1. Justina Pomeroy SPT Regis University

2.  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.  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.  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.  Change in cognitive function.  Range of mental status changes 5

6.  Delirium accounts for 10-15% of admissions to acute care hospitals 3  Mental status changes evolve over time.  Delirium 4

7.  Vague Diagnosis (137 causes) 2  Alcohol  Endocrine  Insulin  Opiates  Uremia  Trauma  Intracranial  Poisoning/ Drug toxicity  seizure  Key Symptoms 1  Decreased conscious state, drowsy stupor  Delirium~ impaired awareness, easy distraction, confusion, and disturbances of perception  Lethargy~ abnormal drowsiness, sluggishness, laziness

8.  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.  Gait: Ambulates with shuffled, festinating steps Contact Guard Assist (CGA) with FWW, ambulating 200 feet.  Transfers CGA  Berg balance test 24/56

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

14.  Pt presentation changed drastically in a short period of time.  Physical Functioning  Mental Status- Dizziness and confusion  Medications:Carbidopal Leva, Resperidone Tab, Clonidine Tab, Clonazepam, Perphenazine, Denytoin Sodium

15.  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.  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.  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?

19.  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. 5 th 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