Gaits and Balance Presentation

7/29/2019 Gaits and Balance Presentation

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GAITS AND BALANCE DISORDERJemima Afriyie


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Content

1 Dizziness Vertigo

2

Syncope

3

Delirium

Confusion

4


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1. Dizziness

This is asensation of unsteadiness and

light-headedness..It may be mild

brief symptomthat occurs by itself


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Some misleadinglyinappropriate use of termare mental confusion,

blurred vision, headachetingling.


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VERTIGOAn illusion thatone or onessurrounding arespinning. It is dueto disturbance of the semicircularcanals in the

inner ear or thenerve tractsleading fromthem .


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Balance or Equilibrium, is primarily measured bythree sensory systems:

The eye (visual) systemThe balance (vestibular) system of the inner earThe general sensory system including motion,

pressure, and position (proprioception) sensors in joints, muscles, and skin.

The brain( Cerebellum), in turn, processes these data

and uses the information to make adjustments of ourhead, body, joints, and eyes. When all three sensorysystems and the brain are properly functioning, thefinal result is a healthy balance system.


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CausesPhysiologic

When the brain isconfronted with anintersensory mismatchamong the 3 stabilizingsensory systems Vestibular system is

subjected to unfamiliarhead movements towhich it is unadapted e.gseasick.

Unusual head or neck positions

Following a spin

Pathologic

Lesions of the visual,somatosensory or vestibularsystems Vestibular dysfunction

involving either its endorgan, nerve, or centralconnections such as BPPV,Menieres disease and

Labyrinthitis


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After cessation of prolongedrotation or motion

The right and lefts labyrinths arealternately excited and inhibited

Firing frequency of the two end organs reverse orinbalanced in 8 th nerve activity(the side with the

initial y increased rate decreases and the other sideincreases)


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Motion or a sense of rotation in the oppositedirection is experienced or suporious left-

right difference

Unequal neural input to the brainstem and ultimately cerebral cortex

vertigo


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Other Vertigos

This occurs with disease that involve thenerve in the cerebellopontine angle.

Although less severe, the adjacent auditorydivisions of the 8 th cranial nerve is usuallyaffected which explains the frequentassociation of vertigoMost common cause of the 8 th cranial neverdysfunction is Schwannoma or ameningioma

Vertigo of vestibular

nerve origin


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Central Vertigo

Lesions of the brainstem or cerebellumthat cause acute vertigo.


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Treatement

Epley Maneuver( particularly for BPPV)


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Syncope is a transient, self-limited loss ofconsciousness and postural tone due to acuteglobal impairment of cerebral blood flow.

The onset is rapid, duration brief, and recoveryspontaneous and complete.

It may occur suddenly without warning or maybe preceded by symptoms of faintness (presyncope)


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Clinical Manifestations

Dizzyness or dysequilibrium visual

changes greying out - mentalclouding deafness nausea loss of postural tone

Rostral to caudal progressionMyoclonus jerking not seizureactivity

Rapid recovery of consciousness withouta post-ictal confusion or exhaustionNo focal neurologic before or after event


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Causes


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Neurocardiogenic(Vasovagal)

Frequently recurrent and commonlyprecipitated by a hot or crowded environment,alcohol, extreme fatigue, severe pain, hunger,emotional or stressful situations

Episodes are often preceded by presyncope


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Patho....


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Syncope.....

DiagnosisHistory and physicalBP in both armsBP lying, sitting and

standingECG, cardiac event

monitor or looprecorder

Rarely EEGMRI and CT of little use

if neuro exam is

normal

Treatment

Cardiac pacemaker,medications if low CO,defibrillator

Removal of offendingmedicationsTreatment of vascular

disease

Counciling and recognition paperbag Autonomic insufficiency

SSRI, NaCl, midodrine,


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Vedio....


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Confusion and Delirium


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Confusion

An acute or chronicdisorganized mental state inwhich the abilities to

remember , think clearly andreason are impaired.

Its one of the most commonproblems encountered inmedicine .


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AcuteConfusion

Chronicconfusion

Arises as a symptomof Delirium in which

brain activity is affectedby fever, drugs, poisonsor injury

People with acuteconfusion may alsohave hallucinations andbehave violently

Often associated withalcohol dependence,

long term use of antianxiety drugs.


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Delirium, a term used to describean acute

confusional state, remains a majorcause of

mortality and morbidity,contributing billionsof dollars yearly to health care

costs in theUS.


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Delirium

It is a neuropsychiatric syndrome alsocalled acute confusional state or acutebrain failure that is common among the

medically ill and often is misdiagnosed as apsychiatric illness which can result in delayof appropriate medical intervention. There

is significantly mortality associated withdelirium so identifying it is crucial!


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DSM IV Criteria1. Disturbance of consciousness with

reduced ability to focus, sustain orshift attention.2. A change in cognition or development

of perceptual disturbances that is not

better accounted for a preexisting,existed or evolving dementia.3. The disturbance develops over a short

period of time and tends to fluctuate

during the course of the day4. There is evidence from this hx, PE orlabs that the disturbance is caused bythe physiological consequence of amedical condition.


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Clinical characteristics

Develops acutely (hours to days)Characterized by fluctuating level

of consciousness

Reduced ability to maintainattention( hallmark sign) Agitation or hypersomnolence

Extreme emotional labilityCognitive deficits can occur

Cli i l h t i ti iti


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Clinical characteristics: cognitivedeficits

Language difficulties: word finding difficulties,dysgraphiaSpeech disturbances: slurred, mumbling,

incoherent or disorganized

Memory dysfunction: marked short-term memoryimpairment, disorientation to person, place,time.

Perceptions: misinterpretations, illusions,delusions and/or visual (more common) orauditory hallucinations

Constructional ability: cant copy a pentagon


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Category in diagnosing DeliriumHyporactive Hyperactive Mixed

Patients arewith drawn andquiet

ProminentapathyPsychomotor

slowing

Classic example iscognitivesyndrome

associated withsevere alcoholwithdrawal.Prominenthallucinations

AgitationHyper arousal

Autonomicinstability

The mostcommon typesare hypoactive

and mixedaccounting forapproximately80% of deliriumcases


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Etiology

It is usually multifactorialSystemic illnessMedications- any psychoactive

medication can cause deliriumPresence of risk factors( 60yrs and >,

Male, depression)

M h th i t i l di g


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Many hypotheses exist including:Neurotransmitter abnormalitiesInflammatory response with increased

cytokinesChanges in the blood-brain barrier permeabilityWidespread reduction of cerebral oxidative

metabolismIncreased activity of the hypothalamic-pituitary

adrenal axis

The Confusion Assessment


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The Confusion Assessmentmethod(CAM) Diagnostic algorithm

The diagnosis of delirium requiresthe presence of

features 1 and 2 and of either 3 or4.

Feature 1: Acute onset and fluctuating course


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Feature 1: Acute onset and fluctuating courseThis feature is satisfied by positive responses tothese questions:

a. Is there evidence of an acute change inMental status from the patients baseline?b. Did the abnormal behaviour fluctuate during

the day-that is, tend to come and go- or did itincrease or decrease severity?Feature 2: Inattention

This feature is satisfied by a positive response tothis question:a. Did the patient have difficulty focusing

attention

F t 3 Di i d thi ki


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Feature 3: Disorganized thinkingthis feature is satisfied by a positive

response to this questions:a. Was the pxs thinking disorganizedor incoherent such as unclear orillogical flowFeature 4: Altered level of consciousness

This feature is satisfied by any answerother than alert to this question:


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Video


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i li i


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Dementia vs DeliriumDementia has an insidious onset, chronic

memory and executive function disturbance,tends not to fluctuate. In delirium cognitivechanges develop acutely and fluctuate.

Dementia has intact alertness and attentionbut impoverished speech and thinking. In

delirium speech can be confused ordisorganized. Alertness and attention waxand wane.


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Gaits and Balance Presentation

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