Neuro Final Exam: Right Hemisphere Dysfunction and Treatment

RHD deficits

attention: arousal and lethargy, orientating to environment, sustained attention: easily distracted, selective attention, unilateral or hemispatial inattention/neglect, visuoperceptual deficits

RHD visuoperceptual deficits

visual attention, integration, memory, spatial orientation, topographical orientation

visuoperceptual deficit

difficulty identifying real objects or recognizing pictures or drawings of objects; shows up when drawings are incomplete or distorted or changed from a traditional prototype

spatial orientation

our body’s position in space relative to objects/locations

topographical orientation deficits

difficulty following familiar routines, reading maps, giving directions and performing other tasks that depend on internal representations of external space

unilateral or hemispatial inattention/neglect (left neglect)

hallmark of RHD, not all individuals have it, varying degrees of severity, more severe with right parietal lobe damage, two types egocentric and allocentric

egocentric unilateral spatial neglect

makes errors on the contralateral space defined by midline of the body, head, or retina

allocentric unilateral spatial neglect

makes errors on the contralateral side of individual items regardless of where the items appear with respect to the viewer

commonly observed behavior in left neglect

does not respond to people/objects left of midline, problems attending to left in self-care tasks, moving, attending to, and recognizing left limbs, bumping into walls, doorways, and objects on left side, missing left half of printed materials, decreased use of margins and spacing during writing, inability to localize sounds from left, limited to no awareness of neglect, decreased participation in rehab process

cognitive deficits in RHD

attention/information processing, memory, EF (problem solving, reasoning, judgement)

communication deficits in RHD

communicative efficiency and specificity, literal/concrete, hard time with abstract concepts, difficulty with eye contact, processing complex inferences, implied meaning, appreciation of shared knowledge, may present with mild word retrieval deficits, verbosity, difficulty with body language and reading facial expressions, dysarthria

affective and emotional deficits in RHD

reduced use of facial expression and prosody to convey emotion (flat affect), reduce comprehension of facial expression and prosody of others, denial of deficits/awareness/insight, lability, misidentification syndromes (rare, prosopagnosia), agitation, confusion, psychosis (rare)

goals of RHD assessment

gather patient information, identify strengths and weaknesses, does patient have cog comm deficits characteristic of RHD, develop goals and treatment plan, duration and frequency of treatment, prognosis, discharge recommendations

considerations for RHD assessment

left inattention, visual and perceptual deficits, identifying the gist/main idea, pragmatics, greater incidence of dysphagia than LHD, assess for arousal/alertness

RHD formal assessments

Mini Inventory of Right Brain Injury (MIRBI), The Rehabilitation Institute of Chicago Evaluation of Communicative Problems in RHD (RICE-R), The Right Hemisphere Language Battery (RHLB-2), RBANS

Mini Inventory of Right Brain Injury (MIRBI)

administer to patients with RHD moderate to severe, 10 subsections

MIRBI subsections

visual scanning, integrity of gnosis, integrity of body image, visuoverbal processing, visuosymbolic processing, integrity of visuomotor praxis, higher level language skills, expressing emotion, general affect

Right Hemisphere Language Battery (RHLB-2) and RBANS

used for dementia and neurocognitive assessment, similar tasks to CLQT but used with higher functioning patients, has good sensitivity for identifying higher level deficits, tests of immediate memory, visuospatial/constructional, language, attention, and delayed memory

RHLB and RBANS tests

immediate and delayed memory, visuospatial/constructional, language, attention

RBANS

standardized on dementia; can be used with high level cognitive impaired patients of any diagnoses

nonstandardized tests of RHD

pragmatic tests, Wechsler Adult Intelligence Scale (WAIS), neglect tests: Behavioral Inattention Test (BIT), cancellation tasks, line bisection, freehand drawing, drawing from a model, description of visual scene: cookie theft, normal rockwell pictures

prognosis variables in RHD

age, education, vocation, time post onset, site and size of lesion, comorbidities, motivation

poor prognostic indicators in RHD

severe inattention deficits, severe neglect, denial of deficits or decreased awareness

rehab programs and treatment approaches for RHD

same settings as TBI, multidisciplinary/interdisciplinary teams, environmental compensation, component retaining/skill building, compensatory training, functional training, cognitive awareness training

severe deficits in RHD

attention/arousal, neglect, denial of deficits, impulsiveness, safety awareness

therapy for severe attention/arousal deficits in RHD

first deficit to target if impaired, raise head of hospital bed and reposition to increase arousal, cold washcloth on face, rub sternum, sessions will be short, salient yes/no questions and orientation questions, similar sustained attention tasks as in patients with TBI but make sure to consider visual deficits, neglect may interfere with responses, place stimuli in patient’s right hemisphere, arrange choices vertically vs horizontally

therapy for severe neglect deficits in RHD

restructure the environment during early recovery, environmental modification through right sided placement, move nurse station call button, remote, light switch, food tray with water, personal items, visitors stand on patient’s right side, watch on right arm, orientation aids on right side, compensation may begin through attention to left with cues and redirection

compensation strategies for treatment of moderate neglect deficits

communication partners stand on patient’s left, important objects placed on the left, orientation aids and schedules in hospital room or on wheelchair in left, verbal reminders during tasks to look left, visual and tactile reminders

therapy for severe denial of deficits, impulsiveness and safety awareness in RHD

may require restraints, supervision from staff/family, place visual reminders on right side (“call nurse for help”), verbal repetition of safety reminders better than visual; “do not get out of bed without calling for help”, train staff to check on frequently to reduce risk of falls

moderate deficits in RHD

prosody and pragmatics

therapy for prosody deficits in RHD

explain prosody to patient and family, patient’s tone of voice and affect may not be an accurate measure of feelings or interest level, drills for identifying and/or producing prosodic elements, challenging to generalize, success often depends on level of awareness

therapy for pragmatic deficits in RHD

present a script of an inappropriate conversation, have patient identify and correct and incorrect, topic maintenance, appropriate topics, group therapy, provide patients with prompts via direct verbal cues, visual cues, nonverbal cues to target use of pragmatics with multiple partners, similar treatment in TBI, feedback critical as this level

sample goals for moderate to severe RHD

patient will maintain arousal for 2-3 simple cognitive tasks in a 15 minute session with mod-max verbal and tactile cues to increase attention to task; patient will demonstrate awareness of left neglect during functional tabletop activities with 75% accuracy and direct verbal cues to increase safety and attention to left visual field