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Delirium
Published in Henry J. Woodford, Essential Geriatrics, 2022
Clues to the diagnosis of NCSE include subtle rhythmical twitching or myoclonus of the eyelids, periorally or in the extremities. Automatisms may be present. These are repetitive, unconscious, purposeless movement patterns. Examples include orofacial movements (e.g. lip smacking, chewing, yawning, grimacing or rapid blinking) and hand/arm movements (e.g. picking at clothes, rubbing or tapping).55 Ocular movement abnormalities (e.g. nystagmus, hippus (rhythmic dilation and contraction of the pupils) or eye deviation) may be seen. Other reported features include catalepsy (a condition of increased muscular tone and fixed posture where the limbs may remain in the same position when moved, termed ‘waxy flexibility'), echolalia (patients repeat things said to them), emotional lability and mute episodes. On the other hand, people with metabolic encephalopathy are more likely to have asterixis or multifocal myoclonus, and so these features make NCSE less likely. The clinical features that help diagnose NCSE in older people are summarised in Table 7.4.56 Diagnosis can be challenging in post-ictal states and with drug/alcohol withdrawal. Most older people diagnosed with NCSE have either subtle motor features, known epilepsy, a seizure prior to onset or a history of relevant drug withdrawal (i.e. benzodiazepines).56 Epilepsy can also cause recurrent, unexplained, confusional events (see page 229).
Drug Withdrawal: Recognition and Treatment
Published in Frank Lynn Iber, Alcohol and Drug Abuse as Encountered in Office Practice, 2020
Some change in energy level is usually prominent. The patient is usually agitated and hyperactive during the initial interview, shifting position of the arms and legs frequently and “fidgeting”. There is often a complaint of sleep and eating difficulties, but somnolence and hyperphagia are rarely seen. There is inappropriate temperature regulation, with sweating and heat intolerance most common but inability to stay warm sometimes noticed. Pupillary dilatation, hippus, and tremor are common. There are no confirmatory laboratory tests for withdrawal. The electroencephalogram is fairly typical of withdrawal states, showing asymmetrical hyperactivity.
Examine the speech
Published in Hani TS Benamer, Neurology for MRCP PACES, 2019
Normal rhythmic variation in the size of the pupil when exposed to light is not a relative afferent pupillary defect (the pupil keeps constricting and slightly dilating several times per second when exposed to light). This is a normal phenomenon called hippus.
A dangerous chase: severe neurocognitive impairment and death following smoked heroin
Published in Clinical Toxicology, 2018
Alessandro Cancelliere, Eike Blohm, Mark Neavyn
We report the case of a 25-year-old man with acute encephalopathy following inhalation of heroin pyrolysate vapors, a practice known as “chasing the dragon”. On presentation to the emergency department, he was oriented to place only, with impaired attention, short-term memory deficits, difficulty following complex commands, right-left confusion, agraphia, apraxia, and dysarthria. Neurological examination was significant for mydriasis with hippus, Babinski response, dysmetria, truncal and gait ataxia, and dysdiadochokinesia. Apart from heroin use, the patient had no prior medical conditions or substance use.
Management of digital eye strain
Published in Clinical and Experimental Optometry, 2019
Chantal Coles‐brennan, Anna Sulley, Graeme Young
A similar study suggested that the visual fatigue experienced by computer users may be associated with hippus (rhythmic contraction of the pupil).1997 Taptagaporn and Saito1990 examined the change in pupil size following computer work using positive and negative display polarities. Only small changes in pupil size were observed for the positive display (dark character on bright background). In this study, a majority of the subjects preferred the positive display to the negative display. The authors concluded that a positive display is more ergonomic.