Delirium, seizures, and disorders of consciousness

Question 1

Clinical presentation of delirium

Answer 1

confusion/disorientation; severely impaired attention; amnesia; psychomotor agitation; irritability; disturbed sleep-wake cycle; delusions and illusions/hallucinations; often underlying dementia

Question 2

Core symptom of delirium

Answer 2

severely impaired attention

Question 3

Onset and course of delirium

Answer 3

rapid onset (typically in hospital) but transient/reversible and has a fluctuating course with sundowning

Question 4

5 causes of delirium

Answer 4

drug-induced, metabolic (e.g. hypo/hypernatremia, hypoglycemia), infectious (e.g. UTI, pneumonia), post-seizure state, acute post-traumatic confusion, alcohol withdrawal syndrome

Question 5

Examples of drugs that induce delirium

Answer 5

opiates, steroids, anesthesia, medication overdose

Question 6

Pathophysiology of delirium

Answer 6

multiple pathways but cholinergic system dysfunction is primary

Question 7

Diagnostic tests for delirium

Answer 7

check temperature (febrile/fever symptoms), blood tests (infections and toxicology), EEG (diffuse slowing), CT or MRI if no obvious systemic cause

Question 8

Clinical management for delirium

Answer 8

treat underlying systemic illness, low environmental stimulation, supervision, frequent reorienting, medication for severe agitation

Question 9

3 main differences between delirium and dementia

Answer 9

onset, course, blood test results

Question 10

Epilepsy

Answer 10

recurrent seizures

Question 11

Seizure

Answer 11

paroxysmal electrical discharges of the brain (overactivation of neurons)

Question 12

Simple partial seizure

Answer 12

focal seizure with preserved awareness

Question 13

Complex partial seizure

Answer 13

focal seizure with impaired awareness

Question 14

Grand mal

Answer 14

generalized tonic-clonic (extension and contraction)

Question 15

Convulsion (clonic)

Answer 15

involuntary repetitive muscular contractions due to paroxysmal electrical discharges

Question 16

2 most common types of seizures

Answer 16

complex partial then generalized TC

Question 17

Characteristics of focal seizures

Answer 17

aura and motor features depend on site of origin; head and eyes turn away from seizure site; arrest of speech; tonic extension of contralateral limbs; ipsilateral automatisms; can have retained awareness or LOC; post-ictal fatigue, aphasia, and intense emotion

Question 18

Examples of automatisms in focal seizures

Answer 18

lip-smacking, chewing, fumbling of the hands

Question 19

Characteristics of generalized TC

Answer 19

often no warning (but prodrome possible); sudden LOC and drop/fall; tonic and clonic phase; post-ictal conditions

Question 20

Tonic phase in generalized TC

Answer 20

back, neck, arm, and leg musculature flexion and paused breathing for 10-20s

Question 21

Clonic phase in generalized TC

Answer 21

violent rhythmic spasms of entire body that are gradually decreasing in amplitude/frequency

Question 22

Post-ictal conditions of generalized TC

Answer 22

motionless and limp in a coma; often confused and agitated with eye opening

Question 23

4 neurophysiological phases of a seizure

Answer 23

(1) cluster of pathologically excitable neurons fire faster; (2) discharge intensity overcomes inhibitory influence; (3) spreads to neighboring regions; (4) post-ictal neuronal glucose depletion

Question 24

3 main causes of seizures

Answer 24

idiopathic (unknown origin or cause); trauma or tumor; genetic/familial

Question 25

3 diagnostic tests for seizures

Answer 25

interictal EEG, specialized EEG with inpatient observation, MRI (for focal lesions)

Question 26

Treatments for seizures

Answer 26

antiepileptic medications, ketogenic diet (for children), surgery (for 25% with medication-refractory focal)

Question 27

3 DoC states

Answer 27

coma, vegetative state, minimally conscious state

Question 28

Coma

Answer 28

no eye opening (either spontaneously or after stimulation), oriented or voluntary motor or verbal responses (including vocalization)

Question 29

Vegetative state

Answer 29

preserved physiological functions (cardiac, respiratory, sleep/wake cycles) without clear signs of awareness of the self or environment; only reflexive behaviors

Question 30

Minimally conscious state

Answer 30

shows some oriented (i.e. environmentally contingent) behavior, not attributable to reflexes

Question 31

What is the best outcome for most patients with DoC?

Answer 31

permanent severe disability

Question 32

Treatments for DoC

Answer 32

amantadine daily for 4 weeks during weeks 4-16 for posttraumatic coma/VS; experimental therapies (e.g. repetitive transcranial magnetic stimulation, deep brain stimulation)

Question 33

3 main clinical challenges with DoC

Answer 33

misdiagnosis is common (30-40%); cognitive-motor dissociation (15-20%); management of pain and medical complications (e.g. hypertonia, UTI, pneumonia)

Question 34

Cognitive-motor dissociation

Answer 34

aka covert consciousness; detection of volitional brain activity through fMRI or EEG in people who appear unresponsive