Sarah Wilson Lecture 2 Cognition And Neuroscience

Front 1

What are two critical questions that need to considered if a neuropsychologist recommends brain surgery to a patient with severe epilepsy?

Back 1

1. Does the patient have medically intractable epilepsy?

2. If so, is it surgically remedial, as in is there a localised region of the brain where the epilepsy is triggered, so that resection of this area can lead to an epilepsy-free life?

Front 2

What are two major co-morbidities with epilepsy?

Back 2

Depression and Anxiety

Front 3

First step is to take a case history of the patients.

Back 3

Febrile convulsion, age 9 months

•  Clusters of seizures, aged 7, 14, & 21 yrs

•  Age 28, regular focal seizures; FLE –  sensation of anxiety and fear in body and head, light-headedness, altered state of consciousness

–  duration 30-60s; clusters of 5-10

–  frequency; up to 2-3 per day

–  worsening severity –  GTCS; 2 per week

–  precipitated by fatigue, stress

•  Polytherapy with anticonvulsants –  carbamazepine, phenytoin

Front 4

Then take a cognitive case history, and what first hypothesis might you form?

Back 4

•  Above average student

•  Cognitive complaints: –  word finding difficulties –  poor memory for verbal material –  worse after a seizure

•  Ictal semiology included speech arrest but some preservation of language comprehension •  Reduced verbal fluency post-ictally

*Maybe it's around Broca's area, if the language circuit is implicated

Front 5

What is meant by the term underemployment?

Back 5

Where a person is not fulfilling their vocational goals based on their training because of their disability.

Front 6

In the case study presented by Sarah, what other risks did the epilepsy pose for the patient to live out a "good life"?

Back 6

Her compromised ability to parent her daughter.

Front 7

When someone comes into the clinic for a characterisation of assessment, what are the steps undertaken to do this?

Back 7

1. Medical history

2. Cognitive history

3. Psychiatric Assessment (psychogenic seizures)

4. Psychosocial assessment (treatment expectations)

Front 8

What do you take in someone's medical history?

Back 8

1.Family history of illness?

2. Which is dominant hand?

3. Co-morbidities?

4. What spurred illness? Utero (cortical dysplaesia), tumur, head injury?

5. Focal or general seizures? (is it worsening?)

6. Duration and frequency of seizures?

7. Precipitated by?

Front 9

What do you take in someone's cognitive history?

Single positron emisson tomography (SPET)

Back 9

1. Estimate of IQ?

2. Cognitive complaints? cognitive tests

3. Are these cognitive complaints heightened post seizure?

4. doubling of consciousness? (in the scanner, can see other areas inhibiting, which helps localise seizure to one network)

5. Ictal semiology (ie symptoms of seizure) - motor cortex = spasms, visual cortex = perception disruptions, frontal lobe = cognitive disruptions

6. brain scanning, video EEG, fMRI & MRI, PET (brain metabolism at rest) & SPET (brain metabolism in action)

Front 10

What is perilesional reorganisation?

Back 10

reorganisation of the tissue around the brain injury, so that the surrounding tissues can compensate for deficits resulting from the lesion.

*Better outcome than contralateral reorganisation

Front 11

What do you take in someone's psychiatric assessment?

Back 11

1. Mental State Examination (diagnose any existing condition according to the DSM - done by a psychiatrist) E.g. Diagnosis of Anxiety

2. Rule out psychogenic seizures (origin from psychological mechanisms, not epileptigenic mechanisms) [psychogenic seizures are higher in epileptic patients as a co-morbidity, than the general population]

Front 12

What is one treatment for Anxiety Management?

Back 12

Systematic desensitisation (behavioural treatment) [rather than medicinal treatment]

Front 13

What is Systematic Desensitisation?

Back 13

Great for Phobias-

Create a hierarchy of fears, starting with the lowest arousal one, and gradually build that up (systematic training) in combination with relaxation to extinguish/mitigate the phobia.

Front 14

What is another treatment for Anxiety Management?

Back 14

Progressive Muscle Relaxation Training (PMRT)

Front 15

What is Progressive Muscle Relaxation Training (PMRT)?

*This has more generalised effects for treating anxiety, not only getting patients into the theatre room

Back 15

Tensing your muscles and then relaxing them, training a ‘relaxation response’ for a group of muscles voluntarily.

*Theory goes, that with anxiety there is tension, and training muscles to relax can release that tension, and thus some anxiety

Front 16

What do you take in someone's psychosocial assessment?

Back 16

1. Illness perceptions (which are big predictors of treatment compliance and surgery outcome), their perceptions of illness, and patient beliefs

2. Family and cultural beliefs

3. Pre-operation expectations/treatment expectations

4. Resources in place to teach patient to be well after surgery?

Front 17

Is brain surgery for treatment of epilepsy a placebo effect?

Back 17

There were randomised control trials done with patients on the surgery wait-list as controls, so yes it has been demonstrated to be effective.

*It is unethical for this procedure not to be done on patients who are recommended that it would be beneficial, so control trials couldn't strictly be done

Front 18

Why is it important to give patients realistic expectations post-operation, such as swelling/headaches?

Back 18

This knowledge will help them (hopefully) to behave in ways that will enhance recovery, and not jeopardise it.

Front 19

What are the placebo issues that can negatively impact a patients recovery post-op?

Back 19

Exceedingly High or Low Treatment Expectations will negatively impact recovery.

Front 20

How can the placebo issues be minimised?

Back 20

Provide many counselling sessions before the operation unpack their treatment expectations, and guide them to manage their expectations more realistically, more in line with scientific evidence. [called psychoeducation]

*make sure goals are achievable, and challenge the ones that are less achievable

Front 21

Not only do neuropsychs prepare patients for post-op, but also for the operation itself. What preparation is given for Intraoperative Mapping?

*This improves treatment efficacy and patient outcomes

Back 21

1. Giving information, effective communication, andreassurance
2. Cognitive and behavioural strategies effectiveimmediately before and during the procedure

e.g. relaxation techniques, refocusing of attention, positive coping strategies, direct pretreatment modeling, positive affirmation during the procedure

*This helps mapping occur for longer, as patient can cope more with surgery with these strategies -which gets a more accurate mapping done

Front 22

How long does it take for the swelling post-operatively to not impact upon cognitive functioning?

Back 22

3 months

Front 23

Post-operatively, what do patients commonly perceive as the "burden of normality"?

Back 23

When patients pace themselves too fast for their recovery to keep up with, and they feel disheartened that they can't do everything they want to do immediately

Front 24

What is the common timeframe for patients to psychologically adjust after their operation?

Back 24

About 24 months

*has profound effects on the sense of self