Elder has neuro deficits? Pinpoint the true cause

Don't assume it's baseline

If you fail to confirm that neurological deficits are a normal baseline for your elder patient, this may be a dangerous assumption. To avoid this mistake, ask others about the patient's baseline, advises Nadya Valdovinos, RN, TNCC, an ED nurse at Northwestern Memorial Hospital in Chicago, and read past medical notes and transfer records.

You may need to contact family members, case managers, or nursing home personnel, says Joan Somes, PhD, MSN, RN, CEN, FAEN, staff nurse/department educator, St. Joseph's Hospital, St. Paul, MN, who know the patient and how he or she functions normally. "Ask 'What is different today?' That may help to pinpoint the problem," says Somes. "Asking the patient what is different is also an option."

Did injury occur?

If you identify neurological deficits in an elder trauma patient, you'll need to determine if this is normal for your patient or a result of his or her injury, says Jenny Baquero, RN, an ED nurse at Baptist Hospital of Miami.

"A vast amount of the elderly patients that come through our ED suffer from dementia or Alzheimer's," she notes. "But you need to assume the patient has head trauma, until proven otherwise through exams."

Baquero recently cared for a woman in her 80s with headache, nausea, and vomiting after a fall injury the previous day, but the family didn't know if she had hit her head or if there was any loss of consciousness. "She was only oriented to name only, which was not her baseline, and she just kept repeating that her head hurt," she says.

Baquero immediately did a neurological assessment and activated the ED's head-injury protocol, which orders basic lab work and a CT of the brain. "This was one of those cases where I had the gut feeling that it was something," she says. In this case, a family member told Baquero that although the patient did have beginning signs of dementia, her current mental status was still not usual.

Shortly after taking the patient to CT scan, the radiologist called Baquero to report that she had a skull fracture and hemorrhagic contusions of the frontal lobes. "I immediately got an ED physician to see her, and the patient was admitted to the hospital," she says. (See related stories on acute mental status changes, and assessment of possible trauma, below.)

Sources

For more information on mental status changes in elder patients, contact:

  • Joan Somes, PhD, MSN, RN, CEN, FAEN, Staff Nurse/Department Educator, St. Joseph's Hospital, St. Paul, MN. Phone: (651) 232-3000. E-mail: somes@blackhole.com.
  • Nadya Valdovinos, RN, TNCC, Emergency Department, Northwestern Memorial Hospital, Chicago. E-mail: nvaldovi@nmh.org.

Patients may be in danger: ID acute changes

Take immediate action if you recognize any acute change in an elder's neurological status, advises Nadya Valdovinos, RN, TNCC, an ED nurse at Northwestern Memorial Hospital in Chicago. "Patients who come in with neurological deficits and who are ignored can be in great danger," she says. The patient could be having an acute stroke that can be treated effectively if recognized early enough, adds Valdovinos.

Unless you know that mental-status deficits are normal for your patient's baseline, take these steps immediately, says Joan Somes, PhD, MSN, RN, CEN, FAEN, ED educator at St. Joseph's Hospital in St. Paul, MN:

Obtain a 12-lead EKG.

"Tachycardia, bradycardia, and new rhythm disturbances lead to poor perfusion to the brain and, thus, the changes," says Somes. "If there is an old EKG in the system to compare to, that is an added bonus."

Obtain a pulse oximetry level.

If the patient is hypoxic, this may explain global as well as lateralizing weakness," says Somes. "We have seen strokes clear simply by normalizing oxygen saturations."

Obtain a chest X-ray and urine specimen.

"Pneumonia and urinary tract infection are two of the common causes of changes in mentation in the older adult," says Somes.

Obtain an electrolyte panel.

"Electrolyte imbalances may be another cause of weakness or changes," says Somes.

Obtain a blood sugar level.

"Geriatric patients do not always show evidence of blood sugar abnormalities. Altered mental status may be the first indication they are hyperglycemic," says Somes.

Obtain a head CT scan.

"A head CT to look for stroke, especially bleeding, is important," says Somes. Many geriatric patients present with changes in ability or deficits, she adds, and it turns out to be a chronic subdural hematoma or a small lacunar stroke.

"Many stroke symptoms are subtle," says Somes. "The CT with angiograms, magnetic resonance imaging, or perfusion scans are how they can be identified and potentially reversed."

Obtain a blood urea nitrogen and creatinine level.

These may show dehydration or renal failure, or both, says Somes. "Either can lead to changes in the patient's ability, or lead to deficits or the source of the deficits," says Somes.

Identify the patient's current medications.

Somes recently cared for a patient who had increasing weakness, to the point of nearly arresting. "It turned out that the patient's multiple meds were interacting, leading to renal failure, as well as liver failure, accentuating a dehydration state, and making the patient toxic on many of her meds," says Somes. These led to hyperkalemia, hypotension, and bradycardia.

"Any or all of these could have led to this patient's condition. She was unlucky enough to have several things causing her problems," says Somes.

If you know what medications your patient is taking, says Somes, this can often identify the reason for altered mental status. "Recognizing medication types that interact or cause renal or hepatic failure often leads to a quicker identification why the patient might have changes," she says.


Clinical Tip

Examine patient to ID possible trauma injury

If you note mental-status changes in your elder patient, it can be hard to determine whether these are related to an illness or injury, says Nadya Valdovinos, RN, TNCC, an ED nurse at Northwestern Memorial Hospital in Chicago. "One way to rule out injury is by examining the patient for bruising, hematomas, and abrasions that could indicate any sort of injury," says Valdovinos.