Curriculum standards
Knowledge guides
LG17: Disorders of consciousness and sleep
Key presentations and conditions
Advanced Trainees will have a comprehensive depth of knowledge of these presentations and conditions.
Less common or more complex presentations and conditions
Advanced Trainees will understand these presentations and conditions.
Advanced Trainees will understand the resources that should be used to help manage patients with these presentations and conditions.
Epidemiology, pathophysiology, and clinical sciences
Advanced Trainees will have a comprehensive depth of knowledge of the principles of the foundational sciences.
Investigations, procedures, and clinical assessment tools
Advanced Trainees will know the scientific foundation of each investigation and procedure, including relevant anatomy and physiology. They will be able to interpret the reported results of each investigation or procedure.
Advanced Trainees will know how to explain the investigation or procedure to patients, families, and carers, and be able to explain procedural risk and obtain informed consent where applicable.
Important specific issues
Advanced Trainees will identify important specialty-specific issues and the impact of these on diagnosis and management and integrate these into care.
Presentations – disorders of consciousness
- Anxiety
- Confusion or somnolence
- Dizziness
- Fainting / Loss of consciousness
- Fever
- Hallucinations
- Headache
- Heart palpitations and/or shortness of breath
- Muscular difficulties:
- coordination problems
- stiffness
- weakness and/or paralysis
- Nausea and/or vomiting
- Pain
- Pins and needles and/or sensory loss
- Seizures
- Shakiness
- Speech and/or swallowing difficulties
Presentations – disorders of sleep
- Concentration / Memory impairment
- Episodes of incomplete awakening and limited responsiveness
- Excessive daytime sleepiness, narcolepsy, and sleep attacks
- Insomnia
- Loud snoring
- Morning headaches
- Sleep paralysis
- Waking gasping or choking during the night
Conditions – cognition
- Delirium
- Metabolic and inherited disorders
- Neurodegeneration
Conditions – inflammatory and infectious
- Demyelinating disease
- Encephalitis:
- autoimmune
- infective
- vasculitis
- Meningitis
- Systematic inflammatory disorders
- Systemic infection
Conditions – metabolic and toxic
- Hepatic
- Hypoglycaemia
- Kidney failure
- Prescribed and illicit drugs
Conditions – other
- Epilepsy, especially sudden unexpected death in epilepsy (SUDEP)
- Obstructive sleep apnoea
- Syncope
- Traumatic brain injury, including:
- concussion
Conditions – structural
- Raised intracranial pressure
- Space-occupying lesions:
- abscess
- haemorrhage
- tumour
- Stroke
- Subarachnoid haemorrhage
For each presentation and condition, Advanced Trainees will know how to:
Synthesise
- recognise the clinical presentation
- identify relevant epidemiology, prevalence, pathophysiology, and clinical science
- take a comprehensive clinical history
- conduct an appropriate examination
- establish a differential diagnosis
- plan and arrange appropriate investigations
- consider the impact of illness and disease on patients and their quality of life when developing a management plan
Manage
- provide evidence-based management
- prescribe therapies tailored to patients’ needs and conditions
- recognise potential complications of disease and its management, and initiate preventative strategies
- involve multidisciplinary teams
Consider other factors
- identify individual and social factors and the impact of these on diagnosis and management
Presentations
- Non-rapid eye movement (REM), such as:
- confusional arousal
- night terrors
- sleep talking
- somnambulism
- REM sleep behaviour disorder (RBD)
- Sleep attacks
Conditions
- Sleep disorders, such as:
- hypersomnia
- narcolepsy
- parasomnia
For each presentation and condition, Advanced Trainees will know how to:
Synthesise
- recognise the clinical presentation
- identify relevant epidemiology, prevalence, pathophysiology, and clinical science
- take a comprehensive clinical history
- conduct an appropriate examination
- establish a differential diagnosis
- plan and arrange appropriate investigations
- consider the impact of illness and disease on patients and their quality of life when developing a management plan
Manage
- provide evidence-based management
- prescribe therapies tailored to patients’ needs and conditions
- recognise potential complications of disease and its management, and initiate preventative strategies
- involve multidisciplinary teams
Consider other factors
- identify individual and social factors and the impact of these on diagnosis and management
- Conditions required for brain death diagnosis
- Neuroanatomy, neuropharmacology, and neurophysiology of brain and brainstem mechanisms involved in the maintenance of normal consciousness
- Neuroanatomy, neuropharmacology, and neurophysiology of normal sleep function
- Pathological mechanisms that result in decreased consciousness
- Pathological mechanisms that result in disturbed sleep and describe the way disorders of sleep can present
Assessments
- Epworth Sleepiness Scale
- Glasgow Coma Scale
Cerebrospinal fluid (CSF) procedures and investigations
- Lumbar puncture (LP) and interpretation of investigation results, such as:
- CSF analysis:
- cell count
- cytology
- immunological tests, including:
- encephalitis panel
- paraneoplastic
- microbiological tests
- oligoclonal bands
- protein level
- sugar level
- xanthochromia
- opening pressure
- CSF analysis:
Clinical neurophysiology investigations
- EEG:
- sleep-deprived EEG
- standard EEG
- video EEG
- Evoked potentials:
- brainstem
- somatosensory
Neurogenetic investigations
- Genetic testing, including, but not limited to:
- chromosomal testing, such as:
- karyotype
- microarray
- genomic testing, including whole exome or genome sequencing
- mitochondrial genome sequencing
- targeted panel testing
- chromosomal testing, such as:
- Referral to a neurogeneticist
Neuroimaging investigations
- CT, including:
- CT angiography
- perfusion
- venography
- MRI, including:
- functional (fMRI)
- magnetic resonance:
- angiography (MRA)
- spectroscopy (MRS)
- venogram (MRV)
- with contrast
- PET
- Single photon emission computed tomography (SPECT)
- Vascular imaging:
- catheter angiography
- doppler ultrasound
Neuropsychological investigations
- Cognitive screening:
- Addenbrooke’s Cognitive Examination
- Mini-Mental State Examination
- Referral to a neuropsychologist
Other investigations
- Cardiac investigations:
- 24-hour ECG monitoring
- ECG
- echocardiography
- Lung function tests:
- formal lung function tests
- vital capacity
- Other laboratory tests, such as:
- autoimmune serology
- B12 level
- electrolytes
- full blood count and inflammatory markers
- hepatic and renal function
- metabolic testing, including:
- glucose level
- heavy metal and other toxins, including:
- alcohol
- ammonia levels
- drugs
- micronutrients
- Multiple Sleep Latency Test (MSLT)
- Polysomnography
- Conditions that mimic disturbance of consciousness, such as:
- acute aphasia
- functional disorders, including:
- non-epileptic status epilepticus
- locked-in syndrome
- stroke
- Conditions that result in prolonged disturbance of consciousness, such as persistent vegetative state and minimally conscious state
- Overlap with specific neurological syndromes, such as Parkinson disease and REM sleep behavioural disorders
- Prognosis and implications of sleep disorders, such as driving
- Role of neurologist in neuroprognostication for serious intercranial injury, including hypoxic ischaemic encephalopathy and subarachnoid haemorrhage