With our population continuing to live for longer, doctors are beginning to learn about new conditions that affect our ageing population. Hemispatial neglect is a condition that causes patients to ‘ignore’ half of their space after a trauma to the brain which withdraws the ability to respond to sensory stimuli on the affected side. This article will discuss the causes of and treatments for hemispatial neglect, including the disabling effects on the individual.
At the beginning of the 20th Century, the average life expectancy was said to be about 50 for a female, and 47 for a male. But in the space of just over 100 years, this has soared to about 81 for a female, and 77 for a male. Changes to our general lifestyle, such as improved hygiene and diet, and our improved medical knowledge, like the ability to use antibiotics to treat disease, have contributed to these significant changes for our society.
This elongated life expectancy means that we’re more susceptible to conditions that were previously a very low threat. For example, although they can and do occur at all ages, three quarters of all strokes happen after the age of 65, so strokes are usually considered a higher risk for more elderly people. In addition, the number of patients suffering from ischemic strokes, the strokes that block blood vessels in the brain, is increasing, so clot-busting therapies are being administered to save these stroke patients. More people than ever are surviving strokes, enabling us to become more aware of post-stroke conditions that would have been previously unheard of.
Hemispatial neglect is one such condition that results after traumas to the brain, typically following a stroke. It is an enormously debilitating condition that causes a patient’s brain to essentially ignore all stimuli from one side of their surroundings and, in severe cases, to ignore limbs on the neglected side. Neglect is more common following damage to the right side of the brain (meaning that the left side of space will be neglected), although has been documented following damage to the brain’s left side.
There can be a substantial range of neglect severity, which could cause patients to neglect:Their own body or personal space – Patients may ‘ignore’ any stimuli coming from one or both of their limbs on the neglected side. They may refuse to accept that the limb is theirs, increasing the risk of injury if they are caused to forget pain and sensory stimuli from the neglected body part.The space within their reach – This could cause a patient to ignore objects immediately outside of their line of vision, like books on the table for example, so may believe they are losing items leading to feelings of paranoia.The area beyond the body’s current contact – The patient may have control over their limbs and recognise objects in their immediate vision, but ignore larger, further away objects like other people or cars which could pose a threat.
The Effects of Hemispatial Neglect
The effects of neglect on the individual are quite substantial. Simple tasks like reading and writing become more complicated, as patients will completely ignore the left side of a page, so the words will become detached and meaningless. Patients suffering from hemispatial neglect have also been known to apply makeup to half of their face, eat half of their plate of food, and are often at increased risk of injuring the contralesional side of their body (the side that they neglect) if they collide with obstacles like door frames or walls. In addition, it can be hard for a patient with hemispatial neglect to integrate fully back into society, as simple tasks like crossing a road will become dangerous if they forget to check for oncoming traffic on the neglected side. The neglect will also make patients almost entirely dependent on others and incredibly isolated from society, as tasks like efficiently carrying out personal care by themselves will become near impossible. Neglect patients will also lose their eligibility for a driving license and are often not entitled to an electric wheelchair, which places further obstacles in the way of their social recovery, even if good physical recovery is made.
It is also the patients’ family who are affected by neglect. Sufferers are often in complete denial about their condition, so it can be very tough on family members to accept the new challenges faced by their loved one. Neglect is usually triggered by a traumatic brain injury, so the family will be dealing with the aftermath of this, plus this new, difficult lifestyle. The patient may also mistakenly ignore family relatives if they are standing on the neglected side, which can be heartbreaking for all involved.
There are a number of tests currently in practice, which are being used to diagnose hemispatial neglect. To determine the severity of the patient’s neglect, a 30 centimetre line may be drawn on a piece of paper in front of the patient, who will be asked to bisect the line. The professionals will expect the line to be bisected at the midpoint of 15 centimetres, indicating that the patient is not suffering from neglect. If the patient bisects the line at 17 centimetres (from the left), the doctors will know that the amount of the line that is being seen a line that is about 26 centimetres in length, which will indicate that the patient is suffering from mild neglect. However if the line is bisected at about 28 centimetres from the left, the patient will be seeing a line that is about four centimetres in length, showing a neglect of a far more severe nature.
Figure 1: Line A shows the expected bisection from a patient who is not suffering from neglect. However, lines B and C show the bisection attempts from moderate and severe neglect impairments respectively. The patient will bisect the line they see, be it the full length or a shortened length, so this is used as a clear method of testing the neglect’s severity.
Figure 2: This is another method of diagnosing neglect. Figure 2 shows an illustration of how a patient suffering from neglect may sketch a clock face, on the right, compared to an average drawing of a clock face on the left.
As we are still in the process of learning about hemispatial neglect, the treatments are still in the pioneering stage. Currently, doctors and hospital professionals try and bring the patient’s attention to their neglected side, in the hope that this will make them acknowledge and accept it. Rehabilitation can also be carried out by a multi-disciplinary team including doctors, psychologists, physiotherapists and occupational therapists to try and reduce the implications of neglect. I was able to observe this rehabilitation first hand when I spent time in Dr Sakel’s Neuro-Rehabilitation department, based in Canterbury, where I learnt about how possible new technologies involving electrical currents may help in the treatment of hemispatial neglect. Dr Sakel’s team has researched the benefits of stimulating the brains of such patients, which has so far been successful. More research is planned into this
While hemispatial neglect is not yet completely understood it is hoped that, as our medical knowledge and treatments advance, we will one day have all the answers regarding this fascinating and intriguing, yet disabling condition.
AcknowledgementsI would like to thank Dr Mohamed Sakel and the Neuro-Rehabilitation team at Kent and Canterbury Hospital for inviting me into their department and giving me the opportunity to learn about neurological conditions such as hemispatial neglect. This has provided me with a very insightful view into aspects of medicine that I hadn’t previously explored, and I have thoroughly enjoyed the journey.
- Hemispatial Neglect: Clinical Features, Assessment and Treatment. British Journal of Neuroscience Nursing 2014. M Gallagher, D Wilkinson and M Sakel 2013:9;273-7 http://www.magonlinelibrary.com/doi/abs/10.12968/bjnn.2013.9.6.273
- Galvanic Vestibular Stimulation in Hemi-Spatial Neglect. Frontiers in Integrative Neuro Science Special Edition 2014. D Wilkinson, O Zubko, M Sakel, S Coulton, T Higgins and P Pullicino (free access)