Week 2- TBI: Arousal And Cognitive Considerations Flashcards
PART 1: INTRODUCTION
PART 1: INTRODUCTION
What are the 5 levels of Arousal?
- Full Consciousness
- Lethargy
- Obtundation
- Stupor
- Coma
What are the major domains of Cognition? (6)
- Attention
- Memory
- Intelligence
- Executive Function
- Social Cognition
- Judgement
What are the main (5) Cognition-based outcome measures?
- GOAT
- O-Log
- Moss Attention Scale
- Agitated Behavior Scale
- Rancho Los Amigos Levels of Cognitive Recovery (RLAS-R)
Describe the 10 levels of the RLAS-R.
What is a good way to remember the first 8 levels?
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)
When do we progress a patient from a RLAS-R level I to level II?
-Whenever we start to see a generalized response to noxious stimuli. May have NOT PURPOSEFUL vocalization.
What is the typical generalized response seen when providing noxious stimuli to a RLAS-R level II?
-Posturing
When do we progress a patient from a RLAS-R level II to level III?
- 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.
PART 2: DISORDERS OF CONSCIOUSNESS
PART 2: DISORDERS OF CONSCIOUSNESS
Consciousness = _______ + ________
- Wakefulness (ability to open eyes and have basic reflexes)
- Awareness (complex thought processing)
When patients are in RLAS-R level I-III, we will also describe them as having Disorders of _________.
-Consciousness (I=Coma, II=Vegetative State, III=Minimally Conscious)
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.
- 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.
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
- 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.
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”.
-“MCS is a condition of severely altered consciousness in which minimal but definite behavioral evidence of self or environmental AWARENESS is demonstrated”.
The reemergence of eye opening is signaling that the _________ system has regained control of wakefulness.
-Reticular System
How long until Vegetative State is considered persistent?
-1 year
1 of what (4) behaviors must be present to distinguish MCS from VS?
- ) Simple command following.
- ) Gestural or verbal yes/no responses (regardless of accuracy).
- ) Intelligible verbalization.
- ) Movements of affective behaviors that occur in contingent relation to relevant environmental stimuli and are not attributed to reflexive activity.
VS vs MCS, does it matter? Why?
-Yes, the prognosis of MCS is significantly more favorable relative to VS.
What are the criteria for emergence from MCS?
1.) Functional interactive communication.
OR
2.) Functional use of TWO different objects.
PART 3: DOC OUTCOME MEASURES AND POC
PART 3: DOC OUTCOME MEASURES AND POC
What is the biggest standardized outcome measure for DOC population?
-John F. Kennedy Coma Recovery Scale (CRS-R)
How often is the CRS-R performed? Why?
-Multiple times a day to catch reproducible, purposeful responses.
The JFK CRS-R includes 23 items and is split into what 6 subscales?
- Auditory
- Visual
- Motor
- Oromotor
- Communication
- Arousal
You SEE and HEAR a COMA
What is the second most widely used outcome measure for Disorders of Consciousness?
-Disorders of Consciousness Scale (DOCS)
- 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).
-neurobehavioral
What are (6) things important for rehabilitation of DOC?
- Positioning
- Tone Management
- Sensory Stimulation
- Equipment Prescription
- Family Training
- Family Education
While still in the VS/MCS stages, cognition goals are largely based off of what?
-CRS-R
PART 4: RLAS 4-10
PART 4: RLAS 4-10
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.
- short-term
- aggressive or flight
- hostile
- heightened
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.
- not agitated
- disoriented
- goal directed behavior
- NEW
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.
- Inconsistently oriented
- non-distracting
- simple
- memory, problem solving, and learning capabilities
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.
- Consistently oriented
- non-distracting
- MinA, carry over
- superficial awareness (but unaware of impairments and disabilities and limits)
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.
- Consistently oriented
- assistive memory
- no assistance
- underestimates
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 ______.
- 2 consecutive hours
- assistive memory
- independently
- SbA
- SbA
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.
- multiple tasks
- assistive memory
- time
- cues
PART 5: ADDITIONAL OUTCOME MEASURES
PART 5: ADDITIONAL OUTCOME MEASURES
What are 5 Outcome Measures used?
- GOAT
- O-Log
- MARS
- ABS
- RLAS-R
Galveston Orientation and Amnesia Test (GOAT):
- Normal = ______
- Borderline = _______
- Impaired = _______
- Normal = 76-100
- Borderline = 66-75
- Impaired = <66
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)?
- Place, Time, Situation
- > 75 GOAT, >25 O-Log
- O-Log
Moss Attention Rating Scale (MARS):
- Measures ___________ responses that affect attention.
- Involves the rating of what 3 major factors?
- Higher scores = _______ attention
- behavioral responses
- Irritability, Initiation, Sustained attention
- better attention
Agitated Behavioral Scale (ABS):
- WNL = _______
- Mild agitation = ________
- Moderate agitation = _______
- Severe agitation = ________
- WNL = 21 or below
- Mild agitation = 22-28
- Moderate agitation = 29-35
- Severe agitation = 35 or above
