Transcript Altered Mental StatusAMS

Justina Pomeroy SPT
Regis University
 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?
 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
 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)
 Change
in cognitive function.
 Range of mental status changes5
 Delirium
accounts for 10-15% of admissions to
acute care hospitals3
 Mental status changes evolve over time.
 Delirium4

Vague Diagnosis (137 causes)2
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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
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Additional considerations for PT’s
 PIP: “To get stronger and walk better”
 Observation of Pt presentation:
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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

 Gait:
Ambulates with shuffled, festinating
steps Contact Guard Assist (CGA) with FWW,
ambulating 200 feet.
 Transfers CGA
 Berg balance test 24/56
 In
the Acute setting the primary treatment
strategy is to use pharmacological
interventions.3
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Sedatives
Neuroleptics (tranquilizing psychiatric
medication)
Antidotes (counteract or neutralize effects of a
poison)
 Limited
amount of research on Physical
Therapy Interventions with AMS so……

Rhythmic auditory stimulation in gait training for
Parkinson's disease patients.6
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15 PD patients and 11 control subjects (2 groups)
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Rhythmic Auditory Stimulus (RAS) as part of a home-based gait training program.
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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
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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.
 Goals
for PT with this pt in relation to PD
 Functional impairment goals
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Gait (stride length, heel strike)
Balance (dynamic)
General lower extremity strengthening
 Prognosis~
Good; Based on PLOF, pt
presentation, and other prognostic factors
 Think
BIG principles
 Gait training
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Appropriate phases/ pattern
 Balance
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training
Biodex
Four square step
 Strength
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training (B LE)
Ankle weights
Theraband exercises
 Pt
presentation changed drastically in a short
period of time.
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Physical Functioning
Mental Status- Dizziness and confusion
 Medications:Carbidopal
Leva, Resperidone
Tab, Clonidine Tab, Clonazepam,
Perphenazine, Denytoin Sodium
 Berg
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Initial Eval: 24/56
2 weeks with Therapy: 33/56
D/C: Not Tested due to pt’s compromised state
 FIM:
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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
 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.
 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?
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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