Non-motor impairments after ABI

Define consciousness

Complex arousal state that implies self awareness (knows who they are, where they are), unity (internal/external stimuli make sense) and intentionality (goal oriented behavior)

What is the glasgow coma scale used for, what scores indicate which severity levels? What populations does it have limited use with?

GCS is for acute assessment of TBI.

• Severe brain injury: 3-8

• Moderate brain injury: 9-12

• Minor brain injury: 13-15

Limited use w/ intubated pts, and infants/toddlers (ped version for infants/toddlers)

The first 3 rancho levels of cognitive function are levels of what?

Comatose states, so a person w/ altered level of consciousness for any comatose states.

Rancho level 1

Name: No response

Assistance: Total

Key characteristics: No observable response to external stimuli. Same as a vegetative state, brain dead.

Rancho level 2

Name: Generalized response

Assistance: Total

Key characteristics: Inconsistent, non-purposeful responses; same response regardless of stimulus

Rancho level 3

Name: Localized response

Assistance: Total

Key characteristics: Specific, inconsistent responses; reacts to painful stimuli; more responsive to familiar people

Rancho level 4

Name: Confused, agitated

Assistance: Maximal

Key characteristics: Bizarre, hyperactive, non-purposeful behavior; agitation from internal confusion (No awareness of context, location, situation → confusion → frustration/agitation); no short term-memory

Rancho level 5

Name: Confused, inappropriate, non-agitated

Assistance: Maximal

Key characteristics: Follows simple commands inconsistently; inappropriate verbal behavior (inappropriate given current context); poor memory; can perform tasks if demonstrated (not just instructed)

Rancho level 6

Name: Confused, appropriate

Assistance: moderate

Key characteristics: Follows simple directions consistently; retains old learning (previous trade/career for example); lacks new learning; some awareness (potentially the correct emotional response, but the wrong intensity) but poor safety insight (doesn’t understand personal limitations).

Rancho level 7

Name: Automatic, appropriate

Assistance: minimal

Key characteristics: Performs routine automatically; superficial awareness of condition; poor judgment and safety; interested in structured activities (Can follow very structural/automatic schedule, needs assistance in that schedule being created).

Rancho level 8

Name: Purposeful, appropriate

Assistance: Stand-by

Key characteristics: Oriented; completes familiar tasks independently; some awareness of deficits; uses memory aids; better emotional response (correct intensity of emotional response)

Pt can create their own structure here, and can be more ind if using memory aide like google calendar.

Rancho level 9

Name: Purposeful, appropriate

Assistance: Stand-by on request

Key characteristics: Shifts tasks independently; recognizes impairments with support; uses compensatory strategies; needs help anticipating problems (Pt can ask for help with a current problem, but can’t forsee/plan for a problem themselves).

Rancho level 10

Name: Purposeful, Appropriate

Assistance: Modified Independent

Key characteristics: Independently managing tasks w/ aids; anticipating obstacles; appropriate social interactions; may still struggle under stress. (Main issue is inc. struggling in overly emotional/stressful environments).

Describe the tests for sustained attention

Digit repetition: Say 1 #, pt repeats, then 2#, all the way till failure. 7 digit repetition is normal success rate for normal population

Test of vigilance: Give series of individual letters, have pt tap table every time they hear specific letter (“a” for example). Normal is 0 mistakes in 1 min, helpful for aphasia

Describe tests for divided attention

Basically just things requiring dual attention.

Cognitive-Cognitive

Cognitive-motor

Motor-motor

Define cognition

Set of mental processes by which individuals acquire, process, store, and use information

Several domains including memory, executive function, etc.

Describe the tests for cognitive function.

Cog-Log: Testing multiple cog domains (primarily memory & executive function). Administered multiple times per day. Can a pt remember while using working memory to problem solve, also delayed recall at the end of the test. Cut-off score is 25 (<25 is impaired cognition).

Galveston Orientation and Amnesia Test (GOAT): Assesses orientation, retrograde (can’t remember old memories) and anterograde (can’t form new memories) amnesia. Administered once daily. Scoring > 78 for three consecutive days clears post-traumatic amnesia (PTA).

Define perception

Integration of sensory information into a meaningful representation. (Making info from several sensory modalities make sense)

Describe Pusher Syndrome. What type of disorder is it, what hemisphere is it associated with, damage to what area, which direction does pt push, when does it typically resolve?

Perceptual disorder usually involving non-dominant hemisphere so R hemisphere. Pt actively pushes away from unaffected side, onto affected side. Typically leaning 20ish deg from midline.

Damage to posterolateral thalamus, insula, and/or post-central gyrus, typically resolves in 6 mo, often occurs w/ neglect.

What scale is typically used to assess Pusher Syndrome?

Scale for contraversive pushing (SCP)

It measures spontaneous body posture, use of nonparetic extremities (abduction & …), and resistance to passive correction of tilted posture.

Describe unilateral neglect. How common is it, what is it, damage to what area, spatial vs body/personal.

30% of strokes. Disorder of perception, attention, action on space opposite to cerebral lesion (can’t integrate on CL side). Usually R parietal association area, so L hemispatial neglect common type.

Spatial: Inattention/neglect to visual stim in CL extrapersonal space.

Body/personal: Failure to report, respond, orient to body side (personal space) CL to lesion.

Describe apraxia. How common, what is it, damage to what area?

30-80% of strokes (dominant hemi stroke 50-80% ; non-dominant hemi stroke 30-50%). Can’t perform tasks/actions on command even though physically capable of doing those tasks spontaneously. Damage to parietal association areas, frontal motor connections.

Describe constructional, ideomotor, ideational aprazxia.

Constructional: Can’t reproduce a figure (draw, build tower, recreate spatial orientation).

Ideomotor: Can perform task spontaneously, but not on command (can’t motor plan)

Ideational: Can’t produce movement spontaneously or on comand (doesn’t understand the action, especially w/ multi-step problems).

Define communication.

The exchange of information, ideas, or feelings through nonverbal or verbal methods.

Describe aphasia in general. What 3 aspects of communication can be affected, how common in stroke/TBI?

Aphasia is an impaitment in fluency, repetition, and/or comprehension of communication.

Fluency: rate, flow, ease of speech production.

Repetition: ability to repeat words, phrases, sentences.

Comprehension: Ability to understand spoken language.

20-40% strokes, 11-30% TBI pts.

What deficits are usually seen with Broca’s aphasia?

Decreased fluency, and difficulty w/ speech production. Also often struggles to understand sentences w/ complex structures. (fluent aphasia).

What deficits are usually seen with Transcortical Motor aphasia?

Decreased fluency. Primarily an issue with connecting Broca’s area to other motor areas.

What deficits are usually seen Global with aphasia?

Generally disruption to both Broca’s and Wernicke’s areas, so dec. fluency, repetition, and comprehension. This person would have difficulty producing, repeating, and understanding speech.

What deficits are usually seen Wernicke’s with aphasia?

Dec. repetition, and comprehension. Primarily an issue with comprehension.

What deficits are usually seen with Transcortical Sensory aphasia?

Decreased comprehension. Primarily an issue with connecting Wernicke’s area to other sensory areas.

What deficits are usually seen with Conduction aphasia?

Issue w/ arcuate fasciculus. Can look like global aphasia, but primarily a dec. in repetition.

What % of pts suffer a neuropsychiatric disorder after stroke vs TBI?

33-50% of pts after stroke

65% of pts w/ one dx after TBI

40% of pts w/ two dx after TBI

What are common effects/results of pts having a neuropsychiatric disorder after stroke/TBI? These disorders often reported as more or less troubling than cognitive/physical impairments?

Inc. likelihood of functional impairment, dec. social function, poorer health-related QOL scores.

Neuropsychiatric disorders are commonly reported as more troubling than cognitive/physical impairments.

When would a neuropsychiatric disorder be a primary vs secondary impairment/etiology? How good is the evidence on efficacy of interventions with treating these conditions?

Primary when d/t damage to an area that releases serotonin for example. Damage to the frontal pole, especially lateralized to the left side (slide 8 ) would be an example of this. Secondary if more of a situational thing like d/t weakness which is leading to lower QOL and inability to participate in social functions.

Limited evidence on intervention efficacy, no clear consensus on tx approach.

What is behavioral dyscontrol, and what are the three types?

Tendency toward impulsive reactions toward internal/external stimuli.

• Agitation

• Disinhibition

• Aggression

Define agitation. What is it often linked to, and what can it be associated with?

State of restlessness and inc. psychomotor activity reflecting underlying emotions.

Often linked to “confused” states early after injury

Associated w/ long-term behavioral presentation like getting stuck @ a Ranchos level (especially 4-6) for long period.

What neuropsychiatric factors are associated with agitation/aggression?

• Adverse environment (excess stimuli → overwhelmed)

• Medical illness

• Aggression as direct effect of brain injury

• Depression

• Sundowning (pattern of night time agitation)

• Insomnia (not sleeping well)

• Anxiety

• Psychosis

Define disinhibition, what are it’s two types? Is it typically associated with stroke or TBI more?

Inappropriate, nonaggressive responses reflecting an inability to appreciate behavioral norms.

Two types: Physical, verbal

Typically associated more w/ TBI than stroke.

Describe the types of physical disinhibition.

Inappropriate sexual advances

Impulsivity, including lack of insight into personal deficits/safety risks. Impulsivity is also associated with stroke.

Describe the types of verbal disinhibition.

• Poorly considered utterances: Saying whatever they think (“you look really old today”) no filter

• Breaking rules of discourse: Not actively listening, constantly interrupting. Suddenly changing subjects.

• Egocentric perspective: Everything in conversation is about them. You say your aunt went to the hospital, they tell you about when their aunt went to the hospital years ago and just keep going on about it.

Define Aggression. What are risk factors for it, and name a few common treatment medications.

Verbal outburst or physical violence directed at objects or people.

Risk factors: Emotional dyscontrol (aggitation), major depression, frontal lobe damage, pre-injury aggression

Treatment: Valproate (neuropsychiatric med), beta-blockers, psychostimulants (like adderall when attention is part of the issue), SSRI (if associated w/ depression)

Is aggression more associated with stroke or TBI?

TBI

Describe the types of aggression including reactive, nonreflective, nonpurposeful, explosive, periodic, ego-dystonic. Are these categories exclusive?

• Reactive: Physical/emotional response is out of proportion to stimulus

• Nonreflective: No premeditation/planning, automatic response

• Nonpurposeful: No specific trigger to aggression, it serves no long term aims/goals

• Explosive: No gradual buildup, just sudden explosion of aggression

• Periodic: Brief outbursts of rage/aggression, then long periods of relative calm

• Ego-dystonic: Pt is upset, concerned, embarrassed after outburst rather than blaming others to justify their behavior. Some insight into their aggression.

These categories are not exclusive, they can intermix.

Define mood. What are the 3 types of mood disorders?

Sustained, pervasive shift in emotion and/or feeling.

• Depression

• Anxiety

• Apathy

Which is the most common neuropsychiatric diagnosis after stroke and TBI?

Depression

Define depression. What are risk factors and treatment methods for it?

Depressed mood, decreased capacity for pleasure

Risk factors: Frontal pole (TBI), left injury lateralization (TBI), older age, female, less education, prior psychiatric disorder, stroke severity

Treatment: SSRIs, tricyclic antidepressants, neuromodulation (stroke) also evidence for Transmagnetic stimulation as tx.

Define anxiety. What are the two common types?

Excessive worry, nervousness or unease about an anticipated event or situation.

Can be generalized or associated w/ posttraumatic stress disorder (GAD or PTSD).

What are predictors, risk factors, and treatment methods for anxiety?

Predictors (stroke): Inc. severity of stroke, premorbid depression, early anxiety (inc. risk of long term anxiety), Cognitive impairment

Risk factors (TBI): Older age, female, prior psychiatric disorders, longer LOC phase, shorter post-traumatic amnesia (PTA) phase (could inc. PTSD, remembering more events around a traumatic accident)

Tx: SSRI, benzodiasepines, SSNRIs

Define Apathy. What things is it associated with, and what can it be related to?

Decrease in motivation.

Associated w/ dysfunctional reward network (Ventral striatum/nucleus accumbens, ant. cingulate cortex, etc.), and/or comorbid depression.

Can be related to cognition, behavior, emotion/social interactions.

How is apathy treated?

Dopamine-agonists, psychostimulants like adderall, acetylcholinesterase inhibitors, SSRIs (if comorbid w/ depression)

Compare/contrast qualities of apathy and depression.

Apathy: reduced initiative, needs prompting to start tasks, persists less in activities, less interested in events, blunted emotional responses, lack of concern.

Depression: Low mood, sadness, feelings of guilt, feelings of worthlessness, frequently comorbid w/ anxiety disorders, suicidal ideation

Both: Loss of pleasure (anhydonia), reduced energy, physical/mental slowing.