SECTION I – CLINICAL ISSUES - Welcome to Senior PsychCare
Volume IIRESOURCE MANUALBIOSPSYCHOSOCIAL DUTIES AND RESPONSIBILITIES FOR MANAGEMENT OF PSYCHOLOGICAL AND PSYCHIATRIC ISSUESThis information contained in this manual is the property of SENIOR PSYCHCARE. It is not to be reproduced in any media without permission from Dr. Leo Borrell. Should the relationship between SENIOR PSYCHCARE and the provider be terminated for any reason, this manual will be returned to SENIOR PSYCHCARE within five (5) business days. This information is confidential and proprietary and property of SENIOR PSYCHCARE. In view of the nature of the material, it is understood that use of this material without permission would be detrimental to SENIOR PSYCHCARE and its employees and a violation of accepted professional business standardSenior PsychCare Dr. Leo J. Borrell, CEO Randy Frapart, CFOJudy Borrell, Secretary-treasurerDr. Tayfun Karakoc, Chief Medical Officer HoustonCorporate OfficeDallas Regional Office4635 Southwest Freeway, Ste. 635Dr. Elizabeth Klepper Corp. Clinical DirectorHouston, Texas 770272300 Valley View Lane, Ste. 330(713) 850-0049Irving, Texas 75062(214) 423-7777Houston Regional OfficeSebastian Laroche, Regional DirectorSan Antonio Regional Office4635 Southwest Freeway, Ste. 635Tom Forsberg, Regional ManagerHouston, Texas 7702785 Northeast Loop 410, Ste. 220(832) 370-5470San Antonio, Texas 78216(682) 234-9101Renee Fitzwater, Executive Director Dallas2300 Valley View Lane, Ste. 330Amanda Vasquez Executive Director AustinIrving, Texas 75062Coordinator Family Therapy(832) 597-380085 Northeast Loop 410, Ste. 220 SanAntonio, Texas 78216Diego Basagoitia, Director of IT and ComplianceGina Myers, Director HR4635 Southwest Freeway, Ste. 6354635 Southwest Freeway, Ste. 635Houston, Texas 77027Houston, Texas 77027(713) 850-0049(281) 733-1035Catherine Azodi, Compliance ManagerJerry Agua, Controller4635 Southwest Freeway, Ste. 6354635 Southwest Freeway, Ste. 635Houston, Texas 77027Houston, Texas 77027(281) 620-3686(248) 757-3822Houston Region StaffSan Antonio Region StaffJanet Arceneaux, PhD.Vinod Alluri, M.D.Olufunilola Atandeyi, NPLivina Akpunku, NPAbioloa Atobatele, NPBerthony Bien-Amie, NPSofia Beltran, PsychologistLori Blakely, LCSWNeedhi Bhaga, PsychologistGail Clark, PAShannon Boyer, PsychologistKendel Cohen-Selig, LCSWTerri Clark, NPJulie Gilmore, LCSWLeslie Crossman, PsychologistDavid Johnson, M.D.Perpetua Eze, NPRoxanna Medrano, NPTayfun Karakoc, M.D.Kellye Mixson, NPKrista Lewis, NPLawanda Myers, LCSWDaylong Long, NPAndrew Pratt, PAAde Omigie, NPLinda Pusateri, LCSWDiane Schaefer, LCSWEilen Reilly, NPMichelle Times, NPPaloma Solis-Garcia, NPPaul Wadler, PsychologistCynthia Stewart, LCSW-PTBridgit Williams, LCSWMonique Straker, NPVivian Young, NPAmanda Vasquez, LCSWStormy Valdesino, NPDallas Region StaffHoward Walker, LCSW-PTAmy Abadia, LCSWUzma Ahmed, M.D.Chima Asikaiwe, M.D.Shannon Campbell, LCSWMary Cannon, LCSWAmanda Chappelle, NPNancy Craft, LCSWKet Davis, NPTricia Davis, LCSWMary Edwards, NPTheresa Edwards, NPPeter Formusoh, NPVictoria Forsberg, NPNatassia Greer, PsychologistLoyce Hopkins, LCSWKyle Johnson, NPRebecca Korn, LCSWWendy Lewis, NPFrancheska Martinez, LCSWPeter Moenga, NPOfear Moore, NPAlisha Neal, LCSWTeressa Rashid, PAJennifer Rawley, PsychologistKendall Reese, NPTascha Reese, LCSWStephanie Stockton, NPJulie Thomison, NPDeborah Tome, LCSWLieu Vuong, PsychologistMarlon Womack, NPDenise York-Florez, NPBIOPSYCHOSOCIAL PSYCHOLOGICAL AND PSYCHIATRIC TECHNICIAN’S GUIDE (RESOURCE MANUAL)TABLE OF CONTENTSHow Doctors Make Decisions Initiating Care Improvement7Introduction9Psychotropic Medication Protocols Index12Worksheet for Decision Making Capacity22Clinical Status: A Daily Forum for Resident Discussion and Education24Billing Codes Used by Senior PsychCare28PHQ-9 Patient Depression Questionnaire34Memory Box37Suicide Risk Scale39FAST Scale44Black Box Warning:47Activating and Sedating Properties of Medications Used for the Treatment of Major Depressive Disorder and Their Effect on Patient FunctioningSenior PsychCare Referral Form75DSM-V Abbreviated78Mild Cognitive Impairment96Brief Mental Status Exam (MSE) Form102MoCA108Behavioral Round Process at Senior PsychCare113Long Term Health Information Practice and Documentation Index115Evidence-based Psychosocial and Behavioral Interventions with Dementia123Index of Senior Minutes124Mid-Level Guidelines Table of Contents127Resource Manual for Developing Huddles128A Learning Organization134Training Module for Optimal Results Required for Medications in Psychopharmacology with Special Focus for Dealing with Resistant and Non-Compliant Patients137How Doctors Make Decisions Initiating Care ImprovementThis manual for professional care of seniors was developed from a variety of resources that address better care for seniors. This kind of geriatric care is relativity new and standards of care are dictated by CMS reimbursement and insurance. Emergency service theory is limited outcome research lead is based on clinical ryder. There is limited information that has been validated and is not age specific. Thus most professional care service is not scientifically validated based on age, severity of illness, multiple diagnoses, and varied medical diagnoses. It is important to realize that employees of SPC psychiatric technicians are not legal psychiatric technicians. Psychiatric technician is a legal term which requires individuals to have a certain level of training in policies dictated by different state and federal agencies. Because of this, individuals as employees of SPC should not identify as psychiatric technicians but should describe themselves as psychiatric technicians.OverviewThis manual was designed to develop protocols for those who work in LTC for services employed by Senior PsychCare or related companies. This is to assist psychiatric technicians techniques to improve a standard in the lives of all healthcare providers. The resource was developed as a psychiatric technician training system.IntroductionThis guide is intended for use by person assets Senior PsychCare Psychological and Psychiatric Technician’ “psychiatric technician in the primary care clinic” course. This book is not attempting to describe every clinical scenario encountered, but start the process of developing fundamental skills for every patient. No prior medical training or knowledge is required to understand the concepts presented herein. To truly understand and be able to apply the terms and heuristics described, you must interact with what you read. Learning is an active process! It is expected at the end of each chapter to make questions for yourself and other professionals as well as your immediate supervisor. Submit a minimum of three questions for yourself and answer them and provide this information to your immediate supervisor and other psychiatric technicians at your monthly case review.The ideas in this book are not written in stone. We try to balance the boundary between providing excessive and insufficient amounts of information – are anyone new to the profession! This leads to generalization that are exactly that – they are true most of the time but may not be true all of the time. They can be helpful for learning concepts, but you should consult a formal medical resource to learn more. This is learned by admitting your successes and failures and may be updated from time to time. If you think there is information that should be included please bring this to the attention of the clinical supervisor and management team. Please put this request in writing. Volume II – Resource Manual are miscellaneous topics that may have to be addressed or discussed with other professionals on Long Term Care staff. It is not a comprehensive review but addresses issues that the management team thinking are important and may need to be researched more thoroughly to arrive at Standard Operating Procedures and to develop policies and procedures. For details of clinical specifics of clinical care, please see addendum “Medication Protocols”.INTRODUCTIONWHY SENIOR PSYCHCARE MUST USE RATING SCALESBy Henry A. Nasrallah, MDIn an editorial published in Current Psychiatry 10 years ago, I cited a stunning fact based on a readers’ survey: 98% of psychiatrists did not use any of the 4 clinical rating scales that are routinely used in the clinical trials required for FDA approval of medications for psychotic, mood, and anxiety disorders.As a follow-up, Ahmed Aboraya, MD, DrPH, and I would like to report on the state of measurement based care (MBC), a term coined by Trivedi in 2006 and defined by Fortney as “the systematic administration of symptom rating scales and use of the results to drive clinical decision making at the level of the individual patient.”We will start with the creator of modern rating scales, Father Thomas Verner Moore (1877-1969), who is considered one of the most underrecognized legends in the history of modern psychiatry. Moore was a psychologist and psychiatrist who can lay claim to 3 major achievements in psychiatry: the creation of rating scales in psychiatry, the use of factor analysis to deconstruct psychosis, and the formulation of specific definitions for symptoms and sign of psychopathology. Moore’s 1933 book described the rating scales used in his research. Since that time researchers have continued to invent clinician rated scales, self report scales, and other easures in psychiatry. The Handbook of Psychiatric Measures, which was published in 2000 by the American Psychiatric Association Task Force chaired by AJ Rush Jr, includes 240 measures covering adult and child psychiatric disorders.Recent research has shown the superiority of MBC compared with usual standard care (USC) in improving patient outcomes. A recent well-designed, blind rater, randomized trial by Guo et al showed that MBC is more effective than USC both in achieving response and remission and reducing the time to response and remission. Given the evidence of the benefits of MBC in improving patient outcomes, and the plethora of reliable and validated rating scales, an important question arises. Why has MBC not yet been established as the standard of care in psychiatric clinical practice? There are many barriers to implementing MBC including: Time constraints (most commonly cited reason by psychiatrists)Mismatch between clinical needs and the content of the measure (ie, rating scales are designed for research and not for clinician’s use)Measurements produced by rating scales may not always be clinically relevantAdministering rating scales may interfere with establishing rapport with patientsSome measures, such as standardized diagnostic interviews, can be cumbersome, unwieldy, and complicatedThe lack of formal training for most clinicians (among top barriers for residents and faculty)Lack of availability of training manuals and protocolsClinician researchers have started to adapt and invent instruments that can be used in clinical setting. For more than 20 years, Mark Zimerman MD, has been the principal investigator for the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) Project, aimed at integrating the assessment methods of researchers into routine clinical practice. Zimmerman has developed self report scales and outcome measures such as the Psychiatric Diagnostic Screening Questionnaire (PDSQ), the Clinically Useful Depression Outcome Scale (CUDOS), the Standardized Clinical Outcome Rating for Depression (SCOR-D), the Clinically Useful Anxiety Outcome Scale (CUXOS), the Remission from Depression Questionnaire (RDQ), and the Clinical Useful Patient Satisfaction Scale (CUPSS).We have been critical of the utility of the existing diagnostic interviews and rating scales I developed the Standard for Clinicians’ Interview in Psychiatry (SCIP) as a MBC tool that addresses the most common barriers that clinicians face. The SCIP includes 18 clinician rated scales for the following symptom domains: generalized anxiety, obsessions, compulsions, posttraumatic stress, depression, mania, delusions, hallucinations, disorganized thoughts, aggression, negative symptoms, alcohol use, drug use, attention adeficity, hyperactivity, anorexia, binge eating, and bulimia. The SCIP rating scales meet the criteria for MBC because they are efficient, reliable, and valid. They reflect how clinicans assess psychiatric disorders, and are relevant to decision making. Both self report and clinican rated scales are important MBC tools and complementary to each other. The choice to use self report scales, clinician rated scales, or both depends on several factors including the clinical setting (inpatient or outpatient), psychiatric diagnoses, and patient characteristics. No measure or scale will ever replace a seasoned and experienced clinician who has been evaluating and treating real world patients for years. Just as thermometers, stethoscopes, and laboratories help other types of physicians to reach accurate diagnoses and provide appropriate management, the use of MBC by psychiatrists will enhance the accuracy of diagnoses and improve the outcomes of care.On a positive note, I have completed a MBC curriculum for training psychiatry residents that includes 11 videotaped interviews with actual patients covering the major adult psychiatric disorder: generalized anxiety, panic, depressive, posttraumatic stress, bipolar, psychotic, eating, and attention deficit hyperactivity. The interviews show and teach how to rate psychopathology items, how to score the dimensions, and how to evaluate the severity of the disorder(s). All of the SCIP’s 18 have been uploaded into the Epic electronic health record (HER) system at West Virginia University hospitals. A pilot project for implementing MBC in the treatment of adult psychiatric disorders at the West Virginia University residency program and other programs is underway. If we instruct residents in MBC during their psychiatric training, they will likely practice it for the rest of their clinical careers. Except for a minority of clinicians who are involved in clinical trials and who use rating scales in practice, most practicing clinicians were never trained to use scales. For more information about eh MBC curriculum and videotapes, request for Dr. Borrell to contact Dr. Aboraya at aborayascip@ or visit scip-.Today some barriers that impeded the implementation of MBC in psychiatric practice have been resolved but much more work remains. Now is the time to implement MBC and provide an answer to AJ Rush, who asked “Isn’t it about time to employ measurement based care in practice?” The 3 main ingredients for MBC implementation – useful measures, integration of HER, and health information technologies – exist today. We strongly encourage psychiatrist, nurse practitioners, and other mental health professionals to adopt MBC in their daily practice.Senior Psych Care Protocols for Medication Management and Disruptive BehaviorTable of Contents Disclaimer ......................................................................................................................... i Protocols for Medication Management – Post Test .................................................... ii 10 Principles of Ethics Among Geriatrics and Long-Term Care Facilities ..................iv Required Reading/Forms Before Assuming Clinical Responsibilities What Makes Work Relationships Work? (with questions) ............................................ v Work Relationship Assessment Form (with questions) .......................................... vii SPC Memorandum of Understanding ......................................................................... viii Table of Contents ............................................................................................................ ix Date of Publication and Distribution Record.....................................................xvii SECTION I – CLINICAL ISSUES 286512-38099 Chapter 1: Introduction (including Rating Scales) Chapter 2: Dementia (see BMS net review with minimal data set)Chapter 3: Medicare Regulations and Documentation Chapter 4: Types of Agitated Behaviors in Dementia Section I - Chapter One - Introduction The State of Mental Healthcare in Nursing Homes – A Review by Dr. Leo Borrell……………………………………………….…….1 Elements of the SPC Psychiatric Program ......................................................................................................................4 Frequent Fluctuation of Symptoms of Alzheimer Disease Progression Requires Weekly Monitoring And Medication Adjustment .....................................................................................................................................5 Role of the Psychiatrist ..................................................................................................................................................7 SPC - Continuing Medical Education Units and In-Services ........................................................................................... 9 Pearls of Wisdom: Regarding the Administrative Guidelines of F329 Tags .................................................................10 To Families and Long-Term Care Staff: Alzheimer’s is Not Waiting............................................................................. 13 Nursing Home Rating Systems for Consumers, Families, and Caregivers- How is my Nursing Home Doing? .....................................................................................................................................................................14 Seven Characteristics of Successful Work Relationships .......................................to be done monthly......15 Practices should not view social and task-related relationships as mutually exclusive ............................................. See Patel Gottels work 15 Work Relationship Assessment Form ..........................................................................................................................16 How Improving Practice Relationships Among Clinicians and Nonclinicians Can Improve Quality in Primary Care......................................................................................................................................... 17 Descriptions of Key Characteristics of Complex Adaptive Systems .............................................................................18 Two Views of Quality ...................................................................................................................................................19 An Ongoing Federally Funded Research Program to Understand Primary Care Practice Change and Improvement ....................................................................................................................................20 Definitions and Practical Applications: How Relationships Appear in Practice ........................................................... 21 Vignettes of Two Practices Showing Examples of Each Relationships Characteristic ................................................. 22 The Utility of Mandatory Depression Screening of Dementia Patients in Nursing Homes ......................................... 23 Why Do We Do Screening ............................................................................................................................................24 Information for Clinicians, Administrators, and Primary Care Physicians about Screening ........................................25 The Promise: Rational and Necessity of Cognitive Testing with Seniors in Long-Term Care Facilities ............................(see FAST Scale page 81 Volume II Resource Manual .............26 Borrell Cognitive Neuropsychiatric Inventory (BCNI) is the Exclusive Licensee for CNS in LTC and for use with Seniors ....................................................................................................................................27 More Information on the Borrell Cognitive Neuropsychiatric Inventory (BCNI) for Better Brain Health Assessment and Care ..........................................................................................................................29 Informed Consent for Medication-important information .........................................................................................30 Informed Consent for Medication (1)..........................................................................................................................31 Informed Consent for Medication (2)..........................................................................................................................32 A Guide to the Judicious Use of Laboratory Tests and Diagnostic Procedures in Psychiatric Practice .................................................................................................................................................33 Common Screening Tests and Procedures During the Assessment of New-Onset Psychiatric Illness (Table 1) ......................................................................................................................................... .34 Tests of Electrophysiology: Which to order – and When (Table 2) .............................................................................37 Neuroimaging Tests: Which to order – and when (Table 3)........................................................................................38 Medication, Testing, and Monitoring (Table 4)...........................................................................................................39 Protocols for Physician Notification-Assessing Patients and Collecting Data On Nursing Facility Patients ..................................................................................................................................43 Rating Scales Developing a Baseline and Assessing a Patient’s Response to Medication...............................................................45 What Scales Should We Use in Geriatric Psychiatry? ................................................................................................46 Rating Scales – An Introduction.................................................................................................................................48 Abnormal Involuntary Movement Scale (AIMS) ......................................................................................................50 Alzheimer’s Disease Cooperative Study-Clinical Global Impression of Change (ADCS-CGIC) ..................................53 * Assessing the Degree of Suicidal Risk ....................................................................................................................55 Barnes Akathisia Rating Scale (BAS, BARS)...............................................................................................................56 Clinical Dementia Rating Worksheet-Memory Questions for informant.................................................................58 Clinical Dementia Rating Worksheet-Orientation Questions for informant ...........................................................59 Clinical Dementia Rating Worksheet-Judgment and Problem Solving Questions for informant ............................60 Clinical Dementia Rating Worksheet-Community Affairs Questions for informant ................................................61 Clinical Dementia Rating Worksheet-Home and Hobbies Questions for informant ...............................................62 Clinical Dementia Rating Worksheet-Memory Questions for subject ....................................................................64 Clinical Dementia Rating Worksheet-Orientation Questions for subject ................................................................65 Clinical Dementia Rating Worksheet-Judgment and Problem Solving Questions for subject ................................66 Clinical Dementia Rating (CDR) ...............................................................................................................................67 Cohen-Mansfield Agitation Inventory-Community Form (CMAIC) ..........................................................................68 Confusion Assessment Method (CAM) ....................................................................................................................71 Cornell Scale for Depression in Dementia (CSDD) ...................................................................................................72 Dependence Scale....................................................................................................................................................74 Functional Assessment Staging (FAST) Scale……………………………………………………………………………………………………….76 Geriatric Depression Scale (GDS) .............................................................................................................................79 Mental Status (SLUMS) Examination .......................................................................................................................81 Mini-Mental State Examination (MMSE) .................................................................................................................82 Monitoring and Early Detection of Behavioral Problems ........................................................................................84 Monitoring Agitated Behavior Stages – If administered daily, marking one or more items is predictive of an acute illness 25% to 55% of the time How to know if a resident needs more help or a higher level of care .................................................................85 Montreal Cognitive Assessment (MOCA).................................................................................................................86 Neuropsychiatric Inventory-Nursing Home (NPI-NH) ..............................................................................................87 PHQ-9 Flow Chart – Monitoring of Depression Response to Treatment.................................................................90 PHQ-9 Nine Symptom Check List .............................................................................................................................91 PHQ-9 – How to Score .............................................................................................................................................. 92 Physical Self-Maintenance Scale (PSMS) and Instrumental Activity of Daily Living (IADL) ......................................93 Screening Protocol for Psychiatric and Psychological Services................................................................................95 Simpson-Angus Scale (SAS) ......................................................................................................................................98 Suicide Lethality Scale............................................................................................................................................100 The Pittsburgh Sleep Quality Index (PSQI) ............................................................................................................102 Toronto Side Effects Scale (Patient Self-Report) ...................................................................................................104 The Wisconsin Star Method………………………………………………………………………………………………………………………………105 Overview of Mental Healthcare of Seniors................................................................................................................106 The Benefits of Good Mental Health Care in Dementia Problems............................................................................107 The Consequence of Poor Mental Health Care in Dementia Problems ....................................................................108 Develop a System that is Consistent and Makes the Appropriate Care Available ....................................................109 Uncooperative Mrs. Adams Got Her Way .................................................................................................................113 Useful in Predicting Onset of an Acute Illness 25% to 55% of the Time....................................................................115 How to Know if a Resident Needs More Help or a Higher Level of Care ..................................................................115 What you Don’t Know can Hurt Your Resident .........................................................................................................116 Abuse and Neglect Policy ..........................................................................................................................................117 Patient Living at Home in the Community/Patient Living in Assisted Living Facility .................................................118 Breaking the News: Do Patients Want to Know That They Have Dementia? ...........................................................119 Training for: Dementia Functional Assessment ........................................................................................................122 Functional Assessment Staging (FAST) ......................................................................................................................123 The Natural Progression of Alzheimer’s Disease (Chart) ..........................................................................................125 Loss of Function over Time (Chart) ...........................................................................................................................125 The Natural Progression of Alzheimer’s Disease - Discussion ...................................................................................126 *Mild Cognitive Impairment (MCI): A common unrecognized problem ..(see new DSMS page 77 Volume II Resource Manual....127 Common and Relevant Drug Interactions Chart .......................................................................................................129 *An Administrator’s Perspective on Mental Health in Assisted Living .....................................................................135 A Psychiatric View of Goals in Long-Term Care .........................................................................................................139 Medicaid Preferred Drug list and Prior Authorization Program ................................................................................141 Medication Questions ...............................................................................................................................................142 Quality Pharmaceutical Care in Long-term Care .......................................................................................................144 Quality Indicators Which are Valid ............................................................................................................................147 The Economics of Medication Use, Quality Care from an Administrator Perspective, Quality Care for Dementia Makes Dollars and Sense, Reality of Disclosure And Individuals with Dementia ............................................................................................................................148 Psychiatric and Psychotherapy Economic Considerations.........................................................................................149 Section I - Chapter Two – Dementia Standard of Care in Dementia ...................................................................................................................................150 Early and Progression Signs of Normal Pressure Hydrocephalus ( NPH)..................................................................151 NPH, Alzheimer’s Disease, and Parkinson’s Disease..................................................................................................152 Normal Pressure Hydrocephalus (NPH).....................................................................................................................153 Antidementia Medication (Acetylcholinesterase Inhibitors: Aricept, Exelon) .............................................155 Section I - Chapter Three – Medicare Regulations and Documentation Medicare Information and Regulation: Selected Items.............................................................................................159 The Law and the Medical Record ..............................................................................................................................160 Section I - Chapter Four – Types of Agitated Behaviors in Dementia See also: Addenda – Barriers Related to Organizational Changes and Implementation of Behavior Management A,B, & C Four Agitation Theories .............................................................................................................................................167 SPC Model to Understand Agitation..........................................................................................................................168 Personal and Environmental Correlates of the Different Types of Agitation ............................................................170 Treatment of Agitation and Aggression in Dementia................................................................................................172 Agitation and Dementia.............................................................................................................................................175 The Natural Progression of Alzheimer’s Disease.......................................................................................................175 Causes of Psychiatric Symptoms and Behavior Can Overlap ....................................................................................176 Quick Review for Management of Challenging and Disturbing Behavior .................................................................177 Preferred Medications for Subtypes of Agitation .....................................................................................................180 Managing Resident Behaviors – Apply the 5R’s (Reengage, Reassure, Restate, Redirect, and Restrict...................................................................................................................................................................181 Quick Review 1 – Domains for Assessment and Potential Intervention....................................................................187 Quick Review 2 – Examples of Scales to Describe Scope and Severity of Behaviors.................................................188 Quick Review 3 – Categories of Approaches to Managing the Individual with Dementia ........................................188 Quick Review 4 – Environmental Aspects that can be Assessed and Adapted to Optimize Quality of Life of Individuals with Dementia..........................................................................................................189 Quick Review 5 – Problem Solving Outline for Challenging Behavior .......................................................................189 Quick Review 6 – Examples of Relevant Factors in Describing Behaviors .................................................................190 Quick Review 7 – Explaining the Basis for Proposed Interventions to Individuals and Families (see page 126) ..190 Quick Review 8 –Examples of Triggers and their Possible Management ..................................................................191 Quick Review 9 – Situations where Medical Interventions for Disruptive Behavior May be a Primary Option.......................................................................................................................................191 Quick Review 10 – Examples of Complications from Treating Behavior ...................................................................191 Nursing Staff Report Worksheets..............................................................................................................................192 Weekly Aide Report Worksheet ................................................................................................................................193 Department Head/Charge Nurse Competency Checklist Skill 36 – Abuse and Neglect ...........................................194 Skill 36 – Abuse and Neglect Answer Guide ..............................................................................................................195 Approaching and Treating Behavioral Issues in Patients Suffering from Dementia..................................................196 Psychiatric Options in the Treatment of Seniors.......................................................................................................202 Overview of Mental Healthcare of Seniors................................................................................................................204 Summary Table of Indications and Medications .......................................................................................................205 Common and Relevant Drug Interactions Chart........................................................................................................206 Annual Cost of Therapy .............................................................................................................................................207 SECTION II – PSYCHOTROPICS See also: Gurwitz JH, et al. The incidence of adverse drug events in two large academic long-term care facilities. The American Journal of Medicine 2005;188;251-258. Gurwitz JH, et al. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. JAMA 2003;289(9):1107-1116. 228600-28574 Mjoseth J. Adverse drug events in nursing homes: Common and preventable. Section II - Chapter One – Medication Strategies Assessing Patients and Collecting Data on Nursing Facility Patients.(see SPC research on reducing psychotropic medication).208 The Minimum Data Set 3.0 (MDS 3.0) SPC Support to Nursing Homes.....................................................................211 The Minimum Data Set as a Tool for the Psychiatrist................................................................................................212 Medication Management..........................................................................................................................................223 Antipsychotics............................................................................................................................................................224 Antidepressants.........................................................................................................................................................225 Medication Agitation Sundowning + Pain .................................................................................................................227 Monitoring Response to Medication Treatment.......................................................................................................228 Algorithm 2. Monitoring Response to Therapy .........................................................................................................229 Medication for Insomnia, Agitation, Psychosis, and Aggression ...............................................................................232 Alzheimer’s Management and Medication ...............................................................................................................233 Monitoring Medications............................................................................................................................................237 Behavioral Medicine Rounds.....................................................................................................................................238 SPC-Behavioral Rounds .............................................................................................................................................239 Understanding Why Patients Who Take More than Nine Medications May or May Not be Receiving Quality Care (Letter from Department of Aging and Disability Services-DADS)......................................241 Nine or More Medications: May or May not be Considered Quality Care................................................................242 Unforeseen Penalties – The Quality Indicator and the Use of Nine or More Medications .......................................245 Improving Patient Safety Through Detection of Adverse Medication Effects...........................................................249 Admission Medication Monitoring Care Plan for Falls ..............................................................................................251 Admission Medication Monitoring Care Plan for Delirium........................................................................................251 Medications Associated with Delirium......................................................................................................................254 Yale Delirium Prevention Trial Risk Factors and Intervention Protocols ...................................................................254 Pharmacologic Therapy for Delirium.........................................................................................................................255 Risks with Medication-Related Problems..................................................................................................................256 Antihypertensives......................................................................................................................................................257 Dermatologics............................................................................................................................................................259 Examples of Medications with Anticholinergic Properties........................................................................................264 Potential Adverse Consequences of Medications with Anticholinergic Properties ..................................................265 Symptoms, Signs, and Conditions That May Be Associated With Medications ........................................................266 Antidepressant Adverse Effects in the Elderly...........................................................................................................269 Exelon Patch ..............................................................................................................................................................274 Neuroprotection, Anticholinesterase, Aricept, Namenda (Interactions) ..................................................................275 Namenda ...................................................................................................................................................................275 Treatment of Mild Cognitive Impairment..................................................................................................................277 Delirium vs. Dementia ...............................................................................................................................................278 Parkinsonism – Managing Psychosis..........................................................................................................................278 Treatment of Parkinson’s Disease .............................................................................................................................278 Treatment of Lewy Body Disease ..............................................................................................................................278 Delirium Assessment – Update on Delirium: Diagnosis, Management, and Pathophysiology .................................279 Keys to Diagnosis: Confusion Assessment Method (CAM) .......................................................................................279 Confusion Assessment Method (CAM) Diagnostic Algorithm ...................................................................................282 Confusion Assessment Method (CAM) In the ICU.....................................................................................................285 Antipsychotics – Typical and Atypical........................................................................................................................286 Schizophrenia ............................................................................................................................................................289 The Psychosis of Schizophrenia Versus the Psychosis of Alzheimer’s Dementia ......................................................290 Differential Diagnosis of Schizophrenia.....................................................................................................................291 Course of Schizophrenia – Stages of Illness...............................................................................................................292 Course of Schizophrenia – (Subtype Course).............................................................................................................293 Schizophrenia Research.............................................................................................................................................294 SOP: Clozapine (Clozaril) Protocols............................................................................................................................295 Clozapine – Attachment A: Informed Consent (medication).....................................................................................299 Treatment of Selected Syndromes and Disorders with Antipsychotics.....................................................................300 Bipolar Disorder – Aging Related Issues: A Health Services Perspective...................................................................301 Bipolar Disorder – Practice Guideline for the Treatment of Patients........................................................................303 Metabolic Syndrome: Neuroleptic Malignant Syndrome and Serotonergic Syndrome ............................................................................307 Suggested Metabolic Monitoring Protocol for Persons Taking Atypical Antipsychotics .......................................313 Pseudobulbar Affect (PBA): A Disruptive Neurologic Condition–Involuntary Emotional Dyscontrol........................314 Indications for Mood Stabilizers in Elderly Patients ..................................................................................................316 Sleep Problems – Use of Trazodone..........................................................................................................................317 Insomnia Assessment ................................................................................................................................................319 Major Causes of Primary Insomnia (Table)................................................................................................................320 Secondary (Medication-Associated) Causes of Insomnia (Table)..............................................................................320 OBRA Guidelines for Use of Pharmacologic Agents for Sleep Induction (Table).......................................................325 Recommended Hypnotic Agents in the Long-Term Care Setting (Table) ..................................................................325 Drugs Used in the Treatment of Insomnia (Table) ....................................................................................................326 Good Sleep Hygiene Principals in the Long-Term Care Setting (Table) .....................................................................327 Inappropriate Medications in the Elderly Relative to Insomnia (Table)....................................................................327 Management of Depression in Nursing Home Residents: Consensus Statements On Which the Panel Reached Agreement.............................................................................................................329 Antidepressants.........................................................................................................................................................330 Recognition, Diagnosis, and Treatment of Treatment-Resistant Depression in the Geriatric Population........................................................................................................................................333 Toxic Effects-Serotonin Syndrome and Discontinuation Syndrome..........................................................................328 SSRI Discontinuation Syndrome ................................................................................................................................336 A Novel Ten-Step Titration of Patients Discontinuing SSRI’s.....................................................................................337 A Proposed Algorithm for Decision Making Regarding the Use of Antipsychotics In Older Adults with Dementia-related Psychosis and/or Agitation .....................................................................338 Pharmacological Alternatives to Antipsychotics with at Least 1 Positive Randomized Controlled Trial for Agitation and/or Psychosis in Patients with Dementia.....................................339 Stimulants..................................................................................................................................................................340 Anticonvulsants .........................................................................................................................................................342 Valproate...................................................................................................................................................................344 Treatment of Anxiety and Panic Disorder (Antianxiety Medication).........................................................................346 Panic Disorder............................................................................................................................................................347 Unknown Effectiveness – Why Beta Blockers are Not Approved..............................................................................347 Characteristics of Commonly used Benzodiazepines in the United States................................................................348 Guidelines for Tapering Diazepam.............................................................................................................................349 Myths and Reality on Causes of Depression Medication ..........................................................................................350 Table 1. Naranjo causality scale.............................................................................................................................351 Table 2. Consult Patient’s Medication List if Signs of New Psychiatric Symptoms ................................................351 Table 3. Possible Mechanisms of Drug-Induced Depression .................................................................................352 Table 4. Evidence for DID Associated with Drug Classes .......................................................................................353 Section II - Chapter Two – Pain Management and Depression Medications for psychiatric symptomsPharmacological Management of Pain (Also used for Depression)...........................................................................355 FDA Approves Duloxetine to Treat Chronic Musculoskeletal Pain............................................................................356 Section II -Chapter Three – Off Label Prescriptions: Liability and Legality Issues Off Label Prescriptions: Liability and Legality Issues .................................................................................................357 Section II - Chapter Four – Drug Induced Disorders Akathisia ....................................................................................................................................................................359 Dystonia (Acute) ........................................................................................................................................................359 Toxic Effects – Serotonin Syndrome..........................................................................................................................359 Neuroleptic Malignant Syndrome .............................................................................................................................359 Parkinsonism .............................................................................................................................................................360 Tardive Dyskinesia .....................................................................................................................................................360 Tardive Dystonia........................................................................................................................................................361 Tremor (Topiramate “Topamax” is not approved for use by SPC staff) ....................................................................361 Neuropsychiatric Medicine (for treatment of essential tremor)...............................................................................361 Quality Improvement in Long-Term Care: Psychotropic Assessment Tool (PAT)......................................................363 Psychotropic Assessment Tool (PAT) - form..............................................................................................................365 Pros and Cons of Medications: Quality, Price, and Danger .......................................................................................366 Annual Cost of Therapy .............................................................................................................................................367 SECTION III – PSYCHOSOCIAL AND LEGAL ISSUES Section III - Chapter One – Team Approach: Role of Counseling The Role of Psychotherapy........................................................................................................................................368 Treatments for Depression in Older Persons with Dementia....................................................................................369 Caring for the Chronically Mentally Ill in NursingHomes…………………………………………………………………..………380 Cognitive and Emotional Oriented Therapies for Dementia and Alzheimer’s...........................................................383 Psychotherapies – Different Strokes for Different Folks ...........................................................................................385 Resistant Patient/Refusal of Care-Collaborative Treatment is the Answer...............................................................386 Section III - Chapter Two – Making Decisions and Dementia *Brief Evaluation of Executive Dysfunction: An Essential Refinement In the Assessment of Cognitive Impairment..............................................................................................................387 Decision Making About Feeding for Persons with Advanced Dementia ...................................................................389 *Ten Myths About Decision Making Capacity ... .......................................................................................................392 Model Questions for Assessing Capacity...................................................................................................................397 Health Care Decision Making Capacity – A Legal Perspective for Long-term Care Providers ...................................399 Assessing Capacity in the Older Patient – Clinical Geriatrics.....................................................................................405 Assessing the Competency of Patients with Alzheimer’s Disease Under Different Legal Standards – A Prototype Instrument .....................................................................................407 Competency in Alzheimer’s Disease..........................................................................................................................411 Decision Making and Dementia.................................................................................................................................413 *Guidelines for Evaluating Decision-makinCapacity.................................................................................................414 Brief Evaluation of Executive Dysfunction: An Essential Refinement in the Assessment of Cognitive Impairment..........................................................................................416 Screening Tests of Executive Function ......................................................................................................................418 *Sexuality in the Nursing Home ................................................................................................................................419 Inappropriate Sexual Behaviors.................................................................................................................................422 Engage Resistant Patients in Collaborate Treatment ..............................423Worksheet for Decision-Making Capacity “Ask In Order To Know”I. Ability to Choosea. Have you made the decision about treatment?YES/NOIf Yes What is it?b. Why?II. Ability to Understand Informationa. Tell me about:i. Nature of your condition:ii. Treatment or test recommended?iii. What are the risks or discomforts of the tests ortreatment?iv. What other treatment would you consider?v. What do you think will happen with:1. No treatment2. TreatmentIII. Ability to Appreciate Situation and ConsequencesWhat do you think is wrong with your health or causing yoursymptoms?b. Do you think treatment can:i. Help?ii. Harm?c. Do you know other treatment that I or others have told youabout? What are they?d. What do you think will happen if you do not get treatment ordiagnostic tests?IV. Ability to Reasona. Tell me how you reached your decision to have/not have testsor treatment?b. What was most important in making those decision?c. How did you balance these things?Engage resistant patients in collaborative treatment - First identify andon what they really want. (see pharma psychotherapy)David Mee-Lee, MDSee also the following articles:Roy-Byrne P, et al. Brief intervention for anxiety in primary care patients. viewarticle/589932Haas L. Effective collaboration: Psychologists and primary care physicans. 2009. W, et al. Stepped collaborative care for primary care patients with persistent symptoms of depression. Arch Gen Psychiatry. 1999:56;pp 1109-1115Powers T. Collaborative care for patients, Interns and Physicians. 2009 JM & Harney PA. Treatment-resistant depression and the collaborative treatment relationship. 1999 status: a daily forum for resident discussion and staff education.Hutcheon RG1,? HYPERLINK "" Iorlano M,?Thomas MK.Author informationAbstractA forum at which the timely transmission of critical clinical information is coupled with a formal interdisciplinary teaching program has tremendous value in the long-term care setting. We have combined features of morning report used in teaching hospitals with attributes of "stand-up" meetings to fill this need. Each morning we hold Clinical Status, a gathering of representative staff from all neighborhoods (units) at which we discuss problems that have occurred during the previous 24 hours; admissions, discharges, and transitions; Center-wide concerns such as infection control measures; and upcoming events such as celebrations, lectures, and memorials. In addition, short educational presentations are made by staff members at each session. A survey of attendees confirms our impression that Clinical Status is regarded as an informative, stimulating and vital aspect of life at the Center.Copyright ? 2010 American Medical Directors Association. Published by Elsevier Inc. All rights reserved.Elizabeth Seton Pediatric Center is a 136 bed long term care and rehabilitation facility located inn New York City. Our infants, children, and adolescents have complex medical, physical, and developmental problems and most will have a shortened life span. At this time, 8 of our residents are ventilator dependent; 17 require assisted ventilation; 59 have tracheostomies; and 105 received nutrition through gastrostomy, jejuenostomy, or nasogastric tubes. All resident require some, if not total, assistance with activities of daily living.Seventy five percent of the residents at the center are admitted for long term care. They are expected to stay with us until reaching 21 years of age at which time they transfer to adult care facilities. As one would expect, however, some of these residents do not live to age 21 and others transfer to different care environments before age 21. The remaining 25% of our residents are admitted for short term care. These children may receive intensive rehabilitation, medical management of problems too great to be handled in the home, feeding therapy or respite care. The length of stay for these admissions ranges from a few weeks to 6 to 12 months and the goal for these residents is discharge to their families. An additional small group of children are admitted specifically for end of life care. There were 97 admissions and 95 discharges in 2009.Physically, Elizabeth Seton Pediatric Center is divided into 7 neighborhoods (units), 6 of which have 20 beds and 1 of which has 16 beds in an isolation room. The neighborhoods are roughly characterized by the acuity, respiratory needs, development and chronological ages of the residents. One neighborhood serves as the admissions unit: it is here that most new residents are aditted and evaluated and, following a 2 to 3 week say transitioned to the most appropriate of the other neighborhoods. The John A. Coleman School is located in the building and provides classroom education for 110 residents. The remaining residents attend schools outside the center or receive bedside instruction.Each neighborhood is guided bya tea leader and 1 to 2 associate leaders who devote 20% of their time to administration of the neighborhood and 80% to their area of expertise. Our full time pediatricians have fixed assignments, generally 1 pediatrician to 2 neighborhoods, and a pediatric nurse practionaer provide clinical services and leadership in the admissions unit.Two notable trends have taken place at the center over the past 8 to 10 years. First the number of residents with multiple complicated medical problems and equipment needs has increased. This made it clear that we needed to develop a mechanism for the timely transmission of clinical information about new and established resdients, the discussion of issues such as infection control problems and transitions and the education of staff memebers. Second there has been a parallel rise in the breadth of expertise among staff members which makes an interdisciplinary education program both necessary and viable. We looked to morning report as carried out by training programs at acute care facilities and the interdisciplinary stand up model used in adult long term care as guides to developing a mechanism to meet these needs.Traditionally morning report is a regular meeting of physicians in training and depending on the nature and needs of the program, a mix of administrative level phsycians, generalists, subspecialists, ancillary personnel and students. Its goals include provision of education, development of house staff problem solving skills, enhancement of interactions among learners and educators of various levels, discussion of complicated cases and evaluation of house staff.. A different approach to information exchange is the use of daily stand up meetings for problem solving. These short (10-15 minute) issue centered conferences take place at a fixed time and place, require attendance by a small number of key individuals and have goals that include solving specific problems, team building and improved communication.METHODSClinical Status takes place each morning at 9”00 am and lasts for a maximum of 30 minutes. It is led by the medical director and additional attendess include, but are not limited to, the night nursing supervisor, teams leaderws and at least one representative from each neighborhood; attending phsycians; nutritionists; physical, occupational, and speech therapists; creative arts therapists; child life therapists; recreation specialists; the ceter administrartor; the director of nursing and the director of rehabilitation services; the infection preventionsist and representative from the John A. Coleman School.The meeting begins with the night supervisor delineating the total census and indicating the number of residents may be in acute care facilities, on home visit, or otherwise out of the building. This is followed by a report of problems that have occurred during the past 24 hours. This includes children who have developed acute illnesses orother changes in status. Decisions about room and neighborhood closure are made at this time. We then discuss residents who will be moving to different neighborhood, the steps taken to enhance a smooth transfer and scheduling of pretransition meetings.During the second part of Clinical Status, jaor centerwide isseus are brought up. Not unespcedely great emphaisis has been placed on review of and planning for general infection control problems.The last component of Clinical Status is the more formal educational program. Staff members of all disciplines are given the opportunity to give a 10-15 minute presentation according to a repeating monthly schedule. The presentation amy be made by the responsible individual or a designated substitute. RESULTSClinical Status in the form described has developed over a 3 year period. Initially attendance was spare and the educational presentation were made only by attending physicians on an intermittent schedule. It became apparent that not only were the presentations well received but also all staff members had something to offer. In response to popular demand, the schedule was expanded to include a wide variety of presentation.DISCUSSIONWe have been greatly encouraged by the acceptance and success of Clinical Status at Elizabeth Seton Pediatric Center. It has been recognized as a valuable tool for the exchange of information in a setting that allows free exchanbe of ideas and thoughts. Rather than seeing the educational presentations as a burden, staff have actually requested to be put on the schedule so that this component now takes place daily. Individuals have the opportunity to share knowledge, showcase progress and increase general understanding of their area of expertise.The transcisciplinary nature of the program cannot be overemphasized. We now have a greater appreciation of the work done with all of our colleagues.Senior PsychCare Psychiatric Diagnostic ProceduresPsychiatric diagnosis evaluation with medical services include:Patient history, mental status and other physical examination elements. The evaluation may include communications with family or other sources, prescriptions of medication, and review of laboratory or other diagnostic studies.*Codes 90791, 90792 are used for the diagnostic assessment or reassessment and do not include psychotherapeutic services. Psychotherapy services, including for crisis, may not be reported on the same day.90791Psychiatric diagnostic evaluation90792Psychiatric diagnostic evaluation with medical servicesAdditional Code that may be used:Code 90785 is an add on code for interactive complexity to be reported in conjunction with codes for diagnostic psychiatric evaluation (90791, 90792)??????????? Psychiatric procedures may be reported?with interactive complexity when at least one of the following is present:The need to manage maladaptive communication (related to, eg. High anxiety, high reactivity, repeated questions, or disagreement) among participants that complicate delivery of care.Caregiver emotions or behavior that interferes with the caregiver’s understanding and ability to assist in the implementation of the treatment plan.Use of play equipment, other physical devices, interpreter or translator to communicate with the patient , because the patient is not fluent in the same language as the provider or has not developed or has lost either the expressive language communication skills to explain his/hers symptoms and response to treatment, or the receptive communication skills to understand the Provider.CPT Code 90785 Interactive complexity (List this code separately in addition to the code for primary procedure)?The total time spent with the patient should be reported on the visit notes, but time is not a part of the factor in determining to use CPR CODE 90785.NURSING FACILITY SERVICESThe following codes are used to report evaluation and management services to patients in nursing facilities, intermediate care facilities or long term care facilities.INITIAL NURSING FACILITY CARE99304Initial nursing facility care, per day, for the evaluation and management of a patient which requires these three components; A detailed or comprehensive history;A detailed or comprehensive examination;And medical decision making that is straightforward or of low complexityUsually, the problem(s) requiring admission are of low severity. Typically 25 minutes are spent at the bedside and on the patient’s floor or unit.99305Initial nursing facility care, per day, for the evaluation and management of a patient which requires these three components; A comprehensive history;A comprehensive examination;And medical decision making of moderate complexityUsually, the problem(s) requiring admission are of moderate severity. Typically 35 minutes are spent at the bedside and on the patient’s floor or unit.99306Initial nursing facility care, per day, for the evaluation and management of a patient which requires these three components; A comprehensive history;A comprehensive examination;And medical decision making of high complexityUsually, the problem(s) requiring admission are of high severity. Typically 45 minutes are spent at the bedside and on the patient’s floor or unit.SUSEQUENT NURSING FACILTY CARE99307Subsequent nursing facility care, per day for the evaluation and management of a patient, which requires at least two of these three key components: A problem focused history;A problem focused examination;Straight forward medical decision making.Usually, the patient is stable, recovering, or improving. Typically 10 minutes are spent at the bedside and on the patient’s facility floor or unit.99308Subsequent nursing facility care, per day for the evaluation and management of a patient, which requires at least two of these three key components:1 An expanded problem focused interval history;2. An expanded problem focused examination;3. medical decision making of low complexity.Usually, the patient is responding inadequately to therapy or has developed a minor complication. Usually 15 minutes are spent at the bedside and on the patient’s facility floor or unit.99309Subsequent nursing facility care, per day for the evaluation and management of a patient, which requires at least two of these three key components:1. A detailed interval history;2. A detailed examination;3. medical decision making of moderate complexity.Usually, the patient has developed a significant complication or a significant new problem. Typically 25 minutes are spent at the bedside and on the patient’s facility floor or unit.99310Subsequent nursing facility care, per day for the evaluation and management of a patient, which requires at least two of these three key components:1. A comprehensive interval history;2. A comprehensive examination 3. medical decision making of high complexity.Usually, the patient may be unstable or may have developed a significant new problem requiring immediate Provider attention. Typically 35 minutes are spent at the bedside and on the patient’s facility floor or unit. Assisted Living Nursing Facility CareNew Patient99341 Assisted Living facility care, per day, for the evaluation and management of a patient which requires these three key components: A problem focused history A problem focused examinationStraightforward decision making of low severityTypically 20 minutes are spent face-to-face with the patient and/or family99342 Assisted Living facility care, per day, for the evaluation and management of a patient which requires these three key components: An expanded problem focused history An expanded problem focused examinationMedical decision making of low complexityTypically 30 minutes are spent face-to-face with the patient and/or family99343 Assisted Living facility care, per day, for the evaluation and management of a patient which requires these three key components: A detailed history A detailed examinationMedical decision making of moderate to high severityTypically 45 minutes are spent face-to-face with the patient and/or family99344 Assisted Living facility care, per day, for the evaluation and management of a patient which requires these three key components:A comprehensive history A comprehensive examinationMedical decision making of moderate to high severityTypically 60 minutes are spent face-to-face with the patient and/or family.Established Patient99347 Assisted Living facility care, per day, for the evaluation and management of a patient which requires these three key components: A problem focused history A problem focused examinationStraightforward decision making Usually, the presenting problem(s) are self-limited or minorTypically 15 minutes are spent face-to-face with the patient and/or family99348 Assisted Living facility care, per day, for the evaluation and management of a patient which requires these three key components: An expanded problem focused history An expanded problem focused examinationMedical decision making of low complexityUsually, the presenting problems(s) are of low to moderate severityTypically 25 minutes are spent face-to-face with the patient and/or family99349 Assisted Living facility care, per day, for the evaluation and management of a patient which requires these three key components: A detailed history A detailed examinationMedical decision making of moderate to high severityUsually, the presenting problem(s) are moderate to high severityTypically 40 minutes are spent face-to-face with the patient and/or family99350 Assisted Living facility care, per day, for the evaluation and management of a patient which requires these three key components: A comprehensive history A comprehensive examinationMedical decision making of moderate to high severityUsually, the presenting problem(s)are moderate to high severity. The patient may be unstable or may have developed a significant ne problem.Typically 60 minutes are spent face-to-face with the patient and/or familyPsychotherapy Codes90832Psychotherapy, 30 minutes with patient90834Psychotherapy, 45 minutes with the patient90837Psychotherapy, 60 minutes with patientPsychotherapy for Crisis90839Psychotherapy for crisis; first 60 minutes90840Each additional 30 minutesdo not report 90839, 90840 in conjunction with 90791, 90792, psychotherapy codes 90832-90838)Family Therapy90846Family therapy without the patient present 50 minutes90847Family therapy with the patient present 50 minutePHQ-9 Patient Depression Questionnaire For initial diagnosis: Patient completes PHQ-9 Quick Depression Assessment. If there are at least 4 ?s in the shaded section (including Questions #1 and #2), consider a depressive disorder. Add score to determine severity. Consider Major Depressive Disorder - if there are at least 5 ?s in the shaded section (one of which corresponds to Question #1 or #2) Consider Other Depressive Disorder - if there are 2-4 ?s in the shaded section (one of which corresponds to Question #1 or #2) Note: Since the questionnaire relies on patient self-report, all responses should be verified by the clinician, and a definitive diagnosis is made on clinical grounds taking into account how well the patient understood the questionnaire, as well as other relevant information from the patient. Diagnoses of Major Depressive Disorder or Other Depressive Disorder also require impairment of social, occupational, or other important areas of functioning (Question #10) and ruling out normal bereavement, a history of a Manic Episode (Bipolar Disorder), and a physical disorder, medication, or other drug as the biological cause of the depressive symptoms. To monitor severity over time for newly diagnosed patients or patients in current treatment for depression: 1. Patients may complete questionnaires at baseline and at regular intervals (eg, every 2 weeks) at home and bring them in at their next appointment for scoring or they may complete the questionnaire during each scheduled appointment. 2. Add up ?s by column. For every ?: Several days = 1 More than half the days = 2 Nearly every day = 3 3. Add together column scores to get a TOTAL score. 4. Refer to the accompanying PHQ-9 Scoring Box to interpret the TOTAL score. 5. Results may be included in patient files to assist you in setting up a treatment goal, determining degree of response, as well as guiding treatment intervention. Scoring: add up all checked boxes on PHQ-9 For every ? Not at all = 0; Several days = 1; More than half the days = 2; Nearly every day = 3 Interpretation of Total Score Total Score Depression Severity 1-4 Minimal depression 5-9 Mild depression 10-14 Moderate depression 15-19 Moderately severe depression 20-27 Severe depression PHQ9 Copyright ? Pfizer Inc. All rights reserved. Reproduced with permission. PRIME-MD ? is a trademark of Pfizer\5 Reasons to Make a Memory Box for Alzheimer’sFor loved ones, parents or seniors with Alzheimer’s disease, a memory box can help recall events and people from the past. These memories can stimulate the senior, prompting conversation with loved ones.?Whether a?family photo, newspaper clipping or other prop; memory boxes hold items that bring us back to a moment in time that we hold dear.?When a senior who has?Alzheimer’s?opens a memory box, it can stir thoughts of happy moments in life and give that person something to talk about.Reasons to Create a Memory Box for Alzheimer’sMemory boxes?can link loved ones to their identity,?with keepsakes emphasizing an overall holiday, person or theme that lifts the senior’s spirit. Though it will take time to find which?keepsakes to store in the memory box, it is worth the effort.Here are five reasons to make?a memory box for a senior loved one with Alzheimer’s:Exercise, touch and other senses used in the creation of a memory box will become more important for a loved one to rely on as Alzheimer’s progresses.Fond memories of a senior’s?history,?personal interests and youth can be explored.Memory boxes can inspire conversation with caregivers, children or grandchildren.More insight into your loved one and their past will be gained. When you search for keepsakes to include in a memory box, you may find special items you did not realize the senior still had or was interested in.Spurred creativity from the creation of a memory box. The senior may be inspired to create another box about a different life event or memory.Ways to Make a Memory BoxA memory box can be as decorative or as simple as you like. It can be a plastic bin or a shoe box, whichever you prefer. Ideally, it will be easy to access and lift, store a number of items of reasonable shapes and sizes, and fit on your loved one’s lap or a small table.If the memory box has compartments, make sure they suit the senior’s dexterity and?that the senior can open the memory box easily.Learn more from these tips about ways to choose keepsakes for your?memory box:Choosing KeepsakesItems stored in a memory box should be personal, like a baby’s toy or postcard. The memory box should reflect the senior’s interests or a moment in history that has meaning to that individual.When you choose keepsakes for the memory box, consider:Safety:?Avoid heavy or sharp items.Significance:?Focus on items linked to?positive memories.Texture:?Items should be easy to handle; texture itself can help stir memories.Uniqueness:?If an item is irreplaceable, leave it out.Bear in mind that a loved one?may not recognize items right away or understand why they were included. So,?consider labeling each item?with a sticker or tag. You can also list the items on a piece of paper, and write a phrase or sentence about each one.Keepsake IdeasHere are some suggestions for keepsakes you might include in a senior’s memory box:A baby toyA baseball or cardsA keychainA letterA recipeArtwork by children or grandchildrenDried flowersFamily photosPostcardsSheet musicVacation souvenirsYou can create multiple memory boxes with?different themes with your loved one — maybe one could hold memories of children and another of a favorite hobby, for instance. The keepsakes do not have to fit into a single box.When you open the memory box with your senior loved one, ask the senior to share his?or her memories with you. You may find that an item that was meant to stir a certain memory brings on another. Or, it could inspire a waterfall of thoughts and conversation, leaving you with new, lasting memories of your senior loved one.SUICIDE RISK SCALEInstructions: During assessment, utilizing questioning and observation techniques, check off the categories below which most closely apply to the patient's situation or behavior under low or high intensity. (Below please circle one for each item.)*This is only a guideline based on clinical experience. This scale should be used to assist in making clinical decision and interviewing the atient. SPC does not nece tres onsibili for action taken usin this instrument.LOW INTENSITY INDICATORSSCOREHIGH INTENSITY INDICATORSSCOREMild/Moderate anxietyo- 1-2-3High anxiety or panic0-1-2-3-4-56-7-8-9-10Mild de ression0-1-2-3Withdrawn or isolated0-1-2-3-4-5No Social Su ort0-1-2Previous suicide attem ts5-6-7-8-9-10Constructive co in strate ies0-1-2Destructive co in strate ies0-1-2-3-4-5Declarative statements0-1-2Verbal statements of intent0-1-2-3-4-56-7-8-9-10Professional help in the past, or no positive ex eriences associated with the is hel0-1Negative view of professional help in the pastO-1-2-3-4-56-7-8-9-10Non-verbal behavior indicating selfdestructiveness0-1Non-verbal behavior indicating selfdestructive thou htso- 1-2-3-4-56-7-8-9-10Score on Combined Low and High Intensity Indicators:Score is 0-20:Suicide Risk IIf Manipulative or impulsive gesture with no intent consult by Psychotherapist and review by Psychiatrist in 7-10 days.Patient to be consulted by a Psychotherapist and reviewed by Psychiatrist with any High indicators in 7 days.Score is 21-39:Suicide Risk IlAssess for suicide ideations every shift. Patient to be consulted by Physician and reviewed by a Psychiatrist for higher level of observation with any High indicators in 48 — 96 hrs .To be consulted in 24-48hrs and consider possible transfer for hospitalization by a Psychiatrist or M.D.Score is 40-79: Suicide Risk IllQ15 min ObservationScore is 80-125: Suicide Risk IVI : I ObservationForms on SPC/Nursing Home Forms/ Suicide Risk Scale Revised 11/4/04Guidelines for Utilizing Suicide Risk ScalePURPOSETo provide safety and to prevent injury from suicideTo recognize possible causes and warning signs of suicideFUNDAMENTAL INFORMATIONCausesIt is impossible to say what causes suicide. People who have certain types of problems are more likely to attempt, or actually commit, suicide.Manic-depressive individuals have the highest reported rate of completed suicides.Psychotics are more likely to complete suicides than the average person who makes an attempt.Serious Illness Those who believe they are seriously ill (real or imagined).Loss of spouse, child, friend, home or pet.Fear of aging The elderly have a high suicide rate.Warning SignsMost suicide attempts are preceded by warning signs. DO NOT IGNORE WARNING SIGNS. Valid suicide attempts and suicides have occurred in nursing facilities. Some warning signs are:Depression — Depression lasting an extended period of time.Previous suicide attempt — Anyone who has previously attempted suicide should be taken seriously if new threats are made.Making final arrangements — Depressed persons who are making final arrangements such as getting wills and insurance papers in order, giving away prized possessions, or inquiring about funeral arrangements should be asked about their feelings and thoughts.Suicide threats or similar statements — Often people who commit suicide talk about it first. They may say something very direct, threaten to end their lives, or talk about wanting to be dead. They may make less direct statements like: "My family would be better off without me"; or, "I don't want to be a burden."Sudden marked changes in behavior or personality — A normally outgoing person may become quiet and spend a lot of time alone. A sudden end to sadness, depression, or withdrawal may mean that the resident has decided to commit suicide.ASSESSING THE DEGREE OF SUICIDAL Intensity of RiskRISKBehavior m? Sympt01nModerateHi hAnxietMildModerateHi h, or anic stateDe ressionMildModerateSevereIsolation-withdrawalVague feelings of depression, no withdrawalSome feelings of helplessness, hopelessness, and withdrawalHopeless, helpless, withdrawn & self-deprecatingDaily functioningFairly good in most activitiesModerately good in some activitiesNot good in any activitiesResourcesSeveralSomeFew or noneCoping strategies & devices bein usedGenerally constructiveSome that are constructivePredominantly destructiveSignificant othersSeveral who are availableFew or only one availableOnly one, or none availablePsychiatric help in astNone, or positive attitude towardYes, and moderately satisfied withNegative view of help receivedLife-styleStableModerately stable or unstableUnstableAlcohol and dru useInfre uentl to excessFre uentl to excessContinual abusePrevious suicide attem tsNone, or of low lethaliNone to one or more of moderate lethaliNone to multiple attempts or hi lethalitDisorientation and disor anizationNoneSomeMarkedHostilitLittle or noneSomeMarkedSuicidal planVague, fleeting thoughts but no planFrequent thoughts, occasional ideas about a IanFrequent or constant thoughts with a specific planPROCEDUREI. Review the resident's level of suicidal risk using the table "Assessing the Degree of Suicidal Risk"If the risk is moderate or high, contact the family and physician and fax a psychiatric/psychological consultation referral form to Senior Psych Care.If social services is interacting with the health care professionals, include this information in the plan of care and reference in the progress notes.If a resident verbalizes suicidal thoughts or feelings, it is important not to be judgmental. e Be sympathetic.Do not say, "That is terrible, you should be ashamed of yourself."Do not be afraid to use the word "suicide."Ask if the person is thinking about suicide; saying the words out loud will not promote suicidal thoughts.Ask questions.Find out their feelings, thoughts and plans. How, when, where? In general, the more specific the plan, the greater the risk.Report the information you have gathered to the charge nurse and administrator. Document findings. Make decision with DON or nursing staff if the facility can keep the resident safe or if the resident needs to be transported to the hospital emergency room.Get rid of sharp objects, ropes, and medications; keep residents away from windows, open stairways, etc. Remember that the resident is torn between wanting to live and wanting to die.Keep a spark of hope alive by:Assuring residents that you want to help;Suggesting other courses of action that may solve their problems or help them feel better;Offering hope; andDemonstrating that you care.If the risk is immediate, do not leave the resident alone.Notify the administrator or DON of threat or attempt.Nursing will contact the physician.Ask the physician if a psychiatric consultation should be ordered.Social worker should be ready to add any significant psychosocial information.Notify all shifts.DOCUMENTATIONl . In the care plan, record: behavior;planned interventions;safety precautions;2. In the progress notes, record:the level of emotional stability and/or suicide risk;observations and findings of physicians, psychiatrists, and other health care; professionals;physician and family/responsible party notification and their responses.FAST SCALE LEVEL CLINICAL CHARACTERISTICS 1 2 3 4 1 No Cognitive Decline No demonstrated memory deficits No subjective cases of memory deficit Functions independently 2 Very Mild Cognitive Decline (forgetfulness) Subjective cases of memory deficit (placement of familiar objects, names he/she knows well) No problems completing tasks or at social functions 3 Mild Cognitive Decline (Early Confusion) Memory deficit evident on intensive interview Denial of deficits Expresses concern regarding deficits Problems performing in demanding situations (work or social) 4 Moderate Cognitive Decline (Late Confusion) Decreased knowledge of current and recent events Memory deficits regarding personal history Decreased ability to concentrate on serial subtractions Difficulty with complex tasks Denial of deficits Withdraws from challenging situations 5 Moderately Severe Cognitive Decline (Early Dementia) Disorientation to time (date, day of week, seasons, etc.) or place Immediate memory relatively intact Needs assistance in choosing clothing Wears clothing appropriately (hearing aid, glasses, carries purse, etc.) Feeds self (may need meal set up) Sleep disturbances Wanders. looking for a way out (purposeful) Tearfulness Catastrophic reactions Some resistance to care-giving Needs verbal cues for ADLs - follows instructions 6 Severe Cognitive Decline (Middle Dementia) Unable to recall most recent events Repetitiveness Removes/won’t wear clothing appropriately (hearing aid. glasses. etc.) Refuses to change clothing Bathing problems Feeds self with set-up; cues; assist Sleep disturbances Catastrophic reactions Great resistance to care-giving Purposeless wandering Cannot complete two-stage instructions 7 Very Severe Cognitive Decline (Late Dementia) Speaks only one word in an average day No verbalization Unable to smile Cannot feed self Cannot complete simple tasks Unable to sit up independently Cannot walk without assistance Unable to hold head up Black-box warnings: How they can improve your clinical practiceCurrent Psychiatry. 2019 December;18(12):18-26JBy?Matthew A. Schreiber, MD, PhD??Michelle Wiese, MD, MPHAuthor and Disclosure InformationA better understanding of these warnings leads to safer, more effective prescribing.PDFPDF?PDF?DOWNLOADRecently, the FDA issued “black-box” warnings, its most prominent drug safety statements, for esketamine,1?which is indicated for treatment-resistant depression, and the Z-drugs, which are indicated for insomnia2?(Table 1). A black-box warning also comes with brexanolone, which was recently approved for postpartum depression.3?While these newly issued warnings serve as a timely reminder of the importance of black-box warnings, older black-box warnings also cover large areas of psychiatric prescribing, including all medications indicated for treating psychosis or schizophrenia (increased mortality in patients with dementia), and all psychotropic medications with a depression indication (suicidality in younger people).In this article, we help busy prescribers navigate the landscape of black-box warnings by providing a concise review of how to use them in clinical practice, and where to find information to keep up-to-date.What are black-box warnings?A black-box warning is a summary of the potential serious or life-threatening risks of a specific prescription medication. The black-box warning is formatted within a black border found at the top of the manufacturer’s prescribing information document (also known as the package insert or product label). Below the black-box warning, potential risks appear in descending order in sections titled “Contraindications,” “Warnings and Precautions,” and “Adverse Reactions.”4?The FDA issues black-box warnings either during drug development, to take effect upon approval of a new agent, or (more commonly) based on post-marketing safety information,5?which the FDA continuously gathers from reports by patients, clinicians, and industry.6?Federal law mandates the existence of black-box warnings, stating in part that, “special problems, particularly those that may lead to death or serious injury, may be required by the [FDA] to be placed in a prominently displayed box” (21 CFR 201.57(e)).When is a black-box warning necessary?The FDA issues a black-box warning based upon its judgment of the seriousness of the adverse effect. However, by definition, these risks do not inherently outweigh the benefits a medication may offer to certain patients. According to the FDA,7?black-box warnings are placed when:an adverse reaction so significant exists that this potential negative effect must be considered in risks and benefits when prescribing the medicationa serious adverse reaction exists that can be prevented, or the risk reduced, by appropriate use of the medicationthe FDA has approved the medication with restrictions to ensure safe useCritiques of black-box warnings focus on the absence of published, formal criteria for instituting such warnings, the lack of a consistent approach in their content, and the infrequent inclusion of any information on the relative size of the risk.9?Suggestions for improvement include offering guidance on how to implement the black-box warnings in a patient-centered, shared decision-making model by adding evidence profiles and implementation guides.10?Less frequently considered, black-box warnings may be discontinued if new evidence demonstrates that the risk is lower than previously appreciated; however, similarly to their placement, no explicit criteria for the removal of black-box warnings have been made public.11When a medication poses an especially high safety risk, the FDA may require the manufacturer to implement a Risk Evaluation and Mitigation Strategy (REMS) program. These programs can describe specific steps to improve medication safety, known as elements to assure safe use (ETASU).4?A familiar example is the clozapine REMS. In order to reduce the risk of severe neutropenia, the clozapine REMS requires prescribers (and pharmacists) to complete specialized training (making up the ETASU). Surprisingly, not every medication with a REMS has a corresponding black-box warning12; more understandably, many medications with black-box warnings do not have an associated REMS, because their risks are evaluated to be manageable by an individual prescriber’s clinical judgment. Most recently, esketamine carries both a black-box warning and a REMS. The black-box warning focuses on adverse effects (Table 1), while the REMS focuses on specific steps used to lessen these risks, including requiring use of a patient enrollment and monitoring form, a fact sheet for patients, and health care setting and pharmacy enrollment forms.13Activating and Sedating Properties of Medications Used for the Treatment of Major Depressive Disorder and Their Effect on Patient FunctioningLeslie L. Citrome, MD, MPH; Roger S. McIntyre, MD, FRCPC; J. Sloan Manning, MD; and Diane McIntosh, MD, FRCPCFor patients with major depressive disorder (MDD) who do not achieve sustained remission with antidepressants, atypical antipsychotics have demonstrated efficacy as adjunctive therapy.1,2?Three atypical antipsychotics—aripiprazole, brexpiprazole, and quetiapine extended-release—have been approved by the US Food and Drug Administration (FDA) for adjunctive use in MDD, and a fourth, olanzapine, is approved for use in combination with fluoxetine.?Although the sedative and extrapyramidal side effects associated with first-generation antipsychotics are well known, some second-generation antipsychotics are also associated with substantial sedation and activation effects. In this?Academic Highlights, 4 experts on depression from the fields of psychiatry and primary care take a closer look at activation and sedation effects of atypical antipsychotics in patients with MDD. They examine the likelihood of each agent to cause these effects; the impact of these effects on patient functioning, quality of life, and treatment adherence; and the question of whether leveraging activation and sedation to address acute symptoms is ever advisable.HOW DO ACTIVATION AND SEDATION IMPACT CHOICE OF AN ANTIPSYCHOTIC IN MDD PATIENTS?The presentation by Roger S. McIntyre, MD, FRCPC, began by focusing on the reasons why some atypical antipsychotics cause sedation or activation effects and the factors that impact clinicians’ choices of these agents in patients with treatment-resistant MDD.PharmacologyWhy are some agents used in MDD more likely to be activating, while others are more likely to be sedating? Although the answer is not entirely known, some hypotheses exist.Antipsychotics act on multiple receptors, resulting in a response that can manifest as either therapeutic or as a side effect. The effect depends not only on the specific receptor subtype but also on the affinity with which the antipsychotic binds to it. For instance, dopamine-2 (D2) receptor antagonism produces a therapeutic effect that effectively treats psychosis. However, if the affinity of the antipsychotic for the D2?receptor is too high, side effects such as extrapyramidal symptoms (EPS) or elevated prolactin can occur.3Dr McIntyre noted that D2?blocking agents are not known to significantly enhance motivation or reward experiences but that dopamine partial agonism may in fact do just that. The D2?partial agonists that are FDA approved for MDD are aripiprazole and brexpiprazole, and a key issue for these agents is how much?intrinsic activity?(relative efficacy) they have, as high D2?intrinsic activity can lead to hyperkinesias and restlessness.4?Compared with aripiprazole, brexpiprazole has less D2?intrinsic activity, HYPERLINK "" \l "ref4" \o " 4. Maeda K, Sugino H, Akazawa H, et al. Brexpiprazole I: in vitro and in vivo characterization of a novel serotonin-dopamine activity modulator. J Pharmacol Exp Ther. 2014;350(3):589–604. PubMed CrossRef" 4?which could therefore lessen the risk of those effects.Quetiapine and olanzapine have high histaminergic activity, HYPERLINK "" \l "ref5" \o " 5. Richelson E, Souder T. Binding of antipsychotic drugs to human brain receptors focus on newer generation compounds. Life Sci. 2000;68(1):29–39. PubMed CrossRef" 5?which generally speaking, causes sedation. Related to that is the α1?effect; α1?affinity is also linked to sedation and somnolence, as well as other well-known side effects such as postural hypotension.6?Aripiprazole and brexpiprazole have moderate but not high levels of affinity for the histaminergic system,4,7?and that appears to be related to why they are not particularly likely to cause sedation or somnolence.What Influences Real-World Prescription of an Antipsychotic for an MDD Patient?Dr McIntyre highlighted a survey8?that examined determinants driving clinician choice of an adjunctive antipsychotic for patients with MDD. Completed by 411 psychiatrists and primary care physicians, the survey reflected treatment choices for 4,018 MDD patients with inadequate response to their current treatment. Responses indicated that adjunctive antipsychotics were considered in 23.9% of the patients and prescribed in 12.8% of patients.8The top reason for prescribing (52% of respondents) was to improve overall symptoms (Figure 1). Notably, the second most common motivating factor (42%) was “specific drug features,” implying that physicians are making distinctions based on the effects of specific medications to address particular symptoms. These effects included nonsedative calming (20%), sedation (16%), and activation (14%). Dr McIntyre observed that, rather than looking at depression in its totality, clinicians are looking at domains such as arousal and overactivation or, at the other end of the spectrum, fatigue and amotivation. Further, while prominent symptoms like psychosis would undoubtedly influence clinicians to choose an antipsychotic versus another course of treatment, symptoms like agitation, hostility, and irritability seem to then play a role in the choice of one antipsychotic over another.Concern over specific side effects may limit use of adjunctive antipsychotics for some patients with MDD.8?Weight gain (60.0%) and metabolic side effects (57.6%) were of greatest concern for physicians, followed by extrapyramidal symptoms (43.2%), sedation (31.9%), and akathisia (25.6%). Dr McIntyre pointed out that mitigating anxiety and sleep problems with medication would be adjudicated as improving the person’s quality of life, if we assume the absence of significant safety concerns.Anxiety and Sleep Problems in MDDNext, Dr McIntyre discussed the burden of anxiety and sleep problems in MDD as well as the question of how best to address these symptoms in the long term.The Sequenced Treatment Alternatives to Relieve Depression study demonstrated that 46% of MDD patients had high levels of anxiety at baseline,9?and research has indicated that about 40%–50% of MDD patients have an anxiety disorder.10, HYPERLINK "" \l "ref11" \o "11. Zimmerman M, Chelminski I, McDermut W. Major depressive disorder and Axis I diagnostic comorbidity. J Clin Psychiatry. 2002;63(3):187–193. PubMed CrossRef" 11?The addition of the anxious distress specifier to?DSM-5?was an attempt to warn physicians of the hazards posed by anxiety. Anxious distress not only is a predictor of nonresponse12?to conventional antidepressants but also is highly associated with a more complex illness presentation, including higher rates of suicidality.13Sleep disturbances (eg, insomnia, sleep deprivation, alterations in the circadian rhythm) are common chief complaints in people with depression and a frequent reason they see health care providers. Sleep impairment has also been shown to be linked to suicidality,14?as well as impaired cognition,15?which clearly adversely impacts daily functioning. Further, insomnia has been shown to predict future work disability.16Addressing anxiety and insomnia symptoms.?In February 2019, 2 online polls were conducted via the website to assess the treatment choices clinicians are making when faced with a challenging scenario—an MDD patient struggling with insomnia, anxiety, or restlessness or, conversely, lethargy, fatigue, and hopelessness. Both polls indicated that clinicians are indeed considering atypical antipsychotics to address symptoms that remain after antidepressant treatment. The first poll described a patient with treatment-resistant depression and symptoms of anxiety and sleeplessnessThe most commonly selected answer was a sedating atypical antipsychotic: olanzapine or quetiapine. A close second was a less sedating atypical antipsychotic such as aripiprazole or brexpiprazole. A benzodiazepine was the third most popular choice, representing a quarter of the respondents.Dr McIntyre explained that the objective of administering an antipsychotic in someone with high levels of arousal and agitation should be to shift their arousal not to the point where they are sedated and falling asleep during the day, but to the point where they are optimally functional. It is essential, for human function, that people have some degree of arousal and even anxiety; too much or too little, though, is associated with severe impairment.17?As he put it, “The art of selecting an antipsychotic is to choose one that is able to mitigate key distressing symptoms that contribute to functional impairment, such as anxiety or fatigue, without causing harm to the patient.”As indicated by the online poll results, clinicians do indeed sometimes select a particular antipsychotic for its sedating effects. Quetiapine’s sedative effect is well known, and Hermes et al18?showed that clinicians frequently prescribe quetiapine in patients who have problems with sleep. In a double-blind study, HYPERLINK "" \l "ref19" \o "19. Calabrese J, MacFadden W, McCoy R. Double-blind, placebo controlled study of quetiapine in bipolar depression [poster]. 157th Annual Meeting of the American Psychiatric Association; May 1–6, 2004; New York, NY." 19?quetiapine, administered once daily at bedtime, produced improvements in the quality of sleep as measured by the Pittsburgh Sleep Quality Index. Excessive sedation, though, may lead to nonacceptance of treatment: rates of patient withdrawal due to somnolence or sedation in that study were 12.2% for quetiapine 600 mg/d and 9.5% for quetiapine 300 mg/d. Most of these withdrawals occurred during the first week of the study.19Benzodiazepines can also mitigate anxiety when prescribed adjunctively with an antidepressant, HYPERLINK "" \l "ref20" \o "20. Furukawa TA, Streiner DL, Young LT. Antidepressant plus benzodiazepine for major depression. Cochrane Database Syst Rev. 2001;(2):CD001026. PubMed CrossRef" 20?and according to Dr McIntyre, use of antidepressants with sedating qualities, such as trazodone, remains somewhat common. A caveat with benzodiazepines, especially when thinking beyond short-term use, is that they can cause cognitive impairment,21?worsen anhedonia,22?and increase the risk of fractures and falls. He noted that agents such as mirtazapine and anticonvulsants have also sometimes been used to improve sleep.The more sedating antipsychotics such as quetiapine and olanzapine unfortunately often come with the trade-offs of daytime somnolence and excessive sedation. Dr McIntyre commented that, too often, patients for whom a sedating antipsychotic has been prescribed to improve sleep are left indefinitely on the medication without any monitoring of adverse effects that may develop. Clinicians should be mindful of the risk of moving patients too far in the direction of feeling sedated and somnolent the next day—and perhaps having those problems persist.The question “Is there such a thing as ‘helpful’ sedation?” shifts if we consider the possibility of ameliorating excessive activation?in the absence of?sedation or sleepiness. Evidence now indicates that some atypical antipsychotics can reduce anxiety and activation without making patients lethargic. Aripiprazole, an agent not generally associated with excessive sedation, has been shown to be efficacious in treating anxiety in patients who have major depressive disorder with anxious symptoms.23?Dr McIntyre further mentioned that a benzodiazepine is sometimes used in conjunction with nonsedating agents such as aripiprazole in an effort to address sleeplessness. He did express concern that, as an adjunct to selective serotonin reuptake inhibitors or serotonin-norepinephrine reuptake inhibitors in depression, the dosing target for aripiprazole is not always apparent and requires significant titration.Other caveats of the dopamine partial agonists approved for MDD (aripiprazole and brexpiprazole) include the risks of moderate weight gain and akathisia. It should be noted, though, that the risk of weight gain with these agents is lower than that associated with other atypical agents such as quetiapine or olanzapine.24?A recent study25?demonstrated efficacy of brexpiprazole specifically in patients with MDD with anxious distress; brexpiprazole was not associated with activating adverse events such as akathisia or restlessness. Another study26?indicated that brexpiprazole mitigated sleep disturbances in patients with MDD without daytime sedation. Dr McIntyre believed that the possibility of addressing sleep complaints in the absence of a separate medication such as a benzodiazepine would be ideal in that the medication regimen would be simpler and the likelihood of long-term benzodiazepine use would be lessened.Fatigue and Amotivation Symptoms in MDDFatigue, hopelessness, and “flatness” are frequent complaints heard in clinical practice from MDD patients, and, as seen in the survey discussed earlier,8?clinicians seem to prioritize them as reasons to choose an antipsychotic. Essentially, these symptoms are related to amotivation, or the lack of desire to engage with the world, and they can threaten job performance and psychosocial functioning and impact patients’ lives substantially.Addressing fatigue and amotivation symptoms.?The second online poll focused on medication choice in a patient with inadequate antidepressant response and low energy. The most common selection as a next step for this patient was bupropion. The second choice, interestingly, was an atypical antipsychotic such as aripiprazole or brexpiprazole. In distant third and fourth places were psychostimulants and modafinil.The online polls suggested that choice of augmentation on the basis of tolerability profile seemed particularly likely if the symptom profile included fatigue and low energy; the first choice, bupropion, has a mild stimulant effect, while the next choices, aripiprazole or brexpiprazole, are dopamine partial agonists with relatively activating effects. Dr McIntyre observed that clinicians could be choosing these agents with the goal of conferring a “brightening” effect, that is, enhanced motivation, the experience of pleasurable rewards, increased energy, and less hopelessness and pessimism.Indeed, one of the key questions when a patient has an inadequate outcome with an antidepressant is whether to combine antidepressants or add an atypical antipsychotic. There is now evidence suggesting that use of an atypical antipsychotic may, in fact, be superior to the use of an antidepressant such as bupropion in improving overall symptoms in these patients. In a randomized open-label trial, Cheon et al27?showed greater remission rates for aripiprazole versus bupropion at week 6 endpoint (55.4% vs 34.0%, respectively;?P?=?.031). In addition to the positive results seen for aripiprazole, adjunctive brexpiprazole was shown to improve general and cognitive functioning as well as alertness in a 6-week study of patients with treatment-resistant MDD.28As noted earlier, these agents avoid the problematic somnolence and next-day sedation that can occur with some atypical antipsychotics. It appears to be a rational decision, then, to select one of these agents to address symptoms of apathy, fatigue, and anhedonia. The trade-off that comes with this strategy, though, is an increased propensity for akathisia and restlessness. Both aripiprazole and brexpiprazole are associated with higher risks of akathisia versus quetiapine and olanzapine in number-needed-to-harm analyses, as will be discussed in the next section; however, the risk was lower with brexpiprazole versus aripiprazole.29ConclusionClinicians do sometimes select antipsychotics specifically to leverage sedation and activation effects. However, it should be kept in mind that judicious antipsychotic selection requires familiarity with not just the short-term effects but also the potential long-term, possibly adverse, effects of the medication such as impairing sedation or akathisia/restlessness. Dr McIntyre summarized: “The aim should be to alleviate patients’ distress but not leave them cognitively impaired with decreased reaction time and decrease in function. Unfortunately, sedation is often interchangeable with these unwanted adverse events. Essentially, the goal is to provide distress alleviation and target symptom alleviation without burdening the patient.”Patient Perspectives“I have been taking 150 mg?×?2 [of quetiapine] along with 10 mg of Lexapro to help with chronic depression. Due to divorce this summer, I told my doctor I was feeling more depressed and he raised my dose to 200?×?2 at bedtime. I am a teacher, and the last 2 days I have not been able to get up. I start to get dressed and wake up hours later standing at the mirror with a toothbrush in my hand. Lucky for me we don’t have students yet, but I am terrified I will continue oversleeping and miss my classes.”30UNDERSTANDING RISK OF SEDATION AND ACTIVATION USING NUMBER NEEDED TO HARM (NNH)Leslie L. Citrome, MD, MPH, explained how clinicians can meaningfully assess and understand the risks of antipsychotic adverse events, specifically sedation and activation, using the number needed to harm (NNH) statistic. Incorporating NNH analyses in the assessment of adverse event risk represents one component of evidence-based medicine, a philosophy of care that exhorts clinicians to integrate the best available research evidence on efficacy and safety with individualized assessment of patients and their preferences, and then apply this insight to medical decision making.31?He emphasized that evidence-based medicine is not “cookbook medicine” and requires substantial clinical judgment.32?Physicians can use the concepts and tools of evidence-based medicine, such as calculating NNH, to appraise the value of adjunctive antipsychotic use in persons with MDD.How Can We Best Understand Adverse Event Rates?Although the 4 antipsychotics approved as adjunctive therapy in MDD have similar efficacy in reducing depressive symptoms, their adverse effect profiles differ widely.33,34?As also highlighted by Dr McIntyre, clinically relevant concerns have arisen regarding olanzapine’s propensity toward weight gain, quetiapine’s association with sedation, and reports of akathisia with aripiprazole,33?and it is within this context that brexpiprazole has been introduced as a potential alternative choice. But although adverse event rates in persons with MDD are described in the product label of each antipsychotic,35–38?the problem arises as to how clinicians can interpret a rate of akathisia reported as 9% for all brexpiprazole doses compared to a rate of 2% for placebo, or rates of somnolence of 5% versus 0.5%, respectively.38?From examining the relative differences between brexpiprazole versus placebo, it is easily calculated that rates of akathisia are 4.5 times higher and rates of somnolence are 10 times higher for brexpiprazole than for placebo. However, calculating relative differences is misleading for day-to-day clinical practice because the absolute rates, and absolute differences, are low, and thus the adverse effects would be encountered in a small minority of patients.How Is NNH Calculated?To address the issue of interpreting rates of adverse events for one medication compared to another (or to placebo), the “number needed to harm” concept can be helpful.39–42?NNH answers the question “How many patients would you need to treat with Medication A instead of Medication B before you would expect to encounter 1 additional outcome of interest that you would like to avoid?” The?higher?NNH value, the?greater?the advantage for Medication A, as it would take a larger number of patients to be treated with Medication A instead of Medication B before one would expect to see the adverse event being considered. If the rate of an adverse event for each drug is available, NNH is easy to calculate, as follows:NNH?=?1/[fa?–?fb], wherefa?=?rate of adverse event for Medication Afb?=?rate of adverse event for Medication BThe denominator, fa?–?fb, is often called the?attributable risk increase?or?absolute risk increase. Unfortunately for the purposes of comparison, product labels describe studies of medications compared with?placebo, not with other drugs. Thus, we are left to make indirect comparisons: for example, what is the NNH for an adverse event for Medication A versus placebo, and is it bigger or smaller than the NNH for that same adverse event for Medication B versus placebo? The medication with the higher NNH value versus placebo will be the one less likely to be associated with that adverse event. In general, if the NNH is less than 10 when a medication is compared with placebo, the adverse event in question will be commonly encountered in day-to-day clinical practice.What Is an Acceptable NNH?When thinking about NNH, clinicians must consider the relevance of the adverse event for the individual patient being treated, and an acceptable NNH for drug versus placebo depends on the outcome in question. For example, a relatively minor adverse outcome such as transient mild nausea may be inconsequential even though the NNH value may be a single digit. In general, a single-digit NNH (ie, <?10) may be acceptable if the adverse event is mild or moderate, does not lead to discontinuation, is temporary or causes little distress, and does not pose a serious health risk?or?if the need for efficacy is so great that it mitigates the low NNH tolerability limitation.42?An NNH value of 10–100 may be acceptable for adverse events that may lead to discontinuation but are not associated with serious immediate health risks, or when alternative medications do not have a better profile; an example might be moderate weight gain.42?Even higher (>?100) NNH values are usually required for adverse events that pose a significant health paring NNH for Activation and Sedation Among Antipsychotics Approved for MDDActivating and sedating properties of first-line oral second-generation antipsychotics were evaluated in a prior publication29?by examining the rates of adverse reactions as reported in product labeling for the indications of schizophrenia and adjunctive treatment of MDD. Activating adverse events included akathisia, restlessness, agitation, and insomnia. Sedating adverse events included somnolence, sedation, and fatigue.Provides the rates and NNH values for these adverse events for the 4 agents approved for adjunctive MDD treatment, as observed in the short-term acute placebo-controlled clinical trials used to obtain FDA approval. Not all activating or sedating adverse event rates are available, as some of the specific adverse event terms for some of the medications did not meet the minimum frequency threshold for reporting.NNH values less than 10 were reported for aripiprazole for akathisia (NNH?=?5) and for quetiapine extended-release for somnolence (NNH?=?5) as well as the combined terms “sedation and somnolence” (NNH?=?4). These values can be interpreted to mean that for every 5 patients on antidepressant therapy who were randomized to adjunctive aripiprazole instead of to adjunctive placebo, one can expect to encounter 1 additional patient with an adverse event of akathisia, and that for every 4 patients randomized to adjunctive quetiapine extended-release instead of adjunctive placebo, one can expect to encounter 1 additional patient with a complaint of sedation or somnolence. Importantly, the values predict that akathisia with aripiprazole and sedation/somnolence with quetiapine extended-release would occur commonly in day-to-day clinical practice. Forest plots for akathisia adverse events and for somnolence adverse events are shown in?. Although comparisons of adverse events associated with olanzapine-fluoxetine combination versus placebo-fluoxetine combination did not demonstrate any NNH values less than 10 for activating or sedating adverse events, somnolence adverse event reporting came close, with an NNH value of 10.The NNH analysis29?further illustrates that, in contrast to the above agents, brexpiprazole does not appear to be either particularly activating or sedating, with none of the NNH values in either category being a single digit or close to it. Thus, these events would not be expected to occur as commonly with brexpiprazole compared to akathisia with aripiprazole or sedation/somnolence with quetiapine extended-release. Not included in?Table 1,?but of relevance for clinicians, is that the NNH value for the outcome of weight gain of at least 7% from baseline for olanzapine-fluoxetine combination versus placebo-fluoxetine combination was 3, compared with NNH values of greater than 20 for the alternatives.33,34?Therefore, clinically relevant weight gain would be anticipated to occur substantially more frequently with olanzapine-fluoxetine combination than with adjunctive aripiprazole, brexpiprazole, or quetiapine extended-release.Additional ConsiderationsQuantifying the risk of encountering adverse events using NNH allows us to make indirect comparisons in a straightforward fashion. Clinicians should keep in mind, though, that there is substantial heterogeneity in how individual patients tolerate different medications. Although quetiapine extended-release is generally considered sedating, there are patients who tolerate this medication well and have no appreciable sedation, somnolence, hypersomnia, or fatigue. Likewise, some patients who receive aripiprazole do not exhibit akathisia, restlessness, agitation, or insomnia. In addition, there may be a dose-response relationship with these adverse effects, allowing mitigation by dose reduction provided that efficacy is maintained. Past history of tolerability, or lack thereof, to other medications may be helpful in determining an individual patient’s vulnerability to activating or sedating adverse events. Having this prior information enables the clinician to better predict potential medication effects and use NNH information to make an informed individualized treatment decision.CLINICAL PERSPECTIVESJ. Sloan Manning, MD, began by listing important points for clinicians to remember when thinking about sedation and activation effects of atypical antipsychotics in MDD patients. He then outlined the roles of motivational interviewing and collaborative care models in making treatment choices that minimize adverse effects and maximize the likelihood of remission. It shows a useful list of questions for clinicians who are considering leveraging a sedative or activating effect of an antipsychotic to treat a patient with MDD. As echoed by other presenters, Dr Manning cautioned that individual patients can vary unpredictably with regard to the intensity of an adverse effect, the way the effect is expressed, and the patient’s tolerance of it. He further pointed out that primary care physicians can use NNH comparisons, such as those discussed by Dr Citrome, to help guide discussions with patients regarding relative risk. Doing so can help set expectations and guide the selection of the best treatment choice for an individual.Especially in primary care, physicians often hear complaints of poor sleep, and as many as 90% of patients with depression will have problems with sleep quality.43?Poor sleep predicts poorer clinical outcomes in MDD and may be a symptom of the illness itself or a side effect of another medication such as an antidepressant. Thus, these symptoms are thus frequently a priority for both patient and clinician with regard to treatment strategy. Dr Manning highlighted a study demonstrating that sedation may not be necessary in order to achieve sleep improvement. Krystal et al26?used polysomnography and sleep diaries to assess patients with inadequate antidepressant responses and poor sleep efficiencies who were given adjunctive brexpiprazole. In this sample, physiologic measures of sleep and daytime alertness were improved. In fact, insomnia decreased, and functioning assessed by the Massachusetts General Hospital–Cognitive and Physical Functioning Questionnaire improved as well. Furthermore, sleep architecture improvements were noted in sleep efficiency, total sleep time, sleep onset latency, wake-time after sleep onset, and latency to persistent sleep. These data, when combined with NNH measures of sedation, give clinicians a broader sense of the sleep benefits that may accrue beyond first-order patient reports of sedation or somnolence as adverse effects in clinical trials.Using Motivational Interviewing to Minimize Adverse Effects and Optimize Treatment ChoicePatient-centered approaches, such as motivational interviewing (MI), intersect with the conversation around adverse events, as they can be used to inform treatment choice by pinpointing symptoms and adverse effects that may trouble the patient. Motivational interviewing has been introduced into the treatment of depression44?and can be used hand-in-hand with advanced pharmacologic strategies, such as augmenting with an atypical antipsychotic, to foster better outcomes in MDD patients. Originally developed in substance abuse settings, HYPERLINK "" \l "ref45" \o "45. Rollnick S, Miller WR, Butler C. Motivational Interviewing in Health Care: Helping Patients Change Behavior. New York, NY: Guilford Press; 2008." 45?MI is based in empathy, patient autonomy, and recognizing that patients possess expertise in their illness. It encourages psychological attunement between patient and provider, which can increase likelihood of remission regardless of the treatment modality chosen.46,47?Patients who participate in treatment selection may be more adherent and persistent and therefore more successful in reaching treatment goals.To implement MI, the clinician allows the MDD patient to set the agenda for their visits and indicate readiness to proceed with treatment by using “change talk” such as “I can,” “I would be willing,” and “I am ready.” Some open-ended questions could include “What do you hope to achieve in the treatment of your depression?” “How would your improvement impact others?” “How confident are you, on a scale of 1 to 10, that the treatment we are considering is likely to help you?” and “What adverse effects would you most want to avoid?”Questions relating specifically to adverse events include:Is anything about your medication bothering you or causing you to miss doses? Do you wish your treatment could be changed?Is sedation a problem?Is restlessness a problem?followed by…Tell me more about that.How do these effects interfere with your life?In this way, clinicians can draw out which symptoms might be most bothersome, as well as which adverse effects might be tolerable—and which could lead to nonadherence and therefore treatment failure. For instance, sedation could interfere with a patient’s ability to care for their child. Akathisia may distract from a task or foster an irritable mood. The clinician should keep in mind that the overarching goal of treatment is long-term remission, and distressing adverse effects could threaten that goal. With the patient’s permission, the clinician can go on to advise about treatment options that are least likely to cause impairing side effects and most likely to bring about remission.Addressing Symptoms and Side Effects in a Collaborative Care ModelDr Manning described how the collaborative care model can provide a framework that supports adverse event monitoring and helps physicians make informed and responsive treatment choices. Managing treatment-resistant depression in primary care settings can be challenging due to time constraints, lack of resources, and even lack of provider training and experience. Integrating primary care and behavioral care could help close treatment gaps by augmenting clinic resources and offering opportunities for consultation to improve clinical skills. Collaborative care models have been shown to improve outcomes and provide medical care offsets.49, HYPERLINK "" \l "ref50" \o "50. Hunkeler EM, Katon W, Tang L, et al. Long term outcomes from the IMPACT randomised trial for depressed elderly patients in primary care. BMJ. 2006;332(7536):259–263. PubMed CrossRef" 50The primary care provider (PCP) remains the leader of the care team, with the assistance of a collaborative care manager for behavioral treatment and a consultation-liaison psychiatrist. The PCP administers treatment metrics and can also use open-ended questions such as those mentioned in the previous section. The care manager tracks patient progress using a registry or dashboard. Patients receive brief cognitive psychotherapies to create a multidisciplinary treatment milieu. The care manager meets with the psychiatrist at least weekly to discuss treatment issues for MDD patients who fail to respond, remit, or have other problems with pharmacologic management. Recommendations for medication adjustment are communicated to the PCP, who remains responsible for initiating the adjustment and may confer with the psychiatrist. The clinical care manager, as an advocate, can help monitor for important or bothersome adverse effects. If a patient experiences substantial sedation or akathisia that could lead to noncompliance, a clinical care manager can identify the problem early and inform the PCP or consultant psychiatrist, who can then initiate a treatment change, such as switching to another agent to achieve a better result. Patients who remain refractory to care, are diagnostic dilemmas, or are too ill to remain in the PCP setting may be transitioned to specialty care.Pharmacologic interventions delivered in these care models may be more likely to be evidence based, optimized in dosing and duration, and successful in creating remission.51?In these settings, PCPs can acquire new clinical skills and gain experience with pharmacologic strategies for MDD, such as adjunctive use of atypical antipsychotics.SummaryPrimary care providers should ensure that they are familiar with the use of atypical antipsychotics as adjunctive agents for treatment-resistant MDD, as these agents represent tools for achieving remission and recovery. They should understand how to effectively inquire about bothersome symptoms and adverse events in patients with MDD, and they can use motivational interviewing to improve communication along these lines. Integration of primary care and behavioral care may help close gaps in MDD treatment and can offer opportunities for consultation to improve clinical skills and increase PCPs’ knowledge about MDD treatment options such as atypical antipsychotics.Although clinicians may be tempted to use adverse or secondary effects of atypical antipsychotics to improve symptoms, efficacy should remain their central focus, with better tolerability and avoidance of effects such as sedation and akathisia supporting adherence. Maximum, sustained improvements in core depression symptoms should remain a main target of MDD treatmentIMPACT ON PATIENT FUNCTIONINGDiane McIntosh, MD, FRCPC, focused on the impact of sedation and activation effects on patients’ lives as well as strategies for minimizing the risk of their occurrence. She presented 2 cautionary cases that illustrate how a clinician’s initial attempts to manage symptoms led to the development of intolerable sedation and akathisia side effects and explained how treatment might have been optimized instead.Sedation and Its Implications: Short-Term vs Long-TermSedation may be experienced as desirable in the short term, especially for an individual who is enduring an acute exacerbation of their mental illness. Sedating medications can help ameliorate insomnia, anxiety, or agitation, but prolonged use of a sedating treatment can lead to unpleasant side effects: as Dr McIntosh related, “People don’t like feeling drugged or, as my patients sometimes put it, ‘like a zombie.’” Further, excessive sedation can be so functionally impairing that it results in “presenteeism”: the person is at work, but their brain is not. The patient may be too sedated or impaired to do their work properly or efficiently, which could put their job at risk. Dr McIntosh pointed out that excessive sedation could also increase the risk of accidents in multiple settings—whether in the context of safety-sensitive occupations, motor vehicle accidents, or falls. Significantly, fatigue can be a symptom of the primary illness, and if the medication provokes fatigue or is excessively sedating, it might lead both prescriber and patient to conclude that there are untreated symptoms. When medication side effects resemble symptoms of the disorder, the patient may get a sense that their illness is ongoing and that the medication is not effective.Activation: Not Necessarily a Good Thing?Dr McIntosh noted that the terms?sedation?and?activation?can have different meanings for clinicians, depending on the clinical situation. She pointed out that the word?activation?is sometimes used with positive connotations, in the context of improved energy or helping patients “get going” again. However, the same term—activation—also describes adverse events such as restlessness, agitation, or akathisia that can be highly unpleasant, even frightening experiences for the patient and must be regarded as serious issues.It is widely known that many first-generation antipsychotics pose a substantial risk for akathisia. Although the risk may be relatively lower with newer antipsychotics, they still pose a hazard,53,54?and clinicians should always be on the lookout for this side effect because it is easy to miss. Akathisia is considered an extrapyramidal side effect characterized by an intense?feeling?of restlessness or a need to move, rather than by prominent, visibly abnormal movements. Consensus about the relative importance of objective and subjective features for diagnosing akathisia has not been reached.55?It is most often associated with use of high-potency D2?blocking antipsychotics, rapid dose titration, and sudden large dose increases.55,56?Certain groups, including women, those with mood disorders, and those with greater depression severity and more cognitive symptoms, may be at higher risk.55,57,58?The consequences of unrecognized akathisia can be very serious. It is associated with a high rate of treatment nonadherence, resulting in illness exacerbation and recurrence. The akathisia symptoms themselves have also been associated with negative outcomes such as exacerbation of illness, aggression, violence, and suicide.53, HYPERLINK "" \l "ref59" \o "59. Gualtieri CT. The problem of tardive akathisia. Brain Cogn. 1993;23(1):102–109. PubMed CrossRef" 59Recognition of problematic activation effects.?As suggested by Dr Citrome’s NNH analyses, akathisia is a common clinical outcome when prescribing aripiprazole. Dr McIntosh expressed that her general preference would be to choose an agent from the outset that is less likely to cause excessive activation or sedation effects in the long run. Clinicians should monitor their patients carefully for symptoms of excessive activation. They should know how to differentiate akathisia from anxiety, agitation, and tardive dyskinesia and know how best to proceed if they encounter a patient who is experiencing akathisia.A main reason for failing to recognize activation-related symptoms is that patients often struggle to describe their experience and may say, “I’m anxious” or “I feel agitated”53; or simply, “I can’t get comfortable,” “I’m jumping out of my skin.”60?Further, akathisia may be missed if it occurs in areas other than the legs, if other prominent psychiatric symptoms are present, or if there are no other apparent extrapyramidal signs.61?Clinicians sometimes fail to ask patients who are prescribed an antipsychotic about akathisia; they may limit their assessment to objective, obvious restlessness, or they may adhere too strictly to research diagnostic criteria regarding how akathisia will present.61Anxious?patients experience worry or fear and physical manifestations (eg, sweating, palpitations, tremor, restlessness), HYPERLINK "" \l "ref53" \o "53. Lohr JB, Eidt CA, Abdulrazzaq Alfaraj A, et al. The clinical challenges of akathisia. CNS Spectr. 2015;20(suppl 1):1–14, quiz 15–16. PubMed CrossRef" 53?but they don’t experience the urgent “I need to move” sensation that defines akathisia.Agitation?is an observable sign.53?It may include pacing, fidgeting, or foot-tapping and can be both an emotional and a physical experience, overlapping with anxiety. Dr McIntosh emphasized that both anxiety and agitation should be treated with a sense of urgency, but differentiated.Tardive dyskinesia, in contrast to akathisia, may or may not be distressing to the patient. The involuntary movements can be observed during an appointment. Akathisia tends to occur in the lower limbs; tardive dyskinesia, in the extremities and face. Tardive dyskinesia is chronic and potentially irreversible. Whereas tardive dyskinesia may actually worsen if the medication is stopped, at least in the short term, stopping the medication usually provides immediate relief of akathisia.Activation: Not Necessarily a Good Thing?Dr McIntosh noted that the terms?sedation?and?activation?can have different meanings for clinicians, depending on the clinical situation. She pointed out that the word?activation?is sometimes used with positive connotations, in the context of improved energy or helping patients “get going” again. However, the same term—activation—also describes adverse events such as restlessness, agitation, or akathisia that can be highly unpleasant, even frightening experiences for the patient and must be regarded as serious issues.It is widely known that many first-generation antipsychotics pose a substantial risk for akathisia. Although the risk may be relatively lower with newer antipsychotics, they still pose a hazard,53,54?and clinicians should always be on the lookout for this side effect because it is easy to miss. Akathisia is considered an extrapyramidal side effect characterized by an intense?feeling?of restlessness or a need to move, rather than by prominent, visibly abnormal movements. Consensus about the relative importance of objective and subjective features for diagnosing akathisia has not been reached.55?It is most often associated with use of high-potency D2?blocking antipsychotics, rapid dose titration, and sudden large dose increases.55,56?Certain groups, including women, those with mood disorders, and those with greater depression severity and more cognitive symptoms, may be at higher risk.55,57,58?The consequences of unrecognized akathisia can be very serious. It is associated with a high rate of treatment nonadherence, resulting in illness exacerbation and recurrence. The akathisia symptoms themselves have also been associated with negative outcomes such as exacerbation of illness, aggression, violence, and suicide.53, HYPERLINK "" \l "ref59" \o "59. Gualtieri CT. The problem of tardive akathisia. Brain Cogn. 1993;23(1):102–109. PubMed CrossRef" 59Recognition of problematic activation effects.?As suggested by Dr Citrome’s NNH analyses, akathisia is a common clinical outcome when prescribing aripiprazole. Dr McIntosh expressed that her general preference would be to choose an agent from the outset that is less likely to cause excessive activation or sedation effects in the long run. Clinicians should monitor their patients carefully for symptoms of excessive activation. They should know how to differentiate akathisia from anxiety, agitation, and tardive dyskinesia and know how best to proceed if they encounter a patient who is experiencing akathisia.A main reason for failing to recognize activation-related symptoms is that patients often struggle to describe their experience and may say, “I’m anxious” or “I feel agitated”53; or simply, “I can’t get comfortable,” “I’m jumping out of my skin.”60?Further, akathisia may be missed if it occurs in areas other than the legs, if other prominent psychiatric symptoms are present, or if there are no other apparent extrapyramidal signs.61?Clinicians sometimes fail to ask patients who are prescribed an antipsychotic about akathisia; they may limit their assessment to objective, obvious restlessness, or they may adhere too strictly to research diagnostic criteria regarding how akathisia will present.61Anxious?patients experience worry or fear and physical manifestations (eg, sweating, palpitations, tremor, restlessness), HYPERLINK "" \l "ref53" \o "53. Lohr JB, Eidt CA, Abdulrazzaq Alfaraj A, et al. The clinical challenges of akathisia. CNS Spectr. 2015;20(suppl 1):1–14, quiz 15–16. PubMed CrossRef" 53?but they don’t experience the urgent “I need to move” sensation that defines akathisia.Agitation?is an observable sign.53?It may include pacing, fidgeting, or foot-tapping and can be both an emotional and a physical experience, overlapping with anxiety. Dr McIntosh emphasized that both anxiety and agitation should be treated with a sense of urgency, but differentiated.Tardive dyskinesia, in contrast to akathisia, may or may not be distressing to the patient. The involuntary movements can be observed during an appointment. Akathisia tends to occur in the lower limbs; tardive dyskinesia, in the extremities and face. Tardive dyskinesia is chronic and potentially irreversible. 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Dementia ? Anxiety ? Psychical ? Disorganized Speech ? Interpersonal Conflict ? Elopement ? MR/Develop Disorder ? Depression/Sadness ? High Risk Behavior ? Organic Condition ? Family Issues ? Resistance to ADL/Meds ? Short-Term Memory Prob ? Grief/Loss ? Restlessness ? Long-Term Memory Prob ? Psychosis ? Sexually Inappropriate Beh ? Suicide ? Sleep Disturbance ? Withdraw ? Wandering ? Weight Loss Substance Abuse: 412953115634Current: 387045115634History: Current/Previous Mental Health Diagnosis: Additional Information: Please Attach: ? Facesheet □ Secondary Insurance (If available) ? Signed Consent □ Medicare Card (If available) ? PCP Order (Refer to Senior Psychological Care and/or Senior PsychCare for Eval and Treat) Senior Psychcare 4635 Southwest Freeway Suite 635 | p. 713-850-0049 | f. 800-605-2138 | houstonpcc@DSM-V ABBREVIATEDNEURODEVELOPMENTAL DISORDERSIntellectual DisabilitiesOnset during development with deficits in intellectual, social, and practical areas of functioning: deficits manifest in reasoning, problem solving, and abstract thinking as confirmed by various standardized tests of intelligence. Additionally, adaptive functioning deficits manifested in failure to lived independently and to be socially responsible. Deficits limit functioning in home, school, and community. Communication DisordersPersistent difficulties with onset during early development, in the learning and use of language in its various forms (written, spoken) due to deficits in comprehension or production. Deficits (as being significantly below accepted age norms) manifested in reduced vocabulary, inability to express oneself due to limited sentence structure, and impaired discursive abilities. Difficulties are not attributable to an underlying medical condition. Autism Spectrum DisorderCharacterized by persistent problems in social interaction and communication across a wode range aof activities including reduced ability to share emotions and nonverbal cues and gestures. Also indicated by repetitious behaviors and patterns, insistence on sameness in routines, and fixation on restricted interests. Heightened sensitivity or lack thereof to environmental sensory stimulus.Attention-Deficit/Hyperactivity DisorderCharacterized by chronic inability to pay attention and impulsivity/hyperactivity that impaires functioning and development. Frequently unable to sustain interest in an activity or maintain mental focus required by a task. Easily distracted and forgetful of routine activities. Inability to sit still or remain quiet. Garrulous and impatient. Specific Learning DisorderCharacterized by problems in learning across a range of academic activities. Manifested by poor writing skills and reading comprehension, and/r difficulty in learning numerical concepts and applying numerical reasoning skills. Condition persists despite intervention to improve academic skills and is not better explained by intellectual disabilities, specific sensory deficits, or other extraneous factors. Motor DisordersCharacterized by excessive clumsiness and awkwardness as manifested by poor learning and performance of coordinated motor skills, with performance significantly below accepted age norms. Conditions’ onset is early in development. Stereotypic Movement Disorder: Manifested by repetitious behaviors, or patterns of behaviors, lacking in any obvious purpose. Behavior may include rocking and self-infliction of harm (biting or hitting).TIC DISORDERSCharacterized by chronic, unexpected, quick, impromptu, nonfluid behaviors and /or vocalizations. In the case of Tourette’s disorder, both motor and vocal tics are present concurrently; whereas in persistent (chronic) motor or vocal tic disorder, motor and vocal tics occur separately.Other Neurodevelopment DisordersCharacterized by the manifestation of symptoms of neurodevelopmental disorders that cannot easily be categorized as symptoms in this diagnostic category’ disorders also lead to problems in occupational, social, or other significant areas of functioning. SCHIZOPHRENIA SPECTRUM AND OTHER DISORDERSSchizotypal Personality Disorder: See section on personality disorders for definition. Delusional Disorder: Enduring delusions that may be accompanied by non-prominent hallucinations pertinent to the nature of the delusion itself. Functioning is not significantly affected apart from behaviors specifically related to delusions. Behavior generally does not appear to be odd or peculiar. Types of delusions may be erotomanic, grandiose, persecutory, jealous, somatic, mixed, or unspecified. Brief Psychotic Disorder: Characterized by hallucinations, delusions, disorganized incoherent speech, or grossly disorganized or catatonic behavior. Duration of condition is between 1 day and 1 month. Schizophreniform Disorder: At least two of the following symptoms are manifested for a period lasting between 1 and 6 months: Hallucinations, delusions, disorganized incoherent speech, grossly disorganized or catatonic behavior, negative symptoms such as reduced emotional expressiveness or avolition. Schizophrenia: At least two of the following symptoms are manifested for a period lasting at least 6 months: hallucinations, delusions, disorganized incoherent speech, grossly disorganized or catatonic behavior, negative symptoms such as reduced emotional expressiveness or abolition. Condition has had a significant negative impact on ability to function in areas such as occupation, academic, interpersonal, or self-care. Schizoaffective Disorder: An illness characterized by a continuous period wherein the major symptoms of schizophrenia are present and for the majority of the duration of the condition major mood (depressive or manic) episodes are present. Substance/Medication-Induced Psychotic Disorder: Evidenced by the manifestation of the symptoms of psychotic disorder during or soon after exposure to a substance or medication, or withdrawal therefrom. Psychotic Disorder Due to Another Medical Condition: Condition is the direct consequence of another medical condition. CatatoniaIndicated by the presence of three or more of the following: stupor, catalepsy, waxy flexibility, mutism, negativism, posturing, mannerism, stereotype, agitation, grimacing, echolalia, echopraxia.BIPOLAR AND RELATED DISORDERSBipolar I Disorder: Characterized by the following episodes: Manic Episode: A period of greatly elevated persistent heightened mood characterized by increased activity, energy, or irritability lasting at least a week characterized by the presence of at least three of the following : grandiosity, insomnia, garrulousness, incoherent disconnected rapid successions of thoughts, difficulty in paying attention and focusing, agitation, restlessness, increase in goal directed activity, excessive engagement in unrestrained behaviors with a high likelihood of negative outcomes (e.g., compulsive shopping gambling, entering into high risk business ventures).Hyomanic Episode: Similar to manic episode but period lasts at least 4 consecutive days.Major Depressive Episode: Indicated by the presence of at least five of the following during a sustained 2 week period: persistent negative mood, diminished satisfaction or pleasure from engaging gin nearly all activities, significant weight loss, chronic insomnia or hypersomnia, agitation, fatigue, feelings of worthlessness, difficulty concentrating and focusing, suicidal ideation.Bipolar II Disorder: Conditions for a current or previous hypomanic episode are met and the conditions for a current or previous major depressive disorder must also be met.Cyclothymic Disorder; For a period of at least 2 years, the symptoms of hypomania and depression have appeared numerous times; however, the criteria for a hypomanic episode or major depressive episode have not been satisfied. During the 2 year interval, hypomanic and depressive periods have occurred at least half the time and the patient has not be symptom free for more than 2 months at a time.DEPRESSIVE DISORDERSDisruptive Mood Dysregulation Disorder: Characterized by frequent outbursts of temper over a period lasting at least 1 year with no more than a 3-month period without outbursts. On average outburtsts occur three or more times weekly and individual’s mood is chronically irritable and abgry. Diagnosis is typically made between ages 6 and 18.Major Depressive Disorder: Characterized by the symptoms of major depressive episode.Persistent Depressive Disorder (Dysthymia): Symptoms represent an amalgamation of symptoms of chronic major depressive disorder and dysthymic disorder. Chronic depressed mood persists at least 2 years. While depressed, at least two of the following conditions are manifest: lack of appetite or overeating, insomnia or hypersomnia, fatigue, low self esteem, difficulty in concentrating and indecisive, hopelessness.Premenstrual Dysphoric Disorder: Three necessary conditions must be met in order for this diagnosis to apply:Symptoms must be present during the majority of menstrual cycles: at least five of these symptoms must manifest during the final week before the onset of menses, improvement should be noticeable within a few days after the beginning of menses; symptoms should be minimal or abate the week after menses.At least one of the following symptoms ust manifest: severe mood swings and increased emotional sensitivity, irritability and interpersonal friction, significantly depressed mood, considerable anxiety and emotional agitation.At least one of the following symptoms must be manifest for a cumulative total of at least five when combined with the symptoms in 2 above: decreased interest in daily activities, difficulty in focusing and concentration, significant lethargy, marked changes in eating habits (overeating or fixating on certain foods), insomnia or hypersomnia, feeling so f being overwhelmed, noticeable physical changes such as bloating, weight gain, swelling of joints or muscle pain.OBSESSIVE COMPULSIVE AND RELATED DISORDERSObsessive-Compulsive Disorder: Indicated by the presence of obsessions (unwanted, intrusive thoughts or images that are experienced repeatedly and bring about distress: person tries to counteract and alleviate these thoughts and images with other thoughts or actions) and/or compulsions (repetitive ritualized actions that the individual feels compelled to perform in order to alleviate the distress caused by obsessions). The repetitive rituals are causally unconnected to the obsessions they are attempting to counteract and /or are excessive in the application (for instance, repeatedly checking and rechecking that a door is indeed locked when one confirmation would suffice). Obsessions and/or compulsions endure, lasting at least an hour a day.Body Dysmorphic Disorder: Indicated by inordinate attention to at least one perceived flaw in physical appearance that is unnoticeable or appears slight to other observers. Individual engages in repetitive behavior as a means of obtaining reassurance about appearance concerns.Hoarding Disorder: Indicated by chronic difficulty in getting rid of possession regardless of their value. This behavior stems from a need to save items and the associated distress of being without them. The accumulation of hoarded items is so excessive so as to make living areas difficult to inhabit. Trichotillomania (Hair Pulling Disorder): Repetitive pulling of one’s own hair resulting in hair loss, accompanied by repeated attempts to cease this behavior.Excoriation (Skin-Picking) Disorder: Repeated skin picking behavior resulting in skin lesions, accompanied by repeated attempts to cease this behavior.Substance/Medication Induced Obsessive-Compulsive and Related Disorders: There is evidence that the symptoms of obsessive compulsive disorder transpire concurrently with or following substance intoxication, withdrawal, or following exposure to a medication: the substance/medication under consideration is capable of bringing about severe anxiety. ANXIETY DISORDERSNote: Anxiety disorders typically last at least 6 months, involve a disproportionate fear response relative to the actual danger posed, and involve maladaptive behaviors by the individual to avoid the anxiety provoking entity or situation.Separation Anxiety Disorder: Inordinate anxiety upon separation from parties the individual has formed a close emotional attachment to, as manifested by the presence of at least three of the following conditions: repeated intense anxiety when anticipating or experiencing separation from home or significant others, incessant rumination over the prospect of harm coming to significant attachments, chronic refusal or unwillingness to venture out away from home due to fear of separation, chrnic and significant anxiety about being left alone and separated from attachment figures, refusal or unwillingness to sleep away from home while separated from attachment figures, recurring nightmares about separation, recurring physical problems (headaches, nausea, gastrointestinal distress) when anticipating or experiencing separation.Selective Mutism: Characterized by reticence in situations where speaking is expected: condition interferes with social, educational, or vocational aspects of life; condition lasts at least 1 month: reticence is not due to difficulties with vocabulary or language (e.g., learning a foreign language).Specific Phobia: Characterized by disproportionate fear response to a specific object or situation: the fear response is almost always immediately elicited by the presence of the phobic object or situation: the phobia producing entity is actively avoided or only tolerated with great anxiety: the fear manifested is out of proportion to the actual danger posed by the phobia producing entity: fear and avoidance responses typically persist for at least 6 months.Panic Disorder: A panic attack is a sudden, unexpected, intense fear response during which anxiety rapidly escalates within minutes. In order to quality as a panic disorder a condition must include repeated panic attacks and at least four of the following symptoms: rapid heartbeat, sweating, shaking, shortness of breath, choking sensation, chest pain/discomfort, nausea or gastrointestinal distress, vertigo or sensation of loss of balance or feeling faint and light headed, sensations of heat or cold, paresthesias, derealization, fear of losing emotional control, fear of dying.At least one of the panic attacks has been followed by at least 1 month of one or both of the following: chronic worry about experiencing additional panic attacks (and their possible consequences), a marked effort to engage in behaviors to avoid panic attacks. Agoraphobia: Significant anxiety about at least two of the following scenarios: utilizing public transportation, being in open spaces, being in enclosed spaces, being in a crowd, being alone outside one’s home.NOTE: The above listed scenarios are avoided due to fear of being trapped or fear of experiencing symptoms of panic. Agoraphobic scenarios almost always elicit distress and anxiety. Fear responses typically last at least 6 months, and agoraphobic scenarios are avoided, require the individual to be accompanied, or are endured while experiencing intense fear. Generalized Anxiety Disorder: Inordinate worry about a variety of scenarios, occurring more days than not and lasting at least 6 months. The person finds it difficult to not ruminate about worry causing scenarios. At least three of the following symptoms must be present (with at least one lasting at least 6 months): agitation, loss of energy, difficulty focusing, irritability, muscular tension, difficulty sleeping. Substance/Medication Induced Anxiety Disorders: There is evidence that panic attacks transpire concurrently with or following substance intoxication, withdrawal, or following exposure to a medication: the substance/medication under consideration is capable of bringing about severe anxiety.TRAUMA AND STRESSOR RELATED DISORDERSReactive Attachment Disorder: Indicated by a chronic pattern of emotionally withdrawn behavior with adult caretakers manifested before age 5, and child is developmentally at least 9 months old. Condition is revealed by the presence of both of the following: child rarely seeks comfort when distressed, child is minimally responsive to the comfort provided when distressed. Additionally, at least two of the following manifest: minimal social responsiveness, minimal positive affect, periods of inexplicable irritability, fear, or sadness during periods of nonthreatening interaction with adult caretakers. The child has received extremely insufficient care as revealed by at least one of the following: severe neglect due to chronic lack of adequate emotional care by adult caretakers, instability from having frequent changes in adult caretaker, being raised in setting that severely limit the availability of attachments to adult caretakers. Disinhibited Social Engagement Disorder: Manifested by a child’s pattern of seeking out and interacting with unfamiliar adults, and the presence of at least two of the following: lack of reticence when interacting with unfamiliar adults, overly familiar physical or verbal behavior with unfamiliar adults, little regard for reconnecting with adult caretakers even in unfamiliar environments, unhesitatingly accompanying unfamiliar adults. Posttraumatic Stress Disorder: Condition lasts at least 1 month and results from experiencing actual or threatened death, serious injury, or sexual violence as manifested by at least one of the following; Directly experiencing or witnessing a traumatic event(s)Becoming aware of close friends or family members suffering a traumatic event(s)Repeated exposure to aversive aspects of traumatic eventsIntrusion Symptoms: Presence of at least one of the following after experiencing traumatic event(s):Recurring distressing memories of the eventFrequent nightmares involving the traumatic event(s)Flashbacks that may be accompanied by dissociative reactions as if the individual were reliving the traumatic event(s)Intense reactive distress when in the presence of cues that serve as reminders of the traumatic event(s)Avoidance Symptoms: Chronic avoidance behaviors beginning after occurrence of traumatic event(s), as manifested by at least one of the following: attempts to avoid distressing thoughts, feelings or memories reminiscent of the traumatic event(s); avoidance of external stimuli that may serve as reminders of the traumatic event(s).Negative Mood: Negative transformations of mood or thought related to the traumatic event(s), with onset after the event transpired, and manifested by at least two of the following:Dissociative amnesia – inability to remember details of the traumatic event(s)Chronic and exceedingly negative attidues and expectation about oneself, others, or surroundingsSelf-blame (or blame others) due to chronic inaccurate thoughts about the cause or effect of traumatic event(s)Chronic negative affectLoss of interest in significant activitiesAlienation from othersChronic inability to experience positive affectArousal Symptoms: Significant changes in sensitivity to traumatic event(s) starting or worsening after the traumatic event(s), as indicated by at least two of the following;Unprovoked irritability and temper tantrumsIrresponsible self-destructive activitiesHypervigilanceHeightened startle reactionDifficulty in focusing and concentratingDisrupted sleep patternsNOTE: The condition may also be accompanied by dissociative symptoms (i.e., depersonalization and derealization). Manifestation of the condition may also have delayed expression when full diagnostic criteria are not manifest until at least 6 months after the traumatic event(s).Acute Stress Disorder: The symptoms of this disorder are the same as those for posttraumatic stress disorder. At least nine symptoms manifest started immediately after the trauma and lasting from 3 days to 1 month. Adjustment Disorders: manifested by the appearance of emotional or behavioral symptoms as a reaction to definitive stress inducing events, with such symptoms making their appearance within 3 months of the event(s). Symptoms include one or both of the following: severe distress that is disproportionate to the intensity of the stress producing event., significant deterioration in key areas of functioning. Once the stress producing event(s) or its consequences have ceased, symptoms endure for no more than 6 months. DISSOCIATIVE DISORDERSThe essential feature of these disorders is a disruption in the integration of consciousness as this relates to memory, identity, and perception of the environment. Such disturbances may be gradual, transient, or chronic. The following categories have been identified:Dissociative Identity Disorder: Essential features include the presence of two or more distinct personality states or identities that recurrently assume control of the individual’s behavior, accompanied with the inability to recall important personal information that is too extensive to be accounted for by ordinary forgetfulness.Dissociative Amnesia: The inability to recall important personal information, usually of a traumatic or stressful nature, that cannot be explained with ordinary forgetfulness.Depersonalization/Derealization Disorder: Characterized by a persistent and recurring feeling of being estranged from oneself of being a spectator of one’s own life, and of being detached from ones’ mental processes or body that is accompanied by intact reality testing (i.e. the individual is aware that this is only a feeling of self alienation and not reality as such).SOMATIC SYMPTOM AND RELATED DISORDERSThis category encompasses disorders characterized by the presence of observable physical symptoms that are indicative of a general medical condition yet are not fully explained by a general medical condition, the direct effects of a substance, or another mental disorder. The symptoms must cause clinically significant distress or impairment in social, vocational, or other areas of functioning. Furthermore, the symptoms must be unintentional (not under voluntary control). Some subcategories include the following:Illness Anxiety Disorder: The preoccupation with the fear of having, or the idea that one is afflicted with, a serious disease based on the individual’s misinterpretation of bodily symptoms or functions.Conversion Disorder (Functional Neurological Symptom Disorder): Indicated by unexplained symptoms or deficits affecting voluntary motor or sensory functions that suggest a neurological or other general medical condition. Psychological factors are believed to be involved with the symptoms or deficits.Psychological Factors Affecting Other Medical Conditions: A medical condition is negatively affected by psychological factors by exacerbating the medical condition, disrupting treatment, bringing about additional health risks, or exacerbating or eliciting additional symptoms. Factitious Disorders: These disorders are characterized by physical or psychological symptoms that are intentionally produced or feigned in order to pretend to be ill. The conclusion that a particular symptom is intentionally produced is made by reference to direct evidence (e.g. the individual is found to be in possession of drugs that can produce the symptoms) or by a process of elimination whereby alternative causes are ruled out. FEEDING AND EATING DISORDERSEssential feature is the presence of persistent feeding and eating disturbances; includes pica, rumination disorder, and feeding disorder of infancy or early childhood.Rumination Disorder: Characterized by the repeated regurgitation of food for a period lasting at least 1 month.Avoidant/Restrictive Food Intake Disorder: Characterized by a chronic avoidance of, or lack of interest in, eating (due to the sensory attributes of food) to a degree constituting significant weight loss or nutritional deficiency. Condition may require enteral feeding.Anorexia Nervosa: Characterized by the individual’s refusal to maintain an minimally normal body weight, intense fear of gaining weight, and significantly distorted perception of the shape and size of one’s body. Bulimia Nervosa: Characterized by binge eating and inappropriate compensatory methods to prevent weight gain (e.g., induced vomiting, misuse of laxatives and diuretics). Furthermore, self evaluation is excessively influenced by body shape and weight. Binge Eating Disorder: Characterized by periods of binge eating averaging once a week for at least 3 months. Binges are characterized by the rapid consumption of abnormally large quantitiesof food while apparently unable to control this behavior.ELIMINATION DISORDERSThe condition is usually involuntary, and primary physiological causes should be ruled out. To quality for diagnosis, the condition needs to be present for prolonged periods with frequently repeated incident. Encopresis: Involves defecation in inappropriate places or occasions.Enuresis: Involves urination in inappropriate places or occasions. SLEEP-WAKE DISORDERSPrimary Sleep Disorders: Sleep disorders wherein the causal rle of another mental disorder, another medical condition, or a substance has been ruled out.Insomnia Disorder: Characterized by the inability to fall asleep or stay asleep, occurring at least 3 nights a week and lasting at least 3 months. Hypersomnolence Diorder: Characterized by excessive sleep lasting more than 9 ours that is unsatisfying, accompanied by episodes of lapsing into sleep during the day, and difficulty staying awake after awakening fully. Condition occurs at least 3 times per week and lasts at least 3 months. Narcolepsy: Characterized by episodes of an irresistible need to sleep during the same day. Condition occurs at least 3 times per week and lasts at least 3 months. Additionally, this condition is indicated by the presence of at least one of the following: episodes if cataplexy, hypocretin deficiency, rapid eye movement (REM) latency during sleep. Breathing-Related Disorders:These disorders include obstructive sleep apnea hypopnea, central sleep apnea, sleep-related hypoventilation, and circadian rhythm sleep-wake disorders. ParasomniasIndicated by abnormal behavioral or physiological events occurring in association with sleep, specific sleep stages, or sleep-wake transitions. Hence, such disturbances as nightmares, sleep terror, and sleepwalking would be included. Non-Rapid Eye Movement Sleep Arousal Disorders: Characterized by periods of inability to become fully awake; during these periods little orno dream imagery is experienced and individual has no recall of episode afterwards, Condition is indicated by one of the following:Sleepwalking: Characterized by repeated instances of getting upduring sleep and walking about while being relatively unresponsive and difficult to wake up.Sleep Terrors: Characterized by repeated instances of abruptly awakening from sleep ina state of panic. The typical symptoms of a panic attack are present and the person is relatively unresponsive to attempts to be subdued or calmed.Nightmare Disorder: Characterized by repeated instances of enduring extremely threatening dreams that are accurately recalled accompanied by the ability of the individual to wake up completely.Rapid Eye Movement (REM) Sleep Behavior Disorder: Characterized by repeated instances of sudden awakening accompanied by vocalizations and /or complex movements. Episodes occur during REM sleep phases and the individual has no problem waking up completely and being alert.Restless Legs Syndrome: Characterized by a seemingly irresistible need to shift he position of the legs due to discomfort when remaining still. Condition primarily manifests and night and occurs at least 3 times per week for at least 3 months. Substance/Medication – Induced Sleep Disorder: Characterized by a very significant interruption to sleep upon exposure to a medication/substance shortly thereafter, or during withdrawal from. The suspected medication/substance has the propensity to produce these very significant interruptions to sleep. SEXUAL DYSFUNCTIONSDelayed Ejaculation: For a period of at least 6 months, the individual experiences a significant undesired delay in ejaculation, infrequency thereof, or absence of ejaculation on almost all occasion of partnered sexual activity.Erectile Disorder: Indicated by the persistent, recurrent inablity to attain or maintain an adequate erection until the completion of the sexual activity.Female Orgasmic Disorder: Characterized by persistent or recurrent delays in, or absence of, orgasm following a normal sexual excitement phase. Since women manifest wide variability in their orgasmic response, this diagnosis should be made with care; such factors as age, sexual experience, general health and the degree of sexual stimulation applied should all be weighed carefully. Female Sexual Interest/Arousal Disorder: Indicated by greatly diminished or absent sexual interest/arousal lasting at least 6 months. The lack of interest/arousal is present on alost all occasions for sexual activity and there is greatly diminished or absent response to both mental and physical sexual stimulation.Genito-Pelvic Pain/Penetration Disorder: Indicated by genital pain experienced with sexual intercourse: although most commonly present during intercourse, the pain may also be present before or after intercourse. Condition may also include persistent or recurrent involuntary contraction of the perineal muscles surrounding the outer third of the vagiana when vaginal penetration is attempted. Condition lasts at least 6 months. Sleep Terrors: Characterized by repeated instances of abruptly awakening from sleep ina state of panic. The typical symptoms of a panic attack are present and the person is relatively unresponsive to attempts to be subdued or calmed.Nightmare Disorder: Characterized by repeated instances of enduring extremely threatening dreams that are accurately recalled accompanied by the ability of the individual to wake up completely.Rapid Eye Movement (REM) Sleep Behavior Disorder: Characterized by repeated instances of sudden awakening accompanied by vocalizations and /or complex movements. Episodes occur during REM sleep phases and the individual has no problem waking up completely and being alert.Restless Legs Syndrome: Characterized by a seemingly irresistible need to shift he position of the legs due to discomfort when remaining still. Condition primarily manifests and night and occurs at least 3 times per week for at least 3 months. Substance/Medication – Induced Sleep Disorder: Characterized by a very significant interruption to sleep upon exposure to a medication/substance shortly thereafter, or during withdrawal from. The suspected medication/substance has the propensity to produce these very significant interruptions to sleep. SEXUAL DYSFUNCTIONSDelayed Ejaculation: For a period of at least 6 months, the individual experiences a significant undesired delay in ejaculation, infrequency thereof, or absence of ejaculation on almost all occasion of partnered sexual activity.Erectile Disorder: Indicated by the persistent, recurrent inablity to attain or maintain an adequate erection until the completion of the sexual activity.Female Orgasmic Disorder: Characterized by persistent or recurrent delays in, or absence of, orgasm following a normal sexual excitement phase. Since women manifest wide variability in their orgasmic response, this diagnosis should be made with care; such factors as age, sexual experience, general health and the degree of sexual stimulation applied should all be weighed carefully. Female Sexual Interest/Arousal Disorder: Indicated by greatly diminished or absent sexual interest/arousal lasting at least 6 months. The lack of interest/arousal is present on alost all occasions for sexual activity and there is greatly diminished or absent response to both mental and physical sexual stimulation.Genito-Pelvic Pain/Penetration Disorder: Indicated by genital pain experienced with sexual intercourse: although most commonly present during intercourse, the pain may also be present before or after intercourse. Condition may also include persistent or recurrent involuntary contraction of the perineal muscles surrounding the outer third of the vagiana when vaginal penetration is attempted. Condition lasts at least 6 months. Male Hypoactive Sexual Desire Disorder: Characterized by a chronic lack of interest in, or desire for, sexual stimulation or activity. Condition lasts at least 6 months.Premature (Early) Ejaculation Indicated by repeated instances of ejaculation occurring within about one minute after penetration during sexual activity with a partner. Condition lasts at least 6 months and is manifest in almost all instances of sexual activity.Substance/Medication Induced Sexual Dysfunction: Indicated by a sever disruption in sexual functioning upon exposure to a medication/substance shortly thereafter or during withdrawal from. The suspected medication/substance has the propensity to produce these very significant disruptions to sexual functioning. GENDER DYSPHORIAGender dysphoria disorders are manifested by strong, persistent cross gender identification accompanied with persistent discomfort with one’s sex. There must be a strong and persistent cross gender identification that is not due merely to a desire to attain the perceived cultural or social advantages of being the other sex. There must also be present a persistent discomfort with one’s sex or a sense of inappropriateness in the gender role of that sex. Furthermore, disturbance is not due exclusively to the direct physiological effects of a substance. DISRUPTIVE, IMPULSE CONTROL AND CONDUCT DISORDERSThe essential feature of these disorders is the failure to resist an impulse, drive, or temptation to perform an act that is harmful to self or others. Typically, the individual experiences increased tension or arousal before committing the act, followed by relief, pleasure or gratification after completion of the act. Ensuing feelings of guilt, regret, or self-recrimination may or may not be present.Oppositional Defiant Disorder: Characterized by repeated displays of angry, irritable moods, and argumentative, defiant, vindictive behaviors for a period of at least 6 months. Condition is manifest with at least one individual who is not a sibling. Intermittent Explosive Disorder: Characterized by discrete episodes of failure to restrain aggressive impulses, resulting in serous assault or destruction of property. The degree of aggressiveness displayed is grossly disproportional to the objective physical of psychological provocation.Conduct Disorder: Indicated by repeated instances of activity within a 1 year period wherein the individual displays behaviors that may include (with at least one present for 6 months): aggression toward people and animals, destruction of property, deceitfulness or theft, and/or serious transgression of rules.Pyromania: Essential feature is the ignition of fires for pleasure, gratification, and relief of tension. There is a fascination with, curiosity about, and attraction to situation contexts with fire, witnessing its effects, or participating in its aftermath.Kleptomania: Indicated by the repeated failure to resist impulses to steal objects not needed for personal use or monetary value. The theft is not due to vengeance, need for survival, nor is it due to hallucinations. SUBSTANCE-RELATED AND ADDICTIVE DISORDERSThe major feature of these disorders is a cluster of cognitive, behavioral, and psychological symptoms indicative of continued substance use despite significant substance use related problems. One major consideration is that there is a persistent underlying change in brain chemistry lasting beyond detoxification. The behavioral changes manifested due to the altered brain chemistry may include chronic relapses and intense cravings for the substance when presented with substance related stimuli. The classes of drugs that comprise disorders include alcohol, caffeine, cannabis, hallucinogens, inhalants, opioids, sedatives, hypnotics, anxiolytics, stimulant, and tobacco.Non-Substance Related DisordersGambling Disorder: Indicated by persistent and recurrent maladaptive gambling behavior that disrupts personal, family or vocational pursuits.NEUROCOGNITIVE DISORDERSDelirium: Essential feature of condition is a disturbance of consciousness and an alteration in cognition that develops over a short interval. Subtypes include delirium due to general medical condition, substance induced delirium and delirium due to multiple etiologies.Major and Mild Neurocognitive DisordersMajor Neurocognitive Disorder: Indicated by serious cognitive impairment in at least one of the following areas of cognitive functioning: Perceptual motor, or social cognition. The cognitive impairment disrupts the performance of daily activities. The cognitive impairment does not manifest solely in the context of delirium. The condition may result from Alzheimer’s disease, frontotemporal lobar degeneration, Lew body disease, vascular disease, traumatic brain injury, substance/medication use, HIV infection , prion disease, Parkinson’s disease, Huntington’s disease, another medical condition, multiple etiologies or unspecified cause. Dementia: Encompassed under major neurocognitive disorder and retained as an alternative. Dementia includes multiple cognitive deficits and is thus a more narrow diagnosis than major neurocognitive disorder.Mild Neurocognitive Disorder: Indicated by a moderate decrease in cognitive functioning that does not disrupt the performance of daily activities. Other indicators for this condition are similar to major neurocognitive disorder. PERSONALITY DISORDERSGeneral Personality Disorder: Enduring patterns of inner experience and behavior that significantly deviates from the expectations of the individual’s culture, is pervasive and inflexible, originates in adolescence or early adulthood, is stable overt time, and leads to clinically significant distress or impairment in one or more important areas of functioning (E.G., social, academic, or occupational).Paranoid Personality Disorder: Indicated bya pattern of pervasive distrust and suspiciousness of others, such that their motives are interpreted as malevolent. Events and the actions of others are interpreted in the most negative light possible, and convictions of others’ hostility are based on little or no objective evidence. Schizoid Personality Disorder: Essential features include a pervasive pattern of detachment from social relationships and a restricted range of emotions in interpersonal settings. The individual typically will avoid social interaction, prefers solitary activities and interests, and seems to derive little or not pleasure from sensory, bodily, or interpersonal relationships. Affect is usually fat and expressionless, and there is a preference for abstract intellectual interests such as mechanical, mathematical, or computer related pursuits.Schizotypal Personality Disorder: Indicated by repeated instance’s of lacing adequate social or interpersonal skills, accompanied by acute uneasiness with, and diminished ability to, maintain close relationships. Co impending loss, rejection, separation, abandonment, or the loss of external stability and structure can produce profound alterations in self image, affect, cognition, and behavior.Histrionic Personality Disorder: Characterized by pervasive and excessive emotionality and attention seeking behavior, originating in early adulthood and manifesting in a variety of contexts. Individual feels uncomfortable and unappreciated if he/she is not the center of attention . Individual with this disorder will often behave in a melodramatic, histrionic, and flirtatious manner. Narcissistic Personality Disorder: Characterized by a pervasive pattern of grandiosity, need for admiration, and lack of empathy, originating in early adulthood and manifesting in a variety of contexts. The individual has an exaggerated sense of self importance, often displaying a conceited, boastful demeanor while overestimating his/her abilities and accomplishments.Avoidant Personality Disorder: Characterized by an inordinate preoccupation with being disapproved of, socially rejected, or criticized. Individual suffers from chronic feelings of inadequacy and is hypersensitive to the possible negative evaluations of others. Typically, significant interpersonal or social involvement is avoided, due to fear of being exposed, ridiculed or embarrassed. Due to constant need for reassurance, security and certainty of acceptance, individual often leads a rather isolated or restricted social existence.Dependent Personality Disorder; Indicated by an inordinate and chronic need to be taken care of, resulting in submissive clinging behavior and a fear of separation, abandonment or rejection. Due to a self perception of being unable to function without the help of others, the individual displays a variety of submissive and dependent behavior so as to elicity caregiving and nurturing behavior from others. Individual tends to be indecisive about even everyday matters and requires much advice and reassurance from others due to his/her extremely passive nature. Obsessive-Compulsive Personality Disorder: Characterized by a pervasive preoccupation with orderliness, perfectionism, and control originating in early adulthood and manifesting ina variety of contexts. Individual maintains painstaking attention to rules to the extent that the major point of the activity is lost. Perfectionism interferes with the ability to complete tasks. Individual is overly devoted to work to the exclusion of leisure activities and overconscientious about matters of morality. Individual may be unable to throw objects away, reluctant to delegate tasks, miserly and inflexible.Personality Change Due to Another Medical Condition: Indicated by the presence of a persistent personality disturbance attributed to the direct physiological effects of a general medical condition. The personality disturbance must manifest as a significant change from the individual’s previous characteristic personality pattern.PARAPHILIC DISORDERSCondition is manifested by early adulthood and is further characterized by perceptual distortion and odd thinking, speech, beliefs, and behavior.Antisocial Personality Disorder: Essential features include a pervasive pattern of disregard for, and violation of, the rights of others that begins in childhood or early adolescence and continues in to adulthood. Deceit , manipulation, and exploitation are central characteristics of this personality disorder. A pattern of impulsivity may also be present, such that decisions are made capriciously, with little or no forethought or planning.Borderline Personality Disorder: Indicated by a pervasive pattern of inability in interpersonal relationships, of self image and affects, accompanied by marked impulsivity with an onset in early adulthood and present in a variety of contexts. Individual will often be intensely concerned with abandonment and will go to great lengths to avoid real ior imagined abandonment. The perception of The presence of a paraphilia, per se, is not a disorder unless it is accompanied by distress causing impairment in the individual or present a harm, or risk of harm to others. Furthermore, in order to quality as a disorder the condition must endure for at least 6 months.Voyeuristic Disorder: Involves the surreptitious observation of unsuspecting individuals, usually strangers, who are naked, in the process of disrobing, or engaging in a sexual activity. The act of looking is to achieve sexual excitement and possibly orgasm if masturbation is engaged in concurrently with the act of voyeurism Generally, no sexual activity is sought with the individual observed. Exhibitionist Disorder: Involved deriving sexual pleasure or excitement from exposing one’s genitatls toa stranger. Occasionally the individual masturbates while exposing himself/herself. There is usually no attempt to initiate sexual activity with the stranger. Frotteuristic Disorder: Involves repeated instances of experiencing great sexual arousal from rubbing up against or touching nonconsenting individuals as revealed in fantasies, urges, or activities.Sexual Masochism Disorder: Involves acts (real, no simulated) in which the individual derives sexual excitement from being humiliated, beaten, bound, or otherwise made to suffer.Sexual Sadism Disorder: Involves acts (real, not simulated) in which the individual derives sexual excitement from the physical or psychological suffering of the victim.Pedophilic Disorder: Involves sexual activity with a prepubescent child (usually younger than 13 years of age): the pedophile must be at least 16 years of age and at least 5 years older than the child. Both sexual maturity of the child and the age difference must be taken into account. Fetishistic Disorder: Involves the utilization of nonliving objects (the fetish) for purposes of deriving sexual pleasure or producing sexual excitement. The absence of the fetish may be accompanied by erectile dysfunction in males.Transvestic Disorder: Involves cross dressing for the purpose of deriving sexual pleasure or excitement. This disorder is only described for heterosexual males and is not indicated when the cross dressing occurs as an element of gender identity disorder. MEDICATION-INDUCED MOVEMENT DISORDERS AND OTHER ADVERSE EFFECTS OF MEDICATIONThe conditions listed below are not mental disorders, but are nevertheless included because of their relevance to the management of medication for mental disorders and the differential diagnosis of mental disorders. Establishing a direct causal connection between the disorder and a medication suspected of causing it is by no means always clear of even possible, as these disorders may also at times manifest in the absence of the medication.NOTE: Neuroleptic medication have a propensity to induce movement disorders as a side effect.Neuroleptic-Induced Parkinsonism: Characterized by Parkinsonian tremors, muscular rigidity, difficulty in or inability to move (akinesia) or slow movement (bradykinesia). These symptoms typically manifest after a few weeks of beginning a medication or altering its dosage.Neuroleptic Malignant Syndrome: Characterized by excessive perspiration and gernalized muscle rigidity that is unresponsive to treatment. The individual’s mental state is in an altered state of consciousness ranging from stupor to coma, including delirium. Symptoms typically manifest within three days of exposure to dopamine antagonist agents.Brief Mental Status Exam (MSE) FormMental Status ExaminationDepartment of Psychiatry and Behavioral SciencesThe Mental Status Exam is analogous to the physical exam: it is a series of observations and examinations at one point in time. Focused questions and observations can reveal "normal" or pathological findings. Although our observations occur in the context of an interview and may therefore be ordered differently for each patient, the report of our findings is ordered and "paints a picture" of a patient's appearance, thinking, emotion and cognition. The data from the Mental Status Exam, combined with personal and family histories and Psychiatric Review of Systems, forms the data base from which psychiatric diagnoses are formed.Mental Status ExamA synopsis of the four MSE sections is presented below. In following pages, there are elaborations of each section, with sample descriptors.General ObservationsAppearanceSpeechBehaviorCooperativenessThinkingThought ProcessThought ContentPerceptionsEmotionMoodAffectCognitionOrientation/AttentionMemoryInsightJudgmentMSE Components in greater detail: these adjectives and descriptors may be helpful in describing your mental status exam findings. Usually some apply more than others and you may find your own descriptors that fit your patient best.General ObservationsAppearanceHygiene: clean, body odor, shaven, groomingDress: clean, dirty, neat, ragged, climate appropriate?— anything unusual?Jewelry: rings, earrings?— anything unusual?Makeup: lipstick, nail polish, eye makeup?— anything unusual?Other: prominent scars, tattoosSpeechGeneral: accent, clarity, stuttering, lispRate: fast (push of speech) or slowLatency (pauses between questions and answers): increased or decreasedVolume: whispered, soft, normal, loudIntonations: decreased (monotone), normalBehaviorGeneral: increased activity (restlessness, agitation), decreased activityEye Contact: decreased, normal, excessive, intrusiveMannerisms, stereotypies, posturingCooperativenessCooperative, friendly, reluctant, hostileThinkingThought ProcessesTight, logical, goal directed, loosened, circumstantial, tangential, flight of ideas, word saladThought ContentFuture oriented, suicidal ideation, homicidal ideation, fears, ruminative ideasPerceptionsHallucinations (auditory, visual, olfactory)Delusions (paranoid, grandiose, bizarre)EmotionMood(Patient describes in own words and rates on a scale 1-10)Affect(You describe)Type: depressed/sad, anxious, euphoric, angryRange: full range, labile, restricted, blunted/flattenedAppropriateness to content and congruence with stated moodCognitionMemoryImmediate recall, three and five minute delayed recall of three unrelated wordsOrientation/AttentionDay, date, month, year, place, president; Serial 7's (or 3's), WORLD?— DLROW, digit spanInsight/JudgmentGood, limited or poor (based on actions, awareness of illness, plans for the future)Psychiatric Review of SystemsSigns and symptoms of psychiatric illness are often described in the history of present illness. The ROS in psychiatry "covers all the bases" and queries for important signs and symptoms that have not been discussed during the first part of the history. Similar to the ROS in other fields of medicine, the ROS in psychiatry is a systematic inquiry, searching for pertinent positives and negatives over a period of time preceding the time of interviews.Cognitive: memory or concentration changesPsychosisSubstance AbuseMood: depression, mania, suicidal ideation, guiltNeurovegetative: sleep, appetite, libido, interests, energyAnxiety: anxiety symptoms, panic/agoraphobia, obsessions/compulsions, flashbacks/hypervigilanceEating Disorder: anorexia, bulimiaViolence: rages, assaults, homicidal ideationImpulse Control: pathological gambling, trichotillomania, kleptomaniaMental Status Examination TemplateSuggested Texts and references for the Clerkship In Psychiatry:?(suitable for in-depth reading on a patient problem or formulation in a write-up)Bernstein: On Call Psychiatry 1997 UNR BookstoreDSMIV: Quick Reference Guide to the Diagnostic Criteria 1994 UNR BookstoreGoldman: Review of General Psychiatry 1995 Dept. of Psychiatry, (also-may be available from upperclassmen)Grohol: Insider's Guide to Mental Health Resources (an online guide) UNR Main Lib RC437.2.0.78Hales and Yudofsky: The American Psychiatric Press Textbook of Psychiatry Savitt Medical Reference SectionHyman: Manual of Clinical Problems in Psychiatry UNR BookstoreKaplan and Saddock: Comprehensive Textbook of Psychiatry, 1995 Savitt WM 100.C73 vs.\ and IIKaplan and Saddock: Synopsis of Psychiatry, 1998 (can be ordered from the bookstore).Stoudemire: Clinical Psychiatry 1998 - Dept. of Psychiatry (also may be available from upperclassmen)Clinical Manuals (helpful for day to day use In the clinical setting although the drug Information is usually outdated)Psychiatry Clerkship Guide Myrl R.S. Manley Mosby 2003Internet Searches on topics in Psychiatry (for up-to-date information on medications as well as published research in psychiatry)Advanced PubMed search: (at University or with special accessMontreal Cognitive Assessment (MoCA).Administration and Scoring InstructionsThe Montreal Cognitive Assessment (MoCA) was designed as a rapid screening instrument for mild cognitive dysfunction. It assesses different cognitive domains: attention and concentration, executive functions, memory, language, visuoconstructional skills, conceptual thinking, calculations, and orientation. Time to administer the MoCA is approximately 10 minutes. The total possible score is 30 points; a score of 26 or above is considered normal.Alternating Trail Makjgg:Administration: The examiner instructs the subject: "Please draw a line, goingfrom a number to a letter in ascending order. Begin here [point to (l)] and draw a line from I then to A then to 2 and so on. End here [point to (E)]. "Scoring: Allocate one point if the subject successfully draws the following pattern: I —A- 2- B- 3- C- 4- D- 5- E, without drawing any lines that cross. Any error that is not immediately self-corrected earns a score of 0.Visuoconstructional Skills (Cube):Administration: The examiner gives the following instructions, pointing to the cube: "Copy this drawing as accurately as you can, in the space below "Scoring: One point is allocated for a correctly executed drawing.Drawing must be three-dimensionalAll lines are drawnNo line is addedLines are relatively parallel and their length is similar (rectangular prisms are accepted)point is not assigned if any of the above-criteria are not met.Visuoconstructional Skills (Clock):Administration: Indicate the right third of the space and give the following instructions:"Draw a clock. Put in all the numbers and set the time to 10 after Il "Scoring: One point is allocated for each of the following three criteria:Contour (l pt.): the clock face must be a circle with only minor distortion acceptable (e.g., slight imperfection on closing the circle); Numbers (1 pt.): all clock numbers must be present with no additional numbers; numbers must be in the correct order and placed in the approximate quadrants on the clock face; Roman numerals are acceptable; numbers can be placed outside the circle contour;Hands (1 pt.): there must be two hands jointly indicating the correct time; the hour hand must be clearly shorter than the minute hand; hands must be centred within the clock face with their junction close to the clock centre.point is not assigned for a given element if any of the above-criteria are not met. Naming:Administration: Beginning on the left, point to each figure and say: "Tell me the name of this animal "Scoring: One point each is given for the following responses: (1) camel or dromedary, (2) lion, (3) rhinoceros or rhino.Memory:Administration: The examiner reads a list of 5 words at a rate of one per second, giving the following instructions: "This is a memory test. lam going to reada list ofwords thatyou will have to remember now and later on. Listen carefully. When lam through, tell me as many words as you can remember. It doesn 't matter in what order you say them ". Mark a check in the allocated space for each word the subject produces on this first trial. When the subject indicates that (s)he has finished (has recalled all words), or can recall no more words, read the list a second time with the following instructions: "I am going to read the same list for a second time. Try to remember and tell me as many words as you can, including words you said the first time. " Put a check in the allocated space for each word the subject recalls after the second trial.4815840151208At the end of the second trial, inform the subject that (s)he will be asked to recall these words again by saying, "I will ask you to recall those words again at the end of the test.Scoring: No points are given for Trials One and Two.Attention:Forward Digit Span: Administration: Give the following instruction: "lam going to say some numbers and when I am through, repeat them to me exactly as I said them ". Read the five number sequence at a rate of one digit per second.Backward Digit Span: Administration: Give the following instruction: "Now lam going to say some more numbers, but when I am through you must repeat them to me in the backwards order. " Read the three number sequence at a rate of one digit per second.Scoring: Allocate one point for each sequence correctly repeated, (N.B. : the correct response for the backwards trial is 2-4-7).Vigilance: Administration: The examiner reads the list of letters at a rate of one per second, after giving the following instruction: "lam going to read a sequence ofletters. Every time Isay the letter A, tap your hand once. IfI say a different letter, do not tap your hand"Scoring: Give one point if there is zero to one errors (an error is a tap on a wrong letter or a failure to tap on letter A)Serial 7s: Administration: The examiner gives the following instruction: "Now, I will ask you to count by subtracting sevenfrom 100, and then, keep subtracting sevenfrom your answer until I tell you to stop. " Give this instruction twice if necessary.Scoring: This item is scored out of 3 points. Give no (0) points for no correct subtractions, I point for one correction subtraction, 2 points for two-to-three correct subtractions, and 3 points if the participant successfully makes four or five correct subtractions. Count each correct subtraction of 7 beginning at 100. Each subtraction is evaluated independently; that is, if the participant responds with an incorrect number but continues to correctly subtract 7 from it, give a point for each correct subtraction. For example, a participant may respond "92 — 85 — 78 71 — 64" where the "92," is incorrect, but all subsequent numbers are subtracted correctly. This is one error and the item would be given a score of 3.Sentence repetition:Administration: The examiner gives the following instructions: "I am going to read you a sentence. Repeat it after me, exactly as I say it [pause]: I only know that John is the one to help today." Following the response, say: "Now lam going to readyou another sentence. Repeat it after me, exactly as I say it [pause]: The cat always hid under the couch when dogs were in the room.Scoring: Allocate I point for each sentence correctly repeated. Repetition must be exact. Be alert for errors that are omissions (e.g., omitting "only", "always") and substitutions/additions (e.g., "John is the one who helped today;" substituting "hides" for "hid", altering plurals, etc.).Verbal fluency:Administration: The examiner gives the following instruction: "Tell me as many words as you can think ofthat begin with a certain letter ofthe alphabet that I will tell you in a moment. You can say any kind ofwordyou want, exceptforproper nouns (like Bob or Boston), numbers, or words that begin with the same sound but have a different suffix, for example, love, lover, loving. I will tell you to stop after one minute. Are you ready? [Pause] Now, tell me as many words as you can think of that begin with the letter F. [time for 60 sec]. Stop. "Scoring: Allocate one point if the subject generates I I words or more in 60 sec. Record the subject's response in the bottom or side margins.Abstraction:Administration: The examiner asks the subject to explain what each pair of words has in common, starting with the example: "Tell me how an orange and a banana are alike ". Ifthe subject answers in a concrete manner, then say only one additional time: "Tell me another way in which those items are alike ". If the subject does not give the appropriate response (fruit), say, "Yes, and they are also bothfruit. " Do not give any additional instructions or clarification.After the practice trial, say: "Now, tell me how a train and a bicycle are alike ". Following the response, administer the second trial, saying: "Now tell me how a ruler and a watch are alike ". Do not give any additional instructions or prompts.3Scoring: Only the last two item pairs are scored. Give I point to each item pair correctly answered.The following responses are acceptable:Train-bicycle means of transportation, means of travelling, you take trips in both; Ruler-watch measuring instruments, used to measure.The following responses are not acceptable: Train-bicycle = they have wheels; Ruler-watch = they have numbers.10.Delayed recall:Administration: The examiner gives the following instruction: "I read some words to you earlier, which I askedyou to remember. Tell me as many ofthose words as you can remember. Make a check mark ( V) for each of the words correctly recalled spontaneously without any cues, in the allocated space.Scoring: Allocate 1 point for each word recalled freely without any cues.Optional:Following the delayed free recall trial, prompt the subject with the semantic category cue provided below for any word not recalled. Make a check mark (V) in the allocated space if the subject remembered the word with the help of a category or multiple-choice cue. Prompt all non-recalled words in this manner. If the subject does not recall the word after the category cue, give him/her a multiple choice trial, using the following example instruction, "Which ofthefollowing words do you think it was, NOSE, FACE, or HAND? "Use the following category and/or multiple-choice cues for each word, when appropriate:FACE:category cue: part of the body multiple choice: nose, face, handVELVET:categocy cue: type of fabricmultiple choice: denim, cotton, velvetCHURCH:category cue: type of building multiple choice: church, school, hospitalDAISY:category cue: type of flower multiple choice: rose, daisy, tulipRED:category cue: a colourmultiple choice: red, blue, greenScoring: No points are allocated for words recalled with a cue. A cue is used for clinical information purposes only and can give the test interpreter additional information about the type of memory disorder. For memory deficits due to retrieval failures, performance can be improved with a cue. For memory deficits due to encoding failures, performance does not improve with a cue.11.Orientation:Administration: The examiner gives the following instructions: "Tell me the date today". If the subject does not give a complete answer, then prompt accordingly by saying: "Tell me the [year, month, exact date, and day of the week]. " Then say: "Now, tell me the name of this place, and which city it is in.Scoring: Give one point for each item correctly answered. The subject must tell the exact date and the exact place (name of hospital, clinic, office). No points are allocated if subject makes an error of one day for the day and date.TOTAL SCORE: Sum all subscores listed on the right-hand side. Add one point for an individual who has 12 years or fewer of formal education, for a possible maximum of 30 points. A final total score of 26 and above is considered normal.BEHAVIORAL ROUNDS (to be done at least every three months and if possible monthly to be scheduled by psychtech)Leaders in the Mental Healthcare of Seniors Senior Psychological and Senior PsychCare (SPC) have developed Behavioral Rounds to be used as the structure to help synthesize interdisciplinary care planning into the nursing home’s routine operations. Behavioral Rounds are part of the information gathering, interpreting and integration of information, in order to provide optimal care, it is essential necessary for best treatment practices. This process is needed in order to establish goals relating to the quality of care and the quality of life for each resident which benefits nursing home staff, res ident and family members. Behavior Rounds- what are they? An interdisciplinary care plan meeting An opportunity for team members to discuss the care of the residents in the LTC setting 7635241010362Behavioral Round Process Rounds are set up every 30 to 90 days based on the needs of the facility and its residents The SPC treatment team participates in Behavior Rounds with the facility staff Nursing Home representatives such as the social worker, DON, MDS Coordinator, Activities Director, Charge Nurses, PCP and physical therapy staff are all invited to attend Benefits of Behavioral Rounds 3868496-143562 Studies have shown that consistent participation in fully integrated care plan meetings, such as SPC Behavioral Rounds will reduce psychotropic medications, lessen behavioral problems and improve care for the resident Any psychological and neuropsychological evaluations conducted on patients since the last behavioral round will be discussed A list of psychotropic medications for each resident seen for behavioral problems as well as resident’s progress toward treatment goals A record of discussion is documented and available for reviewLong Term Care Health Information Practice AndDocumentation Guidelines September 2001 Developed By: AHIMA/FORE Long Term Care Taskforce Written By: Michelle Dougherty, RHIA HIM Practice Manager, AHIMA In Partnership With -- Beverly Enterprises Extendicare Health Services Genesis Health Ventures Good Samaritan Society Harborside Healthcare Corporation HCR-ManorCare TABLE OF CONTENTS PAGE INTRODUCTION………………………………………………………………………………….. 7 Purpose and Use of These Guidelines……………………………………………………... 7 Transition from Medical Records to Health Information………………………………….. 7 Definition of Long Term Care Facility……………………………………………………. 7 Acknowledgements………………………………………………………………………… 7 Copyright and Use of Report………………………………………………………………. 8 Reference to HIM Practice Standards……………………………………………………… 8 ROLE OF HEALTH INFORMATION STAFF IN LONG TERM CARE FACILITIES………….. 9 Job Qualification, Responsibilities, and Functions of Health Information Staff in a LTC Facility…………………………………………………………………………... 9 2.1.1 Role of the Credentialed Consultant……………………………………………... 9 2.1.2 Role of the Credentialed Practitioner Working in a Long Term Care Facility….. 11 2.1.3 Role of the Non-Credentialed Practitioner Working in a Long Term Care Facility…………………………………………………………………………… 14 Role of the Health Unit Coordinator…………………………………………….. 16 Evolving Role of Health Information……………………………………………. 18 Health Information Department Staffing……………………………………………………18 HEALTH INFORMATION CONSULTANT SERVICES…………………………………………. 19 Frequency of Consultant Visits……………………………………………………………. 19 Performance Expectations for a Consultant……………………………………………….. 20 Consultation Reports………………………………………………………………………. 21 Timeliness of Consultation Reports……………………………………………… 21 Content of Consultation Reports………………………………………………… 22 Distribution of the Consultation Report………………………………………… 22 Retention (Facility and Consultant)……………………………………………... 22 Evaluating Consulting Services…………………………………………………………… 22 PRACTICE GUIDELINES FOR LTC HEALTH INFORMATION AND RECORD SYSTEMS… 26 Record Systems, Organization and Maintenance………………………………………….. 26 Maintaining a Unit Record………………………………………………………. 26 Assigning a Medical Record Number…………………………………………… 26 Maintaining Records in a Continuum of Care ………………………………….. 27 Defining What is Part of the Medical Record…………………………………… 27 Maintenance of the Chart ……………………………………………………….. 27 Identification/Name and Medical Record Number on Pages……………………. 27 Common Chart Forms and Thinning Guidelines ………………………………... 28 Integrating Hospital Records into the Long Term Care Record ………. 30 Thinning the Medical Record …………………………………………………… 31 Maintaining the Overflow Record of Thinned Documents ……………………... 31 4.1.10 Maintaining a “Soft Chart” or "Shadow Record" and Other Types of Records…. 31 4.1.11 Forms Control Processes ………………………………………………………… 32 Audits and Quality Monitoring …………………………………………………………… 33 Qualitative vs. Quantitative Audits and Monitoring …………………………….. 33 Assessing the Quality of Documentation ……………………………………….. 33 Routine Audits/Monitoring (Criteria and Timeframes) …………………………. 34 Focus Audits and Monitoring Systems …………………………………………. 38 Integrating Audits/Monitoring into the QA/QI Program ……………………….. 39 Retention of Audits, Checklists, and Monitoring Record ………………………. 39 Discharge Record Processing …………………………………………………………….. 40 Discharge Record Assembly ……………………………………………………. 40 Discharge Record Analysis……………………………………………………… 42 Timely Completion of a Discharge Record …………………………………….. 42 Incomplete and Delinquent Records …………………………………………….. 42 Maintaining a Control Log for Discharge Records ……………………………… 43 When to Close a Record on Temporary Absence ……………………………….. 43 Closing Records with a Change in Level of Care ……………………… 44 Closing Records with a Payer Change …………………………………. 44 Filing and Retrieval ……………………………………………………………………….. 45 Separate Location for Incomplete Records ……………………………………… 45 Typical Filing Systems ………………………………………………………….. 45 After Hours Retrieval ……………………………………………………………. 46 Storage Systems …………………………………………………………………………... 46 Storage System Options ………………………………………………………… 46 Security Issues: Locking Office and Storage Areas ……………………………. 47 Alternative Storage Areas ………………………………………………………. 47 Retention …………………………………………………………………………………. 48 Retention Guidelines ……………………………………………………………. 48 Destruction ……………………………………………………………………………….. 49 Acceptable Methods of Destruction …………………………………………….. 49 Abstracting Documents Prior to Discharge ……………………………………… 49 Destruction Logs and Witnesses ………………………………………………… 50 Physical Security of Manual/Paper Records ………………………………………………. 50 Maintaining a Record Checkout System ………………………………………… 50 What To Do if a Record is Lost, Destroyed or Stolen …………………………... 51 Disaster Plans ……………………………………………………………………. 52 Confidentiality and Release of Information ………………………………………………. 54 Identification of Confidential vs. Non-Confidential Information ……………….. 55 Resident Access to Their Records ……………………………………………….. 56 Confidentiality, Training and Agreements with Employees and Volunteers ……. 57 Resident Identification Boards at Nursing Stations ……………………………… 58 Maintaining an Access/Disclosure Grid for Employees, Contractors and Outside Parties ……………………………………………………………… 58 Handling a Request for Medical Records ……………………………………….. 61 Review of Authorization for Release of Information ………………….. 61 Preparing a Record for Release ………………………………………… 61 Turn Around Time for Responding to a Request for Copies of Medical Records …………………………………………….. 62 Copy Fees for Release of Information …………………………………. 62 Documenting the Release of Information (Accounting of Disclosures) .. 63 Redisclosure of Health information ……………………………………………… 63 Redisclosure Upon Transfer to Another Healthcare Facility …………... 64 Handling Telephone Requests for Information ………………………………….. 64 4.9.9 Transmitting Patient Information Via Facsimile ………………………………… 64 4.9.10 Responding to a Subpoena or Court Order ……………………………………… 65 Removing Original Records from the Facility ………………………………….. 66 Notice of Information Practices …………………………………………………. 66 Designation of a Privacy Officer ……………………………………………….. 67 Coding and Reimbursement ………………………………………………………………. 67 Training and Resources …………………………………………………………. 67 4.10.2 Frequency of ICD-9-CM Coding ……………………………………………….. 68 4.10.3 Coding and Billing Relationships ………………………………………………. 69 Investigation of Claim Rejection/Denials Due to Coding ……………………… 69 Coding Issues Under Consolidated Billing …………………………………….. 70 Indexes and Registries …………………………………………………………………… 70 Master Patient Index (MPI) ……………………………………………………… 70 Maintaining an MPI ……………………………………………………. 70 Minimum Content ……………………………………………………… 71 Admission/Discharge Register …………………………………………………. 72 Disease Index ……………………………………………………………………. 73 Minimum Statistical Reporting …………………………………………………………… 74 Total Admissions ………………………………………………………………... 74 Total Discharges …………………………………………………………………. 74 Average Daily Census …………………………………………………………… 74 Total Census Days ………………………………………………………………. 75 Length of Stay …………………………………………………………………… 75 Percentage of Occupancy ……………………………………………………….. 75 Electronic Patient Records (On Hold) ……………………………………………………. 75 LEGAL DOCUMENTATION STANDARDS…………………………………………………….. 76 Purpose and Definition of the Legal Medical Record …………………………………….. 76 Legal Documentation Standards ………………………………………………………….. 78 Defining Who May Document in the Medical Record …………………………. 78 Linking Each Entry to the Patient ………………………………………………. 78 Date and Time on Entries ………………………………………………………. 79 Timeliness of Entries ………………………………………………….. 79 Pre-dating and Back-dating …………………………………………… 79 5.2.4 Authentication of Entries and Methods of Authentication …………………….. 79 Signature ……………………………………………………………… 79 Countersignatures …………………………………………………….. 79 Initials ………………………………………………………………… 80 Fax Signatures ………………………………………………………… 80 Electronic/Digital Signatures …………………………………………. 80 Rubber Stamp Signatures …………………………………………….. 80 Authenticating Documents with Multiple Sections or Completed by Multiple Individuals ………………………………………………. 81 Signature Legends ……………………………………………………………… 81 Permanency of Entries …………………………………………………………. 81 Printers ……………………………………………………………….. 81 Fax Copies ……………………………………………………………. 82 Photo Copies …………………………………………………………. 82 Carbon Copy Paper (NCR) …………………………………………… 82 Use of Labels in the Medical Record …………………………………. 82 Specificity ………………………………………………………………………. 83 Objectivity ………………………………………………………………………. 83 Completeness …………………………………………………………………… 83 Use of Abbreviations …………………………………………………………… 83 Legibility ……………………………………………………………………….. 83 5.2.12 Continuous Entries ……………………………………………………………… 83 5.2.13 Completing All Fields …………………………………………………………… 84 Continuity of Entries – Avoiding Contradictions ……………………………….. 84 Condition Changes ………………………………………………………………. 84 5.2.16 Document Informed Consent ……………………………………………………. 84 5.2.17 Admission/Discharge Notes …………………………………………………….. 84 5.2.18 Notification or Communications ………………………………………………… 85 5.2.19 Delegation ……………………………………………………………………….. 85 5.2.20 Incidents …………………………………………………………………………. 85 Make and Sign Own Entries ……………………………………………………. 85 Appropriateness of Entries – Keep Documentation Relevant to Patient Care …. 85 5.3 Legal Guidelines for Handling Corrections, Errors, Omissions, and Other ……………… 85 Documentation Problems …………………………………………………………………. 85 Proper Error Correction Procedure ……………………………………………… 85 Handling Omissions in Documentation …………………………………………. 86 Making a Late Entry …………………………………………………… 86 Entering an Addendum ………………………………………………… 86 Entering a Clarification ………………………………………………… 86 Omissions on Medication, Treatment Records, Graphic and Other Flowsheets … 87 Documenting Care Provided by a Colleague ……………………………………. 87 Patient Amendments to their Record ……………………………………………. 87 6.0 DOCUMENTATION IN THE LONG TERM CARE RECORD …………………………………. 88 Federal Regulations Pertaining to Clinical Records …………………………….. 88 Purpose of the Documentation …………………………………………………. 88 Elimination of Duplication/Redundant Information when Evaluating/Implementing a Documentation System …………………………… 88 6.1 Documentation Content in a Long Term Care Record …………………………………… 89 6.1.1 Admission Record ……………………………………………………………… 89 6.2 Assessments ……………………………………………………………………………… 89 Integrating Assessments with RAI Process ……………………………………. 89 Types of Assessments and Requirements ……………………………………… 89 Preadmission Assessment ……………………………………………. 89 Admission Assessment ……………………………………………….. 90 Fall Assessment ………………………………………………………. 90 Skin Assessment ……………………………………………………… 90 Bowel and Bladder Assessment ………………………………………. 90 Physical Restraint Assessment ………………………………………… 90 Self-Administration of Medication ……………………………………. 90 Nutrition Assessment …………………………………………………. 90 Activities/Recreation/Leisure Interest Assessment …………………… 91 Social Service …………………………………………………………. 91 Mental and Psychosocial Functioning ………………………………… 91 Restorative/Rehab Nursing Assessment ……………………………… 91 Resident Assessment Instrument (RAI) – MDS and RAPS ……………………………… 91 Care Plan ………………………………………………………………………………….. 92 Timeliness ………………………………………………………………………. 92 Care Conference ………………………………………………………………… 92 Admission/Interim Care Plan …………………………………………………… 92 Integrating Acute Problems Into the Care Plan …………………………………. 93 Timeliness of Completion of Care Plan …………………………………………. 93 Authenticating Changes to Care Plan ……………………………………………. 93 6.5 Narrative Charting and Summaries ……………………………………………………….. 93 Admission/Readmission Note …………………………………………………… 93 Content of Narrative Charting …………………………………………………… 93 6.5.3 Monthly Summary Charting …………………………………………………….. 93 6.5.4 Integrated vs. Disciplinary Progress Notes ……………………………………… 94 6.6 Medicare Documentation ………………………………………………………………….. 94 Skilled Nursing/Therapy Charting ………………………………………………. 94 Supporting Documentation for the MDS ……………………………………….. 94 Therapy Treatment Time ………………………………………………………... 94 ADL Charting ……………………………………………………………………. 95 6.6.5 Mood and Behavior Documentation ……………………………………………. 96 6.6.6 Hospital Documentation ………………………………………………………… 96 6.6.7 Medicare Certification/Recertification ………………………………………….. 96 Rehabilitative Therapy Documentation (On Hold) ……………………………………… 96 Physician Documentation …………………………………………………………………. 96 Physician Progress Notes ……………………………………………………….. 96 Dictated Progress Notes …………………………………………………………. 97 NP/PA Documentation ………………………………………………………….. 97 History and Physical …………………………………………………………….. 96 Other Professional and Consultation Records/Notes ……………………………. 96 Documenting Resident Diagnoses ………………………………………………. 96 Supporting Documentation for Diagnoses ………………………………………. 96 Resolving Diagnoses …………………………………………………………….. 96 6.9 Physician Orders ………………………………………………………………………….. 96 Admission Orders ……………………………………………………………….. 96 Content of an Order ……………………………………………………………… 97 Physician Order Recaps/Renewals ………………………………………………. 97 Telephone Orders …………………………………………………………………97 Fax Orders ……………………………………………………………………….. 97 Standing Order Policies …………………………………………………………. 97 Authentication/Obtaining Signatures ……………………………………………. 97 Transcription of Orders and Noting Orders …………………………………….. 97 Contacting the Physician to Obtain an Order …………………………………… 98 Discontinuing an Order When a New Order is Obtained ………………………. 98 6.9.11 Updating/Changing Physician Order Recaps/Renewals After They Have Been Signed …………………………………………………… 98 Processing Physician Orders After Hospitalization (Resume all Previous Orders) ……………………………………………………. 98 Verification of Hospital Orders with Attending Physician ……………………… 98 Accepting Orders From a NP/PA ……………………………………………….. 98 Accepting Orders from Specialists or Consultants ……………………………… 98 Pharmacy Drug Review …………………………………………………………………… 98 Antipsychotic Drug Therapy ……………………………………………………………… 98 6.11.1 Dose Reduction Schedules and Documentation …………………………………. 99 6.12 Medication and Treatment Records ………………………………………………………. 99 6.12.1 Starting new Medication/Treatment Records Upon Readmission/Hospital Return …………………………………………………… 99 6.13 Flow Sheets/Flow Records ……………………………………………………………….. 99 Service Delivery Records ……………………………………………………….. 99 Other Clinical Flow Records ……………………………………………………. 99 Labs and Special Reports …………………………………………………………………. 100 Consents, Acknowledgements and Notices ………………………………………………. 100 Informed Consent for Use of a Restraint ……………………………………….. 100 Consent, Notice and Authorization to Use/Release Clinical Records ………….. 100 Notice of Bedhold Policy and Readmission ……………………………………. 100 Notice of Legal Rights and Services ……………………………………………. 100 Notice Before Transfer ………………………………………………………….. 100 Notice Prior to Change of Room or Roommate ………………………………… 101 6.16 Advance Directives ……………………………………………………………………….. 101 6.16.1 DNR Order vs. Advance Directives …………………………………………….. 101 6.17 Discharge Documentation ………………………………………………………………… 101 6.17.1 Discharge Order …………………………………………………………………. 101 6.17.2 Discharge Note ………………………………………………………………….. 101 6.17.3 Discharge Summary …………………………………………………………….. 101 6.17.4 Transfer Form …………………………………………………………………… 101 6.17.5 Physician’s Discharge Summary vs. Discharge Record ………………………… 101 7.0 CHECKLIST OF HIM POLICY AND PROCEDURES ………Evidence-based Psychosocial and Behavioral Interventions with DementiaAbout Us .......................................................................................................................................1 SPC Behavioral Rounds .............................................................................................................. 18 Benefits of Behavioral Rounds ................................................................................................... 20 Successful Implementation of an Interdisciplinary Team Approach to Reduce Psychoactive Medications in a Community Based Nursing Home (Oaks, SL et al.) .................................... 21 Psychiatric and Behavioral Problems Associated with Dementia – Treatment. Nonpharmacologic alternatives to antipsychotics ................................................................. 22 II. Position Statement of the AAGP for Care of Patients with Dementia Position Statement of the American Association for Geriatric Psychiatry Regarding Principles of Care for Patients with Dementia Resulting from Alzheimer Disease (Lyketsos, CG et al.) . 24 References (Decision Making Capacity Assessment) ................................................................ 36 III. Worksheet for Assessment of Decision-making Capacity Worksheet for Assessment of Decision-making Capacity.......................................................... 44 IV. Dealing with Resistant Patients through Collaborative Therapy Engage Resistant Patients in Collaborative Treatment – First identify and work on what they really want (Mee-Lee, D) .......................................................................................................46Index of Senior Minutes(to be provided to DOM and all admitting PCPs)ITraits of a Successful CNAIIUntitledIIIWorking on the Doctor/Patient Relationship: The Holistic Side of MedicineIVShoe Wear Recommendations for Older AdultsVThe Benefits of ExerciseVIPhysical Conditions Disguised as Mental Health ProblemsVIICriteria for Dying Well – What Families and Professionals Think Is ImportantVIISupporting Culture Change: Working Toward Smarter State Nursing Home RegulationsIXAdvance Care Planning and the Elderly PatientXToronto Side Effect ScaleXIThe Advantage of Psychiatric Involvement in Geriatric CareXIIQuality Mental Health Care for Geriatric Patients in NursingXIIIBreaking the News: Do Patients Want to KnowXIVDementia: FAQ SessionXVPsychotropic Drug IssuesXVI Long Term Cognitive Impact of Anticholinergic Medications in Older AdultsXVIIUse of Anti-Depressants in the Nursing Home and the Use of Depression Screening ToolsXVIIIOverview of Depression in Long-Term ResidentXWhat Is Mild Cognitive Impairment (MCI)?XXBorderline Personality DisorderXXIWhat’s New In the Treatment of MDD XXIISix Signs Your Patient Is at Risk for Treatment Resistant Depression XXIIIHow to Use Light Therapy in Bipolar Disorder XXIVRay Dalios Principles for SuccessXXVPsychosis and DementiaHow Well Do Psychosocial Therapies Manage Psychosis/agitation in Dementia5-Step Evaluation of Dementia Patients with Psychosis and/or Agitation/AggressionTypical Antipsychotics: Safer than Atypicals for Older Patients?Pharmacological Alternatives to Antipsychotics: What the Evidence SaysXXVIChanging the Dance of Couples Mid-Level Guidelines Table of Contents TABIntroduction 1Definition of Psychiatric Mental Health 2Scope of Practice Definition of Psychiatric Mental Health Mid-Levels………….………………………………………………….3Changes in Laws Regarding Prescriptive Delegation to APN/PA 4Texas Medical Board Quick Reference Site Specific Prescriptive Delegation Statue & Rule Chart 5Prescriptive Authority Mid-Levels 6Modification of Registration ANP/PA 7On-Line Supervision & Prescriptive Delegation Registration 8Prescription Information 9Licensed Physician Assistant Questions 10Physicians Assistants in Geriatric Medicine 11Standards of Psychiatric Mental Health Nursing Practice 12Responsibilities of Attending Physicians in LTC 13Will Nurse Practicioners Replace Physicians as Attendings in Long-Term Care? 14Nurse Practicioner/Physician Collaborative Models of Care 15Psychiatric Consultation: When to Request It and What Is the Role of the Consultant 16The Role of the Consultant in Long-Term Care Facilities 17Responsibilities of Attending Physicians in Long-Term Care 18Texas Administrative Code ANP 19Texas Medical Board Rules 20Occupational Code Title 3 Health Professions 21Texas Medical Board Prescriptive Delegation Waiver Requests (and its contents) 22SPC Guidelines on Standards of Care I (and its contents) 23SPC Guidelines on Standards of Care II (and its contents)24Resource Manual for Developing HuddlesHuddle SheetUsing Shift Huddles to Empower LeadersUse Regular Huddles and Staff Meetings to Plan Production and to Optimize Team Communication (ideally done Monday and Friday)Implementing a Daily Team Huddle (optional)Huddle Sheet (TO BE SUBMITTED TO REGIONAL MANAGER)What can we proactively anticipate and plan for in our work day/week? At the beginning of the day, hold a review of the day, review of the coming week and review of the next week. Frequency of daily review is dependent on the situation, but a mid-day review is also helpful.This worksheet can be modified to add more detail to the content and purpose of the huddles.Huddle SheetPractice: Date:Aim: Enable the practice to proactively anticipate and plan actions based on patient need and available resources, and contingency planning.Follow-ups from Yesterday"Heads up" for Today: (include special patient needs, sick calls, staff flexibility, contingency plans)Meetings:Review of Tomorrow and Proactive PlanningMeetings:0 2001 , Trustees of Dartmouth College, Godfrey. Nelson. Batalden. Institute for Healthcare Improvement28Adapted from the original version, Dartmouth-Hitchcock, Version 2, February 2005StuderGroupYA KURON SOLUTIONHOME > RESOURCES > ARTICLES & INDUSTRY UPDATES INSIGHTS BLOGUSING SHIFT HUDDLES TO EMPOWER LEADERSMSNPOSTED APRIL 13, 2016LEADER DEVELOPMENT I MEASUREMENT/HCAHPS/CGCAHPS/VBP I HUDDLESAs a coach with Studer Group, I have the honor of traveling all over the country and seeing the incredible work happening in our medical centers and clinics. Wherever I go, the passion and drive that I see in the healthcare community is the same - healthcare leaders want to create the absolute best place for employees to work, physicians to practice medicine, and patients to receive care. With that determination for creating an organization-wide culture of excellence in mind, executives are focusing more and more on ensuring leaders at all levels receive proper training and development.As managers, directors, and executives, we rely on our supervisors, team leaders, and charge nurses to carry critical messages of change to the front line, yet many of the leaders have never been trained in communication or leadership. In healthcare, we tend to select leaders because they have the best clinical skills or the most experience in their current positions. I've met charge nurses who have fewer than 6 months experience as a nurse. Does this make them bad charge nurses or leaders? Certainly not. However, it does mean that we have an opportunity to commit to their leadership development, particularly when it comes to communication and accountability.With HCAHPS, CG CAHPS, and other patient experience surveys and changes in reimbursement, we are constantly striving to achieve zero harm for our patients, increase quality outcomes, and decrease the variance of care that CARPS surveys measure. However, we still see many front line leaders scratching their heads to find new and innovative ways to impact their results on patient experience surveys.I-low can front line supervisors, charge nurses, and team leaders learn to drive change and impact results on a daily basis? What are the best tools to help leaders communicate results, set expectations for their shift, and hold staff accountable for the expectations set by the leader? One of the best tools for both new and experienced leaders is a huddle at the beginning of the shift. While the concept of a shift huddle is not new, the content of the huddle is where we have opportunity for improvement.Standardizing Shift Huddleswithin departments helps to hardwire new or desired behaviors across the organization. Shift huddles align staff to department goals and allow us to communicate the department's progress on their patient experience efforts. Huddles also provide a set time every shift to thank our teams, reward and recognize accomplishments and share information that connects staff back to their sense of purpose for the work they do every day.Utilizing a standard agenda in shift huddles allows us to expose front line leaders and staff to best practices and empower them to apply these ideas to their daily practice and workflow. The shift huddle agenda includes the following components and is applicable to all departments, not just nursing departments:Wins/Recognition — we want to always start with the positive!Review of current daily dashboard/key resultsReview of the safety and patient experience tactics that are a priority (e.g. AIDET@ or Hourly Rounding@)Other information that the staff needs to be aware of to provide the best care and/or serviceWhile we can create the perfect shift huddle agenda for our teams, true breakthrough in results comes when we recognize key points in implementation of huddles. Ensure shift huddles have these key elements:Shared responsibility. Shift huddles should be led by managers at the beginning of the week with a supervisor/charge nurse leading huddles for the remainder of the week. Remember, this is about developing leaders' communication skills!Mandatory attendance. Include all care delivery staff. Staff should not be able to "opt out," as they will miss critical information about how to have a successful shift.e Active discussions. Rather than dictating the goals for the day, an effective huddle facilitator tries to garner thoughtful responses from the team on HOW they will achieve the goals for their shift. For example, a facilitator might say "What will we do differently today to ensure patient safety and quality?" Standardized agenda. Utilize the standardized agenda and keep the huddle to no more than 5-7 minutes. Open concept. Hold the huddle in an open area where everybody stands up and is ready to go! Inclusive of ali staff. Include care physicians, mid-level providers, and EVS when relevant. Think about all of the staff who come in contact with our patients and families. From first touch to last, it takes all of us to achieve ALWAYS.Shift huddles should be standard for both clinical and non-clinical departments. In fact, at Studer Conferences our faculty and facilitators take time to role play both a clinical shift huddle for a nursing/clinical department and a shift huddle for a non-clinical department. order to develop an accountable culture in our organizations, we have to mentor our front line supervisors to clearly and efficiently communicate the vision we have for excellent patient care. By implementing effective, standardized shift huddles, we begin to develop urgency in a critical mass of front line leaders and empower them with an effective tool to create change in their departments.A LEARNING ORGANIZATIONManager’s Resource ManualPART I, II, III, IV, & VTable of Contents (available on SPC server)Introduction by Dr. Leo J. BorrellPart I: LeadershipThe 7 Principles of Business Integrity (by Robert Moment, 2004)Scientific Management (The Levinson Institute, Inc. 1987)The Aggression IntersectionEducating Upward (The Levinson Institute, Inc. 1980) Choosing an EmployerWhat is a Learning Organization? (by Richard Karash)Ask the question: How am I doing? (by Susan DePhilli)What the CEO Wants you to Know (by Ram Charan)Acknowledgements - ContentsPreface - Business Acumen: The Universal Language of BusinessChapter 1 – What Jack Welch and Street Vendors KnowChapter 2 – Every Business is the Same InsideChapter 3 – Understanding Your Company’s Total BusinessChapter 7 – Making Groups DecisiveChapter 8 – What to Do and How to Do ItManagement Challenges for the 21st Century (by Peter F. Drucker)What Your LEADER Expects of You and what you should expect in return (by Larry Bossidy)Becoming the Boss (by Linda A. Hill)The Practices and Commitments of Exemplary Leadership (by Kouzes and Posner 1995)Tape Measure for a Job Fitting I: An Introduction to Stratified Systems Theory (by Joseph C. Sabbath, M.D. and John Elder)Tape Measure for a Job Fitting II: Stratified Systems Theory in Action (by Joseph C. Sabbath, M.D. and John Elder)Leadership BasicsPower Dependence, and Effective Management (by Kotter)Turning Doctors into Leaders (by Thomas H. Lee)Making Your Job Perfect (by Linda Stockman-Vines)Pay for Performance: Beating “Best Practices” (by Marc Hodok CEO Magazine July/Aug 2006)Performance Measurement: Achieving high performance through alignment and strategic learning (by Floyd Kelly)Can You Measure Leadership? by Gandossy MIT Sloan Fall 2008Are We Making Progress as Leaders? (National Institute of Standards and Technology) baldrige.Progress_Leaders.htmBehavioral Job Descriptions: How and Why (by Harry Levinson, PhD with Janet E. Robinson)Developing Leaders – How Winning Companies Keep on WinningDeveloping Versatile Leadership (by Robert E. Kaplan and Robert B. Kaiser)Developing Multidimensional Leaders (by Nikravan 2011 Chief Learning Officer 2011)The Chief Strategy Officer (by Breene, et al. 2007 HBR)Evolution and Revolution as Organizations Grow (by Larry E. Greiner)Decoding Resistance to Change – strong leaders can hear and learn from their critics (by Ford and Ford, 2009 HBR)Building Resilience in an Age of Crisis (by Lynch and Waitzer, The Globe and Mail, January 17, 2011)Feelings (by Willard Gaylin, MD)Feelings are Important to Recognize (by Willard Gaylin MD)Why Good Leader’s Make Bad Decisions (by Andrew Campbell, Jo Whitehead, and Sydney Finkelstein)Executive Dereailment: The Ten Fatal FlawsThe Problem with Power (Levinston Inst. 1988)Lead Self - Leadership Style/Perception of Self (developed by Center for Leadership Studies, Inc.)Path for Success Worksheet – Setting GoalsHow to Link Strategic Vision to Core Capabilities (by Paul J.H. Schoemaker)What is Vision and Why is it Important?The Vision Trap by LangelerAlternative Budgeting: Companies are still looking for better ways to set performance targets. (by Don Durfee)To Do Lists Can Take More Time Than Doing, But That Isn’t the Point (by Jared Sandberg)The Hidden Language by Natalie MorearTraining Module for Optimal Results Required for Medications in Psychopharmacology with Special Focus for Dealing with Resistant and Non-Compliant PatientsIntroductionThe purpose of this module is to acknowledge the distinction of the interpersonal relationships associated with treatment interventions. The doctor patient relationship is very important and can be used in a ll contexts of the psychiatric treatment, in particularly pharmacologic interventions. It is essential to monitor and use the relationship between the patient and physician to improve compliance. A synergistic effect to the desired pharmacologic effects of treatment stems from a patient’s sense of well-being, resulting from a respectful interpersonal relationship.Overview and FrameworkCase 1Mr. A, a 47 year old married male who worked in the financial institution had been suffering with bipolar disorder for about 15 years. It had been very difficult to stabilize him on medications, and over the years he had vacillated between being depressed and lethargic to being hypomanic and ultimately frankly manic. His mania led him to psychotic thinking and he ended up telling his bosses at work how tot run the company. Eventually he lost his job and was hospitalized. He moved back home from another state and had been my patient for only 6 weeks. I had seen him for four sessions, an hour intake and three half hour “med checks”. In my initial assessment, I felt that he had finally attained some sort of stability since his last hospitalization 6 months before Thus I was surprised when I received a call from our emergency room stating Mr. A was there with his wife. He was quite hypomanic and was refusing medications. I asked the worker in the emergency room if she would put Mr. A. on the phoneDr. A: How are you doing?Mr. A: Great, just great, Doc. How are you?Dr. A: Well I am a bit worried about you. The folks in the emergency room thin you are a bit “up there” and that has me worried, especially since they say you don’t want to take any medication.Mr. A: That’s not tru, Doc. I am happy to take my lithium. I just don’t’ want to take that Risperdal again. You know how groggy it makes me.Dr. A: I know, but I am worried that this is going to lead to your going to the hospital again, and I know how much you hate that. Do me a favor, will you? Would you take that Risperdal now, and I’ll see you first thing in thte morning and we can go from there to figure things out. But I want you to take the medication before you leave the emergency room.Mr. A: Ok Doc sure. I’ll see you in the morning, but you better tell my wife what time the appointment is because I don’t think I’ll remember it.Dr. A: Sure, and thanks.Mr. A: No problem Doc. See ya.Case 1: Shows how a patient would have been much less likely to cooperate with the emergency room clinician’s suggestions and much less likely to respond to his psychiatrist’s advice without a doctor patient relationship. It also shows how the patient was open to discussing his reactions to the medication with his physician.Table 2.1 Advantages to considering the Doctor-Patient Relationship in Medication PrescribingIncreases respect patients have for our profession and increases our respect and understating of them.Builds a foundation upon which difficulties or concerns about medication and the prescribing process can be openly discusses.Leads to increased compliance because it encourages dialogue between physician and patient.Build’s the patient’s self esteem which can enhance the beneficial effects of the medication and strengthen the patient’s ability to tolerate side effects.Provide a model of interpersonal behavior that can be translated to other interpersonal situations for the patient.Reduces the overall stress the patient feels when coming to appointments for medication prescription and maintenance, and thus reduces the overall stress in the patient’s life.Case 2Dr. G: You know when I first brought up the idea that your boss wanted to talk with me all you could say is “no”. You even threatened to go see someone else fi I didn’t stop talking about it. I suggested that I would be willing to hear your viewpoint if you would be willing to hear mine and we did that and we just had a meeting with your boss. She assured you that we were behind you all the way. In fact she even told us about her sister who also had depression. So you and I were able to listen to each other and then decide whether and how to have the meeting. You know sometimes I think your initial reaction and response here happens with you in other circumstances as well that is that you decide something and you don’t want to hear anyone else’s opinions about it. I think if you want you might find it useful to discuss this with dr. H, your therapist during your appointment with him next week. If you do I would appreciate hearing what the discussion was like. Case 2: A benefit of considering, developing, and paying attention to the relationship between oneself as a physician and the patient is that it can serve as a model upon which other relationships can be built or modified.Table 2.2 Establishing and Enhancing the Interpersonal Relationship in Medication PrescribingRemember that a major tenet of the profession of psychiatry is appreciating and understanding the doctor-patient relationship.At the initial appointment, make clear that you want to know things about them that go beyond their symptoms or their specific diagnosis. This involves scheduling enough time during the initial appointment so that some interchange beyond matters relating merely to symptoms and diagnosis can rm patients that you are interested in more than whether or not they have a “chemical imbalance”Reinforce the idea that the patient is an individual with individual responsivity, both in terms o effectiveness as well as side effects to the medications.When actually prescribing medications, let the patients know that you are available between sessions to discuss their worries, concerns or side effects.When actually prescribing medications, attempt to clarify the realistic and unrealisticMaintaining an Interest in Interpersonal IssuesCase 3Mr. D is a 32 year old single professional woman with a family family history of schizophrenia though she herself appears to have suffered throughout her life with mild depression. She has suffered for many years with depressive episodes, one severe enough to lead her to miss 8 weeks of work. She takes citaloproam 40 mg, and she was doing well of that for 6 months before becoming moderately depressed. Previously she had done well for four months on 20 mg of citaloproam, and the citalopram was increased 6 months ago because she had then also had a breakthrough of moderate depressive symptoms. The questions was whether to increase her citaloproma to 50 mg or 60 mg to switch her to another anti-depressant or to perhaps augment her regimen with bupropriaon. She was in psychotherapy with a social worker at the same agency where Dr. D worked.Dr. D: Let me go over the choices I think we have. First we could do nothing but I think you have been struggling with this increasing depression for 3 weeks so I think we would both feel better by doing something. We can increase the citaloproam or change to another antidepressant or another drug.Ms. D: Well I prefer not adding another drug fi we could do something else.Dr. D: Well, my inclination also is to stick with and increase the citaloproam. Let me tell you why. To change to another drug would probably mean depending on the drug choses, taking you off citaloproam and waiging about 10 days before starting the new drug and then we have a 3 week wait to see if the new drug is working better. If we increase the citaloproam now, we know you tolerate the side effects well, and we wil perhaps know sooner whether the increase has worked.Ms. D: I don’t mind just increasing the medication but I am concerned that it will work for awhile and then not work. We have twice has this happen, first when the citaloproam was at 20 mg and now when it is a t40 mg. What will we do then?Dr. D: Well we’ll be in the same boat we are in now except that I would probably switch you then or add another medication though I now you are concerned about too many medications. SO I guess we would switch and let me remind you that there are many antidepressants available to us.Ms. D: That’s okay with me. Let’s increase it but if it works and then fades again, I do want to get off. You know every time I get depressed I am fearful of getting so depressed I will have to stop working again and I don’t think I or my employer could tolerate that happening again. And even if they keep me on, they will probably not see me as very reliable and stop giving me important and interesting assignments.Dr. D: I agree. My goal is to have you remain not depressed. Fortunately this time you are not so depressed that you can’t’ work, so certainly the medications are at least helping to maintain a level where you can do things, not with great joie de vivre but with enough ability to maintain attention and concentration. But I know this isn’t’ good enough for you in the long run. Ms. D: You are right about that. Now if I increase to 60 mg, I will need a prescription today because I will run out before next week.Case 3: Patient and the doctor had an interpersonal relationship. The psychiatrist uses the word “we”, “thinks out loud” and tries tot provide the patient with some sort of choice. The psychiatrist is aware of the patients concerns and the patient feels comfortable that her concern about the symptoms will be considered seriously by the psychiatrist in determine whether or not the medicine should be changed. Table 2.3 Type 1: Helping AllianceThe patient feels that the clinician is warm and supportive.The patient feels the clinician is helping in the common goals of insight and improvement.The patient feels changed by the treatment, for example, describing herself as “improved’ or “less anxious’.The patient feels a rapport with the therapist; the patients feels understood and accepted.The patient feels that the therapist respects and values her.The patients convey a belief in the value of the treatment process in helping her to overcome problems. Psychiatry and the Doctor –Patient RelationshipCase 4Mr. B is a 35 year old middle manager who was admitted to the hospital in a suicidal state. One of the stressors contributing to his increasing depression was his poor relationship with his wife. In fact, his wife refused to drive him the 25 miles to the hospital on the morning of admission even though he expressed suicidal ideation and the fleeting idea of running his car into a bridge abutment. He was passive in light of what he considered to be somewhat abusive but certainly dismissive behavior by his wife, and felt that in the hospital he was just unable to assert himself at home. He remained in the hospital for 5 days during which time substantial doses of an additional antidepressant and a sleeping medication were added to his already preexisting complicated regiment o f psychotropic medications. H eh and orthostatic hypotension, and he felt spacey, dizzy, and at time confused. His bedtime sleeping medication had been increased until he slept through the night, though the said he had told his treating psychiatrist that his sleep was always terrible in the hospital and sleep was not a major concern to him before he came into the hospital. Fortunately his outpatient therapist came to see him on the day designated for his discharge, and noticing his lethargic and hypotensive state requested that the new medication she held for a day so that the patient could drive himself home. The treating inpatient psychiatrist seemed unaware of the fact that the patient had to dive himself home and appeared to have ignored the patient’s statement that he always sleeps poorly while in the hospital . Further it seemed much safer for the patient to make the drive midday one or two days later rather than during evening rush hour with the sun low in the hoisin, the time originally scheduled for the discharge.Case 4: If the patient had to drive home in a drowsy state it could have led to disastrous consequences. The inability of the inpatient psychiatrist to realize the extent of the patients lethargy reveals the psychiatrist adherence to a medication regimen over a patients stated set of feelings and needs.Medication Adherence and Synergism with the Doctor-Patient RelationshipCase 5Mr. E, a 33 year old insurance salesman, presented with all the classic symptoms of major depression. He had been struggling with depression his whole life but was reluctant to take medications for fear they would make him too happy and thus not very considerate of other people in his life, and that they would be addicting.Mr. E: But Doc I can’t keep going on like this.Dr. E: Let e tell you how I think about antidepressant medications. I do not think it makes you so happy that you walk around all day with a grin on your face. :Rather, I think of them as providing a kind of safety net for you. Now when you get depressed, you seem to crash down through a whole house and wind iup in the dank, dark basement. Antidepressants keep you from falling below the first floor. You will still be sad when it is appropriate, you will still be able to show genuine concern for other people and hopefully you will be able to experience a fuller range of positive and negative feeling. These feeling will be safer for you to experience. Also, while these medications are not addicting, people can experience an increase in symptoms if they stop them too suddenly. But if we are careful and do a slow taper when you wish to stop them or when we both feel it is time to stop them, there should be a minimal amount of difficulty. We just need to work together, and you need to keep me informed of your worries and concerns so we can together decide how to proceed and when these problems occur.Case 5: A collaborative approach reassures the patient that he won’t fight with you to discuss the possibility of discontinuing a medication that has been quite intolerable for him. The knowledge that you want to hear how he is really feeling help him to tolerate early side effects. If we miss important clues we may end up with a patient who unpredictably doesn’t take his medication as case 5 has shown.Different elements that convey your interests in the patient as an individual:Repeatedly use the word we rather than I to imply that decisions and discussions are really going to be mutual, cooperative, collaborative effort between the two of usRepeatedly make it clear we encourage the patient to tell us how he feels and reacts, and if he gets worried or concerned, you wan to know about tit.Validate that the patient’s feelings and reactions are importantPont out to the patient that you consider him to be an individualReinforce the idea that you think that taking some medication is important and would help but the medication does not have to be this particular medicationWork jointly to solve problems Enhancing Adherence in the Pharmacotherapy Treatment RelationshipTable 3.1 Obstacles and Interventions for Enhancing Pharmacotherapy AdherencePharmacotherapy adherence obstacleSuggested InterventionsLevel of Distress and MotivationToo LittleAssess suitability of diagnosis and symptoms for pharmacotherapyAssess which symptoms are most important to patientAssess comorbid diagnosisDenialAssess level of denialExternalizationAssess patient’s competence to accept of refuse treatmentMedication EffectsSide effectsChoose Medications with tolerable side effect possibleChoose medication with side effects tolerable to specific patient treatedEducate patients about the side effects to the degree appropriated, in appropriate mannerMonitor clinical and laboratory parameters of side effectsTherapeutic effectsAssess and monitor therapeutic effects of medicationTreatment AccessibilityChaotic life, lack of routineAddress patients life routineDiscontinuous care due to systemAssess continuity of careUnaffordable careAssess cost of treatment including medicationExternal pressures against treatmentAssess social support systemAssess effects of employer or other external sources of potential influenceTreatment relationshipWorking allianceAccess working allianceCountertransferenceAsses countertransferenceTransferenceAssess transference“Relationship” to medicationsAssess relationship to medicationsRole of concurrent psychotherapistAssess influence of concurrent Psychothereapist Forming an Effective Therapeutic AllianceTable 4.1 Common Unrecognized Feelings and Resulting Behaviors in a Single Clinical Intereview in Students, Residents and FellowsUnrecognized feeling elicited after a clinical interviewCommonFears of losing control, addressing psychological material, appearing unpleasant, harming the patientUnique personality issues (e.g. reminds one of own difficult divorce)Performance anxietyUncommonSexual feelings, attitude favoring biomedical data, anger, fear of involvement, intimidation by patient, inadequacy, disdainIdentification with the patientUnrecognized behaviors observed during a patient interviewCommonOver control of the patient an interviewAvoidance of psychological materialSuperficial behaviorPassivityUncommonSeductivenessCritical, intimidating, passive aggressiveLack of respect and sensitivity Withdrawal, distancingThe interview provides a setting for the dialogue that promotes the establishment of the interpersonal relationshipOnce the dialogue is established, it must be maintained while building a sense of trust between the interviewer and patientTrust is established not only between the two people but in the interview process as wellAfter trust and the relationship is established, they must be maintained and strengthened so that a true collaboration process evolves between patient and the physician.Interviewing and the Interpersonal RelationshipUsing the Interview to Establish CollaborationTable 5.1 Interviewing and the Interpersonal RelationshipThe interview provides a setting for the dialogue that promotes the establishment of the interpersonal relationship.Once the dialogue is established, it must be maintained while building a sense of trust between the interviewer and the patient.Trust is established not only between the two people but in the interview process as well.After trust and the relationship is established, they must be maintained and strengthened so that a true collaborative process evolves between patient and the phycician.Enhancing Adherence in the Pharmacoptherapy Treatment RelationshipTable 6.1 Obstacles and Interventions for Enhancing Pharmacotherapy AdherencePharmacotherapy adherence obstacleSuggested InterventionsLevel of Distress and MotivationToo LittleAssess suitability of diagnosis and symptoms for pharmacotherapyAssess which symptoms are most important to patientAsses comorbid diagnosisDenialAssess level of denialExternalizationAssess patient’s competence to accept or refuse treatmentMedication EffectsSide EffectsChoose medications with tolerable side effects possibleChoose medication with side effects tolerable to the specific patient treatedEducate patients about the side effects to the degree appropriated, in appropriate mannerMonitor clinical and laboratory parameters of side effectsTherapeutic effectsAssess and monitor therapeutic efforts of medicationTreatment accessibilityChaotic life, lack of routineAddress patient’s life routineDiscontinuous care due to systemAssess continuity of careUnaffordable careAssess cost of treatment including medicationExternal pressures against treatmentAssess social support systemAssess effects of employer or other external sources of potential influenceTreatment RelationshipWorking allianceAccess working allianceCountertransferenceAssess countertransferenceTransferenceAssess transference“Relationship” to medicationsAssess relationship to medicationsRole of concurrent psychotherapistAsses influence of concurrent psychotherapistCollaborative Therapy Dealing with Negative or Resistant PatientsTry not to move into clinical assessment with negative or resistant patients. Work on exploring their ideas on when, how, and where they feel they can possibly achieve what is important to them. Table one gives insight on how to work and interact with patients who are difficult to engage.Table 1. How to merge the reluctant patient’s goals with clinical needs assessmentQuestions to Prioritize patient GoalsQuestions for clinical needs assessmentMerging patient goals with assessed needsWhat?What does the patient want the most? What undesired consequences will occur if she/he does not get help?What does the clinical assessment indicate she/he needs? What obstacles/assets do you need to address to help him/her get what she/he wants?What treatment contract will drive the treatment plan and organize treatment priorities?Why?Why did she/he seek help now? Has she/he realized or been told they are at risk to lose freedom, health, a relationship, or a job? How committed to change is she/heWhy are the assessed obstacles and resources important to include in a treatment plan? What diagnostic, function, or severity problems do assessment data reveal?Is the treatment plan linked to what he/she wants? Does she/he accept that the treatment priorities will help them get what they want?How?How will they achieve the most important goal? Must you try their preferred treatment before they accept methods you prescribe?How will you develop patient buy in and get him/her to accept the plan?Does he/she believe your strategies will heop get what he/she wants? Will they be actively invested or passively compliant in treatment?Where?Where is he/she willing to be treated? Does he/she have a preferences such as group or residential programs?Where is the appropriate setting for treatment? What is indicated by the placement criteria?Refer her/him to the level of care that merges their preferences with what is clinically indicated and likely to be effectiveWhen?When does he/she want to begin treatment? Is she/he feeling pressure to start? How badly does she/he want treatment or is she/he just complying?When should treatment begin, based on your assessment? What are realistic expectations and milestones in the process?How urgent is treatment? What is the process? What is expected from referral?The Transtheoretical Model identifies which interventions may be effective at various stages of change. A difficult patient may not be vested in what the clinician thinks the problem is or working on that problem. Table two displays the process of change and how the problem can be explored, allowing possible movement to another stage of change.Table 2. Transtheoretical model’l 9 process of change: What happens at each stepProcess of changeThe person….Conscious raisingBecomes aware of a problem from education, advice, self awareness or feedback from othersSocial liberationBegins to think about change because external forces raise awareness Emotional arousalBecomes more convinced of the need to change when faced with a strong and sudden emotional experience related to the problemSelf reevaluationExamines his or her values to see whether or not the behavior conflicts with what is important to him/herCommitmentAccepts responsibility for changing and affirms to self and others the decision to changeRewardUses self praise, positive feedback from others, improved well being or financial security, “natural highs” and other reinforcing benefits to consolidate changeCounteringSubstitutes other responses to counter unhealthy choices and behaviorEnvironmental controlChanges surrounding people, places, or things to reduce the risk of continuing or resuming the problem behaviorHelping relationshipsSeeks assistance from trusted friends, professional, spiritual advisors, or significant others to initiate and sustain the change process ................
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