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Neuro muscular > Arousal, Cognition, attention, dementi > Flashcards

Arousal, Cognition, attention, dementi Flashcards

1
Q

Mental status you should observe

A

Patient history: Note behavior, language, attention, affect

Orientation:
Person, place, time, situation

Alert:
Arousal, Attention, consciousness

Behavior

Cognitive status

Memory
Quick screen: 3 words to remember

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2
Q

What are the type of arousal?

A

Normal: consciousness

Hypoaroused: Lethargic, obtund, stupor,coma, minimally conscious vegetative state, persistent vegetative state

Hyperaroused: Restless, agitated, irritable, unable to self console, hyperactive

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3
Q

What is Hypoarousal?

A

Lethargic: Mildly depressed level of consciousness

Obtund: Significantly diminished, will respond to noxious stimulus but may be confused

Stupor: Minimal arousal and requires vigorous noxious stimulus and minimal arousal

Coma: No arousal, inability to make purposeful response

Minimally conscious vegetative state: Conscious but unaware of their environment and no purposeful attention

Persistent Vegetative state
In state for 1 year or longer after TBI

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4
Q

What are the components to assessing arousal?

A

-Response to stimulus (verbal, pain, light, touch)

-Eye opening

-Motor response

-Verbal response

-Glasgow Coma Scale: gold standard in acute brain injury

-NIHSS: stroke specific

:Outcome measure for stroke severity

:Section 1 examines patients’ level of consciousness and arousal

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5
Q

what is the glassgow coma scale?

A

*Gold standard outcome measure for arousal

*Used immediately following a head injury in the acute phases

*Used to measure change following injury in arousal and neurologic function

*Examines
-Eye opening
-Motor response
-Verbal response

*Ranges from 3-15
Mild: 12-15
Moderate: 9-11
Severe: 3-8

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6
Q

How do you stimulate and improve arousal?

A

*Physical touch
-Hand over hand
-Rubbing

*Noxious Stimulation:
-Sternal rub
-Nailbed pressure

*Sensory stimulation
-Cold or wet towel

*Vestibular stimulation
-Movement

*Environment
Lights
Sounds

*Create daily routines

*Sternal rub: cortical sensory response includes facial grimace can be purposeful, no purpose or no response
Nailbed pressue: fending off, withdrawing, flight flexion, slight extension, no response

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7
Q

what things to do get the patient attention?

A

-Necessary to perform a conscious task

*Direction of awareness 5 categories:

-Focused: process specific information

-Sustained: continuously over time

-Selective: being able to perform with distractions

-Alternating: shifting attention back and forth

-Divided: respond to multiple stimuli simultaneously

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8
Q

The MARS (Moss Attention Rating Scale)

A

-Outcome measure for attention

-Characterizes behavioral responses after brain injury

-22 questions that therapist is rating of person they are examining

Rate 1-5
1 = Definitely false
2 = False, for the most part
3 = sometimes true, sometimes false
4 = True, for the most part
5 = Definitely true

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9
Q

what is affect?

A

*Behaviors that describe mood or emotional state

-Pseudobulbar affect: emotional dysregulation, uncontrolled and exaggerated laughing or crying

-Apathy: shallow or blunted emotional response

-Euphoria: exaggerated feelings of well being

-Depression: poor perception of self and environment

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10
Q

What is cognitive assessment?

A

-Cognition: sort, retrieve and manipulate information

-Helps determine if their may be a limitation in POC or further referral (speech)

-Helps determine fall risk: patients with dementia and cognitive impairment are more likely to fall

-Helps determine discharge plan

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11
Q

What to do when doing a cognitive assessment?

A

*Attention, Arousal, orientation done beside and in subjective assessment

*Executive Function is higher order cognitive planning

*Objective Tests and Outcome Measures

-Clock drawing
-Reasoning
-Recall
-Animal Fluency
-Mini Mental State Exam (MMSE)
-Montreal Cognitive Assessment (MOCA)
-St. Louis University Mental Status Exam (SLUMS)

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12
Q

Examples of cognitive assessment?

A

*Animal Fluency
-Give patient 1 minute to name as many animal as possible. > 65 = 12 animals, < 65 = 18 animals

*Clock Drawing
-Blank sheet of paper and have patient draw clock with numbers 1-12
-Ask patient to draw hands to indicate a time (any time)

*Reasoning
-Say a phrase to a patient and ask them to interpret
“you reap what you sew”

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13
Q

Cognitive assessment explanations?

A

*Retention
-Give patient a list of words for them to remember and have them repeat them to you

*Recall
-Ask later in the screen for the patient to repeat the words back to you

*Mini Mental State Exam
-Used if cognitive issues is expected but undiagnosed

-Measures orientation, recall, short term verbal memory, calculation, language and construct ability

-License must be requested to administer

-Max score 30/30 and less than 24 cognitive impairment

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14
Q

Cognitive Assessment MOCA

A

-Similar to mini mental exam

-Less than 26/30 is indicative of dementia and further testing is indicated

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15
Q

Cognitive Assessment; SLUMS

A

-Similar to MOCA and mini mental but used for lower level cognitive patients

-Less than 25 indicates cognitive dysfunction

-More memory, attention and executive function

-More sensitive for identifying dementia

We as therapists are not allowed to diagnose dementia and based on these assessments but we can document cognitive impairment

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16
Q

What are interventions?

A

*Address mobility, strength and fall risk

*Interventions need to be procedural based instead of explicit

-Even if patients can’t remember, they can develop habits

-Can learn by doing rather than remembering

-Better to use blocked practice and practice in actual context

-Less explicit information and talking, the better ability to learn the task

**Explicit: facts and events and recall, declarative memory

17
Q

What is Delirium?

A

*disrupted consciousness, cognition, or perception that is common in hospitalized older adults.

*Common occurrence postoperatively in older adults and occurs in 80 % of those in the ICU

*Develops in a short period of time

*The type of symptoms and severity fluctuate throughout the day and night.

*Can be hyperactive, hypoactive or mixed

18
Q

What is dementia?

A

*Clinical syndrome of cognitive and functional decline

*Chronic and progressive in nature (not sudden)

*Diagnosed by a careful history, medical and neurological exam, and neurocognitive testing

*Deficits are sufficient enough to cause impaired occupational or social functioning and represent a decline from previous level of function

4 common types: of dementia?

-Alzheimer’s disease
-Vascular dementia
-Dementia with Lewy Bodies
-Frontotemporal dementia

19
Q

What are some mild cognitive impairment?

A

*Altered cognition that fills the gap between normal and dementia

*More memory loss than normal for those their age.

*Symptoms not as severe as those with Alzheimer’s

*Function is largely preserved and they are able to do normal daily activities

*Signs: losing things, forgetting appointments, and trouble finding words, increased forgetfulness of recent events

Not sure if there is correlation to turn into Alz or dementia
Exercise may reduce the progression but no know drugs

20
Q

what is ALzheimers

A

-Most common form of dementia and is associated with advanced age

-Memory decline is the predominant symptom and earliest sign

-Later symptoms: impaired communication, mobility, judgement, swallowing, speaking, behavior, and disorientation

-Amyloid plaques and neurofibrillary tangles are the pathologic changes in the brain

-There is atrophy in the inferior prefrontal cortex of the brain

-Inadequate levels of acetylcholine causes reduced synaptic activity and density

***Disease process may start 20 years before symptoms
Amyloid plaques: protein fragments knows as B amyloid peptides mixed with other proteins
Neurofibrillary tangles are abnormal collections of protein knowns as tau
tau is normal but in AD it clumps on the neurons die

21
Q

What is Vascular dementia?

A

-is a Mental disorder with the main feature of underlying cardiovascular disease

-Often present with Alzheimer’s and Lewy Body Dementia

-Same risk factors as cardiovascular disease

-Brain damage results from vascular strokes

-Can also be multi infarct dementia which a result of multiple large or small infarcts that cause brain loss

-Rate of cognitive decline is similar to AD but the life expectancy is shorter

-Slow processing speed, impaired judgement, impaired ability to make decisions and plan are the first noted symptoms

-Slow gait and poor balance are associated with VD depending on where the ischemia is happening

22
Q

what is lewy body

A

-Similar to AD but have early sleep disturbance and hallucinations

-Have more imbalance and Parkinson’s type movement along with visuospatial impairment

-Caused by the build up of Lewy bodies inside the neurons in the cortex that controls memory and motor control

-Alpha-synuclein (Lewy bodies) are also linked to PD and multi system atrophy

-PD is marked by motor symptoms and LBD is marked by cognitive impairments first

23
Q

what is Frontotemporal Lobe Dementia

A

-Progressive nerve cell loss in the brain’s frontal and temporal lobes

-Causes deterioration in behavior, personality, language and alterations in motor and muscle function

-2nd most common cause of dementia after AD

-These people are less disoriented than AD but have more difficulty with executive function and problem solving

-Usually have preserved memory and spatial orientation

-Lack of insight can be profound but have less trouble negotiating a familiar environment

24
Q

Depression is one of the 3 D’s ?

A

*depression is Most common mental health disorder in adults 65 and older

*Any medical diagnosis can contribute to depression but stroke, cancer, chronic pain, MS are all highly correlated

*Signs of depression include sadness, irritability, cognitive alterations, decreased appetite, self esteem, and energy, loss of interest, anxiety, and reduced concentration

*Geriatric Depression scale is a good tool to catch depression and those who are at risk.

*For these patients chose activities that are engaging and interesting to them.

25
Q

What are vital signs?

A

*Heart rate (HR), respiratory rate (RR), blood pressure (BP), oxygen saturation (O2) all give vital information of a person’s cardio/pulmonary system and status as well as how other systems are working.

*Observation alone of a patient will not tell you cardio/pulmonary status

*Assessing vital signs can also give you information of how a person is responding to exercise and therapy

*Normal ranges for adults
-BP 120/80 mmHg
-RR 12-20 breaths per minute
-HR 60-100 beats per minute, average 60
-O2 sats 100 %

***Many stroke patient suffer from cardiovascular disease which caused CVA. A fib #1 risk factor for ishemic stroke

26
Q

Blood Pressure

A

*The force that blood exerts on an vessel wall

*Pressure is highest in arteries (top number) than veins (bottom number)

*Control center is lower pons and upper medulla
Factors that influence blood pressure:
-Blood volume
-Diameter and elasticity of the arteries
-Cardiac output
-Age
-Physical activity
-Valsalva maneuver

-Orthostatic hypotension
:Hypertension: > 140/90
:Prehypertension: 120-139/80-89
:Hypotension: systolic < 100
:Medical emergency: > 180/110

27
Q

extra info about BP

A

Hemmorhage, dehydration can reduce BP

Increased blood volume CHF can cause increased BP
Inceased arthr and plaques increase BP along with narrowing of arteries

More output = increased pressue

Age: late adolscents BP reaches adult norms gradually rises after birth and reaches peak in late adolescents

Exercise increases cardiac output which will increase BP no change in DBP but increase in SBP. If there is less than 10 point rise in SBP with increases intensity or no rise, indication to stop!

Valsalva: causes decrease in BP then when breath is released causes sudden increase in BP and HR to compensate for the drop

Orthostatic: drop in BP secondary to bed rest, prolonged immobilization gravitational response

28
Q

What is respiratory rate?

A

*Function is to supply the body and organs with oxygen and remove carbon dioxide

*Factors that influence RR
-Age
-Body size and structure
-Exercise
-Body position
-Environment
-Stress
-Pharmacology

**Faster during infants and childhood and and slows into adulthood to 12-20 breaths
Larger individuals have smaller vital capacity that increases RR
Will increase with exercise
Laying flat at increase pressure at the diaphragm
Exposure to pollutents
Depressants will decrease respiration and there are drugs to increase albuterol

29
Q

What is heart rate?

A

*Wave of blood in the artery created by contraction of the left ventricle during a cardiac cycle

*Pulse is when the blood is forced out of the heart into systemic system

*Bradycardia: slow heart rate, below 60 bpm

*Tachycardia: fast heart rate, greater than 100 bpm

*Factors influencing HR
-Age
-Gender
-Stress
-Exercise
-Medications
-Heat and fever

Fetal 120-160 bpm
Newborn 70-170
Adults 60-100
Male and boys typically lower than females
Stress can increase HR
Hr increases with exercise to provide additional blood flow to muscles

30
Q

what is Intracranial Pressue (ICP)

A

*Pressure exerted by fluids (CSF) inside the skull and on the brain tissue

*If pressure is too high, the brain can herniate

*Signs
-Vomiting
-Headache
-Values
-Normal: 4-15 mmHg
-Mild hypertension: 20-30 mmHg
-Sever hypertension: > 39 mmHg

31
Q

what is Hemoglobin and Hematocrit

A

Hemoglobin (Hb)
Amount of hemoglobin in RBCs that transports O2 throughout the body

-Male: 14-17 g/dL
-Female: 12-16 g/dL
-< 8 g/dL no exercise
-8-10 g/dL light exercise
-> 10 g/dL resistive exercise

Hematocrit (Hct)
% of RBCs throughout the body

Male: 40-51%
Female: 36-47%
< 25% no exercise
> 25% light exercise
> 35% resistive exercise

32
Q

what is International Normalizing Ratio (INR)

A

*is How well your blood clots

Normal INR is: .8-1.2
-4: no increase in intensity
-4-5: no resistance
-5-6: no exercise
-> 6: bed rest

33
Q

what are some red flags?

A

_BP >180/90 mmHg

-Labored breathing

-O2 less than 90 %

I-CP > 39 mmHg

-Anemia: hemoglobin < 8 g/dL

-INR: > 5

When in doubt ALWAYS ask and seek MD guidance

Neuro muscular (12 decks)

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