Neglect (hemispatial neglect)

Introduction

Neglect is a condition that primarily occurs when the right hemisphere of the brain is damaged, resulting in loss of function on the left side. This involves a lack of ability to pay attention to the affected side, usually the left.

People with neglect experience this side and the space around it as invisible.

They don't perceive it, feel it or see it.

 

It is an invisible consequence of brain damage, usually as a result of a stroke (cerebral hemorrhage or cerebral infarction).

Officially, neglect is considered a cognitive consequence of brain damage.

 

Neglect is the unconscious failure to perceive what is happening or what can be seen or heard, on one side of the body or in space. The word 'neglect' comes from the Latin word neglēctus/neglegō, which means to ignore or to disregard.

Neglect is also called hemineglect, spatial neglect, or hemispatial neglect.

With neglect people have difficulty responding to or orienting themselves to information on one side of their environment or their own body.

Attention is impaired. Often, there is reduced attention or unconscious perception of one specific side: left or right.
This may involve unconsciously ignoring the affected side, people, objects, or events located on the left (after damage to the right hemisphere) or the right (after damage to the left hemisphere) of the person.

 

 

Not only vision, but also hearing and body awareness may be impaired with neglect.
Neglect is not caused by direct problems with senses such as the eyes, visual field loss (as in hemianopia) or motor problems, but by a disruption in the brain's ability to process sensory information.

Shortly after brain damage, neglect occurs just as often after damage to the left and right hemispheres.
In the chronic phase, it occurs primarily with damage to the right hemisphere (with deficit symptoms in the left).

 

 

Confusion in terminology

Several names are used for neglect. Hemispatial neglect, spatial neglect, and visuospatial neglect describe the neglect of the space next to the person.
The term hemineglect is also used for the same problem, because it involves neglect on one side of the body.
The term is sometimes confused with hemianopia, which means a loss of visual field on one side of the body.
Hemispatial neglect involves visual impairment, while hemineglect does not.

 

Diagnosis

Neglect is diagnosed using a neuropsychological examination. During this examination people can be  asked to copy a picture.

See the picture below for an example. On the left (a) is the example picture, and on the right (b) is the picture copied by someone with left-sided neglect.

 

Neglect can be assessed with an observational checklist, such as the Catherine Bergego scale. This checklist identifies problems in daily life caused by neglect, such as repeatedly forgetting to put on your left or right shoe.

 

Neglect is very common after a stroke or a cerebral hemorrhage, but can also occur after traumatic brain injury, tumors and aneurysms.
It is difficult to determine exactly how often neglect occurs. This is because recognizing the problems can be difficult, precisely because patients are unaware of parts of their surroundings. Another factor is that many people with neglect are unaware that they have neglect.

 

This can make it extra difficult to learn to cope. This is not only difficult for you, but also for your family and friends. Therefore, it's important to get a proper diagnosis and receive information.
Neglect is often confused with another condition in which one fails to notice objects, people, or one's own body on one side because half of the visual field is lost. This is called hemianopia. Read more about
hemianopia.

Problems people may experience with neglect

In relation to the environment:

• When eating, forgetting to finish half of the plate

 

• Failure to notice visitors, doctors, nurses, or the bedside table, and offering food or drinks to one side

 

• When shaving, only one side of the face is shaved

 

• When applying makeup, only one side of the face is shaved

 

• Difficulty finding items on one side of the room

 

• Bumping into things on the affected side (obstacles, doorposts)

 

• In traffic, neglect is life-threatening because road users and signs on the affected side are not noticed

 

• Rooms and hallways on the left side, for example, are passed over, causing people to lose their way

 

• Ignoring people in a group who happen to be on the wrong side. This is not out of unwillingness, but because they are not noticed. Someone may also report being unable to hear anything on one side of the brain, while an audiogram shows that there is nothing wrong with hearing.

 

• People may be unable to move down the middle of a hallway in a wheelchair, but may unknowingly roll to the affected side. With a right-sided head injury, the person may not see much on the left side and steer to the left, With a left-sided brain injury, the person will steer to the right.

 

In relation to one's own body:

• In extreme cases, the patient no longer recognizes his or her own arm and leg as an own limb. She or he feels as if there's a foreign leg lying in bed.
  

 

• For example, he or she may forget to lift the left or right leg out of bed or to remove the foot from the wheelchair support.

 

• When sitting on a chair or lying on a bed, the paralyzed arm hangs down. This easily leads to injuries that are less noticeable due to neglect. For example, the patient may not feel that the hand is stuck in the wheelchair wheel.

 

Brain areas involved in neglect

With neglect the brain damage often occurs in the opposite hemisphere.

Neglect of the left side (left-sided neglect) usually results from damage in the right hemisphere.

Left-sided neglect is more common than right-sided neglect. This is likely because the right hemisphere specializes in spatial perception, that is, knowing where things are located in the environment.

Damage in the right hemisphere is therefore more likely to lead to problems.

There is no single specific brain area responsible for neglect. In many cases, the parietal lobe is damaged, but neglect can also occur with damage to the frontal lobe, cingulate gyrus, corpus striatum (part of the basal ganglia), and the thalamus.

All these brain areas are part of the network involved in spatial attention.

 

Tips for neglect

Neglect can gradually improve, but will often remain as a residual effect.

A neuropsychologist can help with coping.

• Give people with neglect ample time to explore their surroundings.
• Use strategies that help direct your attention to the affected side, such as turning your head, working from left to right, and working according to a fixed plan.
• Encourage people to actively use their visual acuity (which is not affected) to direct more attention to the affected side during activities.

 

Wearing prism glasses is currently being scientifically investigated. While wearing prism glasses, the field of vision is shifted toward the unaffected side. When the glasses are removed, there is an automatic shift of attention toward the neglected side.

More information:

https://pmc.ncbi.nlm.nih.gov/articles/PMC4415396/

 

Some video's on neglect:

Observation checklist to assess neglect: the Catherine Bergego scale

Check:

0 = no neglect

1 = occurs very rarely/corrections are made

2 = occurs frequently/corrections are made only at the last minute

3 = always occurs/no corrections are made

4 = difficult to assess because the patient cannot do this without assistance

5 = situation not observed

 

1. Forgets to care for one side of their face, for example, by combing or shaving.

1☐ 2☐ 3☐ 4☐ 5☐

 

2. Has difficulty putting on and fastening one side of a sleeve, slipper, shoe (or other garment).

1☐ 2☐ 3☐ 4☐ 5☐

 

3. Forgets to eat food on one side of the plate.

1☐ 2☐ 3☐ 4☐ 5☐

 

4. Forgets to clean one side of the mouth after eating.

1☐ 2☐ 3☐ 4☐ 5☐

 

5. Has difficulty looking to one side.

1☐ 2☐ 3☐ 4☐ 5☐

 

6. Forgets one side of a body part, e.g., forgets to put the left/right leg out of bed, forgets to place the left/right arm on the support/armrest, forgets to place the left/right foot on the wheelchair footrest, or forgets to use the left/right arm (if necessary).

1☐ 2☐ 3☐ 4☐ 5☐

 

7. Has difficulty focusing on sounds or people on one side of him/her.

1☐ 2☐ 3☐ 4☐ 5☐

 

8. Bumps into people, doorframes or furniture on one side of the room.

1☐ 2☐ 3☐ 4☐ 5☐

 

9. Has difficulty finding his or her way in familiar areas or in the rehabilitation center, for example, may pass by the elevator or the living room.

1☐ 2☐ 3☐ 4☐ 5☐

 

10. Has difficulty finding personal belongings in the room or bathroom if they are on one side.

1☐ 2☐ 3☐ 4☐ 5☐

 

On which side do these problems usually occur?

(Circle the correct answer) left/right/both/neither

 

Total score:
......./30

• The observer assesses whether the inability to perform an activity is due to neglect or something else (e.g., not being able to do up buttons due to hemiplegia). Paresis or hemiplegia should not be included in the score.
• The 10 items are scored on a 0-3 scale: none, mild, moderate, or severe neglect. If a patient is unable to perform one or more daily tasks for reasons other than neglect, or if the therapist was not present during a particular task, this item is not scored (score 4 or 5).
• Unscored items are not included in the total score. The total score is calculated by adding the item scores, dividing by the total number of scored items, and multiplying the result by 10.
  
• Example: a patient has a score of 4 on one item. The scores for the remaining items are added up, divided by 9, and multiplied by 10.
  
• The maximum score is 30, with 6 being the threshold for neglect. The degree of neglect can be indicated as mild (score 6-10), moderate (11-20), or severe (21-30).

 

More information on Catherine Bergego scale:

https://www.carepatron.com/templates/catherine-bergego-scale-cbs/

 

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