Lecture 9: Altered Cognition Flashcards
The act or process of knowing, including awareness, reasoning, judgement, intutition, and memory
cognition
Lowest level of consciousness
* Can you arouse them?
* Are their sleep wake cycles
* Do they respond to painful stimuli?
* Are they on a vent?
* Do the have DTRs?
Coma
* complete state of unresponsivness
* advanced brain failure
* Unconscious
* Unarousable
* Eyes closed
* No sleep wake cycles
* No response to painful stimuli
* May be ventilatoy dependent
* May not demonstrate reflex reactions
Another name for vegtateive state
* do they have vegetative functions?
* Are they on a vent?
* Are they aware of surroundings? can they have meaningful cognitive and communication
* Do they have reflexes? are the reproducible voluntarily?
* what is considered permanet/persistent vegeatitive state? (TBI vs Anoxic brain injury [I think this is like a stroke or something])
Wakeful unresponsiveness
They have vegtative functions - such as respiration, digestion, and blood pressure control
Can be a weaned off a ventilator if on it prior
Sleep/wake cycles present - wakeful litteraly in the name
No awareess of surroundings - meaningful cognitive and commucation function absent
Reflexive in response to external stimuli - movement will not be reproducible
* They can’t actaully do the movement consciouly but still have the reflex
Permanent/Persistent vegetative state: lacks meaninful motor of cognitive function and a complete absence of awareness of self or the environment for a period greater than 1 year after a TBI anf greater than 3 months after anoxic brain injury
Minimally Conscious State
* What are sleep wake cycles like?
* can these people be aroused? If so wil lthey have awareness of environment/self?
* Will they have an appropriate response that isnt purely reflexive
Irregular sleep-wake cycles
Normilization of “vegetative” functions - respiration, digestion and blood pressure control (note this comes after vegetaive function, so ofc they’ll have evegative functions)
May be aroused, minimal evidence of self of environmental awareness
* makes sense because this is called minimally conscious state
Cognitively mediated behaviors occur inconsistently
* may attach some thought to what they’re doing
Instead of withdrawing or posturing to stimuli, patients will localize to stimuli and may inconsistently reach for objects
* so they might have an appropriate response when you have some stimuli (not just reflexive)
Patients may localize to sound location and demonstrate sustained visual fixation and visual pursuit
* This doesnt necisially mean they’re focused on you, they can just look toward a sound, or fix their vision/have visual pursuit
State of altered mental status and responsiveness
* what kind of stimuli can they respond to?
Stupor
* this is better than minimal conscious state because they now respond more consistently
However, they ony are arousable to strong stimuli (vigorous, unpleasent) - think sternal rub or pinching
Minimal voluntary verbal or motor responses
Sleeping more than awake?
* what are they like when they’re awake?
* What are interactions like?
* What kind of questions should a therapist ask these pts?
Obtunded
* minished arousal and awareness
Drowsy and confused when awake
Non-productive interactions
Therapist: gently shake pt to awaken, use simple questions
* note: you can gentely shake them to wake them up, they dont need that painful stimuli like they did in a stupor
What kind of state is a pt in when they need a painful stimuli to awaken them?
* What about a gentle shake
Stupor
Obtunded
Drowsy but can open eyes on own and respond briefely to questions
* what happens if they are not continusouly stimulated?
* Can they maintain focus?
* Can we work with someone whos lethargic?
Lethargic (we’ve all ben lethargic)
Level of arousabl diminished
Easily falls asleep if not continually stimulated
Difficulty maintaing focus
Therapist: Speak in loud voice, use simple / directed questions
Yes, we can work w/ someone who is lethargic
A&OX4
Alter and oriented to person, place, time and event/situation
Alert = awake, alert and oriented to surroundings
Acute confusional state, reversible
* Common cause of this?
* Do they have hallucinations
Delirum
Deprivation of O2 to the brain (causes s/s), metabolic imbalance, or adverse drugs reactions can all induce confusion
* think having a UTI and being on a lot of meds - once system is cleaned out delirum gets better
Clouding of consciousness, dulling of cognitive processes, impaired alertness
Inattentive, incoherent, and disorganized with fluctuating levels of consciousness
Hallucinations and agitation are also commmon
Is delirum reversible?
Yes
General anestheics are classified according to their 2 primary routes of administration. What are they?
1) Inhalation
2) IV injection
How do the effects of anesthesia work? (which receptors)
Considerable debate about exactly how these drugs cause general anesthesia
At least some of the anesthetic effects of inhaled and IV agents are mediated by specific receptors located on CNS neurons (this is whats producing the effect)
Anesthetics are highly _ soluble
* A lengthly procedure can lead to prolonged sedative-like effects. Why is this?
Lipid soluble
Release from these storage sites may help account for prolonged sedative like effects when the patient is recovering from a lengthy surgical prodcedure
General anesthesia:
Specific anesthetic agents and anesthetic adjuvants are selected according to many factors, including the type of surgical procedure being performed, the surgeions preference, and the pts overall condition
Several different anthestics and anesthetic adjuvants are often combined to provide optimal results during surgery and provide balanced anesthesia
* so we dont just go in all on 1 drug, sprinkle in some other medications
Residual effects of anthestia we as health progessionals should be cognizant that patients may take some time to fully recover from the effects of genreal anesthesia
* so if someone was knocked out for a while we wouldnt want to immediately take them down stairs
Used frequently when a lmited, well defined area of anesthesia is required (EX - most minor surgical procedures)
Local anthesia
* think getting toe ingrown toe nail removed / stuff they do at the dentist
W/ local anthesia
Can be used to temporarily block transmission in the area of
* Peripheral nerve endings
* Along the trunk of a single peripheral nerve
* Along several peripheral nerves or plexuses
* At the leel of the spinal cord
May also be used to block efferent sympathetic activity
* These drugs appear to block transmission along nerve axons by binding to membrane sodium channels and by preventing the hannels from opening during neuronal exciation
Pts may frequently encounter pts using these agents for both short and long term pain contorl and to manage sympathetic activity
* So it the pt has this in the femoral nerve following a total knee, we should no that the quad muscle activity would be inhibitited meaning they wont be able to get as much knee extension / the knee will buckle. Need to be extra careful if they’re mobile/were walking them
The spinal cord has a temporary anthestic block in it. Is this general anthesia or local?
Local
How much sleep is needed for adults?
8-9 hours/night
Infants = 16 hours/day
Teens - 9 hrs/night
however, I wouldnt memeorize she said these #’s were changing
Daytime sleep attacks
Irresistible desire to sleep several times during the day (you can’t fight it)
* how long are you out
* What do you see when you fall asleep
Narcolepsy
Think about video of girl passing out while playing badmitting
Sleep paralysis for 1-2 minutes (so you’re out temporalirly)
Hypnogogic hallucinations at sleep onset
Distortion of rem sleep
Cataplexy happens w/ narcolepsy. What is this?
Sudden brief episodes of muscle paralysis (cant move)
Knowledge check: Which of the following states of consciousness is reversible
delirum
TEST: Psychological disorders often result from neurotransmitter imbalances. What are the 3 neurotransmitters that are often imbalanced in these disorders
* neuroanatomical variants that can cause this (2)
Dopamine
Norepinephrine
Serotonin
can also be due to genetric abnoramlity or inheritated traits
Neuroanatomical variants
* enlarged ventricles
* Regional atrophy (usually fronta, temporal, thalamic)
Two demains of impairment austism spectrum disorder
1) Social communication and interaction
2) Restricted, repetitive patterns of behavior, interests, activities.
Etiology is unclear
* biological/genetic?
* Environmental?
NOTE: prognosis of disease is directly linked to severity
NOTE: you can be severly cognitively messed up with autism but be completely fine functionally
PTSD
* Due to: emotional, mental, spiritual, physical, or sexual trauma
* any age
Risk factors:
* magnitude of the stress
* previous history of traumatization
* Presence of both physical and psychological trauma
* Sleep disturbances
What are our 3 categories within PTSD?
1) Intrusion
2) Avoidance
3) Arousal (hyperarousal)
prefrontal cortex changed a little
* yper vigiliance of intrusive thoughts or fear avoidance after something intense happens
Generalized excessive emotional state of fear and apprehension suually associated w/ a heightened state of physiological arousal
Anxiety disorders
* Generalized anxiet disorder
* Panic attack
* Panic disorder
* Phobias
Etiology - unclear
* genetics?
* neurotransmitters?
* Neurocircuitry?
* Neural hormonal?
* Environmental?
Dont say “its going to be fine, I have anxiety to”
Benzodiazepines - inhibit GABA (which is excitatory but this drug balances it)
shes not holding us to these drug names
What kind of depression is with or without seasonal pattern with or without another medical condition
Major depressive disorder
Etiology of depression
* Neural activity + endocrine + immune response
* Neurotransmitters: noreepi/dopamine/serotonin
may not be just straight up depression
s/s of depression
many names/types for bipolar disorder
age of onset for bipolar disorder
20s
How long do episodes last for bipolar disorder?
Episodes can last for weeks or months in adults, can occur many times a day in children or adolsencents
what are biopolar attacks like?
Irregular and unpredictable
believed causes of bipolar disorder (2)
neurotransmitter imabalnce
genetics
note: it has triggers
drug of choice for treating bipolar disorder
Lithium
KNOW: Most help and important to remember is that PA is also an effective intervention to improve mental health
Term used to describe the more severe forms of mental illness
A group of mental disorders characterized by marked thought disturbance and impared perception of reality
Psychosis
Psychoses
Most common form of psychosis
Schizophernia
* it is estiamted that 1 percent of the worlds population has this disorder
other psychotic disorders include schizoaffective disorder, delusional disorder, brief psychotic disorder, and shared psychotic disorder
Hallucinations, delusions, disorganized thoughts, disinhibition and socially inappropriate behavior, physical agression are all positive or negative psychotic schizophernia symptoms?
* Do they respond well to medication?
Positive psychotic symptoms
* responds well to meds
Inability to engage in normal emotional or social interactions, impared self care, lack of motivation, flattened affect are all positive or negative psychotic symptoms of schizophernia?
* Do they respond well to meds?
* What is diminshed?
Negative
Do not respond well to meds
diminished prefrontal function
Antipsychotic drugs are used to manage mental illness. However, because they have the potential to block dopaminergic receptors, antipsychotics are associated w/ several side effects
* The most serious of these are abnormal movement patterns that resemble tardive dyskinesia, parkinsons disease, and other lesions associated w/ the extrapyramidal system
Knowledge check: racing speech, thoughts, recless behavior, and poor judgement typically acompany which disorder
Bipolar
Result of excessive hypersynchronous discharge of cerebral neruons resulting in paroxysmal alteration of neurologic function
Seizure
* Note: Its a finite event, has a benginning and a set end (unlike epilespy)
Condition of recurrent, unprovoked seizures
define the criterial for this disease
Epilepsy
1) At least two unprovoked or reflexive seizures more than 24 hours apart
2) One unproboked or reflex seizure and a probability of having another seizure similar to the general recurrance risk after two unprovoked seizures (>/60%) over the next 10 years
3) An epilepsy syndrome
Are acute symtpomatic seizures considered epilespy
* what % of seizures are these?
* Male or female gets them more
No
40-50%
Males > Females - this is likely due to things like TBI being more common in males and leads to this
Etiologic factors are varied and include infections, stroke, CNS tumors, metaboic disorders, toxins, and arteriovenous malformations
A transient alteration of behavior brought about by abnormal burst firing of neurons in the cerebral cortex?
Seizure
Why do seizures start?
Excess glutamate and calcium channel activation
Prolonged gebril status epilpticus or hypoxia causes sprouting of excitatory mossy fibers
SENSITIZATION OF NEURONAL TISSUE DUE TO DRUG OR ELECTRICAL STIMULUS
* GRADUALLY AUGMENTED STIMULATION OF THE BRAIN RESULTING IN ELECTRICAL ACTIVITY
Kindling
Seizure has 3 phases, what are they?
1) Prodromal phase
2) Tonic Phase
3) Clonic Phase
Which phase of a sizure is signs/symptoms indicating an impending seizure - only occurs in those seizures that can be proboked
Prodromal phase
Which phase of a sizure is where neurons are tonically depolarized and fire continuously in a sustained, high-frequency discharge
Tonic phase
What phase of a seizure has phasic repolarizations that interrupt continuous firing pattern and gradually restore membrane potentials to normal or to a temporarily hyperpolarized state (postictal depression)
Clonic phase
seizure
knowledge check asked about prodromal phase
What are the two kinds of seizures?
Generalized and focal (partial)
Generailized seizures have 2 subgroups that are
1) tonic-clonic
2) Absence
Focal (partial) seizures have two subgroups that are
1) Simple
2) Complex
Focal seizures (partial)
* how many hemispheres?
* Are they the full brain or more localized?
*
one hemisphere
Localized or more widely distributed (still only one hemisphere)
Clinical or EEG evidence of a local onset
what kind of seziure originates in the hemispheres, activates bilateral neuronal networks?
what does pt look like when they’re having these?
Generalized
can be asymmetric
absence - sudden cessation of ongoing conscious activity
* looks like they’re day dreaming when they have these
seizure
seizure
NOTE: in focal seizures it can affect any lobe. However, the s/s will vary depending on which lobe is targeted. Think seiure in occipital lobe will imapct vision.
Triggers for seizure
Describe the tonic phase of a tonic-clonic seizure?
* how long does it last?
Describe the clonic phase of a tonic clonic seizure?
Tonic phase
* body becomes rigid
* Becomes cyanotic
* Jaw fixed
* Hands clenched
* 30-60 seconds
Clonic phase
* Rhythmic jerk contract/relax
NOTE: Tonic-Clonic seizures also called grand mal seizure
What kind fo seizure is a sudden, brief, single or repetitive muscle contraction of one part or the entire body?
Myoclonic seizure (petit mal)
what does atonic mean?
drop attacks
what parts of the brain are involved w/ tonic clonic seizures (3)
brain stem (and possible the prefrontal cortex and basal ganglia)
These are the anticonvulsant medications. However, shes not going to ask us medication names specifically. Shes going to ask us questions like “what are the side effects of anticonvulsants”
What are the side effects of anticonvulsant medications (used for seizures) (6)
1) Ataxia
2) Incoordiantion
3) Dizziness
4) Sedation
5) Duplopia
6) Tremor
Knowledge check: Which of these is a side effect of anticonulsant medications?
* ataxia
Transient occurance of signs and symptoms due to abnormal excessive or synchronous neuronal activity in the brain
Epilepsy
Clusteros of clinical and EEG feastures that respond to particular treatments and may have specific prognostic implications
* Are they predictable?
Epileptic syndromes
* unpredicatble
* Idiopathic or acquired
* 45 million people worldwide
* peak onset 0-5 or 70+
What are the 3 cateogires of epilepsy
1) Electroclinical syndromes
2) Non-syndromic with structural or metabolic causes
3) Epilepsies of unknown cause
Non-syndromic with structural or metabolic causes (NS releated causes)
TEST How long does a seizure need go last to call 911
5 minutes
What is status epilepticus?
seizure that lasts more than 5 minutes
seizures are so prolonged or so reepeated that recovery does not occur between attacks
get them on the floor
get them on their side to keep airway clear
What percent of people w/ epilepsy can be treated sucessfully w/ antiepileptic drugs
75%
Do antiepileptic drugs cure the disease?
Do not cure the disorder, reduction or elimination of seizures will prevent further CNS damage
cannot withdraw from these drugs most of the time because the risk is to high
behavior or functional changes common w/ antiepeltic drugs
Knowledge check: Seizure lasting how long will warrent emergency measures
5+ minutes
Which disease has a decline from a previously established level of cognitive and fucntional performance of an individual that is sufficient to interfere with daily activities
Dementia
An acquired syndrome of impared cognition produced by brain dysfunction
Dementia
KNOW: Dementia is the 4th leading cause of death in adults
* most common cause is Alzhimers disease (over 70% of dementia cases in people over 70 years old)
Subjective cognitive decline noted w/ people who have dementia (might be diagnosed w/ this before dementia)
cantigories like alzhermiers disease fall under dementia
Knowledge check: something about vascular dementia?
Which disease has senile plaques with extracellular amyloid?
Neurofibrillary tangles prevent neuro transmision
Disruption of function of multiple major neurotransmitters
Alzheimers
risk factors, however, no single identified cause
Which parts of the brain are the amyloid plaques and neurofibrillary tangles (2 places)
Hippocampus
Amygdala
In alzheimers which parts of the brain has decreasing function? (3)
Hippocampus
leads to anterograde amnesia
* forgetfulness
* direction finding
* Spatial sense
* Attentional deficit
Decreasing occipotemporal function
* reading / writing
* facial recognition
Decreasing frontal lobe fucntion
* vacant
TEST: In alzheimers they forget the entire experience (rarely remember later) whereas in age releated memory change they only forget part of the experience
Global Deterioration scale - for dementia
* 1 = normal
* 7 = severe dementia
differential diagnoses for alzhemiers
$
