23 Tables.docx

Alteration Description Perceptual disturbances/psychosis Alterations in ability to interpret environmental stimuli, think clearly and logically, and maintain orientation to person, place, time, and situation - Hallucinations - Delusions - Disordered thinking - Disorientation/confusion...

Alteration Description Perceptual disturbances/psychosis Alterations in ability to interpret environmental stimuli, think clearly and logically, and maintain orientation to person, place, time, and situation - Hallucinations - Delusions - Disordered thinking - Disorientation/confusion - Identify and treat underlying cause - Reduce environmental stimulation - Reality orientation and validation therapy Impaired attention Difficulty sustaining or directing focus - Easily distracted - Avoids situations requiring sustained focus - Difficulty learning - Identify and treat underlying cause - Reduce distractions Memory problems Impairment in ability to recall information - Getting lost - Difficulty with word finding and recognition - Difficulty remembering recent events - Difficulty remembering remote events - Identify and treat underlying cause - Cognitive remediation - Provide compensatory strategies and memory aids **Indicator** **Description** ----------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ Loose associations Pattern of speech in which a person's ideas slip off track onto another unrelated or obliquely related topic; also known as *derailment*. Tangentiality Occurs when a person digresses from the topic at hand and goes off on a tangent, starting an entirely new train of thought. Incoherence/word salad/neologisms Speaking in meaningless phrases with words that are seemingly randomly chosen, often made up, and not connected. Illogicality Refers to speech in which there is an absence of reason and rationality. Circumstantiality Occurs when a person goes into excessive detail about an event and has difficulty getting to the point of the conversation. Pressured/distractible speech Can be identified when a patient is speaking rapidly and there is an extreme sense of urgency or even frenzy as well as tangentiality, making it is nearly impossible to interrupt the person. Poverty of speech The opposite of pressured speech; identified by the absence of spontaneous speech in an ordinary conversation. The person cannot engage in small talk and gives brief or empty responses. Delirium Dementia Depression ------------------------------ ----------------------- ----------------------------- -------------------------- **Onset** Acute, sudden, rapid Slow, progressive Variable **Duration** Hours to days Months to years Episodic **Cognitive impairment** Memory, consciousness Abstract thinking, memory Memory and concentration **Mood** Rapid mood swings Depression, apathy Sadness, anxiety **Delusions/hallucinations** Both; often visual May present in later stages Delusions only **Outcome** Recovery possible Poor Recovery possible Disorder Etiology Clinical Manifestations Onset/Course --------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Dementia due to HIV Infection with HIV-1 produces a dementing illness called HIV-1-associated cognitive/motor complex. Symptoms vary in early stages. Severe cognitive changes, particularly confusion, changes in behavior, and sometimes psychosis, are not uncommon in the later stages. At first symptoms are subtle and may be overlooked. The severity of symptoms is associated with the extent of the brain pathology. Dementia due to traumatic brain injury (see Module 11, Intracranial Regulation) Any type of head trauma. Amnesia is the most common neurobehavioral symptom following head trauma. A degree of permanent disturbance may persist. Dementia due to Parkinson disease Parkinson disease is a neurologic condition resulting from the death of neurons, including those that produce dopamine, the chemical responsible for movement and coordination. It is characterized by tremor, rigidity, bradykinesia, and postural instability. Dementia has been reported in approximately 20--60% of people with Parkinson disease and is characterized by cognitive and motor slowing, impaired memory, and impaired executive functioning. Onset and course are slow and progressive. Dementia due to Huntington disease Huntington disease is an inherited, dominant-gene, neurodegenerative disease. The first symptoms are typically movements that involve facial contortions, twisting, turning, and tongue movements. Cognitive symptoms include memory deficits, both recent and remote, as well as significant problems with frontal executive function, personality changes, and other signs of dementia. The disease begins in the late 30s or early 40s and may last 10--20 years or more before death. Lewy body dementia This disorder is distinguished by the presence of Lewy bodies---eosinophilic inclusion bodies---seen in the cortex and brainstem. Clinically, Lewy body disease is similar to Alzheimer disease; however, there is an earlier appearance of visual hallucinations and parkinsonian features. Irreversible and progressive; tends to progress more rapidly than Alzheimer disease. Vascular dementia Vascular dementia features strokes or infarcts in the blood vessels of the brain. Also caused by hypoperfusion due to blood clots, ruptured blood vessels, or narrowing or hardening of blood vessels. Symptoms vary widely, depending on the severity of the blood vessel damage and the part of the brain affected. Seizures often accompany strokes. Sudden poststroke changes may occur and include confusion, disorientation, trouble speaking or understanding speech, sudden headache, difficulty walking, poor balance, and numbness or paralysis on one side of the face or the body. Cognitive changes may occur suddenly after a stroke or they may have a slower onset. Progression typically follows a "sawtooth" pattern of strokes/ministrokes, followed by decline and stabilization until another vascular event occurs. Ages & Stages Questionnaires (ASQ), Set of questionnaires tailored to detect alterations in development in young children. --------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- American Academy of Pediatrics---Bright Futures Kit for health promotion and prevention published by the American Academy of Pediatrics that includes schedules for screening and care and a variety of questionnaires used to detect health problems, including developmental alterations. Confusion Assessment Method (CAM) Five-minute interview-style exam that screens specifically for signs of delirium. Pediatric versions are available for children 5 years and older (pCAM/psCAM-ICU for critically ill infants and children). Cornell Assessment of Pediatric Delirium Validated, rapid observational tool for screening children in intensive care for delirium. Cornell Scale for Depression in Dementia Nineteen-question tool that involves interviews with both patients and their caregivers; assesses for signs of depression in individuals known to have dementia. Edinburgh Depression Scale Validated 10-item questionnaire used to screen for the presence and severity of symptoms of postnatal depression. Geriatric Depression Scale (GDS) Brief questionnaire (15 or 30 items) that asks patients how they've felt over the past 7 days; assesses for depression in older adults. Hamilton Rating Scale for Depression (HRSD) Twenty-minute, 17-question examination that assesses severity of depression in adult patients. The Weinberg Depression Scale for Children and Adolescents (WDSCA) and the Children's Depression Rating Scale (CDRS-R) are modeled on the HRSD and adapted for children over age 5. Mini-Mental State Examination (MMSE) Thirty-question interview-style exam that assesses a patient's memory, language skills, attention level, and ability to engage in mental tasks; also known as the Folstein Mini-Mental State Examination. It may be modified for use in children over the age of 4. Montreal Cognitive Assessment One-page test that briefly assesses a patient's ability in a variety of cognitive domains, including problem solving and sequencing (traits, similarities), attention (digit span, letter vigilance), memory (word list, orientation), visuospatial construction and reasoning (cube, clock), and language (naming, repetition, word generation). Nonverbal Learning Disabilities (NVLD) Scale Assesses deficits in the areas of motor skills, visuospatial skills, and interpersonal skills. Patient Health Questionnaire (PHQ) Full-length 11-item tool that screens for depression and anxiety, somatic symptoms, and related disorders; abbreviated forms (PDQ-9 and PDQ-2) are used to more selectively screen for depression. Positive and Negative Symptoms Scale (PANSS) Registered nurses and other licensed healthcare providers (HCPs) can administer to detect positive, negative, and other manifestations of psychotic disorders and schizophrenia. May be useful in screening for peripartum psychosis. Postpartum Depression Predictors Inventory (PDPI) Validated short inventory that can be integrated into all phases of perinatal care to predict the risk of maternal depression. +-----------------+-----------------+-----------------+-----------------+ | **Step 1: | | | | | Prepare the | | | | | Patient** | | | | +=================+=================+=================+=================+ | Tell the | - Patient | - Patient | - A number of | | patient you | pays | displays | assessment | | will be | attention | high levels | tools are | | performing a | and asks | of | available, | | series of | questions | confusion, | with some | | tests. Describe | as | anxiety, or | tailored to | | what equipment | appropriate | agitation. | specific | | you'll use. |. | | conditions | | Explain that | | - Patient | and/or | | the exam should | - Patient may | shows signs | populations | | be comfortable | be nervous, | of |. | | and ask the | but this | delusions | | | patient to | should not | or | - Direct | | inform you | interfere | hallucinati | questioning | | should | with the | ons. | may not be | | difficulties | assessment | | appropriate | | arise. Provide | process. | - Patient | for | | an overview of | | pays no | patients | | the assessment | | attention | who are | | activities and | | to the | experiencin | | the order in | | information | g | | which they will | | you | hallucinati | | occur. | | provide. | ons, | | | | | delusions, | | | | - Patient is | or extreme | | | | partially | anxiety. | | | | or fully | | | | | uncommunica | - Questions | | | | tive. | for | | | | | children or | | | | | individuals | | | | | with | | | | | intellectua | | | | | l | | | | | disabilitie | | | | | s | | | | | should be | | | | | modified. | +-----------------+-----------------+-----------------+-----------------+ | **Step 2: | | | | | Observe the | | | | | Patient** | | | | +-----------------+-----------------+-----------------+-----------------+ | Take note of | - Patient | - Poor | - Poor | | the patient's | follows | hygiene | hygiene may | | general | directions. | and/or | be related | | appearance, | | inappropria | to economic | | including | - Patient's | te | circumstanc | | hygiene, | hygiene and | expressions | es. | | posture, body | overall | and body | Patient | | language, and | appearance | language | expressions | | expression. | are | might be | and body | | | acceptable. | reflective | language | | Observe the | | of | may be | | patient's | - Patient's | depression, | congruent | | ability to | expressions | schizophren | with | | follow your | and body | ia, | cultural | | instructions. | language | dementia, | norms that | | | are | or another | are | | | appropriate | cognitive | different | | | to the | disorder. | from the | | | situation. | | provider's. | +-----------------+-----------------+-----------------+-----------------+ | **Step 3: | | | | | Assess the | | | | | Patient's | | | | | Language | | | | | Abilities** | | | | +-----------------+-----------------+-----------------+-----------------+ | Note the tone, | - Patient's | - Problems | - Consider | | rate, | tone, rate, | with | whether the | | pronunciation, | pronunciati | language | patient's | | and volume of | on, | could be a | hearing may | | the patient's | and volume | result of | be | | speech | are | anxiety, | impaired, | | throughout the | appropriate | dementia, | especially | | course of the |. | depression, | when | | exam. Consider | | or an | working | | the patient's | - Patient | expressive | with older | | vocabulary and | speaks | or | adults. | | whether what | easily and | receptive | | | you are saying | naturally, | language | - Don't | | is understood. | without | disorder | assume all | | | searching | related to | patients | | | for words. | brain | are native | | | | injury/illn | English | | | - Patient | ess. | speakers. | | | understands | | Some | | | what you | | patients | | | are saying | | may | | | and | | communicate | | | indicates | | more | | | this | | effectively | | | through | | in another | | | verbal and | | language | | | physical | | and require | | | reactions. | | assistance | | | | | from an | | | - Social and | | interpreter | | | language | |. | | | milestones | | | | | have been | | - Consider | | | met. | | the child's | | | | | stage of | | | | | development | | | | |. | +-----------------+-----------------+-----------------+-----------------+ | **Step 4: | | | | | Assess the | | | | | Patient's Level | | | | | of | | | | | Orientation** | | | | +-----------------+-----------------+-----------------+-----------------+ | Assess | - Patient is | - Reduced or | - Noticeable | | orientation to | fully | varying | decreases | | person, place, | conscious | consciousne | in | | time, and | and alert, | ss | consciousne | | situation. | oriented to | may be due | ss | | | self, | to | during the | | | location, | hypoglycemi | exam may | | | time, and | a, | necessitate | | | situation. | stroke, | immediate | | | | seizure, | medical | | | | delirium, | attention. | | | | or organic | | | | | brain | - Modify | | | | disease. | questions | | | | | for | | | | | children | | | | | according | | | | | to | | | | | development | | | | | al | | | | | level. | +-----------------+-----------------+-----------------+-----------------+ | **Step 5: | | | | | Assess the | | | | | Patient's | | | | | Memory** | | | | +-----------------+-----------------+-----------------+-----------------+ | See whether the | - Patient can | - Inability | - In | | patient knows | recall | to recall | Alzheimer | | name, birth | basic | events from | disease, | | date, and | personal | one's past | loss of | | address. Ask | information | may be | short-term | | the patient for | and provide | suggestive | memory | | a brief summary | an accurate | of | typically | | of places lived | biography | dementia, | precedes | | and jobs held. | appropriate | especially | loss of | | Attempt to | to age and | Alzheimer | long-term | | verify all | development | disease. | memory. | | responses. | al | | | | | level. | | - Alterations | | | | | in memory | | | | | in children | | | | | may suggest | | | | | a problem | | | | | with | | | | | learning or | | | | | intellectua | | | | | l | | | | | function. | +-----------------+-----------------+-----------------+-----------------+ | **Step 6: | | | | | Assess the | | | | | Patient's | | | | | Computational | | | | | Ability** | | | | +-----------------+-----------------+-----------------+-----------------+ | Have the | - Patient can | - Inability | - Patient's | | patient answer | compute the | to perform | responses | | several | correct | simple | may be | | arithmetic | values. | calculation | negatively | | problems. Start | Depending | s | affected by | | with basic | on age and | may be | language | | facts and work | cognitive | suggestive | barriers, | | toward more | stage, | of brain | cognitive | | complicated | patient may | disease or | development | | questions. The | be able to | learning | , | | age and the | identify | problems. | anxiety, | | developmental | numeric | | and/or | | status of the | symbols and | | limited | | patient should | count. | | experience | | be considered. | | | or | | | | | education | | | | | in | | | | | mathematics | | | | |. | +-----------------+-----------------+-----------------+-----------------+ | **Step 7: | | | | | Assess the | | | | | Patient's | | | | | Emotions and | | | | | Mood** | | | | +-----------------+-----------------+-----------------+-----------------+ | Note the | - Patient's | - Mismatch | - Culture, | | patient's | affect | between the | temperament | | affect. Ask how | corresponds | patient's | , | | the patient is | with the | affect and | and | | feeling and | tone and | speech may | development | | whether this is | content of | reflect | impact | | typical. If | speech. | neurologic | emotional | | not, ask about | | or | expression. | | events that may | - Patient's | psychologic | Certain | | have prompted | emotions | problems. | development | | the change. | and mood | | al | | | are | - Absent, | stages are | | Modify | appropriate | excessively | associated | | questions for | given past | subdued, or | with | | children. | events and | excessively | increased | | Children may be | current | animated | lability. | | asked to draw | situation | expressions | | | pictures of how | and | and | | | they are | development | responses | | | feeling or to | al | may be | | | select from a | status. | indicative | | | visual scale. | | of | | | | | psychologic | | | | | disorders. | | +-----------------+-----------------+-----------------+-----------------+ | **Step 8: | | | | | Assess the | | | | | Patient's | | | | | Perceptions and | | | | | Thinking | | | | | Abilities** | | | | +-----------------+-----------------+-----------------+-----------------+ | Note whether | - Patient is | - Patients | - Patient's | | the patient's | aware of | who are | responses | | statements are | reality. | unaware of | may be | | complete, | | reality may | negatively | | rational, and | - Patient's | be | affected by | | pertinent, and | statements | experiencin | language | | whether the | are logical | g | barriers, | | patient seems | and | neurologic | education | | aware of | complete. | disturbance | level, | | reality. | | s | and/or | | | - Patient | or a mental | intellectua | | Ask the patient | correctly | disorder. | l | | to compare two | compares | | disability | | different | two objects | - Illogical, | or level of | | things or | and/or | incomplete | cognitive | | explain the | explains | statements | development | | meaning of a | the meaning | suggest |. | | common phrase. | of a | problems | | | | phrase. | with | - Perceptual | | Ask if the | | concrete | differences | | patient can | - Patient | thought and | in young | | see, hear, | denies | may be | children | | smell, or feel | hallucinati | indicative | may be | | things that are | ons | of a mental | related to | | not apparent to | of any | disorder. | magical | | others. | kind, or | | thinking | | | perceptual | - Absent or | and | | | differences | strange | animism. | | | may be | comparisons | Children | | | explained | and | may h | | | by level of | explanation | | | | cognitive | s | | | | development | are | | | | or | frequent | | | | sociocultur | symptoms of | | | | al | psychologic | | | | factors. | disorders. | | +-----------------+-----------------+-----------------+-----------------+ | **Step 9: | | | | | Assess the | | | | | Patient's | | | | | Decision-Making | | | | | Ability** | | | | +-----------------+-----------------+-----------------+-----------------+ | Ask the patient | - Patient | - Patient | - Consider | | about a | considers | considers | whether the | | personal | possible, | impossible, | patient's | | situation that | probable, | improbable, | options and | | requires good | and | or | decisions | | judgment. | appropriate | inappropria | make | | Determine | options. | te | sense---not | | whether the | | options. | whether | | patient's | - Patient's | | they | | responses | thinking | - Patient's | reflect the | | reflect | and | decision | choice you | | consideration | decision-ma | reflects | would make. | | of viable | king | absent or | | | options and | capabilitie | inadequate | - Decision-ma | | logical | s | considerati | king | | decision | are | on | capacity | | making. | appropriate | of | depends on | | | for age and | available | the stage | | | stage of | options. | of | | | development | | cognitive | | |. | | development | | | | | ; | | | | | refer to | | | | | normal | | | | | characteris | | | | | tics | | | | | of thinking | | | | | associated | | | | | with each | | | | | stage. | +-----------------+-----------------+-----------------+-----------------+ +-----------------------+-----------------------+-----------------------+ | Stage and Age Range | Description | Developments | +=======================+=======================+=======================+ | Sensorimotor | Infants use motor and | Children develop a | | | sensory capabilities | sense of "self" and | | Birth to 2 years | to explore the | "other" and come to | | | physical environment. | understand object | | | Learning is largely | permanence. | | | trial and error. | Behavioral schemes | | | | begin to produce | | | | images or mental | | | | schemes. | +-----------------------+-----------------------+-----------------------+ | Preoperational | Young children use | Children participate | | | symbols (images and | in imaginative play | | 2--7 years | language) to explore | and begin to | | | their environment. | recognize that others | | | Thought is | don't see the world | | | egocentric, and | the same way they do. | | | children cannot adopt | | | | the perspectives of | | | | others. | | +-----------------------+-----------------------+-----------------------+ | Concrete operational | Older children | Children are no | | | acquire cognitive | longer fooled by | | 7--11 years | operations or mental | appearances. They | | | activities that are | understand the basic | | | an important part of | properties of and | | | rational thought. | relations among | | | Logical reasoning is | objects and events, | | | possible but limited | and they are | | | to concrete | proficient at | | | (observable) | inferring motives. | | | problems. | | +-----------------------+-----------------------+-----------------------+ | Formal operational | Adolescents' | Logical thinking is | | | cognitive operations | no longer limited to | | 11 years and beyond | are organized in a | the concrete or | | | way that permits them | observable. Children | | | to think about | engage in systematic, | | | thinking. Thought is | deductive reasoning | | | now systematic and | and ponder | | | abstract. | hypothetical issues. | +-----------------------+-----------------------+-----------------------+