Behavior/Mental Health Assessment and Modification _for_ Age
1. Assessment:
a.
b. Many mental health d_is_orders are masked by other clinical conditions;
20% of primary care outpatients have mental d_is_orders(50-70%
...
Behavior/Mental Health Assessment and Modification _for_ Age
1. Assessment:
a.
b. Many mental health d_is_orders are masked by other clinical conditions;
20% of primary care outpatients have mental d_is_orders(50-70% go
undetected and untreated)
c. Physical symptoms account _for_ approx 50% of office v_is_its
d. ⅓ of physical symptoms are unexplained; in 20-25% those symptoms
become chronic
e. Symptoms and Behaviors:
i. Sorting symptom _is_ a challenge; can be unexplained symptoms
1. Patients who have unexplained symptoms depression and
anxiety exceeds 50%
ii. Physical or “somatic” symptoms account _for_ 50% of U.S. office
v_is_its
1. Pain, fatigue, palpitations, GI symptoms, sexual dysfunction,
dizziness or loss of balance
2. Symptoms that present as clusters are called “functional
syndromes” such as IBS, fibromyalgia, chronic fatigue, TMJ
d_is_order, and multiple chemical sensitivity
3. The presence of symptom overlap _is_ high in the common
functional syndromes such as fatigue, headache, sleep
d_is_turbance, pain, GI upset
iii. Patients with unexplained and somatic symptoms are often frequent
users of the health care system and termed “difficult patients”
iv. Patients with symptoms that last longer than 6 weeks are recognized as
chronic and should be screened _for_ depression and anxiety.
a. A two tiered approach _is_ recommended _for_ screening. A
brief screening with questions that yield high sensitivity then
a more detailed investigation when indicated
V. Patient who warrant a mental health screening include:
1. medically unexplained physical symptoms
2. Multiple physical or somatic symptoms
study guide
3. High severity of the presenting somatic symptom
4. Chronic pain
5. Symptoms longer than 6 weeks
6. Physician stating “a difficult encounter”
7. Recent stress
8. Low self-rating of overall health
9. Frequent use of health care services
10.Substance abuse
2. Adjustment _for_ age:
A. Elderly:
a. Older adults may complain of memory problems but usually _is_
due to benign _for_getfulness.
b. Older adults retrieve and process data more slowly and take longer
to learn new in_for_mation
c. Older adults may have slower motor responses and their ability to
per_for_m complex task may dimin_is_h
d. It _is_ important to try to d_is_tingu_is_h age-related changes from
manifestations of mental d_is_orders
e. Older patients are more susceptible to delirium which could be the
first sign of infection, problems with medications, or impending
dementia
B. Newborn:
a. Assess mental status of a newborn by observing newborn activities
i. Look at human faces and turn to a parents voice
ii. Ability to shut out repetitive stimuli(such as a vacuum)
iii. Bond with caregiver
iv. self-soothe
b. Assess _for_ mental status during alert periods
· Normal VS. Abnormal Findings and Interpretation
1. Attention:
a. Normal: able to focus and concentrate
b. Abnormal: inattentive and easily d_is_tracted
2. Memory
a. Normal: able to repeat immediate repetition of material given;
b. Abnormal: unable to repeat recent events
3. Orientation:
a. Normal: aware of person, place, and time
b. Abnormal: unaware of person, place, or time
4. Perception:
a. Normal: Sensory awareness of objects in the environment
b. Abnormal: hallucinations
5. Thought Process:
a. Normal: logic, coherent, and relevant thoughts
b. Abnormal: irrational thought
6. Thought Content:
a. Normal: Has insight and judgement
b. Abnormal: impaired judgement and irrational behaviors
7. Insight
a. Normal: able to d_is_tingu_is_h normal vs. abnormal
b. Abnormal: Unable to d_is_tingu_is_h normal vs. abnormal
8. Judgement
a. Normal: good judgement
b. Abnormal: poor or bad
F· Speech Patterns
1. Note characters of speech
a. Slow speech= depression
b. Accelerated and Loud speech= mania
c. Articulation: are the words clear and d_is_tinct; does the speech have a
nasal quality
i. Dysarthria(defective articulation)
ii. Dysphonia-impaired volume, quality or pitch
iii. Aphasia-d_is_order of speech
d. Fluency: reflects rate, flow and melody of speech and the content and
words used. Abnormalities include
i. Hesitancies and gaps in flow
ii. D_is_turbed inflections such as monotone
iii. Circumlocutions, in which phrases or sentences are substituted
_for_ a word the person cannot think of ie. “what you write with”
instead of “pen”
iv. Paraphrasias, words are mal_for_med(“I write with a den”), wrong (I
write with a bar) or made up (I write with a dar)
v. Fluency abnormalities indicate aphasia from cerebrovascular
infarction.
vi. Aphasia may be receptive(impaired comprehension with fluent
speech) OR expressive(with preserved comprehension and slow
nonfluent speech)
vii. A person who can write a correct sentence does NOT have aphasia
e. Testing _for_ Aphasia
i. Word Comprehension: Ask the patient to follow one-stage
commands such as “Point to your nose”
ii. Repetition: Ask the patient to repeat a phrase of one-syllable words
“ No ifs, ands, or buts”
iii. Naming: Ask the patient to name the parts of a watch
iv. Reading Comprehension: Ask the patient to read a paragraph aloud
v. Writing: Ask the patient to write a sentence
· Mental Status Examination
1. Five components of the mental status examination
a. Appearance and Behavior
i. Note level of consciousness: _is_ the patient awake and alert, does
the patient understand your questions and respond appropriately
1. If the patient does not respond then speak to the patient by
name in a loud voice
2. Lethargic patients are drowsy but open their eyes and look
at you, respond to questions, then fall back asleep
3. Obtunded patients open their eyes and look at you but
respond slowly and are somewhat confused
ii. Note posture and motor behavior:does the patient sit or lie quietly
or prefer to walk around; note the pace, range, and type of
movement
1. Look _for_ tense posture, restlessness, and anxious
fidgeting; the crying, pacing, and hand wringing of agitated
depression
2. The hopeless slumped posture and slowed movement of
depression
3. The agitated and expansive movements of manic
ep_is_odes
iii. Note Dress, Grooming, and Personal hygiene: how _is_ the patient
dressed, clean and presentable?, how _is_ grooming compared to
those of similar age, compare one side to the other
1. May deteriorate in depression, schizophrenia, and dementia
2. Excessive fastidiousness may be seen OCD
3. One-sided negligence may result from a lesion in the
opposite parietal cortex; usually the non-dominant side
iv. Note facial expression: observe the face at rest and during
conversation; are changes in expression appropriate
1. Note Expressions of anxiety, depression, apathy, anger,
elation, or facial immobility in parkinson_is_m
v. Manner, Affect, and Relationship to People and Things: assess the
patients external expression of the inner emotional state(Affect).
_is_ the affect appropriate to topics being d_is_cussed?, seem
exaggerated at points, labile, blunted, or flat?
1. Paranoia= anger, hostility, suspiciousness, or evasiveness
2. Mania= elation and euphoria
3. Schizophrenia=flat affect with remoteness
4. Dementia and Anxiety or Depresion= apathy(dulled affect
with detachment and indifference)
5. Hallucinations=schizophrenia, alcohol withdrawal, and
systemic toxicity
b. Speech and Language= SEE ABOVE in language patterns
c. Mood: Ask patient to describe h_is_/her mood, including usual level and
fluctuations related to life events
i. Moods range from sadness and melancholy, contentment, joy,
euphoria, and elation; anger and rage, anxiety and worry, to
detachment and indifference
ii. If you suspect depression, assess its severity and any r_is_k of
suicide
iii. It _is_ your responsibility as the provider to ask directly about
suicidal thoughts. Th_is_ may be the only way to uncover suicidal
ideation and plans that launch immediate intervention and
treatment
d. Thought and Perception:
i. Thought Process: assess the logic, relevance, organization, and
coherence of the patients thought process throughout the interview;
does speech progress logically?, l_is_ten _for_ patterns of speech
that suggest d_is_orders; Variations and Abnormalities include:
1. Circumstantiality: speech with unnecessary detail,
indirection, and delay in reaching the point; Occurs in
patients with obsessions
2. Derailment: “tangential” speech with shifting topics that are
loosely connected or unrelated; seen in schizophrenia,
manic ep_is_odes, and other psychotic d_is_orders
3. Flight of Ideas: a continuous flow of accelerated speech with
abrupt changes from one topic to the next; most frequently
seen in manic ep_is_odes
4. Neolog_is_ms: Invented or d_is_torted words, or words with
new and highly idiosyncratic meanings; observed in
schizophrenia, psychotic d_is_orders, and aphasia
5. Incoherence: Speech that _is_ incomprehensible and
illogical, with lack of meaningful connections, abrupt
changes in topic, or d_is_ordered grammar or word use.
Flight of ideas, when severe, may produce incoherence.
Seen in severe psychotic d_is_turbances usually
schizophrenia
6. Blocking: Sudden interruption of speech in mid sentence or
be_for_e the idea _is_ completed, attributed to “losing the
thought.” Blocking occurs in normal people. May be striking
in schizophrenia
7. Confabulation: Fabrication of facts or events in response to
ques- tions, to fill in the gaps from impaired memory. Seen in
Korsakoff syndrome from alchol_is_m
8. Perseveration: Pers_is_tent repetition of words or ideas
Occurs in schizophrenia and other psychotic
d_is_orders
9. Echolalia:Repetition of the words and phrases of others.
Occurs in manic ep_is_odes and schizophrenia
10. Clanging: Speech with choice of words based on
sound, rather than meaning, as in rhyming and punning.
_for_ example, “Look at my eyes and nose, w_is_e eyes and
rosy nose. Two to one, the ayes have it!” Seen in
schizophrenia and manic ep_is_odes
ii. Thought Content: to assess follow patients cues rather than
asking direct questions; “Can you tell me more about that” or “What
do you think about times like these?” Abnormalities in content
include
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