made him dull [intellectually], if quiet. . Unfortunately they never did figure it out and the attacks would eventually return.

Paula used a fast test of autobiographical memory to assess which medication would restore her mental function and mood and personality. It was a slow process. It took years – probably because the treatment was not perfect or adequate, but it was all we were given. In the end her intellect was restored completely. Again, a happy surprise.

Kraepelin noted that a third of his patients with manic depressive insanity had spontaneous recoveries that lasted an average of nine years. Nine years of health! Nine years of normalcy! This helped Kraepelin understand that unlike the effects of a bad head injury, uncontrolled swelling of the head, meningitis , parasites in the brain, or large strokes, or brain tumours, attacks of manic depressive insanity did not seem to leave lasting damage to the brain. The brain function became muted during depressive attacks– the volume of mind is quiet and slowed down- but not turned off; brain function volume is turned up too loud and too fast in mania for decades even, but never forever. Most patients recovered intermittently.

This suggests that we need to look at these patients more closely if we wish to learn more about the brain, the mind and the function of the rest of the body. This suggests that we need to earn more about the secondary effects to the brain, because in all of these cases, problems evident by measuring the vital signs, breathing rate at rest included, pointed to fixable mechanical issues requiring twenty first century medical treatment to help clear the brain and restore the mind.

I think that the emergency department is not the place to learn more about altered mental status in manic depressive insanity or Alzeihmers. I think that psychiatric wards can be remodelled in order to look for the many many secondary injuries and illnesses and syndromes that can cause abnormal states of arousal and cognition.

If the underlying cause is completely reversed and unlikely to re-occur, the patient reached his/her baseline mental status, vital signs are normal and stable, preparing a discharge plan may be considered.

The information presented in italics is from The International Emergency Medicine Education Project Altered Mental Status by Murat Cetin, Begum Oktem, Mustafa Emin Canakci 

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