Delirium: sudden onset often lingering emotional impact

Patients with ICU delirium are less likely to survive and more likely to suffer long-term cognitive damage if they do.  STAT Boston Globe taken 10-17-2016
Parasitemia
Try as he might a patient with delirium cannot complete simple tasks according to Sefton.
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Perseveration, severation, eration, ation

WESTBOROUGH, MA October 14, 2016 What does the term ‘to perseverate’ refer to in clinical terms.  The media attached below will illustrate the concept of perseveration in its clinical presentation. The patient was asked to copy her name.  A model was presented for her by the examiner. Most people have control over behavior through a series of feedback loops that become active in the brain that allow for anticipatory awareness and behavioral prospective as a person reaches full cognitive maturity.  Patients who are recovering from right hemisphere lesions often exhibit the pattern

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Patient asked to copy her name – Frances

of repetition without regard for how appropriate the pattern may be in respect to the task demand. You can see that the patient draws what appear to be tee pee shaped figures and two horizontal lines – perhaps a modified upper case A.  Meanwhile, she repeated the figure until she ran out of paper at the bottom margin.  In blogs already published I have mentioned the term perseveration and made an effort to illustrate its unusual presentation. One can see in the feature image a circular pattern of zeros as a patient attempted the clock drawing.  The patient got stuck making the number 0.  In the recent blog on this topic, I posted a video for the readers use that shows one case of perseveration in an older patient drawing circles over and over.

 

The term refers to the pattern of repeated motor movement in spite of the indication (or feedback) that the response is no longer needed or is inappropriate.  As you can see by this drawing the individual continued to make the same pattern over and over without regard for the task I had assigned – copy your name.

Treatment from serious stroke require months of cognitive rehabilitation in addition to physical and occupational therapy.  patients must be taught to recognize their cognitive vulnerability to errors like this.  As recovery is made most patients establish improved self-monitoring to compensate for their weaknesses. But some fail to re-establish the feedback loops and awareness that allow them to live in the world with the immediate awareness that once is enough and it is okay to stop.

What is post-concussion syndrome?

“The syndrome consists of musculoskeletal pain, headaches, sensitivity to sound and light, sleep disturbance, changes in memory and balance, anxiety and depression. The emotional impact of this leaves patients feeling alone and frustrated” Sefton, 2016

The likelihood of getting a concussion while playing sports is between 10-30 percent of high school and college athletes.  As many as 29 percent of these injured players may go on to experience post-concussion syndrome. It is important for team physicians, trainers, and primary care doctors to understand and treat people with lingering symptoms of concussion.

brain_pictureIn a blog post published in September it is noted that concussion is an invisible injury and recovery takes time – generally 2-3 weeks. The consequence to individual athletes or others recovering from car crash, falls, and any brain trauma can be debilitating and effect a few bodily systems. The emotional stress of lingering symptoms should not be underestimated. Whether it is a professional, elite student athlete or a salesman injured in a car crash there is an experience of stigma associated with the invisible injury of concussion. The emotional impact of this marginalizes patients often leaving them feeling alone and frustrated.

A multidisciplinary approach is best that allows for restoration of physical activity and acknowledgement of both physical and emotional symptoms. Pain management is a useful intervention including aquatics.  My approach to treatment includes biofeedback, education and psychotherapy.  This helps reduce the autonomic effects of acute stress and the inflammatory impact on the fight/flight response – including blood pressure, sleep, and rate of breathing.

Sefton, M. What is PCS: and why do I care? Blog post: https://concussionassessment.wordpress.com/2016/09/30/what-is-pcs-and-why-do-i-care/. Taken October 1, 2016.

What is encephalopathy?

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80-year old right handed woman with sepsis and hypoxemia

WESTBOROUGH, MA October 7, 2016 The clock of the week brings up an interesting question.  What is encephalopathy? I hear that all the time from patients and more likely, family members who are confused as to the definition of encephalopathy.  I will make an effort in this blog to provide some explanation for this.  Look at the clock and see that is quite confused.  Remember prior published clocks and the fact that the directions are exactly the same for every person.  “Draw the face of a clock, put all the numbers on it and set the hands for 11:10”.  Essentially it is a three step command that requires both attention and problem solving.  In prior published blogs and You Tube videos I have made an effort to illustrate the range of clocks given by patients of various diagnostic classifications.

Encephalopathy is a common manifestation in patients with sepsis (infectious illness) such as pneumonia and urinary track infection, delayed hemodialysis, and many others. In refers to brain dysfunction often due to multifactorial issues including metabolic and infectious causes.  According to the Health Line encephalopathy may be temporary or permanent.  The patient who created the illustrated drawing was very cooperative but subject to altered mental status when getting sick, fatigued or on dialysis days.  The treatment for encephalopathy depends on the underlying reason for the AMS but largely is treating the symptom picture to manage the patient comfortably.

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“I want you to make up a sentence…”

Symptoms of encephalopathy often begin rapidly and may be seen as confused behavior, decreased attention, and poor problem solving.  Neuropsychology services across the country are referred these patients in earnest in hope of tracking changes in their cognitive status and behavior.  The assessment process is lengthy.  At some point, patients are asked to make up a sentence containing a noun and a verb as part of the basic cognitive screening.  As you can see from the illustration below, this patient had difficulty with this task.  Almost any sentence will suffice but in this case the woman added the heart to represent the word ‘love’ and placed a smiley face at the bottom of her page to indicate her completion of the task.  Persons with encephalopathy often exhibit unusual limitations in their awareness of their condition and exhibit varying levels of confusion throughout the day.  Slowly these symptoms resolve – sometimes quite rapidly.  Just as rapidly, some patients are vulnerable to altered mental status at the first sign of infection.

Second Impact Syndrome: rare but often fatal

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25-year old Boxer Mike Towell  (BBC photo)
WESTBOROUGH, MA October 8, 2016 Second impact syndrome is a rare but generally catastrophic injury that results from a second blow to the head that immediately follows a concussive injury – often undiagnosed or an injury that was previously diagnosed but not fully healed. The second injury to an already damaged brain results in catastrophic swelling within the brain often incompatible with survival.  Scottish boxer Mike Trowell died of a severe brain injury occurring in a sanctioned boxing match in Glasgow, Scotland on September 29.
Essentially, “second impact syndrome” or SIS results from the brain’s inability to autoregulate cerebral perfusion pressure and swelling as a result of repeated cerebral trauma. This leaves an athlete gravely injured unless immediate neurosurgical intervention can be provided (Bey & Ostick, 2009).  Sadly, even with the best care many patients with SIS succumb to their injuries within a few minutes. Most believe that concussions create a metabolic crisis in the brain that results in a gross change in cerebral efficiency – an inability to match the external cerebral energy demand – especially sporting activity at the elite level.
In general, if the brain fully heals an athlete is at no greater risk of concussion than someone who has never sustained a concussion.  However, when an athlete returns to play before he or she is fully healed they are at high risk for a second or third concussion and at risk for SIS. It is well know that there is a cumulative effect of injury to the brain with repeated trauma. In fact, repeated trauma results in a significant reduction in brain volume that can seriously reduce information processing speed and other neurocognitive functions according to a study in the British Journal of Sports Medicine in 2015. The greater number of fights resulting in more blows to the head has a significant impact on speed of processing. Certainly a well established link between repeated head trauma and dementia, depression, and other signs of neurocognitive decline has been found in U.S. football players.
Boxer fatally injured with second impact that was sustained in a fight in Scotland recently.  Scottish Boxer Mike Towell was critically injured on September 30, 2016 during a fight with Dale Evans in Glasgow, Scotland.  According to the BBC, Towell was knocked to the mat in the first round of a 10 round bout.  He was given a standing 8 count and continued the fight.  Some said he dominated the next two rounds when finally in the fifth round he was again knocked down and the fight was ended.  He was transported to the trauma center in Glasgow ultimately being placed on life support.  He lived 12 hours once the decision had been made to terminate life support.  His partner Chloe Ross reported that Towell had been experiencing headaches in the weeks prior to the fight that were attributed to stress.  Medical authorities may not have allowed Towell to fight had the recent history been known. Towell may have been highly vulnerable to concussion as a result of his boxing history and unique neurocognitive underpinning.  So when he stayed in the fight he unknowingly put himself at risk for lethal injury.
REFERENCES
Bey,T and Ostick, B. Second Impact Syndrome West J Emerg Med. 2009 Feb; 10(1): 6–10 Taken October 1, 2016
Loosemore, M., et al. Boxing injury epidemiology in the Great Britain team: a 5-year surveillance study of medically diagnosed injury incidence and outcome. British Journal of Sports Medicine doi:10.1136/bjsports-2015-094755.