Altered Mental Status Aging Process

1. Altered Mental StatusAging Process February 2015 CE Condell Medical Center EMS System Site Code: 107200E-1215 Prepared by: Sharon Hopkins, RN, BSN Rev 2.13.15

2. Objectives Upon successful completion of this module, the EMS provider will be able to: 1. Given a variety of signs or symptoms, be able to distinguish presence of neurological problems. 2. Predict which patients may be presenting with a stroke based on chief complaint and signs and symptoms. 3. Prioritize transport for patients presenting with a variety of neurological emergencies. 4. Discuss the normal aging process.

3. Objectives cont’d 5. Determine physical and psychological clues that would suggest elder abuse or neglect. 6. Successfully return demonstrate a field neurological assessment. 7. Actively participate in review of selected Region X SOP’s as related to the topic presented. 8. Actively participate in case scenario discussion. 9. Actively participate in successful insertion of an IO needle into a manikin. 10. Review responsibilities of the preceptor role. 11. Successfully complete the post quiz with a score of 80% or better.

4. The Nervous System • Body’s principle control system • Regulation primarily through electrical impulses transmitted thru nerves • 2 main divisions • Central nervous system – brain and spinal cord • Peripheral nervous system (PNS) – with 2 major subdivisions • Somatic NS – voluntary functions • Autonomic NS – involuntary functions – 2 divisions • Sympathetic (SNS) and parasympathetic nervous systems (PNS)

5. Central & Peripheral Nervous System

6. Defining Neurological Problems – Central Nervous System (CNS) Disorders • Key sign is an altered level of consciousness • Loss of ability to respond to stimuli and  awareness of environment • Two mechanisms produce mental status changes • Structural lesions • Destruction or encroachment on substance of brain (i.e.: tumor, trauma/bleeding, degenerative diseases, parasites) • Toxic-metabolic states • Presence of circulating toxins or metabolites or absence of necessary metabolites (i.e.: oxygen, glucose, thiamine (Vit B1))

7. Defining Neurological Problems cont’d • Peripheral nervous system disorders • Malfunction or damage of peripheral nerves results in peripheral neuropathy • Single or multiple nerves can be affected • Single nerves usually from local conditions (i.e.: trauma, infection, compression (i.e.: carpal tunnel)) • Multiple nerve damage characterized by demyelination or degeneration of peripheral nerves • Myelin is protective sheath surrounding nerves • Destruction of myelin leads to sensory, motor or mixed deficits (i.e.: diabetic neuropathy, Guillain-Barre syndrome)

8. Myelin Sheathing

9. Central Nervous System Disorders • Four general categories of common causes • Drugs • Depressants, hallucinogens, narcotics • Cardiovascular insults • Arrest, stroke, shock, dysrhythmias, hypertensive encephalopathy • Respiratory insults • COPD, toxic gas, hypoxia • Infections • AIDS, encephalitis, meningitis, parasites

10. Examples Neurological Disease/Problems • ALS – Lou Gehrig’s Disease • Alzheimer’s disease • Bell’s palsy • Guillain Barre syndrome • Huntington’s disease • Multiple sclerosis • Muscular dystrophy • Parkinson’s disease • Polio • Seizures • Spina Bifida • Stroke • Tumor • Trigeminal neuralgia

11. General Impression • NOT the role of EMS to diagnose the specific neurological disease present • Important to note that SOMETHING neurological is happening! • Obtain adequate history – pertinent past and present • Perform detailed assessment and reassessment • Includes neurological assessment • Watching for trending • Knowing what to do with the trend – action & reporting to MC

12. General Impression cont’d • Form a general impression when first meeting the patient • General impression revised as more information is gathered • General impression guides the responder in choice of intervention • Obtain information from a variety of sources • Scene size up • Evaluation of surroundings • Evidence of toxic exposure or trauma • Clues to the patient’s condition

13. Clues to Patient Conditions General Appearance… Speech… Skin… Posture/gait…

14. Clues - General Appearance Determine patient’s normal or baseline • Is patient conscious? • If not, do they respond to voice (3*), pain (2*) or not at all (1*)? • Is patient alert? • To what degree? • Is patient confused? • Pleasantly confused or using inappropriate words? • Can the patient sit upright? * - reflects GCS score

15. Clues - Patient Speech Determine patient’s normal or baseline • Can the patient speak? • Is the speech clear and coherent with appropriate content to the situation? • Does the patient speak in full sentences? • Remember to document if unable to speak in full sentences (i.e.: “2-3 word sentences”) especially when related to complaints of difficulty breathing • Is the speech slurred?

16. Clues - Patient's Skin Determine patient’s normal or baseline • What is the color – pink, pale, cyanotic? • What is the temperature - warm, hot, cool? • Is the patient dry, diaphoretic or clammy? • Is facial drooping present? • If yes, to which side?

17. Clues - Patient’s Posture/Gait Determine patient’s normal or baseline Is the patient able to maintain an upright position? If the patient is leaning, to which side? If you observe the patient walking, do they have a steady gait or do they stagger?

18. AVPU and GCS • AVPU determines mental status • A – alert and aware of surroundings • V – responds to verbal stimuli • P – responds to painful or tactile stimuli • U – unresponsive • Glasgow Coma Scale – GCS • Used to monitor a patient’s condition • Used as a predictor of morbidity and mortality

19. Assessing Cerebral Function Via Emotional Status • Look for changes from normal or baseline • Mood –affect natural or irritable, anxious, apathetic, depressed, manic, happy? • Thought – logical, appropriate, scattered? • Perception –appropriate interactions and perception of environment? • Judgment – logical, using reasonable and sound judgment? • Memory and attention –short and long term memory intact? Able to pay attention and maintain conversations?

20. Patient Assessment & Monitoring • Need to know patient’s baseline to best make sense of any changes noted • Changes from “normal” must be investigated • Respiratory center is in the brain • Must carefully monitor respiratory patterns if evident problem in central nervous system (CNS) • Remember focus of primary assessment • Determine any life threatening condition and address it

21. Nervous System Evaluation • Evaluation of sensoriomotor status, motor system status, and cranial nerves • Sensoriomotor status - assessment of sensation and motor function • Can you feel this? Can you move that? • Motor system status • Assessment of tone, strength, flexion/extension, coordination, balance • Many motor functions not tested by EMS in the field • Cranial nerves • 12 pairs extend from lower surface of brain

22. 12 Pairs Cranial Nerves • Originate from base of brain • Provide sensory and motor innervation mostly to head and face • Each pair can carry sensory, motor, or both types of fibers • Limited assessment performed in the field • Usually test CN III – pupillary response Details of 12 cranial nerves in handout

23. Acute Stroke – A Neurological Insult • Injury or death of brain tissue • Usually due to interruption of cerebral blood flow • Oxygen deprivation causes damage to affected tissue • 2 categories – occlusive and hemorrhagic • Early recognition and rapid transport can improve patient outcome • High risk history – atherosclerosis, heart disease, hypertension

24. Acute Occlusive Stroke • 85% of incidence of strokes • Caused by blockage of cerebral artery with clot or foreign matter • Embolic stroke from material that travels from a remote site • Thrombotic stroke is buildup on plague in vessel that blocks flow of blood • Ischemia due to inadequate blood supply leads to infarction with death of tissue • As tissue dies, it swells causing further damage

25. Acute Hemorrhagic Stroke • 15% of incidence of strokes • Caused by rupture of a vessel • Bleeds with in the brain – intracerebral • Can bleed in space around outer surface of brain – subarachnoid • Often from congenital blood vessel abnormality • Weakened vessels (aneurysms) or collection of abnormal blood vessels (AV malformations) • Common in hypertensive patient

26. Thrombotic/Embolic Stroke vs Hemorrhage

27. Heightened Suspicion of Stroke • Facial drooping • Arm drift • Unilateral weakness (hemiparesis) • Unilateral paralysis (hemiplegia) • Dysphasia (difficulty speaking) • Aphasia ( inability to speak) • Confusion and agitation • Headache • Dizziness • Visual disturbances • Unilateral numbness or tingling (paresthesia) • Inability to recognize by touch • Gait disturbances • Incontinence • Coma

28. High Index of Suspicion • NOT everyone presents with one of the classic 3 signs of stroke • Facial droop • Arm drift • Speech not clear • Pay attention to the odd complaints • I can’t get out of bed – determine “why” • My legs don’t seem to work – determine “why” • Something is “just not right” – consider if it is cardiac or neurological

29. Predisposing Factors Contributing to Stroke Hypertension – especially poorly controlled Diabetes Abnormal lipid levels – high cholesterol Oral contraceptive use Sickle cell disease Cardiac arrhythmia – notably atrial fibrillation

30. Transport of Patients With Acute Stroke • Transport expedited to closest appropriate hospital • All hospitals in Lake County are designated Primary Stroke Centers • Have internal process to assemble their “stroke team” for patient care • Prepared to quickly obtain a CAT scan • Used to rule out hemorrhagic bleed • Minimize scene time • If there is a delay in transport, make sure it is time well spent • IV’s attempted only if process will not delay transport

31. Minimum Assessment All Potential Strokes • Establishing last known normal time • This is not necessarily the time patient was found! • Cincinnati Stroke Scale • Obtaining capillary blood glucose level • Perform a finger stick versus obtaining from an IV site • Complete a baseline field neurological assessment • GCS • Pupils • Sensory and motor response

32. Field Neurological Assessment • Establish level of consciousness – AVPU scale • Compare to patient’s normal baseline if possible • Obtain GCS – watching for trends • Always give highest score possible • Vital signs – watching for trends • Head insult - B/P;  pulse rate; irregular respirations • Shock - B/P;  pulse rate

33. Field Neuro cont’d • Pupillary reflex – 3rd cranial nerve • Abnormal pupillary response points to same side of head injury • Sensory and motor • What can patient feel? What can patient move? • Abnormal motor and sensory response reflects opposite side of head injury • Blood glucose level • Obtained on all patients with altered level of consciousness and potential stroke

34. What About These Pupils??? Could be normal or point to injury left side of brain • Could indicate exposure to narcotics or response to light • Could indicate exposure to stimulants or response in darkened room • Cataracts

35. The Aging Process – Not For Sissies

36. The Aging Process • Survival rates are up; life expectancy increasing • Birth rates are down • Healthcare providers need to be prepared for an increase in numbers of the aging population • EMS calls are very stressful on the elderly • Elderly often equate illness with death • Often don’t report changes in health – viewed/considered as normal process of aging

37. Understanding Problems of the Aged • Poverty and loneliness prevalent • Social support system declines especially if living alone • Disease and disability often linked to unhealthy and unsafe behaviors • Independence is important concept • Functional impairment affects self sufficiency • Tight finances and limited mobility become issues • Decrease in adequacy of nutrition • Safety issues • Under adherence of medication (reduce doses to save money)

38. On Aging • Aged susceptible to same disease as the young but maintenance, defenses, repair processes are weaker • Progressive loss of function with aging body • Increases likelihood of malfunction • Vital organs lose ability to compensate in times of need • Aged often have more than 1 disease/illness present • Average of 6 medical disorders co-exist in elderly • Disease in 1 organ often leads to deterioration in another system • Presence of co-morbidities/other disease causes vague complaints or non-specific complaints not linked to any one disorder

39. Think About This… • Being “old” does not automatically mean you have dementia • Having dementia doesn’t mean you are old • “Loosing your keys” doesn’t mean you have Alzheimer’s • Not knowing what keys are or what to do with them may indicate Alzheimer’s • 5.2 million Americans have Alzheimer’s • 200,000 are under 65 years of age • 6th leading cause of death in the USA • Women 3:1 over men

40. Road Blocks to Medication Compliance Limited income Memory loss Limited mobility Sensory impairment (hearing, sight, understanding directions) Multiple or complicated drug therapies Fear of toxicity Childproof containers (especially with arthritis) Duration of drug therapy (longer the therapy, the less compliance)

41. Tactics to Increase Medication Compliance Improving patient-physician communication Acknowledging/accepting that a disease or illness is serious Drug calendars or reminder cards Compliance counseling Easy to open packaging Multiple compartment pillboxes Transportation services to pharmacy Clear, simple directions written in large type Ability to read

42. Problems Related to Lack of Mobility in the Elderly Poor nutrition Difficulty with elimination Poor skin integrity Greater predisposition for falls Loss if independence and or confidence Depression from “feeling old” Isolation and lack of social networks

43. Contributory Factors to Communication Difficulties • Sensory changes related to aging • Impaired vision or blindness • Impaired or loss of hearing • Altered sense of taste or smell • Lower sensitivity to pain and touch

44. Impaired Vision Nearsightedness Color blindness – what number do you see? Macular degeneration

45. Common Complaints of the Elderly Fatigue and weakness Dizziness – vertigo – near-syncope Falls Headache Insomnia Dysphagia – difficulty swallowing Loss of appetite Inability to void – constipation - diarrhea

46. Impact On Forming General Impression • Living situation • Level of acuity • Network of social support • Level of independence • Medical history • Sleep patterns • Elderly often vague; consider their complaints as trivial • Often complain of 1 thing which is not the main problem • Healthcare worker often has to “dig” to find the real story

47. Patient Assessment in the Elderly • Obstacles • “Normal vitals” are not normal in the elderly • Pneumonia for example • Fever often absent • Chest pain and cough less pronounced • Etiology (cause) often due to aspiration versus infection

48. Mechanism of Injury - Falls • Fall related injuries leading cause of accidental death in elderly • Intrinsic falls – related to the patient • History of falls, dizziness, weakness, impaired vision, altered gait, CNS problems, decrease mental alertness, certain medications • Extrinsic falls – related to the environment • Slippery floors, no handrails, loose throw rugs

49. Spinal Injuries In The Elderly • Degenerative changes occur in the spine as a person ages • Increases risk of spinal fractures with even minor forces • Odontoid fracture (C2) especially common in elderly • Mechanism of injury in elderly are low impact falls especially falling and striking chin - look for abrasions! • Mechanism in younger aged population are high impact MVC • Neck pain is common without spinal cord injury • Treatment can range from surgery to immobilization in halo vest or collar Halo brace

50. Assessment of Potential Spinal Injuries • Palpate neck feeling for pain or step off • Test strength in all extremities • Test sensation in all extremities • Test ability to shrug shoulders • Document results; continue reassessments • Assume presence of injury until x-ray confirmation obtained • Based on mechanism of injury (MOI), elderly deserve spinal motion restriction/immobilization until proven otherwise • Remember – minimum MOI can relate to significant injury