Fluctuating consciousness

Neuroleptic malignant syndrome is an acute iatrogenic condition caused by neuroleptics, characterized by tremor, catatonia, fluctuating consciousness, hyperthermia, and cardiovascular instability. It is relatively uncommon, occuring in 1-1.5% of patients but is fatal in 11-38%, most often due to cardiovascular collapse (Jahan et al. 1992). The pathogenesis of neuroleptic malignant syndrome is poorly understood, but it is believed to result from altered dopamine and serotonin transmission in the hypothalamus, spinal cord, and striatum. Treatment includes discontinuation of neuroleptics and administration of drugs that increase dopamine transmission bromocriptine or L-dopa (Jahan etal. 1992 Baldessarini 1996). 

Among the complications of neuroleptic chemotherapy, the most serious and potentially fatal complication is malignant syndrome, which is characterized by extreme hyperthermia lead pipe skeletal muscle rigidity that causes dyspnea, dysphagia, and rhabdomyolysis autonomic instability fluctuating consciousness leukeocytosis and elevated creatine phosphokinase levels. 

Delusions, commonly persecutory often ill-formed, changeable Visual hallucinations/illusions are typical any modality is possible Fluctuating consciousness/hyper-alert/drowsy... 

Delirium, e.g. post-narcotic delirium, somnolence or coma, is a common complication involving dementia, with fluctuating attention and consciousness and considerable morbidity. It is not always reversible and there is no specific treatment. Some of the accompanying central cholinergic syndromes can be reversed by ChEIs. 

Delirium is characterized by a disturbance of consciousness and a change in cognition that develops over a short period of time, usually hours or days. The course can fluctuate over the course of the day, usually worsening in the evening. Underlying medical problems such as urinary tract infections in the elderly, substance abuse, or withdrawal symptoms in adults may precipitate delirium.1... 

GEN.36.1. Prigogine, Order through fluctuation Self-organization and social system, in Evolution and Consciousness, Human Systems in Transition, E. Jantsch and C. Waddington, eds., Addison-Wesley, Reading, MA, 1976, pp. 93-133. 

Delirium. Delirium is an abrupt change in mental status often accompanied by agitation and seemingly psychotic symptoms that may resemble mania. Unlike mania, however, delirium is commonly characterized by a fluctuating level of consciousness and disorientation. The chief precipitants of delirium include infections, medications, and metabolic disturbances. Therefore, all patients who present in an acutely agitated state should undergo a comprehensive yet expeditious medical evaluation to rule out potential causes of delirium. This evaluation must include a thorough physical examination and a battery of laboratory tests. 

Delirium. Closely related to the previous disorders is delirium, which includes both psychosis and a fluctuating level of consciousness. The fluctuating sensorium is the key to distinguishing delirium from other causes of psychosis. Medical illnesses or drugs cause delirium it is a medical emergency that requires prompt medical treatment. 

Impaired consciousness is rated according to the Clinician Assessment of Fluctuation Values are fmol/mg tissue, specific binding, mean standard deviation, in autopsy brain Ba - Brodmann areas... 

Serious toxic reactions with delirium can arise when specific serotonin reuptake inhibitors (SSRIs) are taken with other drugs that increase central and peripheral serotonergic activity. Known as the serotonin syndrome , this reaction consists of excitation, restlessness, fluctuations in consciousness, with tremor, rigidity, myoclonus, sweating, flushing, pyrexia, cardiovascular changes, and rarely coma and death (Sternbach, 1991). The syndrome has occurred when SSRIs have been combined with irreversible monoamine oxidase... 

Gortical Lewy body disease produces a clinically distinct dementia syndrome. Two of the three core features of this syndrome involve abnormalities of consciousness, firstly marked fluctuations in consciousness (usually most apparent in applied cognitive performance) and secondly psychosis, in... 

In DLB, fluctuations in both the level of consciousness and in the content of consciousness (hallucinations and delusions) develop. These alterations, together with much of the ensuing cognitive impairment, fluctuate to such an extent that patients can transiently return to being symptom-free in the course of the disease. This temporal pattern implicates functional as opposed to structural neuropathological abnormalities in symptom aetiology. Several neurotransmitter correlates have been identified in autopsy tissue from retrospectively, and more recently, prospectively assessed patients. 

Clinical observations and case reports suggest that fluctuating levels of consciousness (FC) occur in 80-90% of patients with DLB (Byrne et al., 1989 McKeith et al., 1992). In addition, FC occur in 20-25% of patients with AD (Kolbeinsson and Jonsson, 1993 Robertson et al., 1998) and between 35-50% of VaD (Hachinski et al., 1975 Roman et al., 1993) although the periodicity and causality in these dementia subtypes is hypothesized to be different (Walker et al., 2000a). These fluctuations in consciousness are characterized by periodic shifts in the level of arousal ranging from episodes of lucidity to reduced awareness and even stupor. 

Fluctuations in the level of attention or conscious awareness are of particular interest in terms of neurochemical correlates, which may in turn help to identify mechanisms involved in maintaining normal levels of consciousness. There is little direct evidence so far concerning which particular neurochemical parameter might be implicated. However, examination of the pathophysiology of DLB suggests potential mechanisms controlling the level of consciousness. 

Figure lb. Dysfunctional consciousness in DLB reduced ascending activation below an optimal threshold, produces an unstable platform of consciousness, resulting in fluctuating cognitive abilities (Walker BaUard, 1998). 

Pathophysiological model of fluctuating levels of consciousness (Based on the pathofOtyslology at dementia with Lewy bodies)... 

The increasingly well-defined pathophysiology of the degenerative dementias adds a new domain to our understanding of the neural substrates of consciousness. The syndrome of dementia with Lewy bodies is distinguished by severe disturbances in consciousness. Patients with DLB suffer not only fluctuations... 

Concomitant use of a BZD and clozapine may increase the risk of sedation, dizziness, collapse with loss of consciousness, respiratory distress, and fluctuating blood pressure (196). 

Various CNS adverse effects have been reported with CBZ and include sedation, dizziness, ataxia/clumsiness, blurred vision/diplopia, and impaired task performance. Although uncommon, fatal CBZ toxicity does occur. CBZ overdose is characterized by neurological symptoms such as diplopia, dysarthria, ataxia, vertigo, nystagmus, and coma. Infrequently, cyclic coma with biphasic fluctuations of consciousness, seizures, respiratory depression, cardiac conduction defects, and the need for artificial ventilation may occur. Plasma levels are only moderately correlated to severity, but as noted earlier, more than 15 pg/ml in children or 20 pg/ml in adults should be considered serious. Charcoal hemoperfusion or gastric lavage with activated charcoal has been used in such cases, whereas benefit from plasmapheresis is controversial (77, 114, 368). 

Our ups and our downs of behavioral output ride a wave of internal body temperature that mirrors the diurnal fluctuations of temperature that follow the sun s rising and setting. Light, of course, is symphonically orchestrated in the cosmic world of day and night and tells us even consciously what thermal time it is more clearly and crisply than hot/cold sensitivity. 

In a series reported in 2001 of five patients seen for abrupt withdrawal from GBL, symptoms included rapid heart rate, high blood pressure, delusions of being persecuted or harmed, hallucinations, and fluctuating states of consciousness. Most of the patients were body builders, and ranged in age from 23 to 33 years. Patients had been taking GBL for two to nine months, and developed withdrawal symptoms one to six hours after their last dose, with symptoms lasting up to 14 days. 

Acute, sometimes lethal, brain disorder precipitated by total or partial withdrawal from excessive alcohol intake. Shown by confusion, disorientation, fluctuating or clouded consciousness, agitation and insomnia. 

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