The akinetic mutism or greater abulia is a subjective lack of thought, in which the person is not able to initiate any movement or even speech alone. For example, this patient, even though he is thirsty, may be sitting in front of a glass of water without drinking from it. This may be due to damage to brain structures that seem to drive motivation to carry out behaviors, being immersed in a significant state of apathy.
We can define akinetic mutism as a decrease or absence of spontaneous behaviors despite the fact that motor skills are intact, since the origin of the problem, as we said, is motivational (it affects the dopaminergic circuits of the brain).
It is a difficult syndrome to diagnose since it can be part of altered states of consciousness. Sometimes it appears as a continuum, the akinetic mutism being situated between the coma and the return to wakefulness..
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Rodríguez, Triviño, Ruiz and Arnedo (2012) described a curious case of a patient who, after several brain surgeries, presented what is defined as “a blank mind”.
The patient, who we are going to call “Emilio”, was 70 years old when a benign tumor (meningioma) was detected in the cerebral cortex. The patient felt that he had difficulties in naming objects and describing situations, in addition to motor clumsiness when playing the saxophone, a task that he previously performed without difficulties since he played in the band of his town.
He also liked taking care of his garden and was starting to have problems that he did not have before..
A craniotomy was performed to remove the tumor, which was uneventful. A year later, in a review, several tumor nodules were detected, so this patient had to undergo multiple surgical and radiosurgery interventions over 6 years.
This gave rise to different complications, since Emilio came to present right hemiparesis (it is a frequent condition after brain damage in which the right side of the body is weakened) and motor difficulties from which he recovered with treatment..
However, another MRI revealed a new tumor occupying the anterior cingulate cortex. After operating again to remove it, the patient was evaluated, diagnosing his condition as akinetic mutism..
The most common cause of akinetic mutism is vascular, although there are some cases whose origin is the exposure or ingestion of toxins, infections or degenerative processes.
The damaged structures in akinetic mutism seem to participate in the initiation and maintenance of the behavior, as well as the motivation to trigger it.
What do we mean by motivation here? In this context, it is defined as the energy necessary to achieve something that is desired or avoid something aversive and that is influenced by the emotional state. It is as if the will is lacking and the person cannot start to meet their needs, remaining still and silent all the time.
That is why this disorder is called "having a blank mind." In fact, Damasio (1999) describes that patients who have recovered from akinetic mutism, when asked why they did not speak when they had the disease, said “is that nothing came to mind".
The vascular lesions that cause this disease cause heart attacks in:
That damage the anterior cingulate cortex and parts of the frontal lobe. In addition, it not only appears due to injuries in the anterior cingulate cortex, but also due to damage in the connections of the frontal areas with subcortical areas..
To understand the origin of this disorder, it is important to note that one of the main areas that receives dopamine from the meso-cortical dopamine system, since it receives information from deeper areas of the brain that make up the famous brain reward system.
This system is essential to carry out survival motivating behaviors such as perpetuation of the species or search for food. Therefore, it is not surprising that, if the dopamine circuits are damaged, a state of apathy develops..
Damage to the frontal-basal connections of the brain will isolate the frontal areas of structures such as the caudate nucleus, globus pallus, putamen or internal capsule, which are very important for the person to find motivation to perform behaviors.
They damage the back of the cerebellum and the vermis area. It has been found that the cerebellum can be associated with functions such as verbal fluency, working memory, emotions, or task planning (curiously, very typical of the frontal lobe). However, more research is needed to know exactly how it manifests in akinetic mutism..
The most common and distinctive symptoms are:
If there is speech, it is very scarce and is characterized by hypophonia (low volume of the voice), and by dragging of words. Pronunciation and syntax are usually correct, as long as there is no damage to brain structures dedicated to language.
They can understand what is being asked, but it does not seem so at first glance, since when they answer they do not do so consistently. They respond mainly when asked for biographical information, such as their name or date of birth. If they are other types of questions, they prefer to answer with "yes", "no" or monosyllables.
They usually don't initiate conversations, they don't ask questions, they don't even make requests regarding their basic needs: eating, drinking, going to the bathroom. They do not express what they want or seem to do anything to achieve it.
It is often the case that they can only perform actions if someone else helps them to initiate them. They can use the objects without any problem, but they never initiate movement of their own free will. According to the example we gave before the glass of water, if Emilio was thirsty, he would not drink until someone else put the glass in his hand.
It means performing repetitive, purposeless motor actions. For example, in the case of Emilio, he continually folded the end of his shirt with his fingers. Which indicates that there are no problems in the performance of movements, but in the will to start them.
Another distinctive symptom is that these patients, faced with a stimulus that is harmful, can “wake up”, that is, react by shaking and even saying words..
Regarding the emotional states, they seem to be variable in each case. Some have practically imperceptible emotional expressions while others have significant alterations, sometimes typical of frontal brain damage, such as impulsive and uninhibited emotional outbursts..
- Failure to initiate spontaneous voluntary actions.
- They remain still, inactive throughout the day (akinesia). They only carry out automatic behaviors.
- Silence and lack of gestures (for example, they do not indicate signs that show that you are listening or understanding what others are saying).
- They do not usually answer if the questions are open or involve emotional or affective content.
However, symptoms can vary depending on the functional deficits caused by each affected brain area..
Two types of akinetic mutism have been defined depending on where the lesions are in the brain and the symptoms it causes:
It is the most common and is associated with unilateral or bilateral focal lesions of the anterior cingulate cortex.
If this lesion is unilateral, patients usually recover a few weeks later, on the other hand, if it is bilateral, it will present a total loss of the onset of spontaneous behavior that is not reversible. Sometimes the damage can also extend to the supplementary motor area causing deficits in movement..
It occurs due to the involvement of the diencephalon, especially the ascending activating reticular system. This type presents less vigilance than frontal-type mutism and is also distinguished from this in that the patient presents vertical gaze paralysis.
Akinetic mutism is difficult to detect, as it is difficult to assess because it is difficult for patients to respond to tests and must manage to perform an effective neuropsychological evaluation. For this reason, it is easy to confuse akinetic mutism with other conditions or disorders..
Therefore, caution should be taken not to confuse with:
Unlike akinetic mutism, in the vegetative state there is what is known as a vigil coma, a state in which the patient cannot follow external visual stimuli with his eyes, even if they are open; cannot express themselves or follow simple commands.
They do retain some reflexes, but they cannot carry out behaviors because they would need to process with more cortical brain structures that patients with akinetic mutism have intact.
In akinetic mutism, it is unresponsive due to a severe state of apathy and apathy that causes it to not move or speak spontaneously; but unlike minimal awareness, if they can emit coherent responses when prompted and initiate movements when helped.
Movement is not produced by paralysis in the limbs caused by damage to the spinal and corticobulbar tracts, leaving intact most of the cognitive functions, vertical eye movements and blinking (which they frequently use to communicate).
It can be difficult to make a distinction, since in some cases akinetic mutism and aphasia can occur at the same time. The main difference is that the initiative and motivation to communicate is preserved in aphasics, while patients with akinetic mutism lack these..
It would be at a level immediately lower than akinetic mutism, being milder.
The main goal is to reduce apathy. Apathy is characterized by an alteration in the ability to set goals, lack of motivation, loss of initiative and spontaneity, affective indifference.
It is also usually related to a lack of awareness of the disease, which has a very negative impact on the life of the person and their global neuropsychological functioning. It is necessary to reduce this apathy and increase the collaboration of the patient for a satisfactory rehabilitation.
Other goals are to maximize your independence, and to carry out activities of daily living that you used to do normally..
Neuropsychological rehabilitation consists of the application of intervention strategies that seek to ensure that patients and their families can reduce, cope with or manage the cognitive deficit.
For this, it will work directly improving the performance of cognitive functions through repetition of exercises. Deficits can be intervened in 3 ways:
Important aspects to bear in mind:
To reduce apathy, mainly dopamine agonists such as levadopa or bromocriptine, since dopamine pathways are often affected.
Achieving a minimum level of patient collaboration is absolutely necessary to start working. It can start by raising awareness of the deficit, which means that we have to make the person realize that they have a problem and that they must make an effort to recover.
Carry out family activities that are valuable to the person, that can “awaken” previously learned behaviors.
It is essential for this that the family collaborate in therapy, since they are the ones who spend most of the time with the patient. They must be educated so that they adequately manage the environment in which the patient lives, structure the activities of daily life to make them easier.
It is appropriate that they help the patient to initiate actions, trying to make them motivating tasks, and that they adapt to the cognitive level of the affected person.
It is useful to ask family, friends, what the patient liked to do previously, what motivated him, what hobbies he had, etc. In this way we can get to know the affected person better and develop therapeutic activities that motivate and be enjoyable for them..
Break the activities down into small steps and with clear instructions on their execution. When done correctly, you are always given immediate feedback after each step. It is appropriate to ensure that failure does not occur so that it is not frustrated.
Some important points for the execution of activities are:
They must make the patient feel that they are willing to help him, showing affection (but never treating the patient with pain or as if he were a child) and not lose hope.
Try to visualize the situation as hopeful, implying to the affected person that the situation will undoubtedly improve. Give positive expectations for the future, avoid showing tears and complaints in front of the patient because it could sink him.
One technique is back chaining. It is about breaking down the task into steps and asking the patient to take the last step. To do this, first the complete task is done (for example, brushing the teeth), taking the patient's arm and doing all the movements.
The task is then repeated with assistance, but the last step must be done by the patient alone (drying the mouth). Encourage him to do it "now you must dry your mouth with the towel, come on" and reinforce him when he does.
Then the task is repeated until the patient can brush his teeth without any help. This technique has been found to be very useful for patients with motivation problems.
It consists of dividing a task into small, sequential steps and writing them in a list. This allows you to verify that each case is complete. This technique makes it much easier to start, finish and track the activity.
In addition, it reduces fatigue, so that less energy is consumed because the patient does not have to plan, organize and remember the steps necessary to reach a goal. It is very useful to establish a routine of activities that must be done daily, since if they are repeated consistently they can become automatic habits.
In a second moment, another strategy is developed dedicated to increasing the frequency of desirable but infrequent behaviors, rewarding their performance with very pleasant consequences for the patient..
To do this, a list must be made with what the patient is known to like and another list with what he is expected to do to achieve it. In order to know if it is useful for the patient (because it is usually completed by the family), he must assess each point on the list from 1 to 10 according to the degree of difficulty or, according to the degree of enjoyment it produces..
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