Disorders of consciousness and PTA Flashcards by Colleen Caribardi

What are the MOI for disorders of consciousness?

Traumatic brain injury
Non-traumatic/neuronal injury
–> acute hypoxic-ischemic neuronal injury (cardiac arrest, stroke, meningoencephalitis)

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What is the annual incidence of vegetative state Dx in the US?

4200

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What is the incidence rate of minimal conscious state?

Unknown due to there being no diagnostic code in the international classification of diseases

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Post-traumatic cases resulting in vegetative state has a (better/worse) prognosis than non-traumatic cases resulting in vegetative state.

better prognosis

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It is believed that ___% of cases have misdiagnosis when the patient was actually minimally conscious.

40%

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What signals are lost with coma?

functioning of cortex and reticular systems

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How long does a coma normally last?

2 weeks… rarely 2-4 weeks.

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(true/false) There is evidence of sleep/wake cycles on EEG when a patient is in a coma

FALSE (there is not)

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(true/false) Behavioral responses with a coma consist of reflex activity

true

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(true/false) The autonomic system is preserved in vegetative state.

true

–> variable preservation of CN and spinal reflexes

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“wakeful unawareness”

vegetative state

–> no evidence of sustained, reproducible, purposeful, or voluntary behavioral responses to visual, auditory, tactile, or noxious stimuli

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(true/false) A patient in vegetative state has periodic episodes of eye opening

true

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(true/false) A patient in vegetative state does not experience B/B incontinence

false

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definition: “A condition of severely altered consciousness in which minimal, but definite behavioral evidence of self or environmental awareness is demonstrated”

minimally conscious state

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How does MCS differ from a coma and vegetative state?

has a presence of specific behavioral manifestations of consciousness; behaviors occur inconsistently but can be differentiated between reflex and random behavior.

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What marks a person of being out of a minimally conscious state?

Recovery of the capacity to communicate or interact consistently with the environment (functional object use of 2 common articles)

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What are the neuropathologies of a coma?

Hemispheric: bilateral diffuse cortical or subcortical white matter lesions

Brainstem injury: focal lesions of the midbrain or rostral pons

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What is the neuropathology of vegetative state?

moderate to severe ischemic damage involving the thalamus and arterial watershed areas

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What diagnostic imaging can demonstrate preserved ability to process meaningful information where behavioral evidence is not present for a patient in a vegetative state?

PET

–> used to determine the presence and extent of residual cortical activity in patients diagnosed with VS
Radiation burden

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___% of those in a vegetative state have a diffuse axonal injury

71%

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What grades of diffuse axonal injuries tend to be present with those in a vegetative state?

Grades 2 and 3 in addition to thalamic damage

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(true/false) Thalamic lesions are less prevalent in MCS than vegetative state

True (50% MCS… 80% VS)

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What level of consciousness appears to be characterized by greater sparing of cortico-cortical and cortico-thalamic connections?

MCS

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definition: widespread axonal damage with NO focal abnormalities

DAI grade I

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definition: widespread axonal damage with presence of focal abnormalities in the corpus callosum

DAI grade II

definition: widespread axonal damage, focal abnormalities in corpus callosum, and injury to the rostral brain stem w/ tissue tears

DAI grade III

What is an Increasingly utilized noninvasive technique for localizing brain activity?

fMRI

Overall life expectancy is (shortened/lengthened) in those who are in a vegetative state

shortened

If a person has a higher DRS score, they have a (bad/good) prognosis

bad

(true/false) Children who experience traumatic vegetative state can have posttraumatic hyperthermia at any time.

true

(true/false) Any reproducible evidence of volitional responding, however slight, establishes diagnosis of MCS

true BUT responses are infrequent and unpredictable and require a large number of observations to establish if there is a pattern/response to stimuli

What assessment tools should be used in the acute recovery period from DOC?

GCS Glasgow-Liege Coma Scale Swedish Reaction Level Scale

What assessment tools are used in the rehabilitation period after a DOC?

rancho levels DRS CLOCS CNC CRS-R SSAM SMART WHIM WNSSP DOCS

What assessment is a useful adjunct or alternative to standardized measures?

individualized quantitative behavioral assessment (IQBA) --> measurements are developed around specific behaviors or questions of interest in individual patients intended to complement comprehensive neurobehavioral assessment --> useful when behavioral responses are infrequent

(true/false) Consciousness can be directly observed.

FALSE

What are the 5 most common complications of DOC? Other complications?

spasticity (8.3%) UTI (6.4%) aggression (6.4%) sleep disturbance (6.2%) hyperkinesia (4.7%) ------- pneumonia post-traumatic epilepsy post-traumatic hydrocephalus heterotopic ossification dysautonomia

What complication of DOC is the most common reason for acute-care transfers?

pneumonia

What are s/s to look for when suspecting heterotopic ossification?

pain/grimacing warmness swelling

(true/false) it is common for DOC patient to form polyneuropathy

true

What test should you use when testing sensation?

flexor withdrawal

What is the purpose of the JFK coma recovery scale?

assist with: - differential Dx - prognostic assessment - treatment planning

What is the scoring range meanings for the CRS-R? How is the scoring determined?

Lowest item on each subscale represents reflexive activity while the highest items represent cognitively-mediated behaviors --> Scoring is standardized and is based on the presence or absence of operationally-defined behavioral responses to specific sensory stimuli

What is a pro for CRS-R?

Captures emergence from a coma and the progression through disorders of consciousness

When was the DOC scale (DOCS) developed?

2011

GCS has a (low/moderate/high) correlation with mortality.

moderate (not reliable at predicting functional capabilities of survivors)

What type of potentials tell if pathways are intact?

Evoked potentials --> earliest response/cranial and brainstem neurons

What type of potentials are higher level and include the subcortical-cortical circuits?

event-related potentials (ERPs)

What type of evoked potential reveals structural integrity of pathways?

short latency evoked potentials

What event-related potentials are indicative of higher cortical function?

long latency ERPs oddball design: detect an infrequent stimulus within a string of frequent stimuli

Studies suggest ___-___% errors in classifying patients as Vegetative vs. Minimally Conscious

15-43%

What medication accelerates the pace of recovery and is given in the acute phase of recovery?

amantadine

(true/false) a patient can stay agitated for weeks to months after a TBI

true --> episodes can have a spontaneous and rapid onset

(true/false) Majority of expert psychiatrists do not utilize formal assessment of agitation within the clinical setting they practice in.

true

What is the Rancho level for a patient being confused and agitated?

What are descriptors of agitation?

- delirium - akathisia - post-traumatic amnesia - aggression

definition: Syndrome characterized by unpleasant sensations of “inner” restlessness that manifests itself with an inability to sit still or remain motionless

akathisia

What medications can potentially contribute to akathisia?

SSRIs

definition: A subtype of delirium unique to survivors of a TBI in which the survivor is in the state of post-traumatic amnesia and there are excesses of behaviors that include some combination of aggression, akathisia, disinhibition, and/or emotional lability

interdisciplinary

Arousal, attention, memory, and limbic behavioral functions are commonly affected when there is injury to what regions of the CNS?

fronto-temporal systems Subcortical region brainstem

What systems cause cognitive effects with post-traumatic agitation?

dopaminergic system (arousal and attention) noradrenergic system (arousal and attention) cholinergic system (memory)

What systems cause behavioral effects with post-traumatic agitation?

serotonergic (aggression) dopaminergic (akathisia)

What are risk factors for post traumatic agitation?

Fronto-temporal lesions Disorientation co-morbidity complications anticonvulsants

(true/false) Despite the prevalence of aggressive behaviors during the initial recovery phase of TBI, it is rarely measured.

true

What is the ABS scale used to measure?

used to measure agitation in the brain injury population

Why was the ABS scale developed?

Developed to allow objective, sequential assessment of aggressive behaviors to determine if interventions to reduce these behaviors are effective.

What is the grading scale of the ABS?

1 = absent 2= present to slight degree 3= present to moderate degree 4= present to an extreme degree

What does it mean if a person has an ABS score < 21?

WNL

What does it mean if a person has an ABS score of 22-28?

mild agitation

What does it mean if a person has an ABS score 29-35?

moderate agitation

What does it mean if a person has an ABS score > 35?

severe agitation

definition: Learning to associate a response with a consequence- the individual has associated that a specific consequence will follow if they do the appropriate response i.e. “if you finish therapy, you can go have a smoke”

response-consequence learning

definition: Consequence follows response

operant conditioning

definition: Consistent schedule and activities

structured milieu

What is ABC of behavior management short for? What is it used for?

Antecedent : what is causing the behavior Behavior Consequence --> used for behavior modification

What medications can be used to treat PTA?

Carbamazepine Antidepressants B-adrenergic receptor antagonists Antipsychotics benzodiazepines sympathomimetics buspirone amantadine lithium valproic acid

Traditionally _________, such as Ritalin, are found to increase agitation.

psychostimulants