8.1 Neurological Symptoms

Why this cluster is high-yield on CHPN

Patient Care: Symptom Management is Domain 3 on the Hospice and Palliative Credentialing Center (HPCC) CHPN exam: 28 scored items (20.7% of 135 scored questions). This chapter covers the neurological, cardiovascular, and respiratory cluster. Gastrointestinal, nutritional, and integumentary symptoms belong in later Domain 3 sections. CHPN stems almost never ask you to name a textbook emergency in isolation. They ask whether the next action is reversal (steroids plus radiation, hospital transfer) or comfort (home benzodiazepine, positioning, family teaching) given the patient's goals.

Two number traps sit near this content. The CHPN passing standard is a scaled score of 500 on a 200–800 scale, not a raw 75% cutoff. The 500-hour figure in eligibility is practice hours, not the passing score. Keep those separate when a stem mentions "500."

Neurologic events look dramatic, so families and some clinicians default to 911. The CHPN-correct move is to stop the distressing event by a route you actually have, then match the workup and destination to goals. HPCC items use generic drug names; this section does the same.

Seizures

A generalized convulsive seizure is an emergency for the witness even when the patient is enrolled in hospice. The first pharmacologic step is a benzodiazepine you can give now. Lorazepam can be given intravenously, intramuscularly, or as a concentrated oral solution placed in the buccal gutter. Midazolam is the home-hospice workhorse because it can be given subcutaneously, intranasally, or buccally without intravenous access. After the event stops, consider scheduled levetiracetam when the patient can swallow or when a parenteral route exists. Levetiracetam is used often in brain-tumor and hospice protocols because it has fewer cytochrome P450 interactions than older enzyme-inducing antiseizure drugs.

Causes include brain metastases, primary brain tumor, hyponatremia, hypoglycemia, uremia, missed antiseizure doses, and alcohol withdrawal. Exam trap: myoclonus is not a tonic-clonic seizure. Do not "treat a seizure" with only an opioid rotation if the patient is truly convulsing; abort the seizure first, then sort toxicity. For the imminently dying, the goal is to stop the frightening event and support the family, not to obtain an electroencephalogram. If goals remain disease-modifying, transfer and imaging may still be right after the first benzodiazepine dose.

Myoclonus

Myoclonus is involuntary, often multifocal twitching of the face, trunk, or limbs. Two causes dominate hospice items:

1. Opioid-induced neurotoxicity. Neuroexcitatory metabolites accumulate when morphine or hydromorphone doses climb in renal impairment. Meperidine is a classic toxin and should not be used. Treatment: reduce or rotate the opioid (often toward fentanyl or methadone per protocol and specialist support), hydrate only if that still matches goals, and use a benzodiazepine such as lorazepam for the jerks.
2. Uremia after dialysis is stopped or in advancing kidney failure.

Gabapentinoid accumulation can look similar. If myoclonus appears after an opioid increase plus a rising creatinine, think toxicity first, not "the pain dose is too low."

Increased intracranial pressure

Vasogenic edema from brain tumor or metastases produces morning headache, vomiting, confusion, and, late, Cushing physiology (hypertension, bradycardia, irregular respirations). Dexamethasone is the steroid of choice for this edema. Elevate the head of bed (HOB) about 30 degrees, avoid prolonged flat supine positioning, treat nausea, and use seizure precautions. Osmotic agents such as mannitol are hospital tools; they are rarely a home-hospice first move. Radiation or surgical decompression enters the plan only when prognosis and goals still support those trips.

Spinal cord compression

Malignant spinal cord compression is a time-critical oncologic emergency: new or worsening back pain (often thoracic), bilateral weakness, a sensory level, and bowel or bladder change. Hours can determine whether the patient walks. When goals include preserving function, give high-dose dexamethasone and arrange urgent radiation, with surgery on the table if prognosis and anatomy support it. When goals are comfort-only, steroids still reduce edema and pain, opioids and a bowel regimen remain essential, and radiation is used only if the trip still serves comfort.

Terminal restlessness: a pointer, not the full lesson

Picking at bedclothes, moaning, and nonpurposeful movement in the last hours may be terminal restlessness, untreated pain, urinary retention, or delirium. Do not label it "just dying" until you have looked for a reversible cause. Full Confusion Assessment Method (CAM) delirium care is Section 8.2.

Emergency versus comfort

CHPN stem language such as "the family wants everything done" versus "the patient chose comfort-focused hospice" tells you which column to use. Treat the seizure or cord syndrome in front of you either way; what changes is the destination after the first dose. A worked pattern: a patient with known brain metastases seizes at home, then returns to baseline. Give midazolam now. If the patient still wants hospital-level reversal, arrange transfer after the seizure stops. If the plan is home death, start or resume levetiracetam if a route exists, teach the family how to give the next benzodiazepine dose, and stay for a period of observation rather than sending everyone to an emergency department that cannot change the outcome.