TELL ME SOMETHING! How many of you have felt delirious
after studying for hours on end?OR
Who has felt delirious after staring at a computer screen for too long?
OBJECTIVES The student should be able to: Describe the common patient
presentations related to Altered Mental Status
Identify other syndromes or disease processes related to AMS
Recognize the role of PT’s in relation to patients with AMS
PATIENT Hx: Pt was 73 y.o. male referred to the SNF
from the hospital with the following information
Dx: AMS, Acute hypoxia, aspiration pneumonia
Orders: PT Eval and treat Subjective: “My problem is that I can’t
swallow and I am not getting nourishment” PMHx: seizure disorder, Bipolar/
Schizophrenia, HTN, hyponatrimia Possible Parkinson’s Disease
Cardinal clinical features (TRAP)
AMS FACTS Delirium accounts for 10-15% of
admissions to acute care hospitals3
Mental status changes evolve over time. Delirium4
VARIABILITY OF CAUSES OF AMS Vague Diagnosis (137 causes)2
Alcohol Endocrine Insulin Opiates Uremia Trauma Intracranial Poisoning/ Drug toxicity seizure
Key Symptoms1
Decreased conscious state, drowsy stupor Delirium~ impaired awareness, easy distraction,
confusion, and disturbances of perception Lethargy~ abnormal drowsiness, sluggishness, laziness
PATIENT EXAMINATION Additional considerations for PT’s PIP: “To get stronger and walk better” Observation of Pt presentation:
Pt is antisocial with flat affect Standing posture: Pt presents with
anterior trunk lean, flexed knees and hips.
AROM & PROM: decreased hip extension, knee extension and ankle plantar flexion MMT: WFL Sensation: Light touch intact BLE, noted fragile
skin Coordination: Decreased
PT EXAM CONT. Gait: Ambulates with shuffled,
festinating steps Contact Guard Assist (CGA) with FWW, ambulating 200 feet.
Transfers CGA Berg balance test 24/56
HOW DOES EVIDENCE AFFECT MY INTERVENTION? In the Acute setting the primary
treatment strategy is to use pharmacological interventions.3
SedativesNeuroleptics (tranquilizing psychiatric
medication)Antidotes (counteract or neutralize effects
of a poison) Limited amount of research on Physical
Therapy Interventions with AMS so……
EVIDENCE FOR PARKINSON’S DISEASE THERAPY Rhythmic auditory stimulation in gait training
for Parkinson's disease patients.6
15 PD patients and 11 control subjects (2 groups) Rhythmic Auditory Stimulus (RAS) as part of a home-based gait training
program. RAS consisted of audiotapes with metronome-pulse patterns.
Pt’s who trained with RAS significantly (p<.05) improved their gait velocity by 25%, stride length by 12%, and Step cadence by 10%
The Effects of Balance Training and High-Intensity Resistance Training on Persons With Idiopathic Parkinson’s Disease.7
Two exercise training programs with idiopathic Parkinson’s Disease.
Combined group (balance and resistance training), Balance group.
Muscle strength and balance improved substantially in the combined group and only marginally in the balance only group.
INTERVENTIONS: EXERCISE Goals for PT with this pt in relation to PD Functional impairment goals
Gait (stride length, heel strike)Balance (dynamic)General lower extremity strengthening
Prognosis~ Good; Based on PLOF, pt presentation, and other prognostic factors
INTERVENTIONS Think BIG principles Gait training
Appropriate phases/ pattern Balance training
Biodex Four square step
Strength training (B LE)Ankle weightsTheraband exercises
COMPLICATING FACTORS DRUG TOXICITY Pt presentation changed drastically in a
short period of time. Physical FunctioningMental Status- Dizziness and confusion
Medications:Carbidopal Leva, Resperidone Tab, Clonidine Tab, Clonazepam, Perphenazine, Denytoin Sodium
OUTCOMES Berg
Initial Eval: 24/562 weeks with Therapy: 33/56D/C: Not Tested due to pt’s compromised
state FIM:
Initial Eval: CGA with Transfers and ambulation with FWW
2 weeks with Therapy: SBA for transfers and ambulation no AD
D/C: Min-ModA with transfers, wheelchair used for mobility
SUMMARY AMS is a vague diagnosis, with a variety
of causes. When treating pt’s with an admit
diagnosis dig deeper to address underlying pathology or impairments.
Most importantly, pay attention to your patient’s and identify behavior or physical functioning that is abnormal to previous levels in general and in therapy.
CHECK FOR UNDERSTANDING T/F: AMS is a carefully and well defined
diagnosis? T/F: PT’s directly treat the cause of AMS? What are 3 causes for the evolution of
altered mental status in pt’s?
REFERENCES 1.Wikibooks 2. Wrongdiagnosis.com 3. Gerstein, P. Delirium, Dementia, and Amnesia. 2009.
E Med. 4. Lipowski, ZJ. Dilirium (acute confusiona states. 1987.
JAMA 258 (13): 1789-1792 5. Umphred D. Neurological Rehabilitation. 5th ED. 2007.
Pg 714-730. 6. Thaut MH, McIntosh GC, Rice R, Miller R, Rahtbun J,
Brault J. Rhythmic auditory-motor facilitation of gait patterns in patients with Parkinson’s disease. Mov Disord. 1996 Mar; 11(2): 193-200
7. Hirsch M, Toole T, Maitland C, Rider R. The effects of Balance training and High-Intensity resistance training on persons with idiopathic Parkinson’s Disease. Arch Phys Med Rehabil. 2003; 84: 1109-1117