GAITS AND BALANCE DISORDERS

Jemima Afriyie

Content
1 2 3 4
Delirium Confusion Dizziness Vertigo Syncope

. Dizziness

This is a sensation of unsteadiness and lightheadedness.. It may be mild brief symptom that occurs by it self

Some misleadingly inappropriate use of term are mental confusion, blurred vision, headache tingling.

VERTIGO
An illusion that one or ones surrounding are spinning. It is due to disturbance of the semicircular canals in the inner ear or the nerve tracts leading from them.

Balance or Equilibrium, is primarily measured by three sensory systems:

The eye (visual) system The balance (vestibular) system of the inner ear The 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 our head, body, joints, and eyes. When all three sensory systems and the brain are properly functioning, the final result is a healthy balance system.

Causes
Physiologic When the brain is confronted with an intersensory mismatch among the 3 stabilizing sensory systems Vestibular system is subjected to unfamiliar head movements to which it is unadapted e.g seasick. Unusual head or neck positions Following a spin

Pathologic somatosensory or vestibular systems Vestibular dysfunction involving either its end organ, nerve, or central connections such as BPPV, Menieres disease and Labyrinthitis

Lesions of the visual,

After cessation of prolonged rotation or motion

The right and lefts labyrinths are alternately excited and inhibited Firing frequency of the two end organs reverse or inbalanced in 8th nerve activity(the side with the initial y increased rate decreases and the other side increases)

Motion or a sense of rotation in the opposite direction is experienced or suporious leftright difference

Unequal neural input to the brain stem and ultimately cerebral cortex

vertigo

Other Vertigos
Vertigo of vestibular nerve origin This occurs with disease that involve the nerve in the cerebellopontine angle. Although less severe, the adjacent auditory divisions of the 8th cranial nerve is usually affected which explains the frequent association of vertigo Most common cause of the 8th cranial never dysfunction is Schwannoma or a meningioma

Central Vertigo
Lesions of the brainstem or cerebellum that cause acute vertigo.

Treatement
Epley Maneuver( particularly for BPPV)

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Syncope is a transient, self-limited loss of consciousness and postural tone due to acute global impairment of cerebral blood flow. The onset is rapid, duration brief, and recovery spontaneous and complete.

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

Clinical Manifestations
Dizzyness

or dysequilibrium visual changes greying out - mental clouding deafness nausea loss of postural tone Rostral to caudal progression Myoclonus jerking not seizure activity Rapid recovery of consciousness without a post-ictal confusion or exhaustion No focal neurologic before or after event

Causes

Neurocardiogenic(Vasovagal)

Frequently recurrent and commonly precipitated by a hot or crowded environment, alcohol, extreme fatigue, severe pain, hunger, emotional or stressful situations Episodes are often preceded by presyncope

Patho....

Syncope.....
Diagnosis Treatment Cardiac pacemaker, medications if low CO, defibrillator Removal of offending medications Treatment of vascular disease Counciling and recognition paperbag Autonomic insufficiency SSRI, NaCl, midodrine,

History and physical BP in both arms BP lying, sitting and standing ECG, cardiac event monitor or loop recorder Rarely EEG MRI and CT of little use if neuro exam is normal

Vedio....

Confusion and Delirium

Confusion

An acute or chronic disorganized mental state in which the abilities to remember , think clearly and reason are impaired. Its one of the most common problems encountered in medicine.

Acute Confusion
Arises as a symptom of Delirium in which brain activity is affected by fever, drugs, poisons or injury People with acute confusion may also have hallucinations and behave violently

Chronic confusion
Often associated with alcohol dependence, long term use of antianxiety drugs.

Delirium, a term used to describe an acute confusional state, remains a major cause of mortality and morbidity, contributing billions of dollars yearly to health care costs in the US.

Delirium
It is a neuropsychiatric syndrome also called acute confusional state or acute brain failure that is common among the medically ill and often is misdiagnosed as a psychiatric illness which can result in delay of appropriate medical intervention. There is significantly mortality associated with delirium so identifying it is crucial!

1.reduced ability to focus, sustain or Disturbance of consciousness with 2. 3. 4.

DSM IV Criteria

shift attention. A change in cognition or development of perceptual disturbances that is not better accounted for a preexisting, existed or evolving dementia. The disturbance develops over a short period of time and tends to fluctuate during the course of the day There is evidence from this hx, PE or labs that the disturbance is caused by the physiological consequence of a medical condition.

Clinical characteristics Develops acutely (hours to days) Characterized by fluctuating level of consciousness Reduced ability to maintain attention( hallmark sign) Agitation or hypersomnolence Extreme emotional lability Cognitive deficits can occur

Clinical characteristics: cognitive deficits

Language difficulties: word finding difficulties, dysgraphia Speech disturbances: slurred, mumbling, incoherent or disorganized Memory dysfunction: marked short-term memory impairment, disorientation to person, place, time. Perceptions: misinterpretations, illusions, delusions and/or visual (more common) or auditory hallucinations Constructional ability: cant copy a pentagon

Category in diagnosing Delirium

Hyporactive Hyperactive Mixed
Patients are Classic example is The most with drawn and cognitive common types quiet syndrome are hypoactive Prominent associated with and mixed apathy severe alcohol accounting for Psychomotor withdrawal. approximately slowing Prominent 80% of delirium hallucinations cases Agitation Hyper arousal Autonomic instability

Etiology
It is usually multifactorial Systemic illness Medications- any psychoactive medication can cause delirium Presence of risk factors( 60yrs and >, Male, depression)

Many hypotheses exist including: Neurotransmitter abnormalities Inflammatory response with increased cytokines Changes in the blood-brain barrier permeability Widespread reduction of cerebral oxidative metabolism Increased activity of the hypothalamic-pituitary adrenal axis

The Confusion Assessment method(CAM) Diagnostic algorithm

The diagnosis of delirium requires the presence of features 1 and 2 and of either 3 or 4.

Feature 1: Acute onset and fluctuating course This feature is satisfied by positive responses to these questions: Is there evidence of an acute change in Mental status from the patients baseline? b. Did the abnormal behaviour fluctuate during the day-that is, tend to come and go- or did it increase or decrease severity? Feature 2: Inattention This feature is satisfied by a positive response to this question: Did the patient have difficulty focusing attention

a.

a.

Feature 3: Disorganized thinking this feature is satisfied by a positive response to this questions: Was the pxs thinking disorganized or incoherent such as unclear or illogical flow

a.

Feature 4: Altered level of consciousness

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

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Dementia vs Delirium
Dementia has an insidious onset, chronic memory and executive function disturbance, tends not to fluctuate. In delirium cognitive changes develop acutely and fluctuate.

Dementia has intact alertness and attention but impoverished speech and thinking. In delirium speech can be confused or disorganized. Alertness and attention wax and wane.