BioPsychoSocial Assessment Tools for the Elderly - Assessment Summary Sheet Test: Glasgow Coma Scale (GCS) also known as Glasgow Coma Score Year: 1974 Domain: Biological Assessment Tool Category: Mental Health, Physical Functioning/ADLs Variations/Translations: Modified Glasgow Coma Scale (omits abnormal flexion) Setting: Clinical, EMS Method of Delivery: Questionnaire, delivered by expert Description: GCS was initially used to assess level of consciousness after head injury, and the scale is now used by first aid, EMS and doctors as being applicable to all acute medical and trauma patients. In hospital it is also used in chronic patient monitoring, in for instance, intensive care. GCS is used as part of several Intensive Care Unity (ICU) scoring systems, including APACHE II, SAPS II, and SOFA, to assess the status of the central nervous system. A similar scale, the Rancho Los Amigos Scale is used to assess the recovery of traumatic brain injury patients. The scale comprises three tests: eye, verbal and motor responses. The three values separately as well as their sum are considered. The lowest possible GCS (the sum) is 3 (deep coma or death), while the highest is 15 (fully awake person). Best eye response (E) There are 4 grades starting with the most severe: 1. No eye opening 2. Eye opening in response to pain. (Patient responds to pressure on the patient’s fingernail bed; if this does not elicit a response, supraorbital and sternal pressure or rub may be used.) 3. Eye opening to speech. (Not to be confused with an awaking of a sleeping person; such patients receive a score of 4, not 3.) 4. Eyes opening spontaneously Best verbal response (V) There are 5 grades starting with the most severe: 1. No verbal response 2. Incomprehensible sounds. (Moaning but no words.) 3. Inappropriate words. (Random or exclamatory articulated speech, but no conversational exchange) 4. Confused. (The patient responds to questions coherently but there is some disorientation and confusion.) 5. Oriented. (Patient responds coherently and appropriately to questions such as the patient’s name and age, where they are and why, the year, month, etc.) Best motor response (M) There are 6 grades starting with the most severe: 1. No motor response 2. Extension to pain (adduction of arm, internal rotation of shoulder, pronation of forearm, extension of wrist, decerebrate response) 3. Abnormal flexion to pain (adduction of arm, internal rotation of shoulder, pronation of forearm, flexion of wrist, decorticate response) 4. Flexion/Withdrawal to pain (flexion of elbow, supination of forearm, flexion of wrist when supra-orbital pressure applied ; pulls part of body away when nailbed pinched) 5. Localizes to pain. (Purposeful movements towards painful stimuli; e.g., hand crosses mid-line and gets above clavicle when supra-orbital pressure applied.) 6. Obeys commands. (The patient does simple things as asked.) Scoring/Interpretation: A patient is assessed against the criteria of the scale, and the resulting points give a patient score between 3 (indicating deep unconsciousness) and either 14 (original scale) or 15 (the more widely used modified or revised scale). Individual elements as well as the sum of the score are important. Hence, the score is expressed in the form "GCS 9 = E2 V4 M3 at 07:35". Generally, brain injury is classified as: • Severe, with GCS = 8 - that is also a generally accepted definition of a coma • Moderate, GCS 9 - 12 • Minor, GCS = 13. Intubation and severe facial/eye swelling or damage, make it impossible to test the verbal and eye responses. In these circumstances, the score is given as 1 with a modifier attached e.g. 'E1c' where 'c' = closed, or 'V1t' where t = tube. A composite might be 'GCS 5tc'. This would mean, for example, eyes closed because of swelling = 1, intubated = 1, leaving a motor score of 3 for 'abnormal flexion'. The GCS has limited applicability to children, especially below the age of 36 months (where the verbal performance of even a healthy child would be expected to be poor). Consequently the Paediatric Glasgow Coma Scale, a separate yet closely related scale, was developed for assessing younger children. Time to Administer: Varies Availability: Online (see below) Software: N/A Website: http://www.unc.edu/~rowlett/units/scales/glasgow.htm Quantitative/Qualitative: Quantitative Validity (Quantitative): N/A Reliability (Quantitative): In a study done with an emergency department, one hundred thirty-one patients were screened and enrolled in the study. Of the 116 remaining patients, the agreement percentage for exact total GCS was 32% (t-b=0.739; Spearman r=0.864). Agreement percentage for GCS components were eye 74% (t-b=0.715; Spearman r=0.757), verbal 55% (t-b=0.587; Spearman r=0.665), and motor 72% (t-b=0.742; Spearman r=0.808). References: McDowell, I. & Newell, C. (1996). Measuring Health: A Guide to Rating Scales and Questionnaires. (2nd ed.). New York: Oxford University Press. Comments: Validity has yet to be tested, however, the GCS is used frequently with traumatic brain injuries.