Arousal, Cognition, Attention, Dementia Flashcards
What is the neurological screen used for?
to screen patients presenting to therapy to determine if further neurological evaluation is appropriate and determing body regions that have deficits
What are we screening for with our neuro screen?
red flags, referral potential, differential diagnosis, and baseline
What is mental status observed by?
patient history
- note behavior, language, attention, affect
Orientation
- person, place, time, situation
alert
- arousal, attention, consciousness
Behavior
Cognitive Status
Memory
What is a quick mental status check?
3 words to remember
What is normal arousal?
consciousness
What is hypoarousal?
lethargic, obtund, stupor, coma, minimally conscious vegitative state, persistent vegetative state
What is hyper aroused?
restless, agitated, irritable, unable to self console, hyperactive
What is lethargy?
mildly depressed level of consciousness
What is obtund?
significantly diminished, will respond to noxious stimulus but may be confused
What is stupor?
minimal arousal and requires vigerous noxious stimulus and minimal arousal
What is coma?
no arousal, inability to make purposeful response
What is a minimally concious vegetative state?
conscious but unaware of their environment and no purposful attention
What is a persistent vegetative state?
in state for 1 year or longer after TBI
How do we assess arousal?
response to stimulus
What is the gold standard to test arousal in acute brain injury?
Glasgow Coma Scale
What are stimuli we can use to assess response?
verbal, pain, light, touch
What kind of response are we looking for when testing arousal?
- eye opening
- motor response
- verbal response
What survery is stroke specific for arousal?
NIHSS
What does section 1 of the NIHSS examine?
the patients level of conciousness and arousal
When is the Glasgow Coma Scale used?
immediately following a head injury in the acute phases
What does the Glasgow coma scale measure?
change following injury in arousal and neurologic function
What does the Glasgow Coma Scale examine?
- eye opening
- motor response
- verbal response
What is the scoring of the Glasgow Coma Scale?
mild: 12-15
moderate: 9-11
severe: 3-8
What are physical touch ways to stimulate and improve arousal?
- hand over hand
- rubbing
What are noxious stimuli ways to stimulate and improve arousal?
- sternal rub
- nailbed pressure
What are some sensory stimulation ways to stimulate and improve arousal?
- cold or wet towel
What are some vestibular stimulationways to stimulate and improve arousal?
movement
What are some environemental ways to stimulate and improve arousal?
lights, sound
What is attention necessary for?
to perform a conscious task
What are the 5 categories of attention?
- focused
- sustained
- selective
- alternating
- divided
What is focused attention?
process specific information
What is sustained attention?
continuously over time
What is selective attention?
being able to perform with distractions
What is alternating attention?
shifting attention back and forth
What is divided attention?
respond to multiple stimuli simultaesously simultaneously
What is MARS?
Moss Attention Rating Scale
What is MARS for?
outcome measures for attention, characterized behavioural responses after brain injury
What is MARS made up of?
- 22 questions that therapist is rating of person they are examining
What are the ratings for MARS?
1= definitely false
2= false for the most part
3= sometimes true sometimes false
4= true for the most part
5= definitely true
What is affect?
behaviors that describe mood or emotional state
WHat is pseudobulbar affect?
emotional dysregulation, uncontrolled and exaggerated laughing or crying
What is apathy?
shallow or blunted emotional response
What is euphoria?
exaggerated feelings of well being
What is depression?
poor perception of self and environment
What is cognition?
the ability to sort, retrieve and manipulate information
What does a cognitive assessment determine?
if a patient may have a limitation in pOC or need further referral (speech?)
What kind of patient is more likely to fall?
patients with dementia and cognitive impairment
What does a cognitive assessment help a PT determine related to POC?
discharge plan
When is attention, arousal and orientation done?
bedside and in subjective assessment
What are some cognitive assessment objective tests and outcome measures?
- clock drawing
- reasoning
- recall
- animal fluency
- mini-mental mental state exam (MMSE)
- Montreal cognitive assessment (MOCA)
- St. Louis University Mental Status Exam (SLUMS)
What is animal fluency?
give patient 1 minute to name as many animals as possible
> 65 yo = 12 animals
< 65 = 18 animals
What is clock drawing and how is it helpful?
blank sheet of paper and have patient draw a clock with numbers 1 - 12
- ask patient to draw hands to indicate a time (any time)
How can we test reasoning?
say a phrase to a patient and ask them to interpret
- “you reap what you sew”
How do we test retention?
- give the patient a list of words for them to remember and have them repeat them to you
How do we test recall?
ask later in the screen for the patient to repeat the words back to you
What is the mini mental state exam?
- used if cognitive issues is expected but undiagnosed
- measures orientation, recall, short term verbal memory, calculation, language and construct ability
- LICENCE MUST BE REQUESTED TO ADMINISTER
What is the max score of MMSE? What indicates a cognitive impairement?
- 30/30 max
- less than 24 = cognitive impairment
What is the scoring of MOCA?
- less than 26/30 is indicative of dementia and further testing is required
What is the scoring of SLUMS?
- less than 25 indicates cognitive dysfunction
What does SLUMS contain more of?
memory, attention and executive function questions
Which test is more sensitive for identifying dementia?
SLUMS
Where should our interventions start?
- address mobility, strength and fall risk
Interventions need to be _____________ based instead of explicit
PROCEDURAL
Even if patients cant remember they can develop …
habits
Patients can learn by ____ rather than remembering
doing
The less explicit information and talking, the ______ ability to learn the task
better
What are the 3 Ds?
- delirium
- depression
- dementia
What is delirium?
disrupted consciousness, cognition, or perception that is common in hospitalized older adults
Is delirium common?
YES - occurs in 80% of those in the UCY
How long does it take delirium to develop?
SHORT PERIOD OF TIME
What are the symptoms of delirium?
fluctuate throughout day and night
- can be hyperactive, hypoactive or mixed
What is dementia?
clinical syndrome of cognitive and functional decline
What is the prognosis of dementia?
chronic and progressive in nature (NOT SUDDEN)
How is dementia diagnosed?
by a careful history, medial and neurological exam and neurocognitive testing
With dementia, what are the deficits?
cause impaired occupational or social functioning and represent a decline from previous level of function
What are the 4 common types of dementia?
- Alzheimer’s disease
- vascular dementia
- dementia with Lewy Bodies
- Frontotemporal dementia
What is a mild cognitive impairment?
altered cognition that fills the gap between normal and dementia
What are the characteristics of a mild cognitive impairment?
- 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
What are signs of a mild cognitive impairement?
- losing things, forgetting appointments, and trouble finding words, increased forgetfulness of recent events
What is the most common form of dementia?
Alzheimer’s
What is the dx of alzheimer’s associated with?
advanced age
What is the predominant and earliest sign of alzheimer’s?
Memory decline
What are later symptoms of alzheimer’s?
impaired communication, mobility, judgement, swallowing, speaking, behavior, and disorientation
What are the pathological changes that cause alzheimer’s?
amyloid plaques and neurofibrillary tangles
What area has atrophy with dementia?
inferior prefrontal cortex
What are there inadequate levels of with alzheimer’s?
acetylcholine causes reduced synaptic activity and density
What is vascular dementia?
mental disorder with the main feature of underlying cardiovascular disease
What also comes with vascular dementia often times?
ALzheimer’s and Lewy Body Dementia
What has the same risk factors as vascular dementia?
cardiovascular disease
What can result from vascular strokes?
BRAIN DAMAGE
What can vascular dementia also be?
multi infarct dementia which is a result of multiple large or small infarcts that cause brain loss
What is the rate of cognitive decline like with vascular dementia?
similar to alzheimer’s disease but LIFE EXPECTANCY IS SHORTER
What are some symptoms of vascular dementia?
slow processing speed, impaired judgment, and impaired ability to make decisions and plan are the first symptoms
What physical symptoms are associated with vascular dementia?
slow gait and poor balance depending on where the ischemia is happening
What is Lewy Body dementia?
- similar to Alzheimer’s disease but has early sleep disturbance and hallucinations
- have more imbalance and PKD type movement along with visuospatial impairment
What causes Lewy Body dementia ?
the build-up of Lewy bodies inside the neurons in the cortex that control memory and motor control
What are lewy bodies also linked to?
parkinsons and multi-system atrophy
What makes lewy body different from parkinsons?
- PKD is marked by motor symptoms and lewy body is marked by cognitive impairments first
What is frontotemporal lobe dementia?
- progressive nerve cell loss in the brains frontal and temporal lobe
What does frontotemporal lobe dementia cause?
deteriation in behavior, personality, language and alterations in motor and muscle function
Frontotemporal lobe dementia is the ___ mot ccommon cause of dementia
2nd
How does frontotemporal lobe dementia differ from alzheimers?
frontotemporal dementia people are less disoriented than AD but have more difficult with executive function and problem solving
What is perserved with frontotemproal dementia?
memory and spatial orientation
What do those with frontotemporal dementia have less trouble with?
negotiating a familiar environment
What can be profound with frontotemporal dementia?
lack of insight
What is the MOST COMMON mental health disorder in adults 65 and older?
depression
What can contribute to depression in older adults?
any medical diagnosis but stroke, cancer, chronic pain, MS are all highly correlated
What are signs of depression?
sadness, irritability, cognitive alterations, decreased appetite, self-esteem, and energy, loss of interest, anxiety and reduced concentration
What is a good tool to catch depression in an older population?
Geriatric Depression Scale
What can we do for patients with depression?
choose activities that are engaging and interesting to them
What are the normal vital sign ranges for adults (BP, RR, HR, O2)?
BP: 120/80
RR: 12-20 breaths per minute
HR: 60-100 bpm, avg 60
O2: 100%
