Week 2- TBI: Arousal And Cognitive Considerations

Question 1

PART 1: INTRODUCTION

Answer 1

PART 1: INTRODUCTION

Question 2

What are the 5 levels of Arousal?

Answer 2

• Full Consciousness
• Lethargy
• Obtundation
• Stupor
• Coma

Question 3

What are the major domains of Cognition? (6)

Answer 3

• Attention
• Memory
• Intelligence
• Executive Function
• Social Cognition
• Judgement

Question 4

What are the main (5) Cognition-based outcome measures?

Answer 4

• GOAT
• O-Log
• Moss Attention Scale
• Agitated Behavior Scale
• Rancho Los Amigos Levels of Cognitive Recovery (RLAS-R)

Question 5

Describe the 10 levels of the RLAS-R.

What is a good way to remember the first 8 levels?

Answer 5

I.) No Response: Total Assistance
II.) Generalized Response: Total Assistance
III.) Localized Response: Total Assistance
IV.) Confused/Agitated: Maximal Assistance
V.) Confused, Inappropriate Non-Agitated: Maximal Assistance
VI.) Confused, Appropriate: Moderate Assistance
VII.) Automatic, Appropriate: Minimal Assistance for Daily Skills
VIII.) Purposeful, Appropriate: Stand-by Assistance
IX.) Purposeful, Appropriate: Stand-by Assistance on Request
X.) Purposeful, Appropriate, Modified Independent

No General Located a Confused Co-in in a CAP (app)

Question 6

When do we progress a patient from a RLAS-R level I to level II?

Answer 6

-Whenever we start to see a generalized response to noxious stimuli. May have NOT PURPOSEFUL vocalization.

Question 7

What is the typical generalized response seen when providing noxious stimuli to a RLAS-R level II?

Answer 7

-Posturing

Question 8

When do we progress a patient from a RLAS-R level II to level III?

Answer 8

• When the patient demonstrates a localized response to noxious stimuli. Patient will withdrawal or vocalize to painful stimuli.
• Patient will also start to respond to non-noxious stimuli.

Question 9

PART 2: DISORDERS OF CONSCIOUSNESS

Answer 9

PART 2: DISORDERS OF CONSCIOUSNESS

Question 10

Consciousness = _______ + ________

Answer 10

• Wakefulness (ability to open eyes and have basic reflexes)

- Awareness (complex thought processing)

Question 11

When patients are in RLAS-R level I-III, we will also describe them as having Disorders of _________.

Answer 11

-Consciousness (I=Coma, II=Vegetative State, III=Minimally Conscious)

Question 12

Level 1 (Coma) - No Response: Total Assistance

• Complete failure of _______ system.
• No ___________ eye opening.
• Unable to be awakened by application of vigorous ________ stimulation.
• All behavioral responses consist entirely of _______ activity.
• Loss of function both _______ and _________ system.
• Rarely lasts longer than __-__ weeks.

Answer 12

• Complete failure of AROUSAL system.
• No SPONTANEOUS eye opening.
• Unable to be awakened by application of vigorous SENSORY stimulation.
• All behavioral responses consist entirely of REFLEX activity.
• Loss of function both both CORTEX and RETICULAR system.
• Rarely lasts longer than 2-4 weeks.

Question 13

Level 2 (Vegetative State) - Generalized Response: Total Assistance

• Complete absence of behavioral evidence for self or environmental ____________.
• Preserved capacity for spontaneous or stimulus-induced arousal. (_____ _______ (spontaneously))
• • _____/_____ cycles on EEG

Answer 13

• Complete absence of behavioral evidence for self or environmental AWARENESS.
• Preserved capacity for spontaneous or stimulus-induced arousal (EYES OPEN (spontaneously)).
• • SLEEP/WAKE cycles on EEG.

Question 14

Level 3 (Minimally Conscious State) - Localized Response: Total Assistance

-“MCS is a condition of severely altered consciousness in which minimal but definite behavioral evidence of self or environmental ___________is demonstrated”.

Answer 14

-“MCS is a condition of severely altered consciousness in which minimal but definite behavioral evidence of self or environmental AWARENESS is demonstrated”.

Question 15

The reemergence of eye opening is signaling that the _________ system has regained control of wakefulness.

Answer 15

-Reticular System

Question 16

How long until Vegetative State is considered persistent?

Answer 16

-1 year

Question 17

1 of what (4) behaviors must be present to distinguish MCS from VS?

Answer 17

1. ) Simple command following.
2. ) Gestural or verbal yes/no responses (regardless of accuracy).
3. ) Intelligible verbalization.
4. ) Movements of affective behaviors that occur in contingent relation to relevant environmental stimuli and are not attributed to reflexive activity.

Question 18

VS vs MCS, does it matter? Why?

Answer 18

-Yes, the prognosis of MCS is significantly more favorable relative to VS.

Question 19

What are the criteria for emergence from MCS?

Answer 19

1.) Functional interactive communication.
OR
2.) Functional use of TWO different objects.

Question 20

PART 3: DOC OUTCOME MEASURES AND POC

Answer 20

PART 3: DOC OUTCOME MEASURES AND POC

Question 21

What is the biggest standardized outcome measure for DOC population?

Answer 21

-John F. Kennedy Coma Recovery Scale (CRS-R)

Question 22

How often is the CRS-R performed? Why?

Answer 22

-Multiple times a day to catch reproducible, purposeful responses.

Question 23

The JFK CRS-R includes 23 items and is split into what 6 subscales?

Answer 23

• Auditory
• Visual
• Motor
• Oromotor
• Communication
• Arousal

You SEE and HEAR a COMA

Question 24

What is the second most widely used outcome measure for Disorders of Consciousness?

Answer 24

-Disorders of Consciousness Scale (DOCS)

Question 25

- The DOCS is a bedside test measuring ____________ functioning during recovery. - It evaluates a patient as they are brought through a series of test stimuli by modalities (No response, Generalized response, Localized response).

Answer 25

-neurobehavioral

Question 26

What are (6) things important for rehabilitation of DOC?

Answer 26

- Positioning - Tone Management - Sensory Stimulation - Equipment Prescription - Family Training - Family Education

Question 27

While still in the VS/MCS stages, cognition goals are largely based off of what?

Answer 27

-CRS-R

Question 28

PART 4: RLAS 4-10

Answer 28

PART 4: RLAS 4-10

Question 29

RLAS-R IV - Confused/Agitated: Maximal Assistance: -Absent _____-_____ memory -May cry out or scream out of proportion to stimulus even after its removal. -May exhibit _________ or ______ behavior. -Mood may swing from euphoric to _______ with no apparent relationship to environmental events. Unable to cooperate with treatment efforts. -Alert and in __________ state of activity.

Answer 29

- short-term - aggressive or flight - hostile - heightened

Question 30

RLAS-R V - Confused, Inappropriate Non-Agitated: Maximal Assistance: - Alert, not ________ though may have infrequent outbursts. - _________; severely impaired recent memory. - Lack of self monitoring or _____ _______ behavior. - Unable to learn _____ tasks.

Answer 30

- not agitated - disoriented - goal directed behavior - NEW

Question 31

RLAS-R VI - Confused, Appropriate: Moderate Assistance: - Emerging awareness of appropriate response to self, family, and basic needs. - _________ _______ to person, time, and place. - Able to attend to highly familiar tasks in ____-________ environment for short duration and w/ assist. - Consistently follows _______ directions. - For the first time, we will see slight improvement in _______, _______ _________, and _________ capabilities.

Answer 31

- Inconsistently oriented - non-distracting - simple - memory, problem solving, and learning capabilities

Question 32

RLAS-R VII - Automatic, Appropriate: Minimal Assistance: - _________ ________ to person and place with highly familiar environments. ModA for orientation to time. - Able to attend highly familiar tasks in a ____-_________ environment for at least 30 minutes with MinA to complete tasks. - _____ supervision for new learning. Demonstrates _____ ______ of new learning. - Superficial _________ of their condition. - Unrealistic planning for the future, unable to think about consequences, and overestimates abilities.

Answer 32

- Consistently oriented - non-distracting - MinA, carry over - superficial awareness (but unaware of impairments and disabilities and limits)

Question 33

RLAS-R VIII - Purposeful, Appropriate: Stand-By Assistance: - __________ _________ to person, place, and time. - Independently attends to familiar tasks for 1 hour in distracting environment. - Able to recall and integrate past and recent events. - Uses _________ memory devices to recall daily schedule, "to do" lists and record critical info for later use with SbA. - Requires _____ assistance once new tasks are learned. - Overestimates or _____________ abilities.

Answer 33

- Consistently oriented - assistive memory - no assistance - underestimates

Question 34

RLAS-R IX - Purposeful, Appropriate: Stand-By Assistance on Request: - Independently shifts back and forth between tasks and completes them accurately for at least __ consecutive hours. - Uses _______ memory devices to recall daily schedule, "to do" lists independently. - Initiates and carries out steps to complete familiar personal, household, work, and leisure tasks ___________. (Completes unfamiliar tasks with assistance when requested). - Accurately estimates abilities but requires ______ to adjust to task demands. - Able to self monitor appropriateness of social interaction with ______.

Answer 34

- 2 consecutive hours - assistive memory - independently - SbA - SbA

Question 35

RLAS-R X - Purposeful, Appropriate: Modified Independent: - Able to handle _______ tasks simultaneously in all environments but may require periodic breaks. - Able to independently procure, create, and maintain own _________ memory devices. - Independent in carrying out familiar and unfamiliar tasks but may require more _____ and/or compensatory strategies to complete them. - Lose the need for _______, needs extra time. - Social interaction behavior is consistently appropriate.

Answer 35

- multiple tasks - assistive memory - time - cues

Question 36

PART 5: ADDITIONAL OUTCOME MEASURES

Answer 36

PART 5: ADDITIONAL OUTCOME MEASURES

Question 37

What are 5 Outcome Measures used?

Answer 37

- GOAT - O-Log - MARS - ABS - RLAS-R

Question 38

Galveston Orientation and Amnesia Test (GOAT): - Normal = ______ - Borderline = _______ - Impaired = _______

Answer 38

- Normal = 76-100 - Borderline = 66-75 - Impaired = <66

Question 39

The Orientation Log (O-Log): - What 3 things does it look at? - >___ on GOAT and >____ on O-Log → no longer in PTA - Is O-Log or GOAT better prediction of rehabilitation outcomes with post-traumatic amnesia (PTA)?

Answer 39

- Place, Time, Situation - >75 GOAT, >25 O-Log - O-Log

Question 40

Moss Attention Rating Scale (MARS): - Measures ___________ responses that affect attention. - Involves the rating of what 3 major factors? - Higher scores = _______ attention

Answer 40

- behavioral responses - Irritability, Initiation, Sustained attention - better attention

Question 41

Agitated Behavioral Scale (ABS): - WNL = _______ - Mild agitation = ________ - Moderate agitation = _______ - Severe agitation = ________

Answer 41

- WNL = 21 or below - Mild agitation = 22-28 - Moderate agitation = 29-35 - Severe agitation = 35 or above