Anne Vanderbilt DOS Course 2015

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1 Anne Vanderbilt DOS Course 05 # Mrs. A Case: Mental Status Assessment Presentation- Ms. A is a 55 year old woman who presents to clinic with complaints of memory loss and difficulty concentrating. She first noticed this problem about a year ago after her mother died and it has been gradually getting worse. Her husband comments that she would forget her head if it was not attached to her. She is having significant marital conflict. She works full time as an administrative assistant in a busy office. No one has seemed to notice this problem at her job but she feels like she is getting less work done. PMH : HTN, hyperlipidemia PSH : c-section x Meds: HCTZ & Atorvostatin, omega 3 fish oil and Vitamin D 3 Questions to consider: What other symptoms do you want to ask about? What is her family history? What is her intake of ETOH / substances? Can you get information from a friend or family to validate function? What tool will you use to measure Mental Status Assessment Key Points Many conditions cause mild memory loss and lack of concentration ranging from simple stress, to alzheimer s disease Depression often presents with memory difficulties and lack of concentration Tools for depression include : Patient Health Questionaire (PHQ) /9 Geriatric Depression Scale (GDS) Beck Depression Inventory Mr. J Case # Presentation. Mr. J is a 6 year old male presents to clinic with complaints of memory loss and difficulty concentrating. He reports that he just doesn t feel as sharp as usual. Previously he had a great memory but now he needs to write everything down or else he forgets things like appointments. His wife notes that he is not as organized as he was before and takes longer to complete task such as changing the oil in the car. He works as an engineer and he thinks he is getting less complex assignments that usual. PMH: MI s/p CABG, hypothyroidism, sleep apnea Medications: Synthroid, Lopressor, ASA- CPAP nightly

2 Anne Vanderbilt DOS Course 05 Questions to consider: What other symptoms do you want to ask about? What is his family history? What is his intake of ETOH / substances? Can you get information from a friend or family to validate function? How different is his cognition than baseline? What time frame? What is his baseline education and why is that relevant? What tool will you use to measure cognition? Mental Status Assessment Not all memory loss is dementia Normal age related changes include slower processing speed and some mild short term memory loss Mild Cognitive impairment in some cognitive deficits that do not affect function Some Common tools to assess cognition are: Folstein Mini-Mental Status Assessment, ( MMSE) Montreal Cognitive Assessment ( MOCA), St. Lous University Mental Status Exam(SLUMS) Tools are influenced by education level, vision and hearing

3 general assessment series Best Practices in Nursing Care to Older Adults From The Hartford Institute for Geriatric Nursing, New York University, College of Nursing Issue Number 4, Revised 0 Editor-in-Chief: Sherry A. Greenberg, PhD(c) MSN, GNP-BC New York University College of Nursing The Geriatric Depression Scale (GDS) By: Sherry A. Greenberg, PhD(c), MSN, GNP-BC, Hartford Institute for Geriatric Nursing, NYU College of Nursing WHY: Depression is common in late life, affecting nearly 5 million of the 3 million Americans aged 65 and older with clinically significant depressive symptoms reaching 3% in older adults aged 80 and older (Blazer, 009). Major depression is reported in 8-6% of community dwelling older adults, 5-0% of older medical outpatients seeing a primary care provider, 0-% of medical-surgical hospitalized older adults with 3% more experiencing significant depressive symptoms (Blazer, 009). Recognition in long-term care facilities is poor and not consistent amongst studies (Blazer, 009). Depression is not a natural part of aging. Depression is often reversible with prompt recognition and appropriate treatment. However, if left untreated, depression may result in the onset of physical, cognitive, functional, and social impairment, as well as decreased quality of life, delayed recovery from medical illness and surgery, increased health care utilization, and suicide. BEST TOOL: While there are many instruments available to measure depression, the Geriatric Depression Scale (GDS), first created by Yesavage, et al., has been tested and used extensively with the older population. The GDS Long Form is a brief, 30-item questionnaire in which participants are asked to respond by answering yes or no in reference to how they felt over the past week. A Short Form GDS consisting of 5 questions was developed in 986. Questions from the Long Form GDS which had the highest correlation with depressive symptoms in validation studies were selected for the short version. Of the 5 items, 0 indicated the presence of depression when answered positively, while the rest (question numbers, 5, 7,, 3) indicated depression when answered negatively. Scores of 0-4 are considered normal, depending on age, education, and complaints; 5-8 indicate mild depression; 9- indicate moderate depression; and -5 indicate severe depression. The Short Form is more easily used by physically ill and mildly to moderately demented patients who have short attention spans and/or feel easily fatigued. It takes about 5 to 7 minutes to complete. TARGET POPULATION: The GDS may be used with healthy, medically ill and mild to moderately cognitively impaired older adults. It has been extensively used in community, acute and long-term care settings. VALIDITY AND RELIABILITY: The GDS was found to have a 9% sensitivity and a 89% specificity when evaluated against diagnostic criteria. The validity and reliability of the tool have been supported through both clinical practice and research. In a validation study comparing the Long and Short Forms of the GDS for self-rating of symptoms of depression, both were successful in differentiating depressed from non-depressed adults with a high correlation (r =.84, p <.00) (Sheikh & Yesavage, 986). STRENGTHS AND LIMITATIONS: The GDS is not a substitute for a diagnostic interview by mental health professionals. It is a useful screening tool in the clinical setting to facilitate assessment of depression in older adults especially when baseline measurements are compared to subsequent scores. It does not assess for suicidality. FOLLOW-UP: The presence of depression warrants prompt intervention and treatment. The GDS may be used to monitor depression over time in all clinical settings. Any positive score above 5 on the GDS Short Form should prompt an in-depth psychological assessment and evaluation for suicidality. MORE ON THE TOPIC: Best practice information on care of older adults: The Stanford/VA/NIA Aging Clinical Resource Center (ACRC) website. Retrieved July, 0, from Information on the GDS. Retrieved July, 0, from Blazer, D.G. (009). Depression in late life: Review and commentary. FOCUS, 7(), Greenberg, S.A. (007). How to Try This: The Geriatric Depression Scale: Short Form. AJN, 07(0), Harvath, T.A., & McKenzie, G. (0). Depression in Older Adults. In M. Boltz, E. Capezuti, T.T. Fulmer, & D. Zwicker (Eds.), A. O Meara (Managing Ed.), Evidencebased geriatric nursing protocols for best practice (4th ed., pp. 35-6). NY: Springer Publishing Company, LLC. Koenig, H.G., Meador, K.G., Cohen, J.J., & Blazer, D.G. (988). Self-rated depression scales and screening for major depression in the older hospitalized patient with medical illness. JAGS, 36, Sheikh, J.I., & Yesavage, J.A. (986). Geriatric Depression Scale (GDS). Recent evidence and development of a shorter version. In T.L. Brink (Ed.), Clinical Gerontology: A Guide to Assessment and Intervention (pp ). NY: The Haworth Press, Inc. Yesavage, J.A., Brink, T.L., Rose, T.L., Lum, O., Huang, V., Adey, M.B., & Leirer, V.O. (983). Development and validation of a geriatric depression screening cale: A preliminary report. Journal of Psychiatric Research, 7, Permission is hereby granted to reproduce, post, download, and/or distribute, this material in its entirety only for not-for-profit educational purposes only, provided that The Hartford Institute for Geriatric Nursing, New York University, College of Nursing is cited as the source. This material may be downloaded and/or distributed in electronic format, including PDA format. Available on the internet at and/or notification of usage to: hartford.ign@nyu.edu.

4 Geriatric Depression Scale: Short Form Choose the best answer for how you have felt over the past week:. Are you basically satisfied with your life? YES / NO. Have you dropped many of your activities and interests? YES / NO 3. Do you feel that your life is empty? YES / NO 4. Do you often get bored? YES / NO 5. Are you in good spirits most of the time? YES / NO 6. Are you afraid that something bad is going to happen to you? YES / NO 7. Do you feel happy most of the time? YES / NO 8. Do you often feel helpless? YES / NO 9. Do you prefer to stay at home, rather than going out and doing new things? YES / NO 0. Do you feel you have more problems with memory than most? YES / NO. Do you think it is wonderful to be alive now? YES / NO. Do you feel pretty worthless the way you are now? YES / NO 3. Do you feel full of energy? YES / NO 4. Do you feel that your situation is hopeless? YES / NO 5. Do you think that most people are better off than you are? YES / NO Answers in bold indicate depression. Score point for each bolded answer. A score > 5 points is suggestive of depression. A score 0 points is almost always indicative of depression. A score > 5 points should warrant a follow-up comprehensive assessment. Source: This scale is in the public domain. The Hartford Institute for Geriatric Nursing would like to acknowledge the original author of this Try This, Lenore Kurlowicz, PhD, RN, CS, FAAN, who made significant contributions to the field of geropsychiatric nursing and passed away in 007. general assessment series Best Practices in Nursing Care to Older Adults A series provided by The Hartford Institute for Geriatric Nursing, New York University, College of Nursing hartford.ign@nyu.edu HARTFORD INSTITUTE WEBSITE CLINICAL NURSING WEBSITE

5 Issue Number 3, January 999 Series Editor: Meredith Wallace, PhD, RN, MSN, CS The Mini Mental State Examination (MMSE) By: Lenore Kurlowicz, PhD, RN, CS and Meredith Wallace, PhD, RN, MSN WHY: Cognitive impairment is no longer considered a normal and inevitable change of aging. Although older adults are at higher risk than the rest of the population, changes in cognitive function often call for prompt and aggressive action. In older patients, cognitive functioning is especially likely to decline during illness or injury. The nurses assessment of an older adult s cognitive status is instrumental in identifying early changes in physiological status, ability to learn, and evaluating responses to treatment. BEST TOOL: The Mini Mental State Examination (MMSE) is a tool that can be used to systematically and thoroughly assess mental status. It is an -question measure that tests five areas of cognitive function: orientation, registration, attention and calculation, recall, and language. The maximum score is 30. A score of 3 or lower is indicative of cognitive impairment. The MMSE takes only 5-0 minutes to administer and is therefore practical to use repeatedly and routinely. TARGET POPULATION: The MMSE is effective as a screening tool for cognitive impairment with older, community dwelling, hospitalized and institutionalized adults. Assessment of an older adult s cognitive function is best achieved when it is done routinely, systematically and thoroughly. VALIDITY/RELIABILITY: Since its creation in 975, the MMSE has been validated and extensively used in both clinical practice and research. STRENGTHS AND LIMITATIONS: The MMSE is effective as a screening instrument to separate patients with cognitive impairment from those without it. In addition, when used repeatedly the instrument is able to measure changes in cognitive status that may benefit from intervention. However, the tool is not able to diagnose the case for changes in cognitive function and should not replace a complete clinical assessment of mental status. In addition, the instrument relies heavily on verbal response and reading and writing. Therefore, patients that are hearing and visually impaired, intubated, have low English literacy, or those with other communication disorders may perform poorly even when cognitively intact. MORE ON THE TOPIC: Folstein, M., Folstein, S.E., McHugh, P.R. (975). Mini-Mental State a Practical Method for Grading the Cognitive State of Patients for the Clinician. Journal of Psychiatric Research, (3); Foreman, M.D., Grabowski, R. (99). Diagnostic Dilemma: Cognitive Impairment in the Elderly. Journal of Gerontological Nursing, 8; 5-. Foreman, M.D., Fletcher, K., Mion, L.C., & Simon, L. (996). Assessing Cognitive Function. Geriatric Nursing, 7; Permission is hereby granted to reproduce this material for not-for-profit educational purposes only, provided The Hartford Institute for Geriatric Nursing, Division of Nursing, New York University is cited as the source. Available on the internet at notification of usage to: hartford.ign@nyu.edu.

6 The Mini-Mental State Exam Patient Examiner Date Maximum Score Orientation 5 ( ) What is the (year) (season) (date) (day) (month)? 5 ( ) Where are we (state) (country) (town) (hospital) (floor)? Registration 3 ( ) Name 3 objects: second to say each. Then ask the patient all 3 after you have said them. Give point for each correct answer. Then repeat them until he/she learns all 3. Count trials and record. Trials Attention and Calculation 5 ( ) Serial 7 s. point for each correct answer. Stop after 5 answers. Alternatively spell world backward. Recall 3 ( ) Ask for the 3 objects repeated above. Give point for each correct answer. Language ( ) Name a pencil and watch. ( ) Repeat the following No ifs, ands, or buts 3 ( ) Follow a 3-stage command: Take a paper in your hand, fold it in half, and put it on the floor. ( ) Read and obey the following: CLOSE YOUR EYES ( ) Write a sentence. ( ) Copy the design shown. Total Score ASSESS level of consciousness along a continuum Alert Drowsy Stupor Coma "MINI-MENTAL STATE." A PRACTICAL METHOD FOR GRADING THE COGNITIVE STATE OF PATIENTS FOR THE CLINICIAN. Journal of Psychiatric Research, (3): 89-98, 975. Used by permission. A series provided by The Hartford Institute for Geriatric Nursing (hartford.ign@nyu.edu)

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8 PATIENT HEALTH QUESTIONNAIRE-9 (PHQ-9) Over the last weeks, how often have you been bothered by any of the following problems? (Use to indicate your answer) Not at all Several days More than half the days Nearly every day. Little interest or pleasure in doing things 0 3. Feeling down, depressed, or hopeless Trouble falling or staying asleep, or sleeping too much Feeling tired or having little energy Poor appetite or overeating Feeling bad about yourself or that you are a failure or have let yourself or your family down Trouble concentrating on things, such as reading the newspaper or watching television 8. Moving or speaking so slowly that other people could have noticed? Or the opposite being so fidgety or restless that you have been moving around a lot more than usual 9. Thoughts that you would be better off dead or of hurting yourself in some way FOR OFFICE CODING =Total Score: If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Not difficult at all Somewhat difficult Very difficult Extremely difficult Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. No permission required to reproduce, translate, display or distribute.

9 VAMC SLUMS Examination Questions about this assessment tool? Name Age Is patient alert? Level of education / / / /3 /3 /5 / /4 / /8. What day of the week is it?. What is the year? 3. What state are we in? 4. Please remember these five objects. I will ask you what they are later. Apple Pen Tie House Car 5. You have $00 and you go to the store and buy a dozen apples for $3 and a tricycle for $0. How much did you spend? How much do you have left? 6. Please name as many animals as you can in one minute animals 5-9 animals 0-4 animals 3 5+ animals 7. What were the five objects I asked you to remember? point for each one correct. 8. I am going to give you a series of numbers and I would like you to give them to me backwards. For example, if I say 4, you would say This is a clock face. Please put in the hour markers and the time at ten minutes to eleven o clock. Hour markers okay Time correct 0. Please place an X in the triangle. Which of the above figures is largest?. I am going to tell you a story. Please listen carefully because afterwards, I m going to ask you some questions about it. Jill was a very successful stockbroker. She made a lot of money on the stock market. She then met Jack, a devastatingly handsome man. She married him and had three children. They lived in Chicago. She then stopped work and stayed at home to bring up her children. When they were teenagers, she went back to work. She and Jack lived happily ever after. What was the female s name? When did she go back to work? TOTAL SCORE What work did she do? What state did she live in? HIGH SCHOOL EDUCATION SCORING LESS THAN HIGH SCHOOL EDUCATION 7-30 Normal MNCD* Dementia -9 * Mild Neurocognitive Disorder SH Tariq, N Tumosa, JT Chibnall, HM Perry III, and JE Morley. The Saint Louis University Mental Status (SLUMS) Examination for Detecting Mild Cognitive Impairment and Dementia is more sensitive than the Mini-Mental Status Examination (MMSE) - A pilot study. J am Geriatri Psych (in press).