ALTERED MENTAL STATUS

AMSJustina Pomeroy SPT

Regis University

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)

AMSWHAT DO WE KNOW? Change in cognitive function. Range of mental status changes5

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?

QUESTIONS??

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