Term
|
Definition
• Most widely cognitive test for dementia
• Takes seven minutes to complete
• What cognitive functions does it test for?
– Orientation
– Recall
– Attention
– Calculation
– Language manipulation – Constructional praxis |
|
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Term
|
Definition
• Maximum scoreis 30 points
• A score of less than 24 suggests dementia or delirium
• Test not sensitive for mild dementia
• Scores may be influenced by age, education, language, motor, and visual impairments |
|
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Term
| Other Tests for Evaluation of Cognitive Impairment and Dementia |
|
Definition
• Montreal Cognitive Assessment (MoCA)
• Clinical Dementia Rating (CDR)—Alzheimer’s
• Brief cognitive assessments: – Mini-Cog
– Informant interview
– Short, portable mental status questionnaire – Clock drawing
• Neuropsychological testing
• Assessment of premorbid ability
• Of course, PE, labs, neuroimaging, and brain biopsy are other assessments |
|
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Term
|
Definition
• Whatisthe(year),(season),(date),(day),
(month)? 5 Points
• Wherearewe:(state),(county),(townorcity),
(hospital), (floor)? 5 Points |
|
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Term
|
Definition
• Namethreecommon
objects (apple, table, penny). Take one second to say each.
• Thenaskthepatienttorepeat all three after you have
said them.
• Giveonepointforeachcorrectanswer.
• Thenrepeatthemuntiltheylearnallthree. Count trials and record.
• Trials______,3Points |
|
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Term
| Attention and Calculation |
|
Definition
• Spell“world”backwards.
• Thescoreisthenumber of letters in correct order.
• (D_L_R_O_W)
• Orserial7’s.Counting
back from 100. Stop after five answers.
• 5Points
-dementia lab finding- Lewy bodies |
|
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Term
|
Definition
• Askforthethreeobjectsrepeatedabove.
• Giveonepointforeachcorrectanswer.
• Note:recallcannotbetestedifallthreeobjects were not remembered during registration.
• 3Points |
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Term
|
Definition
• Hold up two items and have patient name them: “pencil” and “watch”
• 2 Points
• Repeat the following: “No ifs, ands or buts”
• 1 Point |
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Term
|
Definition
| intelligence, judgement, and behavior |
|
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Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
• Follow a
three-stage command:
– “Take a paper in
your right hand, fold it in half, and put it on the floor.”
– 3 Points
• Close your eyes
• 1 Point |
|
|
Term
| factors that inc dementia risk |
|
Definition
| BP, blood sugar, blood size, inflammation, cortisol, stress, genetics, sedentary lifestyle |
|
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Term
|
Definition
• Write a sentence.
• 1 Point
• Copy the following design • 1Point |
|
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Term
| Despite technological advances in neuroimaging |
|
Definition
there is still no way of directly observing cognitive function.
• Neuroscientists and clinicians still rely on the mental status or neuropsychological exam for much of their info on the functioning of the brain. |
|
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Term
| Methods of Examining Cognition |
|
Definition
• Bedside or clinic mental status testing
– Initial assessment of cognition and mental status and can be brief or more extensive depending on the setting and level of concern
• Mental status scales
– Usually used as tool for screening or a baseline measure to follow patients over time
• Neuropsychological testing for extensive evaluation |
|
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Term
|
Definition
• Psychologicalequivalent of the physical exam
• Describes the mental state and behaviors of the person being seen
• Includes objective observations from the clinician
• Includes subjective descriptions given by the patient |
|
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Term
|
Definition
• Distinguish normal from abnormal cognition, and dementia
from delirium or primary psychiatric disease
• Patterns of deficits in the MSE can sometimes allow a preliminary hypothesis as to the underlying pathogenesis of a dementing process
• Measure of the severity of a patient’s problems that can be monitored over time |
|
|
Term
|
Definition
• MSE provides info for diagnosis and assessment of a disorder and response to treatment.
• Think of MSE as a snapshot in time.
• If another provider sees your patient, it allows that provider to determine if your patient’s status has changed without previously seeing the patient—continuity
of care. |
|
|
Term
|
Definition
• To properly assess, we must need to be aware of the education, cultural, and social factors
of our patients.
• We must know what “normal” is for our patient. |
|
|
Term
Parts of your mental status and cognition assessed in your HPI
– Can evaluate: |
|
Definition
• Attention
• Speed of responses
• Ability to answer questions and provide relevant information • Overall appearance
• Degree of cooperation
Can guide you to performing a more complete analysis in detail MSE |
|
|
Term
|
Definition
• Establish rapport
• Make the patient feel comfortable
• Quiet room
• No distractions |
|
|
Term
| Components of the Mental Status Exam (MSE) |
|
Definition
• Appearance—observed
• Level of consciousness/alertness (arousal)—observed
• Orientation—inquired
• Attention and concentration (attention span)—observed/inquired
• Speech and language—observed
• Behavior—observed
• Attitude—observed
• Mood—inquired
• Affect—observed
• Thought content—observed/inquired
• Thought process—observed/inquired
• Memory—observed/inquired
• Visual spatial perception—observed/inquired
• Higher cortical functioning and reasoning/executive function—observed/inquired
• Praxis—observed/inquired
• Calculations—observed/inquired
• Suicidality and homicidality—inquired
• Insight and judgment—observed/inquired |
|
|
Term
|
Definition
• Gait
• Posture/build
• Clothes/dress
• Grooming
• Prominentphysical abnormalities
• Emotionalfacialexpressions
• Neatly dressed with attention to detail |
|
|
Term
| Level of Consciousness (Arousal) |
|
Definition
• Can be assessed as soon as
you introduce yourself to the patient
• Conscious?
• Confused?
• Alert?
• Attentive?
• Sleepy?
• Stuporous?
• Asleep?
• Unresponsive? |
|
|
Term
| Level of Consciousness (Arousal) |
|
Definition
• If the patient doesn’t respond to your introduction, ask the patient to squeeze your hand if the patient can hear you
• No response, tap patient
• Squeeze nipple or apply pressure under bony ridge of the eyebrow or sternal rub
• If no response, patient in a coma |
|
|
Term
|
Definition
• What is your full name?
• Where are we at (floor, building, city, county, and state)?
• What is the full date today (date, month, year, day of the week, and season of the year)?
• How would you describe the situation we are in? |
|
|
Term
| Attention and Concentration |
|
Definition
• Attention—ability to focus, direct cognitive processes, and resist distraction
• Concentration—ability to focus and sustain attention over
a period of time
• In the medical interview, you may note the patient:
– Having difficulty concentrating – Easily distracted by stimuli
– Lose train of thought
– Rambling
• DigitSpanTest
– The examiner recites number digits at the rate of one number per second and asks the patient to repeat back the number sequence in exactly the same order. The string of digits increases in length. A normal span is seven digits plus or minus two digits for adults, regardless of age or educational level
• Serial7’s
• WORLDbackwards |
|
|
Term
| Attention and Calculation |
|
Definition
• More complex tests are judged based on time, including the trail-making tests, symbol-copying tasks,
(digit symbol) and letter cancellation tasks. These are typically administered in the neuropsychological setting. |
|
|
Term
|
Definition
• Is it normal in tone, volume, and quantity?
• Possible descriptors:
– Talkative,spontaneous,expansive,paucity
• Rate: possible descriptors:
– Fast,slow,normal,pressured
• Volume (tone): possible descriptors:
– Loud,soft,monotone,weak,strong,mute
• Fluency and rhythm: possible descriptors:
– Slurred,clear,withappropriatelyplacedinflections,hesitant,withgood articulation, aphasic
• Repetition: no, ands, ifs, or buts
• Naming: name pictures or objects
• Comprehension: three-step command
• Reading
• Writing |
|
|
Term
|
Definition
• Pleasant
• Cooperative
• Agitated
• Appropriate for the particular situation
• Mannerisms
• Gestures
• Movements—tremor, tics
• Psychomotor activity
• Expression
• Eye contact
• Ability to follow commands/requests
• Compulsions—hand wringing |
|
|
Term
|
Definition
• Cooperative
• Hostile
• Open
• Secretive
• Evasive
• Suspicious
• Apathetic
• Easily distracted
• Focused
• Defensive |
|
|
Term
|
Definition
• How do they feel?
• How are their spirits?
• You may ask this directly: – Are you happy?
– Sad?
– Depressed?
– Energized?
– Elated?
– Lonely?
– Angry/irritable/edgy?
• Is it appropriate for the particular situation?
• Mood and affect can be incongruent in the case of pseudobulbar palsy in which tearfulness/laughing is disproportionate to the underlying feeling, and in brain injury or multiple sclerosis in which euphoria in some cases covers up clinical depression.
• Neuropsych scales:
– Minnesota Multiphasic Personality Inventory – Beck Depression Inventory
– Geriatric Depression Scale
– Neuropsychiatric Inventory |
|
|
Term
|
Definition
• How do they appear to you?
• Interpretation based on your observations
of their interactions during the interview
• An observed expression of inner feeling—possible descriptors:
– Appropriateness to situation, consistency with mood, congruency with thought content
– Fluctuations: labile, excitable, even
• Does the tone of their voice change? – Flat affect (unchanging throughout) – Excitable
– Appropriation
– Range: broad, restricted
– Intensity: blunted, flat, normal intensity
– Quality: sad, angry, hostile, indifferent, euthymic, dysphoric, detached, elated, euphoric, anxious, animated, irritable
• Do they make eye contact? Are they evasive? |
|
|
Term
|
Definition
• A description of what the patient
is thinking about. Refers to the themes that occupy the patient’s thoughts
and perceptual disturbances
• Are they paranoid? Delusional (hold beliefs that are untrue)?
– Ifso,aboutwhat?
• Phobic?
• Hallucinating (you need to ask if they see or hear things that others do not)? Can be auditory (AH), visual (VH), tactile or olfactory
• Fixated on a single idea? If so, about what? Is the thought content consistent with their affect?
• Depersonalization: sensation of unreality concerning oneself or parts of oneself
• “What do you think about when you are sad/angry?”
• “What’s been on your mind lately?”
• “Do you find yourself ruminating about things?” (preoccupations)
• “Are there thoughts or images that you have a really difficult time getting out of your head?”
• “Are you worried/scared/frightened about something?” (illusions)
• “Do you have personal beliefs that are not shared by others?” (Delusions are fixed, false, unshared beliefs.)
• “Do you ever feel detached/removed/changed/different from others around you?”
• “Do things seem unnatural/unreal to you?” (derealization)
• “Do you think someone or some group intends to harm you in some way?”
• [In response to something the patient says] “What do you think they meant by that?”
• “Does it ever seem like people are stealing your thoughts, or perhaps inserting thoughts into your head? Does it ever seem like your own thoughts are broadcast out loud?”
• “Do you ever see (visual), hear (auditory), smell (olfactory), taste (gustatory), and feel (tactile) things that are not really there, such as voices or visions?” (Hallucinations are false perceptions).
• “Do you sometimes misinterpret real things that are around you, such as muffled noises or shadows?” (Illusions are misinterpreted perceptions).
• This is a description of the way in which they think.
• Are their comments logical and presented in an organized fashion?
• If not, how off base are they?
• Are their thoughts appropriately linked or simply all over the map?
• Assess logic, relevance, organization, flow, and coherence of thought in response to general questioning during the interview.
• Possible descriptors:
– Linear,goal directed, circumstantial, tangential, loose associations, incoherent, evasive, racing, blocking, perseveration, flight of ideas |
|
|
Term
|
Definition
• Circumstantial: provide unnecessary detail but eventually get to the point
• Tangential: move from thought
to thought that relate in some way but never get to the point
• Loose: illogical shifting between unrelated topics
• Flight of ideas: quickly moving from one idea to another—see with mania
• Thought blocking: thoughts are interrupted
• Perseveration: repetition of words, phrases, or ideas
• Word salad: randomly spoken words |
|
|
Term
|
Definition
• Recent memory:
– “What is my name?”
– “Whattimewasyourappointment with me for today?”
• Short-term/immediate memory is assessed:
– Listingthreeobjects
– Thenaskingthepatienttorepeatthem
to you to ensure that they were heard correctly
– Andthencheckingrecallatfiveminutes
– Digitspan(aswelearnedabove)
• Long term/remote memory can be evaluated by asking about the patient’s job history, where they were born and raised, family history, past presidents, etc. |
|
|
Term
| Visual Spatial Perception |
|
Definition
• Problems with visual spatial perception are suggested by a history of losing objects, getting lost, or difficulty navigating familiar or unfamiliar terrain.
• May exhibit visuospatial neglect when observed by others to ignore visual stimuli in one visual field (usually the left) as when searching for objects in the refrigerator or ignoring half their plate at meal time.
• Visuospatial functions encompass perceptual and constructional abilities, which are typically assessed through copying/drawing designs and building/assembly tasks with blocks.
• Draw a diamond, overlapping pentagons, a three-dimensional cube, or more complex designs (Rey-Osterrieth diagram). Line bisection and Letter Cancellation tests can be useful to elicit visuospatial neglect. |
|
|
Term
| Higher Cortical Functioning and Reasoning/Executive Function/Intellectual |
|
Definition
• Involves interpretation of complex ideas, including volition, planning, purposive action, and effective performance that enable a person to engage successfully
in appropriate, goal-directed, socially responsible, and self-serving behavior
• Prefrontal cortex and connections through the caudate nuclei are main source of executive function
• Assess information—name five of the largest cities in the country and the current president
• Assess vocabulary—grade/high school |
|
|
Term
| Higher Cortical Functioning and Reasoning/Executive Function/Intellectual |
|
Definition
• For example, you may ask them the meaning of the proverb phrase:
– “People in glass houses should not throw stones.”
– A few common interpretations include:
• Concrete(“Don’tthrowstonesbecauseitwillbreaktheglass”) • Abstract(“Don'tjudgeothers”)
• Bizarre
• Assess similarities
– An apple and an orange – A watch and a ruler |
|
|
Term
|
Definition
• Workingmemoryistheabilitytotemporarilyhold information in mind and manipulate the information in order to carry out complex cognitive tasks.
– It is often tested with serial reversal tasks (digits backwards) or sequencing of mixed
numbers and/or letters of alphabet in ascending order.
• Thisincludestheabilitytodivideattentionandability to change sets (mental flexibility).
– Examples include the Trailmaking Test, part B, and the Wisconsin Card Sorting Test.
• Motorprogramming
– Imitate simple rhythms (clap, clap, tap, knock) or copy a sequence of m’s and n’s.
– Another example is the Luria “fist-edge-palm” test, in which the patient is asked to tap that aspect of their hand to the desk in repeated sequences.
– Impaired patients typically demonstrate perseveration, which refers to the phenomenon of being “stuck-in-set” and continuing elements of previous actions into the present activity.
• The ability to inhibit responses:
– This can be tested by ”go/no go” tests.
– “Tap when I tap once” and to “not tap when I tap twice.” Another test of this function is the Stroop Color-Word Interference.
• Abstract reasoning is a related executive function and usually assessed by asking the patient to interpret similarities and differences (between word pairs such as watch-ruler, child-midget), idioms (warm-hearted), and proverbs (“a rolling stone gathers no moss”) |
|
|
Term
|
Definition
• Definition: of or relating to involuntary motor activity caused by an idea; refers to the performance of learned motor movements in the absence of primary deficits in motor and spatial abilities
• Problems with ideomotor praxis may be obvious when patient or family member reports difficulty dressing, feeding, and bathing that is not explained by gross motor deficits
• Demonstration using a comb, hammer, fork
• A step-wise series of coordinated tasks “take this piece of paper, fold it in half, and place it in the envelope” is another way to demonstrate praxis
• Asignificantlanguagedisorderormotordeficit can affect the ability to assess praxis.
• Morespecificorisolatedproblemswithpraxis suggest involvement of the dominant
parietal lobe.
• Ideomotor apraxia is a relatively prominent feature of corticobasal degeneration. |
|
|
Term
|
Definition
• Can they perform simple addition, multiplication?
• Serial 7’s, starting with 100 and subtracting 7 is a common test.
• Are the responses appropriate for their level of education?
• Have they noticed any problems balancing their checkbooks or calculating correct change when making purchases?
• This is also a test of the patient’s attention span/ability to focus on a task. |
|
|
Term
|
Definition
• If there is any concern regarding possible interest in committing suicide or homicide, the patient should be asked this directly, including a search for details (specific plan, time, etc.)
• Possible questions for patient:
– “Do you ever feel that life isn’t worth living? Or that you would just as soon be dead?”
– “Have you ever thought of doing away with yourself? If so, how?” – “What would happen after you were dead?” |
|
|
Term
|
Definition
– “Do you think about hurting others or getting even with people who have wronged you?”
– “Have you had desires to hurt others? If so, how?”
• Note:These questions have never been shown to plant the seeds for an otherwise unplanned event and may provide critical information, so they should be asked! |
|
|
Term
|
Definition
• Insight: awareness of one’s own illness and or situation
• Judgment: ability to anticipate the consequences of one’s behavior and make decisions to safeguard your well-being and that of others
• Provide a common scenario and ask what they would do |
|
|
Term
| insight and judgement questions |
|
Definition
• “If you found a letter on the ground in front of a mailbox, what would you do with it?”
• “How do you understand your problems?”
• “How would you describe your role in this situation?”
• “Do you think that these thoughts, moods, and perceptions are abnormal?”
• “How do you plan to get help for this problem?”
• “What will you do when _____________ occurs?”
• “How will you manage if ____________ happens?”
• “If you were in a movie theater and smelled smoke, what would you do?” |
|
|
Term
|
Definition
• Delirium: Also referred to as altered mental status, delta MS, acute confusional state, or toxic metabolic state.
• Very common condition
(particularly among hospitalized patients) notable for an acute, global change in mental status that can be the result of physiologic derangement anywhere within the body.
• Causes include infection, hypoxia, toxic ingestion, impaired ability of the body to handle endogenously produced toxins (liver or kidney failure), etc.
• There is a wide spectrum of presentations, ranging from unarousable to extremely agitated. Patients may appear quite ill, with markedly abnormal vital signs that in themselves can suggest the cause of the delirium (hypotension, infection).
• They are frequently confused, disoriented, agitated, and uncooperative. Formal evaluation of mood, affect, memory, judgment, or insight can be hopeless. Thought process is disordered and content notable for delusions, paranoia, and hallucinations.
• In general, the diagnosis is suggested by the time course of the illness
(the change is acute).
• Treatment is dictated by
the underlying insult, which can generally be determined after a detailed history (usually with the help of others who are familiar with the patient), review of medications, thorough examination, and appropriate use of lab and radiologic testing.
• The elderly as well as those with multiple medical problems (conditions which frequently coexist) are at the highest risk for developing this condition.
– Delirium in this patient subset can be provoked by seemingly minor precipitants.
• Initial presentation of psychotic disorders as well as dementia can be mistaken for delirium (and vice versa). This can only be sorted out with time and appropriate testing, though these distinctions are extremely important. |
|
|
Term
|
Definition
• Dementia is a final common pathway for multiple disorders characterized by its slow, progressive nature, taking months to years to develop.
• Quite uncommon under 50, the incidence increases markedly with age.
• Patient’s appearance and
behavior vary with the extent of involvement.
– This ranges from well groomed, alert, and cooperative to agitated, unable to care for themselves, and incapable of answering even simple questions.
• Mood and affect can range widely and may or may not be appropriate for the given situation.
• Thought process and content have similar variability.
• Memory, judgment, and higher cortical function deteriorate with time.
• Since this is a progressive disease, presentation will depend on the level of advancement.
• Contributions from other acute, reversible medical problems must be ruled out on the basis of history, examination, and laboratory testing. |
|
|
Term
|
Definition
• Appearance: Disheveled, somnolent, slouched down in chair, uncooperative
• Behavior: psychomotor retarded, poor eye contact
• Speech: moderate latency, soft, slow with paucity of content
• Mood: “really down”
• Affect: blunted, mood congruent
• Thought process: linear
and goal directed with paucity of content
• Thought content: +SI, +AH, +paranoia, -VH, -HI
• Cognition: alert, focused, MMSE:24- missed recall of two objects, two orientation questions, two on serial sevens
• Insight: fair
• Judgment: poor |
|
|
Term
|
Definition
• An acronym of its four questions
• Widely used screening test for problem drinking and potential alcohol problems
• The questionnaire takes less than
one minute to administer and is
often used in primary care as a quick screening tool rather than as an in-depth interview for those who have alcoholism
• The CAGE questionnaire does not have a specific intended population, and it is meant to find those who drink excessively and need treatment |
|
|
Term
|
Definition
| • Two or more positive responses correlate with substance abuse. |
|
|
Term
|
Definition
| “Have you ever felt that you should Cut down on your drinking?” |
|
|
Term
|
Definition
| “Have people Annoyed you by criticizing your drinking?” |
|
|
Term
|
Definition
| “Have you ever felt bad or Guilty about your drinking?” |
|
|
Term
|
Definition
| “Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (Eye-opener)?” |
|
|
Term
|
Definition
• Referral—addiction psychiatrist, psychologist, or addiction treatment program
• Address issues
• In any hospital setting in which access to alcohol may be limited, always monitor for signs/symptoms of alcohol withdrawal, even in patients who have not screened positive for an alcohol problem |
|
|
Term
|
Definition
• If a clinician suspects that the patient is minimizing their alcohol use, more qualitative questions (about quantity, frequency, pattern of drinking) should be asked to better determine the nature and extent of the problem.
• Other validated tests for further assessment include:
– https://pubs.niaaa.nih.gov/publications/ AssessingAlcohol/index.htm |
|
|
Term
| CAGE Questions Adapted to Include Drug Use (CAGE-AID) |
|
Definition
• Have you ever felt you ought to cut down on your drinking or drug use?
• Have people annoyed you by criticizing your drinking
or drug use?
• Have you felt bad or guilty about your drinking or drug use?
• Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of
a hangover (eye-opener)? |
|
|
Term
|
Definition
Implicit Associations
• How do people make sense of the world?
• How do they perceive self and other, us and them?
• How does the mind do it’s complex, unconscious work? |
|
|
Term
| Features of Implicit Associations |
|
Definition
Implicit biases are pervasive.
– 80% elderly/young; 75% black/white; 68% gay/straight People are often unaware of their implicit biases
– It Ain’t Me!
People differ in levels of implicit bias
– Ethnocentrically organized
Implicit biases predict behavior and judgment |
|
|
Term
| Cognitive Shortcut Triggers: |
|
Definition
• Lack of Certainty
• Greater Complexity
• Time Pressure
• Resources Constraints
• High Cognitive Demand |
|
|
Term
| Just Talking About Implicit Bias Decrease It |
|
Definition
– Kunda, 2003: “The motivation to avoid prejudice may inhibit
stereotype activation”
– Rudman, 2001: “implicit associations are sensitive to environmental influences, including priming effects”
– Burgess, 2006: “activation of egalitarian norms has the potential to prevent stereotype activation”
– Galinsky, 2000: “Perspective-taking appears to diminish not just the expression of stereotypes but their accessibility.” |
|
|
Term
| 5 Strategies to Decrease Implicit Bias |
|
Definition
1. Enhance internal motivation of clinician
2. Increase clinician understanding about psychological basis of bias
3. Enhance confidence of provider
4. Enhance emotional regulation skills
5. Improve partnership-building |
|
|
Term
|
Definition
• Taking the point of view of another
• Related to empathy
• Some element of ego overlap
• Can reduce stereotyping and increase feelings of affiliation |
|
|
