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1 Florida State University Libraries Electronic Theses, Treatises and Dissertations The Graduate School 2015 Competency in Cognitive and Behavioral Disorders Management Workshop Lisa Granville, Hal H. (Hal Huntey) Atkinson, Zaldy S. (Zaldy Sy) Tan, and Leslie Evertson Follow this and additional works at the FSU Digital Library. For more information, please contact
2 # Name: FACULTY EDITION Competency in Cognitive and Behavioral Disorders for Medical Students, Residents, and Other Health Care Practitioners Medical School: Training Level: MS Residency Program: PGY (to be used to send tool kit): Performance Ratings: Station 1: History-taking and Screening Initial A. History: Pass B. Dementia, Delirium, Depression Screening: Pass Station 2: Cognitive & Behavioral Disorder Recognition Pass Station 3: Integrated Screening/Differential Diagnosis Pass Station 4: Formulating a Treatment Plan Pass Do you consent to being contacted for a follow-up survey for the AGS Cognitive and Behavioral Disorders Workshop? Yes No Congratulations on passing the AGS 2015 Competency for Cognitive and Behavioral Disorders! Please submit this completed form to a faculty member. You may keep the rest of this packet.
3 Competency in Cognitive and Behavioral Evaluation for Medical Students, Residents, and Other Health Care Practitioners Introduction: It is now time to put what you have learned into practice. You will need to successfully complete four (4) stations that will check your competency in cognitive and behavioral assessment. Station 1: History-taking and Cognitive/Behavioral Screening A. History - In the space below, write down three questions in assessing a patient presenting with cognitive/behavioral changes. When you re done, find a faculty member and proceed to part B. Answers: 1: What is the nature of the change in behavior/cognition? 2. When was the change in behavior/cognition first observed? 3. What is the course of the change? 4. Any change in performance of ADLs/IADLs? 5: Any recent changes in health status, mood, life situation? B. Cognitive/Behavioral Screening: Perform the Mini-Cog & 2-question depression screen (PHQ-2) on a faculty member. State whether and why each test is positive or negative. 1. Mini-Cog: Answers (2 of 2 to pass): 3 words clock drawing test (CDT) 3 words Interpretation: 3 words recalled = Non-demented; 1-2 words + normal CDT = Non-demented; 1-2 words + abnormal CDT = Demented; 0 words recalled = demented 2. 2-question depression screen: Over the past 2 weeks, have you been bothered by Not at all Several days More than Nearly Half the days Everyday Little interest or pleasure in doing things? Feeling down, depressed or hopeless? Interpretation: PHQ-2 Cut-off score is 3 (Sensitivity 83%; Specificity 90%; PPV 38.4)
4 Station 2: Cognitive and Behavioral Disorder Recognition Background: Mrs. Connor is a 69-year-old wom an who underwent an elective right total hip arthroplasty three days ago. You had perform ed a pre-operative evaluation on the day of adm ission and perform ed Mini-Cog, Confusion Assessm ent Method (CAM) and 2-question depression screen which were all negative. The attending surgeon s progress note today read: Patient is recovering well on post-op day# 3 and has no com plaints. You cam e to her room to check up on her. Instruction: Observe the video and use the CAM to assess the patient s current cognitive/behavioral status. When you are done, please show your answers to a faculty member. Station 3: Integrated Cognitive and Behavioral Screening/Differential Diagnosis Case: HPI: Mrs. Martin is an 82 year-old patient who is new to you presents to urgent care accompanied by her daughter. The patient appears withdrawn, avoids eye contact but smiles at you occasionally. Her daughter Lisa lives out of state and visits her mother approximately once a year. Lisa came to town this morning and was surprised to find that her usually meticulous mother s apartment to be poorly kempt, with rotting food in the refrigerator and mouse droppings on the floor. She also noticed that her mother was not thinking right, easily distracted and appearing not to recall details of conversations. Lisa found out that Mrs. Martin has stopped going to her church and has mostly stayed home since her husband died 6 months ago. Except for weight loss, her review of systems is otherwise negative. Lisa is very concerned and wants to know what is wrong with her mother. PMH: CAD s/p MI 5 years ago; Hypertension; Type II Diabetes; History of UTI s (last episode a year ago); Constipation FH: Mother died age 65 of MI, Father died age 70 with pneumonia; a 90 y.o. sister has forgetfulness SH: Lives alone in elderly apartment, and had been independent in all Instrumental Activities of Daily Living (IADLs) and Activities of Daily Living (ADLs). 6 months ago, she was volunteering with her husband at the local hospital s gift shop and attending church regularly. Widowed for 6 months. Retired nurse. Nonsmoker, no alcohol. Medications: 1. Glipizide 5 mg daily 2. Metoprolol 100 mg daily 3. Hydrochlorothiazide 25 mg daily
5 4. Aspirin 81 mg daily 5. Tylenol PM nightly for insomnia Allergies: None Physical Examination: Vitals: T=98 F BP=125/75 P=63 RR=12 General: Pleasant, thin elderly woman in no acute distress HEENT: No trauma, Extraocular movements intact, Pupils equally round, reactive to light and accommodation; nose, oral cavity and oropharynx clear Neck: No jugular venous distension, lymphadenopathy, thyromegaly, or carotid bruits Heart: Regular rate and rhythm; 2/6 systolic murmur heard best at apex, no radiation Lungs: Symmetric expansion, clear breath sounds Abdomen: Flat, normal bowel sounds, soft, nontender, without masses or hepatosplenomegaly Extremities: peripheral pulses present; no edema Neurological: CN II-XII intact except for moderate hearing loss and visual acuity 50/20, Finger to nose and heel to shin testing normal, muscular strength 5-/5 bilaterally in the upper and lower extremities and symmetric, DTRs normal; light touch and vibratory senses mildly decreased on both feet bilaterally, but sensation otherwise intact. Question 1: Name at least 2 elements each in the history and/or examination that suggests: a.) Dementia b.) Delirium c.) Depression Answer must include: 1) Dementia: Age; Gender; Forgetfulness; Family history of dementia; 2) Delirium: Age; Inattention; Past Medical History; Diphenhydramine (Tylenol PM) 3) Depression: Age; Poor eye contact; Change in life situation (death of husband); Weight loss
6 Question 2: What else is needed to assess this patient s cognitive and behavioral status? IMPORTANT: A FACULTY MEMBER WILL CHECK YOUR SUCCESSFUL RESPONSE TO QUESTION 2 AND GIVE YOU MORE INFORMATION TO ANSWER QUESTION 3. Answer must include: Mini-cog, CAM, AND 2-question depression screen (PHQ-2) If Question 2 is passed, give the learner a card with the following information on it: Mini-Cog: 3/3 registration, 1/3 recall, abnormal clock CAM: unknown onset; positive inattention; non-disorganized thinking; normal level of consciousness Depression screen (PHQ-2): Over the past 2 weeks have you often been bothered by feeling down, depressed, or hopeless? Response: Yes (several days in the last week) Over the past 2 weeks have you often been bothered by little interest or pleasure in doing things? Response: Yes (several days in the last week) Question 3: Given the information you have gathered, what is your most likely diagnosis? Answer: Dementia. (Mini-cog is positive because of delayed recall less than 3/3 and abnormal clock. CAM is negative because of lack of either disorganized thinking or altered level of consciousness. PHQ-2 is negative because total score is less than 3 (refer to table in Station 1)).
7 Station 4: Formulating a Diagnostic and Treatment Plan (continuation from Station 3 for Resident/Practicing health care providers) Question 3: Prescribe your diagnostic and therapeutic plan for each of the 3 D s. Answer must include: Diagnostic (allowed to miss one for each item): a.) Dementia: TSH; B12; CT or MRI b.) Delirium: CBC, Chem 7 (BMP), TSH, Urinalysis c.) Depression: TSH Therapeutic (allowed to miss one for each item): Cue Leaner Treatment Plan for: a.) Dementia: acetylcholinesterase inhibitor and/or memantine (if moderate to severe stage); discontinue diphenhydramine (Tylenol PM) b.) Depression: SSRI; D/C diphenhydramine (Tylenol PM) c.) Delirium: supportive care; treat underlying cause; D/C diphenhydramine (Tylenol PM) Question 4: Mrs. Martin becomes visibly agitated, pulls out the leads of her monitor and tries to get off the gurney. What would you do? a. Give haloperidol 1 mg intramuscularly X 1 and observe for effect. b. Administer 4-point wrist restraint for patient and staff safety. c. Provide hearing aid, eye glasses, reassurance from daughter. d. All of the above. Answer: C. Provide hearing aid, eye glasses, reassurance from daughter (faculty can discuss their approach to the delirious patient). NOTE: Both students and residents will receive credit if they complete through Station 4. FACULTY: Please check the front sheet to ensure that all stations have been completed, tear/collect front sheet and hand the rest of the packet to learner.
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