Neglect: Causes, Symptoms & Treatment

Neglect is a neurological attention disorder in which affected individuals neglect one half of space or one half of the body and/or object. It is an egocentric and an allocentric disorder, respectively.

What is a neglect?

Neglect often presents after hemorrhage of the middle cerebral artery (cerebral artery) and right hemispheric cerebral infarcts. This neurologic disorder is due to a lesion in the parietal lobe of the cortex (cerebral cortex). Diagnosis is often difficult because the symptomatology is varied. Neglect can affect all sensory modalities, and in most cases patients are unaware of their deficits and classify their behavioral abnormalities as normal. Consequently, there is no insight into the disease (anosognosia).

Causes

Neglect develops with damage to specific brain regions, the parietal lobe and the parietal lobe, respectively. This area of the brain is responsible for controlling attention. Possible damage includes brain tumors, stroke, cerebral hemorrhage, traumatic brain injury, meningitis, encephalitis, multiple sclerosis, muscle disease, and peripheral nervous system and neurodegenerative diseases. Most patients with neglect syndrome are affected by a right-sided stroke with damage to the right hemisphere of the brain. They neglect the opposite, left side of the body or space. Left hemispheric cerebral infarction is less severe and occurs less frequently.

Symptoms, complaints, and signs

The patient shaves or washes only one half of the body. He does not respond when approached from the damaged side because he cannot hear or see anything. He bumps or runs into obstacles that are on the neglected side. When eating, he only considers the food on one side of the plate, ignoring the other. If he is supposed to draw a picture, only the parts of the perceived side are included. The reason why the affected persons behave so strangely for outsiders is that they often do not perceive their deficits. For them, their behavior is normal, they lack the insight into their illness, and they react all the more violently when their social environment draws their attention to their behavioral conspicuities. They appear intransigent, defiant, ignorant, indifferent, unfriendly and stubborn. Clinical neuropsychology aims to reduce or eliminate these deficits with various therapeutic approaches. A prerequisite for successful treatment, however, is the patient’s ability to understand. As long as this does not occur, the affected individuals have very little motivation to undergo therapy, and dealing with them remains difficult.

  • Visual attention deficit disorder appears most frequently. Patients do not perceive objects, people, and spaces on the neglected side or perceive them with delay. Their sense of direction is predominantly focused on the non-neglected half.
  • With auditory neglect, hearing is impaired and sounds, conversations, music and speech are not perceived or are perceived in a limited way. If the affected persons are addressed on the neglected side, they do not respond or delayed.
  • With the personal neglect, patients blank out one half of the body and do not perceive incoming stimuli such as touch, pressure pain, injury pain or temperature stimuli. Alternatively, they assign these stimuli to the half of the body that is not neglected.
  • With olfactory neglect, odors are not perceived.
  • Motor neglect results in decreased use of the extremities (hemiacinesis).
  • Representational neglect entails neglect of stimuli in visual perception. Patients perceive objects, premises, people and obstacles only on the non-neglected side, leaving the affected side out of the picture description.

Diagnosis and disease progression

It is an acquired perceptual disorder as a result of stroke or other forms of brain damage. The disturbance process is basically side-inverted, as only the side opposite to the brain damage is neglected.If a right hemispheric brain disorder is present, stimuli from the left side of space or body are not perceived and vice versa. The terms hemineglect, hemiplegic attention deficit, and hemiplegic neglect are used equally. A neclect can affect multiple sensory channels at once, causing visual, auditory, sensory, or motor disturbances. With these complaints, only one side continues to function while the other side is completely exited. Diagnosis is primarily based on behavioral abnormalities, imaging, tissue sampling and muscle biopsies. Simple tests also quickly confirm initial suspicions. Neurologists perform search and crossing-out tests, reading, writing and arithmetic tests, and drawing exercises (visual exploration training) with patients. In therapy, everyday situations are trained taking into account the neglected side. With optokinetic simulation therapy, patients must follow symbols that move toward the neglected side.

Complications

Neglect is already a complication that often develops after stroke. However, when neglect is present, further complications result only from the typical behaviors of the affected person. To prevent this, intensive therapy would be necessary. However, the patient himself is not even aware of the disorder. Therefore, he initially does not suffer from the direct effects of this condition and often does not allow therapy. On this basis, various complications may arise. Since the patient ignores all objects that are imaged due to the damaged hemisphere of the brain, accidents and injuries may occur when colliding with these objects, among other things. Furthermore, without nursing support, the affected person is often no longer able to feed himself sufficiently or to perform the simplest activities in personal hygiene. In severe cases, this can lead to malnutrition without help and to social isolation with a tendency to neglect. However, in about 65 percent of all cases, the neglect disappears within 15 months without any particular complications occurring despite the lack of therapy. In approximately 35 percent of those affected, however, clear symptoms remain, which are then only amenable to symptomatic therapy. A prerequisite for therapy, however, is an understanding of the disease. A complete cure is then no longer possible, however.

When should one go to the doctor?

Behavioral abnormalities or an appearance that is socially perceived as deviating from the norm should be discussed with a doctor. If it comes to a special attitude of the affected person towards his own body, he usually needs help and support. Attention deficit disorder, body schema disorder, and compulsive behaviors should be discussed with a physician. Since the person affected by neglect lacks insight into the illness, it is very unlikely that there is a need for medical clarification of the symptoms. Therefore, a visit to the doctor often does not take place on the patient’s own initiative. Therefore, close relatives, confidants and friends have an increased duty of care. If they notice irregularities, they should gain the confidence of the person affected and discuss further action with a doctor. To ensure that they do not fail in their endeavors, they must first be provided with sufficient information about the clinical picture. A visit to the doctor is advisable for a comprehensive explanation. If the affected person washes or pays attention to one half of the body conspicuously more than the other, this is a sign of a discrepancy. If, in principle, particularities of a perceptual shift are registered in various situations in everyday life by the persons present, a conversation should be sought with the affected person. If smells, sounds or stimuli are not perceived, there is cause for concern.

Treatment and therapy

Relatives can take some steps to make their daily lives easier. Glasses, cups, and plates are placed on the table at a slight angle to the neglected side. All activities are directed to the affected person via the restricted side to train awareness of that side. The bed is positioned so that the patient lies with the healthy side facing the wall. Conscious and patient handling is essential, as the ability to pay attention and concentrate is restricted.Everyday situations, conversations and visits are exhausting. Therefore, repeated breaks are indicated. Excessive criticism and impatience are counterproductive and reinforce the blocking attitude. A small device the size of a cigarette pack serves as a signal generator. A signal sounds at regular intervals and the sufferer must turn off the device with the neglected side. A vibrator can stimulate the muscles and increase sensitivity. Various exercises train eye and head movements. Cue stimuli facilitate perception, for example colored markings on objects, light signals or acoustic stimuli. If there is insight into the disease, the affected person can use the self-functioning technique to motivate himself to consciously perceive his neglected side.

Outlook and prognosis

If a stroke is the cause of neglect, patients must seek emergency medical attention immediately. If neglect occurs alone, affected individuals often have no awareness of illness without treatment. This is evidenced by patients not noticing or disregarding the side of the environment and body opposite the brain lesion. The prognosis worsens because the following senses remain impaired: visual, auditory, tactile, and olfactory. The result is reduced attention to stimuli in the external world. Social participation is impeded because conversational partners are not looked at properly or not even sought out. Due to the reduced perception of motor function, movements of the extremities take place less, resulting in a reduction of musculature and general skills. Patients have difficulty reading, grooming, eating and exercising – all areas of daily life that represent a massive cut in independence. The prospect of improvement increases with neuropsychological therapy because it helps develop disease awareness. Even with treatment, the prospect remains that patients will continue to need assistance in their daily lives. This is especially true for the issue of mobility and requires increased attention from the environment.

Prevention

There is no prevention in the clinical sense, since strokes, cerebral hemorrhages, brain tumors, and other neurological disorders occur unexpectedly and can affect anyone regardless of age and life circumstances. Only a healthy lifestyle can prevent.

Aftercare

Usually, neglect disappears on its own within a few months without treatment. Follow-up examinations are therefore not mandatory. In many cases, they are nevertheless advisable, as healing can be supported by various medical measures. It is recommended to see a neurologist or at least the family doctor on a regular basis. This is especially necessary if the neglect was triggered by a stroke. In addition, there are a variety of optional aftercare measures that can accelerate healing. For example, vibration therapy of the neck muscles, optokinetic stimulation, or visual exploration training are often used for neglect. In addition, the effects of neglect can be improved by wearing so-called prism glasses. However, the specific therapeutic measures for follow-up depend on the type and severity of the disease. In addition, there are a number of measures that the affected person can integrate into his or her everyday life. For example, it is advisable to consciously include the neglected side in activities such as eating, drinking, combing and dressing. In addition, head and eye movements can be specifically trained. In addition, people with a neglect need to take special care in road traffic for a few months. Initially, driving should be avoided. Caution is also required as a pedestrian. Ideally, patients should be accompanied by relatives.

What you can do yourself

To gradually reduce neglect, it is important to regain awareness of the neglected half of the body or side of the room. If possible, it helps to position the bed so that the affected side faces the room. As a result, more stimuli come from the neglected side. Since the neglect is naturally not noticed by the patient himself, he must be repeatedly made aware of it by those around him. Over time, he learns that he must look for objects and noise sources on both sides.If one side of the body is not perceived or not perceived sufficiently, it can help to pay specific attention to this side. Here, the affected arm and leg is firmly creamed, or massaged towards the heart with a massage brush. The unnoticed side should be included in everyday activities as often as possible so that it is again registered in the brain as an associated body area. When eating, both hands should always be at the table, even if only the healthy hand is doing something. The affected person should hold his impaired arm even with the healthy one on his body. In this way, he actively protects it from entrapment or twisting when moving or lying down.