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Terminal
lucidity:
A
review
and
a
case
collection
Michael
Nahm
a
,
Bruce
Greyson
a,
*,
Emily
Williams
Kelly
a
,
Erlendur
Haraldsson
b
a
Division
of
Perceptual
Studies,
Department
of
Psychiatry
&
Neurobehavioral
Sciences,
University
of
Virginia
Health
System,
210
10th
Street
NE,
Suite
100,
Charlottesville,
VA
22902-4754,
USA
b
Department
of
Psychology,
University
of
Iceland,
101
Reykjavik,
Iceland
1.
Introduction
In
a
previous
report
we
described
the
unexpected
return
of
mental
clarity
and
memory
shortly
before
the
death
of
patients
suffering
from
severe
mental
disorders
(Nahm
and
Greyson,
2009).
This
return
of
mental
clarity
often
occurs
in
the
last
minutes,
hours,
or
days
before
the
patient’s
death.
Observations
of
this
phenome-
non
have
so
far
not
received
much
attention
among
psychiatrists
and
other
physicians.
We
referred
to
this
unexpected
symptom
remission
at
the
end
of
life
as
‘‘terminal
lucidity’’.
In
our
previous
report
we
presented
the
results
of
a
literature
survey
of
published
case
reports
of
terminal
lucidity
during
the
last
250
years,
and
included
case
reports
of
terminally
ill
patients
suffering
from
Alzheimer’s
disease
and
from
chronic
schizophrenia.
By
drawing
attention
to
terminal
lucidity,
we
hope
to
stimulate
future
research
into
the
psychopathology
and
neuropathology
of
mentally
ill
patients
who
suffer
from
an
additional
somatic
disease.
Such
studies
could
facilitate
the
development
of
new
therapies,
and
could
contribute
to
an
enhanced
understanding
of
the
factors
governing
the
interplay
between
body
and
mind,
as
well
as
cognition
and
memory
processing.
In
the
current
article,
we
present
further
results
from
our
literature
survey
and
also
include
new
case
reports.
We
show
that
terminal
lucidity
is
not
limited
to
patients
suffering
from
Alzheimer’s
disease
and
schizophrenia,
but
is
also
reported
from
patients
with
brain
abscesses,
tumors,
meningitis,
strokes,
and
affective
disorders.
2.
Prevalence
of
terminal
lucidity
At
present,
we
have
identified
83
cases
of
terminal
lucidity
mentioned
in
the
literature
of
the
last
250
years
and
have
collected
comparable
unpublished
contemporary
accounts.
The
published
cases
were
reported
by
55
different
authors,
mostly
by
profes-
sionals
working
in
the
medical
setting.
Of
the
cases
that
contained
a
description
of
the
course
of
the
illness,
22
patients
were
female
and
32
were
male.
In
addition
to
those
particular
case
references
and
descriptions,
we
identified
18
general
claims
of
physicians
or
caregivers
who
stated
that
they
had
witnessed
terminal
lucidity
in
mental
disorders
but
gave
no
details
of
their
observations.
In
our
literature
survey,
we
were
able
to
find
only
two
sources
that
estimated
the
frequency
of
terminal
lucidity
in
patients
with
mental
disorders.
The
first
is
included
in
a
book
published
in
1844
by
Julius,
who
updated
statistics
performed
previously
by
Thurnam
on
the
patients
of
a
British
asylum
(Julius,
1844).
In
one
table
of
the
book,
Julius
presented
mental
status
changes
at
the
Archives
of
Gerontology
and
Geriatrics
xxx
(2011)
xxx–xxx
A
R
T
I
C
L
E
I
N
F
O
Article
history:
Received
14
December
2010
Received
in
revised
form
22
June
2011
Accepted
25
June
2011
Available
online
xxx
Keywords:
Death
Dementia
Memory
Terminal
symptom
remission
End-of-life
care
A
B
S
T
R
A
C
T
The
unexpected
return
of
mental
clarity
and
memory
shortly
before
death
in
patients
suffering
from
severe
psychiatric
and
neurologic
disorders,
which
we
have
called
‘‘terminal
lucidity’’,
has
been
reported
in
the
medical
literature
over
the
past
250
years,
but
has
received
little
attention.
We
review
a
range
of
terminal
lucidity
cases
in
order
to
encourage
investigation
of
the
mechanisms
involved
and
possible
insights
into
both
the
neuroscience
of
memory
and
cognition
at
the
end
of
life
and
treatment
of
terminal
illness.
These
examples
include
case
reports
of
patients
suffering
from
brain
abscesses,
tumors,
strokes,
meningitis,
dementia
or
Alzheimer’s
disease,
schizophrenia,
and
affective
disorders.
Several
of
these
accounts
suggest
that
during
terminal
lucidity,
memory
and
cognitive
abilities
may
function
by
neurologic
processes
different
from
those
of
the
normal
brain.
We
expect
that
significant
contributions
to
better
understanding
the
processes
involved
in
memory
and
cognition
processing
might
be
gained
through
in-depth
studies
of
terminal
lucidity.
Studying
terminal
lucidity
might
also
facilitate
the
development
of
novel
therapies.
In
addition,
increased
awareness
of
unusual
end-of-life
experiences
could
help
physicians,
caregivers,
and
bereaved
family
members
be
prepared
for
encountering
such
experiences,
and
help
those
individuals
cope
with
them.
ß
2011
Elsevier
Ireland
Ltd.
All
rights
reserved.
*
Corresponding
author.
Tel.:
+1
434
924
2281;
fax:
+1
434
924
1712.
E-mail
address:
cbg4d@virginia.edu
(B.
Greyson).
G
Model
AGG-2557;
No.
of
Pages
5
Please
cite
this
article
in
press
as:
Nahm,
M.,
et
al.,
Terminal
lucidity:
A
review
and
a
case
collection.
Arch.
Gerontol.
Geriatr.
(2011),
doi:10.1016/j.archger.2011.06.031
Contents
lists
available
at
ScienceDirect
Archives
of
Gerontology
and
Geriatrics
jo
ur
n
al
ho
mep
ag
e:
www
.elsevier
.c
om
/lo
cate/ar
c
hg
er
0167-4943/$
–
see
front
matter
ß
2011
Elsevier
Ireland
Ltd.
All
rights
reserved.
doi:10.1016/j.archger.2011.06.031
end
of
life
in
all
139
patients
who
died
in
the
asylum
from
1796
to
1841.
In
13%
of
the
cases,
the
mental
state
was
considerably
improved
at
the
time
the
patients
died.
The
greatest
frequency
of
symptom
remission
at
the
end
of
life
was
displayed
by
patients
diagnosed
with
mania
(16%)
and
melancholia
(17%).
Julius
mentioned
that
in
a
few
cases
of
terminal
lucidity
the
patients
died
of
a
sudden
death
such
as
stroke,
but
he
included
no
case
descriptions
in
his
book.
In
only
2%
of
the
patients
the
terminal
mental
condition
was
considerably
changed
for
the
worse,
in
63%
it
remained
unchanged,
and
in
22%
it
changed
in
quality,
e.g.,
from
mania
to
melancholia
(Julius,
1844).
The
second
publication
containing
quantitative
information
on
the
prevalence
of
terminal
lucidity
was
a
recent
investigation
of
end-of-life
experiences.
In
that
study,
seven
out
of
ten
caregivers
in
a
nursing
home
reported
that
they
had
observed
patients
with
dementia
and
confusion
becoming
lucid
a
few
days
before
death
during
the
past
five
years
(Brayne
et
al.,
2008).
Although
there
are
few
quantitative
estimates
of
the
prevalence
or
degree
of
terminal
lucidity,
a
recent
survey
of
nursing
home
staff
reported
that
‘‘interviewees
from
all
units
reported
first-hand
accounts
of
previously
confused
residents
suddenly
becoming
lucid
enough
in
the
last
days
of
life
to
recognize
and
say
farewell
to
relatives
and
carers’’
(Fenwick
et
al.,
2010).
3.
Causes
and
diagnoses
of
the
mental
disorders
In
the
case
reports
of
the
19th
century,
the
psychiatric
diagnoses
of
the
patients
were
usually
antiquated,
inadequate,
or
absent.
The
most
frequent
diagnoses
were
mania
and
melancholia.
Similarly,
diagnoses
of
the
cases
reported
throughout
the
20th
century
were
often
absent
or
inadequate.
Nevertheless,
there
are
several
cases
containing
distinct
diagnoses
among
the
descriptions
we
retrieved.
Among
them
are
cases
involving
brain
abscesses,
tumors,
strokes,
Alzheimer’s
disease
or
other
dementias,
meningitis,
schizophrenia,
and
probable
affective
disorders.
With
regard
to
dementia
or
Alzheimer’s
disease,
we
have
additionally
collected
eight
general
statements
of
physicians
and
caregivers
who
claimed
that
they
have
observed
incidents
of
terminal
lucidity
but
provided
no
further
details.
With
regard
to
schizophrenia,
similar
statements
were
advanced
by
three
physicians.
In
the
following
section,
we
describe
case
reports
of
terminal
lucidity
that
pertain
to
the
different
diagnostic
categories,
although
for
some
of
these
cases,
particularly
the
earlier
ones,
diagnoses
must
be
regarded
as
provisional.
We
acknowledge
that
some
of
these
cases,
particularly
those
reported
outside
the
medical
setting,
might
contain
retrospective
embellishments,
or
that
in
some
cases
the
improvement
in
mental
state
might
have
coincided
only
accidentally
with
the
approach
of
death.
Neverthe-
less,
this
was
not
the
opinion
of
those
who
reported
the
cases.
It
seems
very
likely
that
terminal
lucidity
does
in
fact
occur
under
a
variety
of
circumstances
and
that
the
published
reports
warrant
attention.
4.
Case
reports
of
terminal
lucidity
4.1.
Brain
abscesses
In
a
case
published
in
1822,
a
boy
at
the
age
of
6
had
fallen
on
a
nail
that
penetrated
his
forehead.
He
slowly
developed
increasing
headaches
and
mental
disturbances.
At
the
age
of
17,
he
was
in
constant
pain,
extremely
melancholic,
and
starting
to
lose
his
memory.
He
fantasized,
blinked
continuously,
and
looked
for
hours
at
particular
objects.
When
he
additionally
started
to
throw
up
frequently,
he
was
admitted
to
a
hospital.
He
was
not
able
to
sit
or
get
out
of
bed.
He
remained
in
the
hospital
in
this
state
for
18
days.
On
the
morning
of
the
19th
day,
he
suddenly
left
his
bed
and
appeared
very
bright,
claiming
he
was
free
of
all
pain
and
feelings
of
sickness.
He
intended
to
leave
the
hospital
the
next
day.
A
quarter
of
an
hour
after
the
attending
physician
left
him,
he
fell
unconscious
and
died
within
a
few
minutes.
The
front
part
of
his
brain
contained
two
pus-filled
tissue
bags
the
size
of
a
hen’s
egg
(Pfeufer,
1822).
In
another
case
published
in
1820,
a
nun
moved
to
her
sister’s
home
when
her
monastery
was
closed.
After
she
seemed
to
recover
from
scarlet
fever,
she
fell
into
a
delirium,
went
‘‘raving
mad,’’
and
was
admitted
to
an
asylum.
She
was
obsessed
with
the
conviction
that
the
monastery
still
existed,
and
violently
insisted
on
returning
to
it.
All
treatments
to
improve
her
condition
were
unsuccessful.
She
lived
under
the
care
of
a
personal
nurse
in
a
single
room
specifically
equipped
for
her,
and
was
regularly
visited
by
her
sister.
After
three
years,
she
developed
a
chronic
fever
caused
by
a
large
abscess.
The
more
her
physical
strength
declined,
the
calmer
she
became.
Three
weeks
before
her
death,
all
traces
of
her
former
madness
had
completely
vanished.
When
her
sister
visited
her,
she
was
intensely
thankful
for
all
that
her
sister
had
done
for
her.
She
remembered
all
details
of
her
insanity,
and
was
regretful.
She
received
the
sacrament
of
the
dying
in
devotion
and
prayed
until
she
died
peacefully
in
the
arms
of
her
brother-in-law.
When
her
cranium
was
removed
for
autopsy,
the
brain
tissue
swelled
forcibly
forth.
The
blood
vessels
were
engorged
with
blood,
and
the
brain
tissue
itself
was
unusually
soft.
It
was
not
possible
to
close
the
skull
again
because
of
the
large
amount
of
swollen
brain
tissue.
The
dura
mater
was
joined
together
with
the
inner
surface
of
the
skull
bone
(Vering,
1820).
4.2.
Brain
tumors
Morse
and
Perry
(1990)
reported
the
case
of
a
5-year-old
boy
who
had
been
in
a
coma
for
three
weeks
dying
from
a
malignant
brain
tumor,
during
which
time
he
was
almost
constantly
surrounded
by
various
family
members.
Finally,
on
the
advice
of
their
minister,
the
family
told
the
comatose
child
that
they
would
miss
him
but
he
had
their
permission
to
die.
Suddenly
and
unexpectedly,
the
boy
regained
consciousness,
thanked
the
family
for
letting
him
go,
and
told
them
he
would
be
dying
soon.
He
did
in
fact
die
the
next
day.
Haig
(2007)
reported
the
case
of
a
young
man
dying
of
lung
cancer
that
had
spread
to
his
brain.
Toward
the
end
of
his
life,
a
brain
scan
showed
little
brain
tissue
left,
the
metastasized
tumors
having
not
simply
pushed
aside
normal
brain
tissue
but
actually
destroyed
and
replaced
it.
In
the
days
before
his
death,
he
lost
all
ability
to
speak
or
move.
According
to
a
nurse
and
his
wife,
however,
an
hour
before
he
died,
he
woke
up
and
said
good-bye
to
his
family,
speaking
with
them
for
about
five
minutes
before
losing
consciousness
again
and
dying.
In
a
case
recently
reported
to
us,
a
42-year-old
investment
manager
had
a
grand
mal
seizure
‘‘out
of
the
blue’’
one
night.
Although
his
EEG
showed
generalized
slowing,
repeated
MRIs
appeared
normal.
Two
months
later,
however,
a
repeat
MRI
showed
a
plum-sized
glioblastoma
multiforme.
By
the
time
he
had
surgery
two
weeks
later,
the
tumor
had
doubled
in
size
and
a
second
had
formed
in
his
speech
center.
Following
two
surgical
excisions,
gamma
knife
radiation,
intrathecal
chemotherapy,
and
steroids,
he
was
able
to
go
back
to
work
part-time.
However,
the
tumor
soon
recurred,
and
after
a
failed
trial
of
an
experimental
oral
chemotherapy
agent,
he
declined
further
treatment
and
enrolled
in
hospice
care
in
his
home.
He
quickly
became
bedridden,
blind
in
one
eye,
incontinent,
and
increasingly
incoherent
in
his
speech
and
bizarre
in
his
behavior.
He
appeared
to
be
unable
to
make
sense
of
his
surroundings,
and
when
his
family
touched
him,
he
would
slap
as
if
at
an
insect.
He
eventually
stopped
sleeping,
talking
deliriously
through
the
night.
M.
Nahm
et
al.
/
Archives
of
Gerontology
and
Geriatrics
xxx
(2011)
xxx–xxx
2
G
Model
AGG-2557;
No.
of
Pages
5
Please
cite
this
article
in
press
as:
Nahm,
M.,
et
al.,
Terminal
lucidity:
A
review
and
a
case
collection.
Arch.
Gerontol.
Geriatr.
(2011),
doi:10.1016/j.archger.2011.06.031
After
several
weeks
of
that,
he
suddenly
one
night
appeared
calm
and
started
speaking
coherently,
and
then
slept
peacefully.
The
following
morning
he
remained
coherent
and
conversed
with
his
wife,
discussing
his
imminent
death
with
her
for
the
first
time.
However,
he
stopped
speaking
later
that
day,
and
lay
immobile
in
his
bed,
not
eating
or
drinking
for
two
more
weeks,
after
which
he
expired
after
several
hours
of
status
epilepticus.
4.3.
Strokes
Noyes
(1952)
described
a
91-year-old
woman
who
had
suffered
two
strokes.
The
first
stroke
paralyzed
her
left
side
and
deprived
her
of
clear
speech.
After
a
few
months,
the
second
stroke
rendered
her
entirely
paralyzed
and
speechless.
A
daughter
cared
for
her.
On
one
occasion,
an
exclamation
from
the
woman
caught
the
daughter’s
attention,
and
she
saw
the
old
woman
smiling
brightly,
although
her
facial
expression
had
been
frozen
since
her
second
stroke.
The
woman
turned
her
head
and
sat
up
in
bed
with
no
apparent
effort.
She
then
raised
her
arms
and
exclaimed
in
a
clear,
joyous
tone
the
name
of
her
husband.
Her
arms
dropped
again,
and
she
sank
back
and
died.
She
may
have
experienced
a
death-bed
vision
of
her
deceased
husband
(Osis,
1961;
Osis
and
Haraldsson,
1977),
but
unquestionably
regained
her
ability
to
use
her
body
and
speech
during
that
experience.
Another
instance
of
terminal
lucidity
involving
strokes
had
been
reported
in
the
19th
century
(Daumer,
1865).
After
a
man
suffered
his
first
stroke,
he
was
almost
entirely
paralyzed
for
11
years.
He
had
also
lost
his
ability
to
read
or
speak.
After
three
years
he
had
learned
to
recognize
certain
persons
and
speech
again,
but
his
mental
faculties
did
not
develop
any
further.
Seven
days
before
his
death
he
suffered
the
second
stroke.
After
this
stroke,
he
regained
almost
full
consciousness.
He
was
able
to
speak
in
full
sentences
and
understood
lengthy
passages
of
speech.
Although
he
was
an
atheist
for
all
his
life,
he
now
asked
to
see
a
minister
and
died
in
peace.
4.4.
Alzheimer’s
disease
and
other
dementias
In
our
previous
publication
(Nahm
and
Greyson,
2009),
we
gave
examples
of
terminal
lucidity
in
patients
with
Alzheimer’s
disease
that
were
reported
by
Brayne
et
al.
(2008)
and
Grosso
(2004).
The
latter
author
described
a
second
case
of
a
demented
patient
who
became
mentally
clear,
recognized
family
members,
and
spoke
coherently
again
shortly
before
she
died.
Osis
(1961)
mentioned
another
demented
patient
who
regained
normal
mentality
prior
to
dying.
Several
terminal
lucidity
accounts
involving
dementia
were
included
in
the
older
literature.
Marshall
(1815)
reported
a
case
of
a
mad
and
furiously
violent
patient
who
suffered
from
memory
loss
to
the
degree
that
he
did
not
even
remember
his
own
first
name.
When
he
fell
seriously
ill
after
more
than
ten
years
in
the
asylum,
he
grew
calmer.
On
the
day
before
he
died,
he
became
rational
and
asked
to
see
a
clergyman.
He
seemed
to
listen
attentively
to
the
minister
and
expressed
his
hope
that
God
would
have
mercy
on
his
soul.
Although
Marshall
(1815)
did
not
describe
the
mental
state
of
the
patient
in
more
detail,
his
report
suggests
that
the
man
had
access
to
memories
of
his
life
again.
Recently,
three
personal
accounts
of
terminal
lucidity
cases
involving
Alzheimer’s
disease
were
related
to
us.
The
first
case
concerned
an
elderly
woman
who
suffered
from
the
illness
for
15
years
and
was
cared
for
by
her
daughter.
The
woman
was
unresponsive
for
years
and
showed
no
sign
of
recognizing
her
daughter
or
anybody
else.
However,
a
few
minutes
before
she
died,
she
started
a
normal
conversation
with
her
daughter,
an
experience
for
which
the
daughter
was
unprepared
and
which
left
her
utterly
confused.
The
second
Alzheimer’s
case
was
remarkably
similar.
In
this
case
it
was
a
woman’s
grandmother
who
had
neither
talked
nor
reacted
to
family
members
for
a
number
of
years
until
the
week
before
she
died,
when
she
suddenly
started
chatting
with
the
granddaughter,
asking
about
the
status
of
various
family
members
and
giving
her
granddaughter
advice.
Her
granddaughter
reported
that
‘‘it
was
like
talking
to
Rip
Van
Winkle’’.
The
third
Alzheimer’s
case
involved
an
81-year-old
woman
who
had
been
demented
for
a
long
time
and
was
living
in
a
retirement
home
in
Iceland.
Her
family
took
turns
visiting
her,
even
though
she
had
neither
recognized
any
of
them
nor
spoken
to
them
for
a
year.
On
one
occasion,
her
son
Lydur
was
sitting
at
her
bedside
working
on
a
crossword
puzzle.
Suddenly
she
sat
up,
looked
him
directly
in
the
face,
and
said,
‘‘My
Lydur,
I
am
going
to
recite
a
verse
to
you’’.
She
then
recited
clearly
and
loudly
the
following
verse,
thought
by
her
son
to
be
quite
relevant
to
her
situation
(translated
into
unrhymed
English
by
E.H.):
Oh,
father
of
light,
be
adored.
Life
and
health
you
gave
to
me,
My
father
and
my
mother.
Now
I
sit
up,
for
the
sun
is
shining.
You
send
your
light
in
to
me.
Oh,
God,
how
good
you
are.
She
then
lay
back
on
her
pillow
and
was
again
nonresponsive,
and
remained
so
until
she
died
about
a
month
later.
Her
son
immediately
wrote
down
the
verse,
thinking
it
was
his
mother’s
poetry;
but
he
later
learned
it
was
the
first
stanza
from
a
psalm
by
an
Icelandic
poet.
4.5.
Meningitis
Osis
and
Haraldsson
(1977)
reported
the
case
of
a
woman
in
her
30s
suffering
from
meningitis,
who
was
severely
disoriented,
drowsy,
and
talking
incoherently
almost
to
the
end.
A
few
minutes
before
she
died
she
came
to
herself.
She
cleared
up,
answered
questions,
smiled,
and
was
slightly
elated.
Besides
other
pathological
findings
on
the
psychological
and
brain
anatomical
level,
the
following
case
from
the
19th
century
also
included
chronic
meningitis.
A
widow
and
mother
of
five
children
lived
in
severe
poverty.
In
time,
she
developed
suicidal
tendencies
and
increasing
signs
of
mental
disorder.
After
having
often
spent
her
days
in
an
apathetic
state,
she
suddenly
became
agitated,
tearing
her
clothes
and
restlessly
walking
about
the
surrounding
fields.
Subsequently
she
was
transferred
to
an
asylum
in
November
1844.
There
she
complained
about
strong
feelings
of
vertigo.
The
memory
of
her
past
was
gone,
she
talked
incoherently,
and
she
stated
that
she
had
never
had
children.
From
December
on,
she
suffered
severe
attacks
of
vertigo
that
sometimes
rendered
her
unconscious,
cold,
and
stiff,
with
only
marginal
pulse.
Even
during
intervals
in
which
she
was
able
to
get
out
of
bed,
she
never
recognized
where
she
was.
In
the
summer
of
1845,
she
suffered
further
attacks
of
bodily
malfunction
that
left
her
increasingly
unresponsive.
The
accompanying
symptoms
pointed
to
some
kind
of
congestion
in
her
brain.
After
her
last
seizure
at
the
end
of
September,
she
was
unresponsive
for
four
months.
After
that,
her
mental
state
began
to
improve
as
her
body
continued
to
weaken.
Before
she
died
in
February
1846,
memories
of
her
entire
life
had
been
restored,
she
knew
where
she
was,
and
she
intimately
thanked
her
caregivers
for
all
they
done
for
her.
She
died
in
full
consciousness.
The
diagnostic
findings
included
a
sharp-edged
piece
of
bone
of
one
to
two
centimeters
in
diameter
at
the
inner
surface
of
the
skull,
and
chronic
meningitis.
The
blood
M.
Nahm
et
al.
/
Archives
of
Gerontology
and
Geriatrics
xxx
(2011)
xxx–xxx
3
G
Model
AGG-2557;
No.
of
Pages
5
Please
cite
this
article
in
press
as:
Nahm,
M.,
et
al.,
Terminal
lucidity:
A
review
and
a
case
collection.
Arch.
Gerontol.
Geriatr.
(2011),
doi:10.1016/j.archger.2011.06.031
vessels
were
engorged
with
blood
and
the
pia
mater
was
swollen
in
a
blister-like
fashion.
Blisters
were
also
found
in
several
other
regions
of
the
brain,
as
well
as
excessive
fluid
in
the
ventricles
that
resulted
in
a
pathological
increase
of
their
normal
volume
(Leubuscher,
1846).
4.6.
Schizophrenia
In
our
previous
brief
report
(Nahm
and
Greyson,
2009),
we
summarized
three
cases
of
terminal
lucidity
in
chronic
schizo-
phrenics
(Turetskaia
and
Romanenko,
1975).
The
three
patients
were
hospitalized
continuously
for
11,
20,
and
27
years
and
displayed
no
lucid
intervals
for
many
years,
the
latter
patient
spending
his
last
17
years
in
a
profoundly
regressed
catatonic
state.
Apart
from
specific
idiosyncrasies,
the
three
patients
were
almost
normal
shortly
before
they
died.
Another
case
involving
schizophrenia
was
mentioned
by
Osis
(1961).
This
severe
schizophrenic
had
been
out
of
touch
with
reality
for
two
years,
but
regained
normal
mentality
shortly
before
death.
4.7.
Possible
affective
disorders
In
a
case
published
in
1840,
a
woman
of
30
years
diagnosed
with
‘‘wandering
melancholy’’
(melancholia
errabunda)
was
admitted
to
an
asylum,
and
shortly
thereafter,
she
became
manic.
For
four
years,
she
lived
exclusively
in
a
confused
and
incoherent
state
of
mind.
When
she
fell
sick
with
a
fever,
she
vehemently
refused
to
take
any
medicine.
Consequently,
her
health
rapidly
deteriorated.
But
the
weaker
her
body
became,
the
more
her
mental
condition
improved.
Two
days
before
her
death,
she
became
fully
lucid.
She
talked
with
an
intellect
and
clarity
that
seemed
to
exceed
her
former
education.
She
inquired
about
the
lives
of
her
relatives,
and
in
tears
regretted
her
previous
intractability
toward
taking
medicine.
She
died
soon
thereafter
(Butzke,
1840).
In
1832,
a
normal
and
seemingly
happy
family
man
fell
sick
with
typhoid
fever.
He
appeared
to
have
recovered,
but
subse-
quently
suffered
more
and
more
from
abdominal
distress.
Eventually,
he
became
increasingly
melancholic
and
distrustful
of
his
own
family
members,
and
he
cried
a
lot
and
refused
to
eat.
By
the
middle
of
1834,
his
condition
deteriorated
and
he
was
transferred
into
an
asylum.
He
was
completely
apathetic,
aboulic,
and
unresponsive,
continuously
standing
or
sitting
on
the
same
spot
and
staring
at
the
ground
if
not
moved
by
caregivers.
No
treatment
changed
his
condition.
After
8
months
in
the
asylum,
he
began
to
suffer
from
an
intestinal
infection
accompanied
by
severe
dysentery,
which
led
to
his
death.
Despite
extraordinary
bodily
suffering,
his
mental
illness
disappeared
in
every
respect
throughout
his
last
week.
His
mental
clarity
had
returned
and
stayed
with
him
until
he
died.
Organic
abnormalities
could
not
be
detected
in
his
brain
on
autopsy
(Jacobi,
1837).
In
another
case
(Bergmann,
1829),
a
young
man
for
several
years
sat
on
a
chair
and
stared
continuously
at
the
floor
in
front
of
him.
He
was
very
stiff
and
had
great
difficulties
with
even
the
slightest
movements
of
his
limbs.
He
could
hardly
walk,
he
never
spoke
a
single
word,
and
he
never
fed
himself
during
these
years.
He
finally
fell
ill
with
typhus.
One
day,
he
became
lucid
again
and
started
to
sing,
including
some
clerical
songs
and
the
famous
Freut
euch
des
Lebens
[Be
glad
to
be
alive].
The
following
day
he
died
peacefully.
In
another
case
from
the
19th
century,
a
man
at
age
22
was
reportedly
scared
by
a
bear
mask
at
a
masked
ball
and
subsequently
became
psychotic.
For
the
next
52
years,
he
continuously
imitated
bear
behavior
by
swinging
his
body
and
uttering
bear-like
growling
sounds.
He
spoke
no
articulate
words
during
these
five
decades.
Then
a
few
weeks
before
his
death,
as
his
terminal
disease
progressed,
he
started
to
answer
questions
again.
Though
his
mental
capabilities
were
limited
to
a
degree
that
he
could
answer
only
using
‘‘Yes’’
and
‘‘No,’’
he
reacted
in
a
precise
and
ordered
manner
that
suggested
he
understood
the
questions
addressed
to
him
(Brierre
de
Boismont,
1862;
Griesinger,
1876).
5.
Discussion
and
conclusion
For
physicians
of
the
19th
century,
terminal
lucidity
was
well
known.
Nevertheless,
discussions
and
case
reports
became
fewer
toward
the
end
of
that
century
and
were
almost
absent
in
the
medical
literature
of
the
20th
century.
The
publication
of
cases
continued
largely
outside
the
medical
setting.
The
only
publica-
tions
on
terminal
lucidity
by
medical
professionals
we
could
find
from
recent
decades
were
the
monograph
on
the
three
schizo-
phrenics
(Turetskaia
and
Romanenko,
1975)
and
a
more
recent
brief
mention
of
terminal
lucidity
in
patients
with
dementia
(Brayne
et
al.,
2008).
Given
the
intriguing
phenomenology
of
some
of
the
case
reports,
we
consider
further
research
into
terminal
lucidity
an
important
task.
Some
of
the
cases
presented,
particularly
those
involving
destruction
of
brain
tissue
caused
by
tumors,
strokes,
or
Alzheimer’s
disease,
pose
difficulties
for
currently
prevailing
explanatory
models
of
brain
physiology
and
mental
functioning.
At
present,
we
think
that
it
is
not
possible
to
formulate
definitive
mechanisms
for
terminal
lucidity.
Indeed,
terminal
lucidity
in
differing
mental
disorders
might
result
from
different
processes,
depending
on
the
etiology
of
the
diseases.
For
example,
cachexia
in
chronically
ill
patients
might
conceivably
cause
shrinking
of
brain
tissue,
relieving
the
pressure
exerted
by
space-occupying
intracra-
nial
lesions
and
permitting
fleeting
return
of
some
brain
function.
As
early
as
1826,
two
distinct
ways
were
described
in
which
terminal
lucidity
can
manifest
(Burdach,
1826).
First,
the
degree
of
mental
derangement
can
decrease
slowly
in
conjunction
with
the
decline
of
bodily
vitality.
The
cases
of
schizophrenia
and
other
cases
of
the
older
literature
belong
to
this
category.
Second,
full
mental
clarity
can
emerge
suddenly
just
before
dying.
The
presented
cases
involving
brain
tumors
and
Alzheimer’s
disease
belong
to
this
second
category.
These
observations
suggest
that
there
may
be
no
unitary
mechanism
behind
terminal
lucidity.
We
hope
that
drawing
attention
to
this
phenomenon
may
stimulate
research
into
the
psychopathology
and
neuropathology
involved
in
near-death
states.
Studying
terminal
lucidity
could
help
elucidate
the
factors
governing
the
peculiar
relationship
between
mind
and
brain,
particularly
as
the
brain
deteriorates
(Fenwick
et
al.,
2010);
and
it
could
facilitate
the
development
of
new
therapies.
In
this
regard,
one
historical
example
is
represented
by
the
research
of
Wagner-Jauregg
(1887).
After
observing
that
symptoms
of
mental
derangement
sometimes
decreased
during
high
fever,
he
developed
fever
therapy
for
general
paresis.
In
1927,
he
received
the
Nobel
Prize
for
Medicine
for
this
achievement
(Nahm
and
Greyson,
2009).
Within
the
past
decade
evidence
has
accumulated
that
the
cognitive
deficits
in
Alzheimer’s
disease
and
related
dementias
may
be
due
not
solely
to
irreversible
neuronal
loss,
but
perhaps
in
part
to
potentially
reversible
functional
impairments
specula-
tively
involving
complex
adjustments
in
molecules,
signaling
cascades,
synaptic
modifications,
neuronal
activities,
or
network
interactions
(Palop
et
al.,
2006;
Savioz
et
al.,
2009).
Although
these
reversible
mechanisms
may
account
for
fluctuating
cognitive
functions
in
some
patients
in
the
early
stages
of
Alzheimer’s
disease
(Gleichmann
and
Mattson,
2010),
it
is
unclear
whether
they
could
explain
the
complete
remission
of
cognitive
deficits
reported
in
terminal
lucidity
(Barton
and
Albright,
2008;
Savioz
et
al.,
2009).
Likewise,
some
patients
for
whom
life
support
has
been
withdrawn
may
manifest
an
M.
Nahm
et
al.
/
Archives
of
Gerontology
and
Geriatrics
xxx
(2011)
xxx–xxx
4
G
Model
AGG-2557;
No.
of
Pages
5
Please
cite
this
article
in
press
as:
Nahm,
M.,
et
al.,
Terminal
lucidity:
A
review
and
a
case
collection.
Arch.
Gerontol.
Geriatr.
(2011),
doi:10.1016/j.archger.2011.06.031
unexplained
transient
surge
of
electroencephalographic
activity
as
blood
pressure
is
lost
immediately
prior
to
death
(Chawla
et
al.,
2009).
Although
these
patients
have
not
been
reported
to
show
any
clinical
evidence
of
cognition,
these
findings
suggest
that
the
neuroscience
of
terminal
states
may
be
more
complex
than
traditionally
thought.
Research
into
terminal
lucidity
might
lead
to
better
under-
standing
of
the
processes
involved
in
memory
and
cognition.
The
unexpected
return
of
mental
faculties
raises
questions
about
cognitive
processing
at
the
end
of
life,
especially
in
diseases
that
involve
the
degeneration
of
the
brain
regions
usually
responsible
for
complex
cognition,
and
may
suggest
new
neuroscientific
models
for
memory
and
cognition
in
terminal
illnesses.
In
addition,
increased
awareness
of
unusual
end-of-life
experiences
on
the
part
of
physicians,
caregivers,
and
bereaved
family
members
could
help
them
prepare
for
witnessing
such
phenomena,
and
thus
better
cope
with
them.
Conflict
of
interest
None.
Acknowledgement
This
work
did
not
receive
any
external
support.
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AGG-2557;
No.
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Pages
5
Please
cite
this
article
in
press
as:
Nahm,
M.,
et
al.,
Terminal
lucidity:
A
review
and
a
case
collection.
Arch.
Gerontol.
Geriatr.
(2011),
doi:10.1016/j.archger.2011.06.031