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Altered Mental Status AMS

Altered Mental Status AMS. Justina 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:

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Altered Mental Status AMS

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  1. Altered Mental StatusAMS Justina Pomeroy SPT Regis University

  2. 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?

  3. 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

  4. 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)

  5. AMSWhat do we know? • Change in cognitive function. • Range of mental status changes5

  6. AMS facts • Delirium accounts for 10-15% of admissions to acute care hospitals3 • Mental status changes evolve over time. • Delirium4

  7. 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

  8. 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

  9. 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

  10. How does evidence affect my intervention? • In the Acute setting the primary treatment strategy is to use pharmacological interventions.3 • Sedatives • Neuroleptics (tranquilizing psychiatric medication) • Antidotes (counteract or neutralize effects of a poison) • Limited amount of research on Physical Therapy Interventions with AMS so……

  11. 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.

  12. 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

  13. Interventions • Think BIG principles • Gait training • Appropriate phases/ pattern • Balance training • Biodex • Four square step • Strength training (B LE) • Ankle weights • Theraband exercises

  14. Complicating factors DRUG Toxicity • Pt presentation changed drastically in a short period of time. • Physical Functioning • Mental Status- Dizziness and confusion • Medications:CarbidopalLeva, Resperidone Tab, Clonidine Tab, Clonazepam, Perphenazine, Denytoin Sodium

  15. Outcomes • Berg • Initial Eval: 24/56 • 2 weeks with Therapy: 33/56 • D/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

  16. 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.

  17. 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?

  18. Questions??

  19. 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. MovDisord. 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

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