Ch-15 Alteration in Cognitive Systems, Cerebral Hemodynamics and Motor Function Flashcards
What does cognitive behavior functional competence mean?
integrated process of cognitive, sensory and motor systems
What is full consciousness?
state of awareness of oneself and appropriate responses to environment
What are the 2 components of consciousness?
arousal (state of awakeness) & awareness (content of thought)
What is structural alterations?
divided according to their location of dysfunction.
What are the disorders of structural alterations?
supratentorial disorders & infratentorial disorders
Where is supratentorial disorders located and how does this affect our body?
located above tentorium cerebelli; produces changes in arousal
Where does infratentorial disorders located and how does this affect the body?
located below tentorium cerebelli; produce decline in arousal by dysfuntion of reticular activating system or brainstem
What is metabolic alterations?
disorders produce a decline in arousal by alteration in delivery of energy substrates
What are the 5 patterns of neurological functions for alterations in arousal?
(1) level of consciousness
(2) pattern of breathing
(3) pupillary reaction
(4) oculomotor responses
(5) motor responses
Which of the 5 patterns is the most critical index of NS function?
level of consciousness
Highest level of consciousness = person _____/oriented to oneself, others, place & time.
alert
T or F: For level of consciousness, the changes indicate improvement or deterioration.
True
What is apneusis?
prolonged inspiratory time and a pause before expiration.
What is ataxic breathing?
complete irregularity of breathing with increasing periods of apnea
T or F: For pattern of breathing, normal breathing = rhythmic pattern.
True
As consciousness diminishes, breathing responds to changes in ______ levels.
PaCO2
Cheynes-Stokes is directly related to _____
PaCO2
What is the altered period of tachypnea & apnea?
Cheyne-Stokes
Pupillary reaction indicate the presence/level of ______ dysfuntion.
brainstem
What causes pinpoint pupils?
hypothermia/opiates
What is the pupil rxn for when ischemia occurs?
dilated/fixated pupils
Oculomotor responses is when resting, spontaneous and reflexive ______ movements change at various levels of brain dysfunction.
eye
What is the normal response for oculomotor responses.
eyes move together to side opposite from turn of head
What is an abnormal response for oculomotor responses?
eyes do not turn together
What is an absent response for oculomotor responses?
eyes move in direction of head movement
What is an example to test oculomotor responses?
Caloric Ice Water Test - injected into ear canal
What is the normal response for caloric ice water test?
eyes turn together to side of head where ice injected
What is the abnormal response for caloric ice water test?
eyes do not move together
What is an absent response for caloric ice water test?
no eye movement
What does motor responses determine?
it determines brain dysfunction & indicate most severely damaged side of brain.
What are some pattern of response for motor responses?
- purposeful
- inappropriate, generalized movement
- not present
Motor signs indicate loss of _______ _______
cortical inhibition
Loss of cortical inhibition = decreased ______ which is associated with performance of ______ reflexes and rigidity.
consciousness; primitive
What disorder is associated with rigidity?
paratonia
T or F: Grasp reflex is an example of primitive reflexes
True
What are some complex reflex-like motor responses? Where does this integrated in?
vomiting, yawning & hiccups; brainstem
Dysfunction of what brain area results in compulsive/repetitive production of vomiting, yawning and hiccups
medulla oblongata
What are the two forms of neurological death?
brain death (1) & cerebral death (2)
What are the two categories of outcomes of alterations in arousal?
disability (morbidity) & mortality
What is brain death?
- brain damaged; irreversible; cannot maintain homeostasis.
- aka total brain death
What form is neurological death is neurological determination of death (NDD) associated with?
brain death
What are the three Canadian criteria for NDD
unresponsive coma (1), no brainstem functions (2) & no spontaneous respiration (e.g., apnea) (3)
What is cerebral death?
- aka irreversible coma
- death of cerebral hemispheres except brainstem and cerebellum
- brain continue to maintain homeostasis.
T or F: Brain death means there is a permanent brain damage.
FALSE; cerebral death
What areas of brain are not affected by cerebral death?
brainstem & cerebellum
What are the three types of cerebral death?
persistent vegetive state (1), minimally conscious state (2) & locked-in syndrome (3)
Which type of cerebral death is associated with blinking as means of communication?
locked in syndrome
What type of cerebral death is associated with complete paralysis of voluntary muscles except for eye movement?
locked in syndrome
In locked in syndrome, content of thought and level of arousal are intact, meaning they are fully ______
conscious
What type of cerebral death is associated with following simple commands, manipulate objects and give yes/no responses?
minimally conscious state (MCS)
What type of cerebral death is responsbile for complete unawareness of self or environment, does not speak, sleep-wake cycles present and cerebral function is absent.
persistent vegetative state
T or F: Minimally conscious state (MCS) is associated with the presence of sleep wake cycles.
False; persistent vegetative state
T or F: Minimally conscious state has something to so with complete unawareness of self or environment.
FALSE; persistent vegetative state
T or F: In persistent vegetative state. the cerebral function is present.
False; absent
T or F: Minimally conscious state includes giving yes/no responses, manipulate objects and follow simple commands.
TRUE
T or F: Arousal encompasses all cognitive function.
FALSE; awareness
What is awareness mediated by?
Executive Attention Networks (EAN)
The EAN, includes selective _____ and _____ and involve abstract reasoning, planning, decision making, judgement and self-control.
attention; memory
What is selective attention?
ability to select information and focus on related specific task
T or F: Selective attention includes selective visual and auditory attention.
True
What are the 3 types of executive attention deficits?
initial detection, mild deficit & severe deficit
Which executive attention deficits is associated with a person failure to stay alert & orientate to stimuli?
initial detection
What is the mild deficit of executive attention deficits?
grooming and social graces are lacking.
Which type of executive attention deficits is associated with motionless, lack of response and doesn’t react with surroundings?
severe deficit
The characteristics of executive attention deficits is the inability to maintain sustained _____ and inability to set _____ and ____ when goal is achieved.
attention; goals; recognize
What is memory?
recording, retention and retrieval of ifo
What is amnesia?
loss of memory
T or F: Retrograde amnesia is the inability to form new memories.
FALSE; anterograde amnesia
T or F: Anterograde amnesia is the difficulty retrieving past memories.
FALSE; Retrograde amnesia
What are the 5 data processing deficits?
- Agnosia
- Dysphasia
- Acute Confusional State & Delirium
- Dementia (Alzeheimer’s)
- frontotemporal dementia
What does data-processing deficits mean?
problems associated with recognizing & processing sensory information
T or F: Agnosia affects more than one sense.
FALSE; affects only one.
T or F: Agnosia is associated with cerebrovascular accidents to specific brain areas.
True
What is agnosia?
-defect of pattern recognition
- failure to recognized form and nature of objects.
What is dysphasia?
impairment of comprehension or production of language
Name the 2 types of dysphasia?
expressive dysphasia & receptive dysphasia
What is another term for expressive dysphasia?
Broca’s dysphasia
What is expressive dysphasia?
loss of ability to produce spoken or writing language
T or F: In expressive dysphasia, verbal comprehension is usually present.
True
What is another term for receptive dysphasia?
Wernicke dysphasia
What is receptive dysphasia?
inability to understand written or spoken language.
T or F: Expressive dysphasia is associated with speech being fluent but words and phrases have no meaning.
False; Receptive dysphasia
The pathology of dysphasia is due to occlusion of middle ____ _____
cerebral artery
One of the ____ major middle cerebral arteries supplies blood to brain
three
What are the causes of acute confusional states and delirium?
drug intoxication, alcohol withdrawal, post anethesia and electrolyte imbalance
Acute confusional states and delirium are the _____ disorders of awareness and may have sudden or ____ onset.
transient; gradual
Where does delirium most commonly occurs?
in critical care unit over 2-3 days
What are the neurotransmitters involved in delirium?
dysfuntion of acetylcholine & dopamine
Another name for delirium?
Hyperactive acute confusional state
Another name of excited delirium syndrome?
agitated delirium
How do you evaluate acute confusional state & delirium?
CAM-ICU: Confusion Assessment Method for Intensive Care Unit
When the person acquires acute confusional states and delirium, there is a disruption of _______ system, thalamus, cortex and _____ system
reticular; limbic
What are some manifestations for acute confusional states and delirium?
terrifying dream, hallucinations, gross alteration of perception, individual cannot sleep
What are some signs for excited delirium syndrome?
rapid breathing, high tolerance to pain and superhuman strenght
T or F: Hyperkinetic delirium is an excited delirium syndrome that can lead to sudden death.
True
What is dementia?
deterioration/progressive failure of many cerebral functions
What causes dementia?
cerebral neuron degeneration, atherosclerosis & genetics
What are some manifestations for dementia?
no specific cure exists, maximizing remaining capacities & helping family to understand
What disease is the leading cause of severe cognitive dsyfunction in older adults/ exact cause is unknown?
Alzheimer’s disease
What are the three forms of Alzheimer’s disease?
(1) Nonhereditary sporadic late-onset AD
(2) Early-onset familial AD
(3) Early-onset AD
T or F: Early-onset AD is very rare.
true
T or F: Early-onset familial AD is the most common form of AD.
False; Nonhereditary sporadic late-onset AD
T or F: Nonhereditary sporadic late-onset has no specific genetic association.
True
What % of Nonhereditary sporadic late-onset AD are there?
70-90%
Which form of AD is linked to chromosomal 21 mutations?
Early-onset familial AD
Which form of AD is linked to chromosomal 19 mutations?
Early-onset AD
T or F: The pathological alterations of all types of Alzheimer’s are different.
FALSE; all pathological alteration of all types of AD are same
The key components of AD are the accumulation of ____ fragments of ______ plaques (1),
loss of _____ in forebrain cholinergic neurons = _____ of neurons, (2)
____ proteins (microtubule) form neurofibrillary tangles within the neuron = _____ neural death (3),
neurofibrillary tangle are concentrated in ______ cortex (4)
Brain atrophy via widening of ____ (grooves) and ____ of gyrus (5)
toxic; acetylcholine, death; tau, increased; cerebral; sulcus, shrinking
T or F: Sulcus are grooves.
True
What are the first symptoms of AD?
memory loss & impaired learning
What are the continuation of symptoms of AD?
- language
- reasoning
- social behavior
- dyspraxia
What is dyspraxia?
loss of movement and co-ordination
T or F: When person has AD, the progression from STM loss to total loss of cognitive function.
true
T or F: The pathophysiological changes of AD can occur decades before dementia syndrome.
true
Which data-processing deficits is previously known as ‘pick disease’?
frontotemporal deficits
T or F: Frontotemporal dementia is the second most know form of dementia.
true
The frontotemporal dementia is an umbrella term for disorders that affect _____ and _____ regions of brain.
frontal; temporal
What are the first symptom of frontotemporal dementia?
apathy, poor judgement/ reasoning, break laws
T or F: Frontotemporal dementia involves mutation of tau encoding genes.
true
Frontotemporal dementia has ____ component with onset at less than _____ years old.
genetic; 60
Seizures represent a _____ of disease, not a specific disease entity.
manifestation
What is seizure?
sudden disruption in brain electrical function caused by ab excessive discharge of cortical neurons (interneurons)
What is epilepsy?
recurrence of seizures where no known cause for seizures can be found.
What are convulsions?
jerky, contact-relax movements associated with seizures.
What are some probable causes of seizures for older adults?
alcohol, drug withdrawal; metabolic disorders; CNS degeneration
What are some probable causes of seizures for young adults?
alcohol, drug withdrawal; brain tumour; peri-natal insults
When does peri-natal insults occur?
between 28 weeks of gestation to 28 days after birth
What are the three anatomy of a seizures?
(1) epileptogenic focus
(2) tonic phase
(3) clonic phase
Which anatomy of seizures involves muscles contraction with increased muscle tone, thus associated with loss of consciousness?
tonic phase
What happens to the brain during clonic phase?
there is reduced in O2, leading to the switch to anaerobic metabolism, thus there is an accumulation of lactic acid
What is the cause of the seizure cessation during clonic phase?
due to epileptogenic neurons being exhauted
T or F: Increase in number of seizures = decrease in brain damage.
FALSE; increase in brain damage
What is the result of clonic phase?
seizure discharge is interrupted, thus intermittent contractions diminish and cease
Which anatomy of seizures involves alternative contraction and relaxation of muscles.
clonic phase
Clonic phase begins when _____ neurons in thalamus and basal ganglia react to cortical excitation.
inhibitory
Where is the focus of epileptogenic seizures?
brain site where seizure originates; aka epileptogenic zone
Neurons in epileptogenic focus are ______ and activated by numerus stimuli
hypersensitive
What is SPECT?
test that detects blood flow changes in brain
T or F: During seizure focus can be determined by activated SPECT.
true
The cerebral blood flow (CBF) related to _____ injury states.
three
What are the three injury states of CBF?
(1) inadequate cerebral perfusion
(2) normal perfusion but with elevated intracranial pressure (ICP)
(3)Excessive blood volume (CBV)
What is the normal ICP?
1-15 mmHg
ICP results from _____ in intracranial content due to tumour, edema, hemorrhage, etc
increase
What is the first thing to be removed in order to increase content?
displacement of cerebral spinal fluid (CSF)
What is the result of continued high ICP?
alterations in cerebral blood volume and blood flow.
What is the result of alterations of cerebral blood volume and blood flow?
four stages of ICP that lead to death
Which stages of ICP is associated with the cranial vasoconstriction and systemic adjustments?
Stage 1
During stage 1 of ICP, the cranial ______ and systemic _____ result in a ______ in ICP.
vasoconstriction; adjustments decrease
T or F: There are no detectable symptoms of ICP during stage 1.
True
During stage 2 of ICP, the pressure begins to affect neuron _____
oxygenation
With the continual expansion of intracranial contents during stage 2, the ICP ______ compensatory mechanisms
exceeds
What are some manifestations during stage 2 of ICP?
confusion, restlessness and lethargy
The pupils and breathing during stage 2 of ICP remain ______
normal
What is best intervention for stage 2 of ICP?
surgical intevention
What is autoregulation?
mechanism to alter diameter of intracranial blood vessels to maintain a constant blood flow during changes in ICP
T or F: Autoregulation is lost in stage 4.
False; lost in stage 3
When autoregulation is loss, ICP approaches _____ pressure.
arterial
During stage 3 of ICP, severe ______, hypercapnia, and _____ occur.
hypoxia; acidosis
What are some manifestations for stage 3 of ICP?
loss of peripheral vision, blindness and tinnitus
During stage 3 of ICP, ______ intervention is ______ here.
surgical; needed
What is the condition of pupils during stage 3 of ICP?
small & sluggish
During stage 3 of ICP, there is ______ of pulse pressure.
widening
Herniated brain tissue in stage 4 of ICP, means there is ______ in blood supply
reduction
During stage 4 of ICP, the brain tissue shifts or _____ from greater pressure to lesser pressure
herniates
T or F: Herniations rapidly increases ICP.
true
What are the conditions of pupils during stage 4 of ICP?
bilateral dilation and fixation
The breathing during stage 4 of ICP is ______
Cheyne-Stokes breathing
The mental status during stage 4 of ICP?
progresses to deep coma
During stage 4 of ICP, surgical intervention is _____ here. Thus ______ occur
futile; death
What are the three types of cerebral edema?
vasogenic edema (1), cytotoxic edema (2) & interstitial edema (3)
What is the most important type of cerebral edema?
vasogenic edema
What causes vasogenic edema?
increased capillary permeability/disruption of BBB
What are some manifestations of vasogenic edema?
consciousness disturbances and increases in ICP
What is the resolution for vasogenic edema?
slow diffusion
During vasogenic edema, the plasma proteins and fluid leak into cranial _____. So the fluid accumulates in _____ matter which leads to ______ of myelinated fibers.
ECF; white; separation
During brain edema, the lateral ventricles are ______ and the _____ flattened
compressed; gyri
In cytotoxic edema the loss of ____ and gain large amounts of of ____ = change in intracellular osmolarity thus the cells _____
K+; Na+; swell
Which type of cerebral edema is associated with toxic factors that affects neural, glial, and endothelial cells which results in loss of active transport mechanisms?
cytotoxic (metabolic) edema
Which type of cerebral edema is associated with the movement of cerebral spinal fluid from ventricles into interstitial space?
interstitial edema
What is the result of interstitial edema?
disappearance of myelination
With interstitial edema, as fluid volume increases around ventricles, there is an increased pressure within ______ matters, which results in disappearance of _______.
white; myelination
What is the condition in which there is an excess of cerebral spinal fluid (CSF) in ventricles or subarachnoid space?
hydroencephalus
What is the cause of hydroencephalus?
- increased CSF production –> obstruction in ventricles –> defective reabsorption of CSF fluid into systemic blood.
What are the 2 types of hydroencephalus?
communicating hydrocephalus & noncommunicating hydrocephalus
T or F: The cause of noncommunicating hydrocephalus is infection.
False; congenital
T or F: Communicating hydrocephalus only occurs in adults.
FALSE; noncommunicating hydroencephalus
T or F: Communicating hydrocephalus is the impairment absorption of CSF from subarachnoid space
True.
What causes communicating hydrocephalus?
infection
T or F: Noncommunicating hydrocephalus is present from birth (congenital)
true
What is noncommunicating hydrocephalus?
obstruction of CSF between ventricles
The word “communicating” refers to fact the _____ can still flow ____ the ventricles.
CSF; between
Hydrocephalus is due to the _____ of CSF flow which increase pressure and ____ of ventricles. Leads to ______ of cerebral cortex and _______ of ______ matter
obstruction; dilation; atrophy; degeneration; white
The manifestations for acute hydrocephalus is the ____ developing of ICP, which leads to deep _____
rapidly; coma
T or F: Hydrocephalus develops slowly for normal pressure hydrocephalus.
true
In normal pressure hydrocephalus, there the dilation of ventricles _____ increased pressure
without
In normal pressure hydrocephalus, the family notices declines in _____.
memory
What are the triad symptoms for normal pressure hydrocephalus?
broad-base gait, falling & incontinence.
What is the tx for hydrocephalus?
shunt procedure
T or F: Shunt procedure is one of the three most common neurosurgical procedures.
true
T or F: Hypertonia is the decreased in muscle tone.
false; hypotonia
People with hypotonia have joints that are _____ which can acquire positions requiring extreme joint mobility
hyperflexible
What are some characteristics of hypotonia?
tire easily (1)
difficulty rising from sitting position (2)
muscle mass atrophy (3)
muscles appear flabby and flat (4)
T or F: Hypotonia is the increased in muscle tone.
FALSE; hypertonia
What are the symptoms of hypertonia?
enlargement of muscle mass, dev of firm muscles and muscle spasms
Which muscle tone is associated with passive movement the occurs with increased resistance?
hypertonia
What are the causes of alterations in muscle movement?
neurotransmitter dopamine involved in several disorders (1) & other disorders are neurological disorder (2)
What is hyperkinesia?
excessive, purposeless movement
What are the 3 types of hyperkinesia?
- Paroxysmal dyskinesias
- Tardive dyskinesias
- Ballism
Which type of hyperkinesia is associated with the muscle disorder with wild flinging movement of limbs?
ballism
What are some characteristics of tardive dyskinesias?
rapid repetitive stereotypical movements like continually chewing or tongue protrusions.
A disorder that involves tardive dyskinesias is _____ syndrome
tourette
Tardive dyskinesias involves _______ movement of face, lips, tongue and extremeties.
involuntary
what often caused tardive dyskinesia?
prolonged antipsychotic meds
Which type of hyperkinesia is associated with involuntary movements that occur as spasms
paroxysmal dyskinesias
What is huntington’s disease known as?
chorea
T or F: Huntington’s disease symptoms are hallmark of hyperkinesia.
true
What is the onset for HD?
25-45 years old
What brain areas involved in HD?
basal ganglia and cerebral cortex
HD is relatively rare degrative _______ disorder
hyperkinetic
What are some manifestations for HD?
- begins in face & arms –> eventually the whole body
- thinking is slow
- alterations in euphoria and depression are common
- involuntary fragmented movements.
HD is an inherited disease, _______ dominant trait
autosomal
T or F: The age of disease onset for HD is determined by number of repeated amino acid chains.
true
HD: increase amino acid chains = _____ toxicity of protein = _______ age of onset
increased; earlier
How many does healthy gene repeats?
10-26
In HD, altered amino acids chain = _____ toxic to neurons
protein
There is a mutation in chromosome ____ for HD that result in _____ long protein caused by cytosine-adenine-guanine (____) trinucleotide.
4; abnormally; CAG
Hypokinesia means there is a _____ in movement
decreased
What is hypokinesia?
loss of voluntary movement despite preserved consciousness.
What are the two types of hypokinesia?
akinesia (1) & bradykinesia (2)
T or F: Bradykinesia is the lack of spontaneous movement or associated movements.
FALSE; akinesia
What is bradykinesia?
slowing of performed movements
What is akinesia?
lack of movement
What is Parkinson’s disease (PD)?
complex motor disorder accompanied by systemic nonmotor and neurological symptoms
When does primary PD begin?
after 40 years old with increased incident after 60 years old
T or F: Secondary PD is the leading cause of neurological disability in people over 60 years old.
FALSE; primary PD
________ intoxication PD is the most common secondary form and most often reversible.
medication
What are the causes of medication intoxication PD?
- neuroleptics –> antipsychotics (treat hallucinations, delusion)
- antiemetics –> prescribed to address nausea and vomiting
- anti-hypersentives
Secondary PD is caused by ______ other than PD (e.g., head trauma, infections, toxins and meds intoxication).
disorder
T or F: PD involves single gene mutations.
FALSE; several gene mutations
What is the pathology for PD?
basal ganglia dysfunction due to misfolded proteins
Symptoms like muscle tremor and rigidity produce _____ movement called _____’s
abnormal; Parkinson
PD: Because of the basal ganglia dysfunction due to misfolded proteins, there is a loss of _____-producing neuorns in ______ ____
dopamine; substantia nigra
What are some manifestations for PD?
- resting tremor, rigidity, bradykinesia, dysarthria
- loss of smell can be an early symptom
Dysarthria = _____ ____
slurring speech
What is the result of disorders of equilibrium?
falls like a post
T or F: PD can make appropriate postural adjustments to tilting
FALSE; can’t make appropriate postural adjustments to tilting
What is the principle feature of Lou Gehrig’s disease?
degeneration of both lower and upper motor neurons
How does Lou Gehrig’s disease affect lower motor neurons?
denervation of motor units
How does Lou Gehrig’s disease affect upper motor neurons?
- decrease in large motor neurons in CNS
- motor neurons death results in demyelination and glia proliferation and sclerosis (scarring)
What are some manifestations for Lou Gehrig’s disease?
- muscle weakness starting in arms and legs, progressing to difficulty speaking and swallowing.
- no associated mental or sensory symptoms.
T or F: There is an associated mental or sensory symptoms in Lou Gehrig’s disease
FALSE; no associated mental or sensory symptoms
What is the tx for Lou Gehrig’s disease?
meds: rilutek extends time before ventilatory assistance is required
