98 年專科護理師訓練 神經系統常見問題之評估 ( 二 )

1. 98年專科護理師訓練神經系統常見問題之評估 (二) 意識不清 Confuse 情緒和行為的改變 Mood & behavior change 成大醫院神經科 黃涵薇醫師

2. Consciousness • Level • The state of arousal • Content • The quality and coherence of thought and behavior (awareness)

3. Thalamocortical radiation thalamus Moruzzi & Magoun, 1949

4. Attention • Attention in both right and left aspects of extrapersonal space is governed by the "nondominant" parietal and frontal lobes. • Insight and judgment are dependent on intact higher order integrated cortical function, especially regarding frontal lobe involvement in scrutinizing incoming sensory information

5. High cortical function 高等皮質功能

6. Terms to describe consciousness • Normal (Clear) consciousness • Confusion • Drowsiness • Stupor • Coma

7. Confusion • A problem with coherent thinking • The p’t doesn’t take into account all elements of his immediate environment • Deficit in working memory (reduced attention) • “clouding of sensorium” • “sun-downing phenomenon” • Missed day/night light cues • Deterioration of suprachiasmatic nucleus of the hypothalamus • Disruption of REM sleep • Delirium "acute confusional state"

8. Drowsiness • The p’t is inability to sustain a wakeful state without the application of external stimuli Stupor • The p’t can be roused only by vigorous and repeated stimuli • Response is absent or slow and inadequate • Common with restless or stereotyped motor activity

9. Coma • The p’t who appears to be asleep and incapable of being aroused by external stimuli or inner need • Degrees of severity : reflexes • Semicoma • Sleep vs. Coma

10. Dilirium (DSM IV) • Disturbance of consciousness with reduced ability to focus, sustain, or shift attention. • This loss of mental clarity is often subtle and may precede more flagrant signs of delirium by one day or more ; Distractibility • A change in cognition or the development of a perceptual disturbance that is not better accounted for by a preexisting, established, or evolving dementia. • memory loss, disorientation, and difficulty with language and speech • The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day. • There is evidence from the history, physical examination, or laboratory findings that the disturbance is caused by a medical condition, substance intoxication, or medication side effect.

11. Additional features with delirium • Psychomotor behavioral disturbances • Hyperactivity • irritability, anxiety, emotional lability, and hypersensitivity to lights and sounds • Hypoactivity • quiet, withdrawn state • Increased sympathetic activity • Sleep-wake reversals • Variable emotional disturbances • fear, depression, euphoria, or perplexity. • Delusion, hallucination

12. Motoric subtypes Lipowsk, 1983 • Hyperactive • Hypoactive • D/D with depression : circadian disturbance • Worse prognosis • Mixed type

13. Nearly 30 percent of older medical patients experience delirium at some time during hospitalization Patients with delirium experience prolonged hospitalizations, functional decline, and are at high risk for institutionalization. Signs of delirium may persist for 12 months or longer, particularly in those with underlying dementia. Mortality associated with delirium is high, approximately twice that of patients without delirium JAMA 2004;291:1753-62

14. Etiological factors of delirium types • Due to a general medical condition • Include due to the physiological effects of a medication • Due to multiple etiologies • Include multiple general medical conditions, multiple medications, or combination • Substance-induced delirium • Substance-withdrawal delirium • Delirium not otherwise specified

15. CNS lesions & delirium (1) • P’t with preexisting CNS illness are especially vulnerable to delirium • Dementia • Parkinsonism • MS • Head trauma • CNS tumors • Seizure disorder • Depression • Alcohol or substance abuse

16. CNS lesions & delirium (2) • Acute or subacute CNS lesions or diseases are commonly associated with delirium in the acute presentation • Head trauma • Stroke • CNS lupus • Giant cell arteritis • Seizures • HIV complex

17. CVD Pulmonary disease Ischemia-hypoxia Hypercapnia Renal disease Liver disease Local or systemic infection Anemia Burns Dehydration Sensory deprivation Poor nutritional status Electrolyte or sugar disturbance Sodium, phosphate Hypo/hyperglycemia Use of physical restraints Polypharmacy Increased age and male gender Sleep disturbance Overall severity of the systemic illness Iatrogenic events (eg. Invasive procedures, urinary catheterization) Non-CNS predisposing factors of delirium

18. Opioids Antihistamines Anticholinergics BZD Barbituates Other sedatives Psychotropics Anticonvulsants Antiparkinsonian Corticosteroids Immunosuppressants CV medications GI medications Antibiotics Muscle relaxants Medications may lead to delirium cholinergic, dopaminergic, GABAergic, opioid-receptor function

19. “DEMENTIA” • D—drug and alcohol-感冒藥水 • E—electrolyte • M—metabolism and nutrition, MS, B12, 葉酸 • EN—endocrine and neurological disease • T—tumor—NPC, hepatoma, Colon CA, pancreas • I—infection 梅毒, HIV,感冒後 • A—autoimmune disorder,such as RA

20. PSYCHOSIS  • Hallucinations • Auditory hallucinations signify a primary psychiatric disorder, such as schizophrenia • Nonauditory hallucinations suggest psychosis in the context of a medical problem such as alcohol withdrawal • Delusions • False beliefs that are firmly held despite obvious evidence to the contrary, and not typical of the patient's culture, faith, or family. • Thought disorganization • Disruption of the logical process of thought may be represented by loose associations, nonsensical speech, or bizarre behavior. • Agitation • Aggression

21. Formal psychotic disorders Schizophrenia (DSM-IV-TR) Schizoaffecive disorder Schizophreniform disorder Brief psychotic disorder Delusional disorder Shared psychotic disorder Substance induced psychosis Psychosis due to a general medical condition Psychosis - Not otherwise specified Other illness may with psychosis Bipolar disorder (manic depression), Unipolar depression Delirium Drug withdrawl A psychotic individual may be able to perform actions that require a high level of intellectual effort in clear consciousness, whereas a delirious individual will have impaired memory and cognitive function

22. Pathophysiology of coma • Morphologic • Infratentorial • Brainstem -- ARAS : direct or indirect • Supratentorial • Thalamus • Widespread bilateral hemisphere • Secondary effect on diencephalons & upper brainstem • Herniation • Metabolic • Disturbance of neuronal activity

23. Brain Herniation • Transfalcial • Horizontal –-- Kernohan-Woltman phenomenon • Transtentorial (Uncal) • Cerebellar tonsiller “Duret hemorrhage”

24. Central syndrome of rostrocaudal deterioration

25. Final diagnosis in 500 p’ts admitted to hospital with “ coma of unknown etiology” Plum & Posner (1980) • Metabolic & other diffuse disorders (65%) • Supratentorial mass lesions (20%) • Infratentorial lesions (13%) • Psychiatric disorders (2%)

26. Metabolic encephalopathy • Functions subserved by complex polysynaptic pathways are affected earlier by metabolic disturbances • Asymmetric motor findings speak against the diagnosis of metabolic encephalopathy • Toxic-metabolic disorders frequently induce abnormal movements • Tremor, asterixis, myoclonus, seizure

27. Metabolic encephalopathy • Generally, the degree of conscious disturbance parallels the reduction in cerebral metabolism/blood flow • CBF • normal : 55 mL/min/100 g • Coma : < 12~15 mL/min/100 g • Arterial PH • Direct effects on neuronal membranes or neurotransmitters and their receptors

28. Exceptions • Neurological problems without focal signs • Meningitis • SAH → meningism • Metabolic problems with focal signs • Hypoglycemic encephalopathy • Hypertensive encephalopathy

29. Other related conditions • (Persistent) vegetative state • Diffuse cerebral injury. Ex. Trauma, anoxia • Akinetic mutism • Bilateral anterior frontal lesions • Lock-in syndrome • Basis pontis lesion • Brain death • Catatonia • Psychogenic unresponsiveness

31. Coma Brainstem function (-) (+) Focal sign Infratentorial Herniation (-) (+) Supratentorial Meningism (-) (+) Metabolic – toxic SAH Meningitis

32. 腦葉皮質功能障礙症狀(1) • Frontal lobe 額葉 • 任一側: 對側運動障礙, 個性改變 • 左: 運動型失語症 motor aphasia • 兩側: 失動 akinetic mutism, 失禁 • Prietal lobe 頂葉 • 任一側:對側感覺障礙, 對側下四分之一視野缺損 • 左: 失用症 apraxia, 失讀症 alexia • 右: 忽略對側 hemineglect , 迷路

33. 腦葉皮質功能障礙症狀(2) • Temporal lobe 顳葉 • 任一側:對側上四分之一視野缺損, 記憶或情緒障礙 • 左: 感覺型失語症 sensory aphasia • 右: 空間觀念障礙 • 兩側: 短期記憶缺損, 冷漠 • Occipital lobe 枕葉 • 任一側:對側二分之一視野缺損, 視幻覺 • 左: 辨色困難 • 兩側: 皮質性失明 cortical blindness

34. Complex partial seizure • Awake but are not in contact with others in their environment and do not respond normally to instructions or questions ; often seem to stare into space • Either remain motionless or engage in repetitive behaviors, called automatisms • facial grimacing, gesturing, chewing, lip smacking, snapping fingers, repeating words or phrases, walking, running, or undressing. • May become hostile or aggressive if physically restrained during the event • Typically last less than three minutes • Postictal phase • often characterized by somnolence, confusion, and headache for up to several hours • the patient has no memory of what took place during the seizure other than, perhaps, the aura. • Nonconvulsive status epilepticus

35. Transient global amnesia • Striking amnesia with preservation of other cognitive domains • Last usually several hours and are without postictal lethargy or other motor manifestations of seizures • Episodes of amnesia that are epileptic in origin will typically also include olfactory hallucinations, abnormal behaviors, and/or motor automatisms, features that are absent in TGA

36. Approach patients with Confusion

37. 焦點病史 • Ascertain the patient's level of functioning prior to the onset of conscious problem • Onset, duration, course • Associated Symptoms • Life event? Head trauma? • Insomnia? Sleepy? Headache/dizziness? • Appetite? Vomiting/diarrhea? • Fever? Palpitations? Dyspnea? • Staggering or ataxic gait? Double vision? Slurred speech? Numbness / weakness of the face or body? Clumsiness, or incoordination? • Medications / Substance

38. 焦點身體檢查 • Physical examination • T/P/R and BP • Skin • Eyes: conjunctiva pale/icteric or not • Breathing sound • Bowel sound • Bladder palpation

39. Eye opening 4 : spontaneous 3 : to speech 2: to pain 1: none Verbal response 5 : oriented 4: confused 3: words 2: sounds 1: none Motor response 6: obey commands 5: localizing to pain 4: withdrawal from pain 3: flexion to pain 2: extension to pain 1: none Glasgow coma scale(Teasdale & Jennett, 1977) VA: aphasia VT: trachea Aphasia? Dysarthria?

40. To check “Attention” • Digit span • Inability to repeat a string of at least 5 digits indicates probable impairment • Vigilance “A” test (逢3舉手) • Read a list of 60 letters, among which the letter "A" appears with greater than random frequency. • More than 2 errors is considered abnormal.

41. Conscious Contentevaluation • JOMAC • Judgment: 失火了要怎麼辦? • Orientation: 人, 時, 地 • Memory: 短期(ex.3 objects in 5 minutes), 長期(ex.住址) • Abstract thinking: 比較物體/成語解釋 • Calculation (ex. 100-7 series, 20-3 series)

43. Localization : Focal sign or not ? • Brainstem reflexes • Pupils / light reflex • Eye position, EOM • Corneal reflex • Oculocephalic reflex (Doll’s eye sign) • Oculovestibular reflex • Respiratory patterns • Gag reflex • Long tract sign • Muscle power (asymmetry?) • Babinski sign

44. 中腦 III 動眼, IV 滑車, VI 外展 • 橋腦 • V 三叉, • VII 顏面, VIII 聽平衡 • 延腦 • IX 舌咽, X 迷走, • XI 副, XII 舌下

45. Pupils & Light reflex ,reactive Hypothalamus miosis tegmentum ,irregular

46. Spontaneous eye movement in comatose patients • Periodic alternating gaze (ping-pong gaze) • Bilateral cerebral damage, rarely posterior fossa lesion • Repetitive divergence • Metabolic encephalopathy • Ocular bobbing • Pontine, extra-axial posterior fossa mass, diffuse encephalopathy • Ocular dipping • Anoxia, post-status epilepticus • Nystagmoid jerking of a single eye • Middle or low pontine Roving eye movement

47. Eye movement - abnormality of gaze • Conjugate gaze • Hemispheric lesion (frontal eye field) • Look to lesion side • Lower pontine tegmentum • Look away from lesion side • Disconjugate gaze • MLF syndrome • Skew deviation

48. Horizontal Gaze pathway Contralateral Frontal eye field (area 8) PPRF

49. 視野檢查 • Confrontation test • (Threaten test)

50. V1 • V 三叉神經 • 顏面感覺 • V1, V2, V3 • 咀嚼肌 • 是否對稱 • 角膜反射 • <五進七出> • Corneal reflex: +/+ V2 V3