week 10 The Nervous Systems
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Family Medicine 03: 65-year-old woman with insomnia
You are doing an eight-week clerkship in a family medicine practice. Christina, the medical assistant, hands you the progress note for the next patient, which identifies the patient as Mrs. Gomez, “a 65-year-old woman who is here today reporting that she can’t sleep.”
Dr. Lee, your preceptor, fills you in: “Mrs. Gomez has been a patient here for several years. Difficulty sleeping is a new issue for her. Her past medical history is significant for hypertension and diabetes. Generally, she has been doing well, although I notice that her last hemoglobin A1c has climbed to 8.7%.”
Common causes of insomnia in the elderly:
- Environmental problems
- Drugs/alcohol/caffeine
- Sleep apnea
- Parasomnias: restless leg syndrome/periodic leg movements/REM sleep behavior disorder
- Disturbances in the sleep-wake cycle
- Psychiatric disorders, primarily depression and anxiety
- Symptomatic cardiorespiratory disease (asthma/chronic obstructive pulmonary disease/congestive heart failure)
- Pain or pruritus
- Gastroesophageal reflux disease (GERD)
- Hyperthyroidism
- Advanced sleep phase syndrome (ASPS)
Common Causes of Insomnia in the Elderly
- Issues that may lead to an environment that is not conducive to sleep.
- Specific examples include: noise or uncomfortable bedding.
- You can teach the patient sleep hygiene techniques that will increase the likelihood of a restful night’s sleep.
- The use of prescription, over-the-counter, alternative, and recreational drugs might affect sleep.
- Patients should be counseled to avoid caffeine and alcohol for four to six hours before bedtime.
- Sleep apnea is common in the elderly, occurring in 20% to 70% of elderly patients.
- Obstruction of breathing results in frequent arousal that the patient is typically not aware of; however, a bed partner or family member may report loud snoring or cessation of breathing during sleep.
- In restless leg syndrome, the patient experiences an irresistible urge to move the legs, often accompanied by uncomfortable sensations.
- In periodic leg movement and REM sleep behavior disorder, the patient experiences involuntary leg movements while falling asleep and during sleep respectively.
- As in sleep apnea, the sleeper is often unaware of these behaviors and a bed partner or family member may need to be asked about these movements.
- Disturbances in the sleep-wake cycle include jet lag and shift work.
- Patients with depression and anxiety commonly present with insomnia.
- Any patient presenting with insomnia should be screened for these disorders.
- Patients with shortness of breath due to cardiorespiratory disorders often report that these symptoms keep them awake.
- Pain or pruritus may keep patients awake at night.
- Those with GERD may report heartburn, throat pain, or breathing problems.
- These patients may also have trouble identifying what awakens them.
- Detailed questioning may be needed to elicit the symptoms of this disorder.
- Elderly patients with hyperthyroidism frequently do not present with typical symptoms such as tachycardia or weight loss, and laboratory studies may be required to detect this problem.
- Circadian rhythms change, with older adults tending to get sleepy earlier in the night. In advanced sleep phase syndrome (ASPS), this has progressed to the point where the patient becomes drowsy at 6 to 7 p.m. If they go to sleep at this hour, they sleep a normal seven to eight hours, waking at 3 or 4 a.m. However, if they try to stay up later, their advanced sleep/wake rhythm still causes them to awaken at 3 or 4 a.m. This can be difficult to distiguish from insomnia.
Sleep Hygiene
Meet the Sleep Disorders Specialists
Helpful Hints to Help You Sleep
Poor sleep habits (referred to as hygiene) are among the most common problems encountered in our society. We stay up too late and get up too early. We interrupt our sleep with drugs, chemicals and work, and we overstimulate ourselves with late-night activities such as television.
Below are some essentials of good sleep habits. Many of these points will seem like common sense. But it is surprising how many of these important points are ignored by many of us. Click on any of the links below for more information:
Your Personal Habits
- Fix a bedtime and an awakening time. Do not be one of those people who allows bedtime and awakening time to drift. The body “gets used” to falling asleep at a certain time, but only if this is relatively fixed. Even if you are retired or not working, this is an essential component of good sleeping habits.
- Avoid napping during the day. If you nap throughout the day, it is no wonder that you will not be able to sleep at night. The late afternoon for most people is a “sleepy time.” Many people will take a nap at that time. This is generally not a bad thing to do, provided you limit the nap to 30-45 minutes and can sleep well at night.
- Avoid alcohol 4-6 hours before bedtime.Many people believe that alcohol helps them sleep. While alcohol has an immediate sleep-inducing effect, a few hours later as the alcohol levels in your blood start to fall, there is a stimulant or wake-up effect.
- Avoid caffeine 4-6 hours before bedtime.This includes caffeinated beverages such as coffee, tea and many sodas, as well as chocolate, so be careful.
- Avoid heavy, spicy, or sugary foods 4-6 hours before bedtime. These can affect your ability to stay asleep.
- Exercise regularly, but not right before bed. Regular exercise, particularly in the afternoon, can help deepen sleep. Strenuous exercise within the 2 hours before bedtime, however, can decrease your ability to fall asleep.
Your Sleeping Environment
- Use comfortable bedding. Uncomfortable bedding can prevent good sleep. Evaluate whether or not this is a source of your problem, and make appropriate changes.
- Find a comfortable temperature setting for sleeping and keep the room well ventilated. If your bedroom is too cold or too hot, it can keep you awake. A cool (not cold) bedroom is often the most conducive to sleep.
- Block out all distracting noise, and eliminate as much light as possible.
- Reserve the bed for sleep and sex. Don’t use the bed as an office, workroom or recreation room. Let your body “know” that the bed is associated with sleeping.
Getting Ready For Bed
- Try a light snack before bed. Warm milk and foods high in the amino acid tryptophan, such as bananas, may help you to sleep.
- Practice relaxation techniques before bed.Relaxation techniques such as yoga, deep breathing and others may help relieve anxiety and reduce muscle tension.
- Don’t take your worries to bed. Leave your worries about job, school, daily life, etc., behind when you go to bed. Some people find it useful to assign a “worry period” during the evening or late afternoon to deal with these issues.
- Establish a pre-sleep ritual. Pre-sleep rituals, such as a warm bath or a few minutes of reading, can help you sleep.
- Get into your favorite sleeping position. If you don’t fall asleep within 15-30 minutes, get up, go into another room, and read until sleepy.
Getting Up in the Middle of the Night
Most people wake up one or two times a night for various reasons. If you find that you get up in the middle of night and cannot get back to sleep within 15-20 minutes, then do not remain in the bed “trying hard” to sleep. Get out of bed. Leave the bedroom. Read, have a light snack, do some quiet activity, or take a bath. You will generally find that you can get back to sleep 20 minutes or so later. Do not perform challenging or engaging activity such as office work, housework, etc. Do not watch television.
A Word About Television
Many people fall asleep with the television on in their room. Watching television before bedtime is often a bad idea. Television is a very engaging medium that tends to keep people up. We generally recommend that the television not be in the bedroom. At the appropriate bedtime, the TV should be turned off and the patient should go to bed. Some people find that the radio helps them go to sleep. Since radio is a less engaging medium than TV, this is probably a good idea.
Other Factors
- Several physical factors are known to upset sleep. These include arthritis, acid reflux with heartburn, menstruation, headaches and hot flashes.
- Psychological and mental health problems like depression, anxiety and stress are often associated with sleeping difficulty. In many cases, difficulty staying asleep may be the only presenting sign of depression. A physician should be consulted about these issues to help determine the problem and the best treatment.
- Many medications can cause sleeplessness as a side effect. Ask your doctor or pharmacist if medications you are taking can lead to sleeplessness.
- To help overall improvement in sleep patterns, your doctor may prescribe sleep medications for short-term relief of a sleep problem. The decision to take sleeping aids is a medical one to be made in the context of your overall health picture.
- Always follow the advice of your physician and other healthcare professionals. The goal is to rediscover how to sleep naturally.
Dr. Lee tells you, “Poor sleeping habits can also cause insomnia. Here is a handout on sleep hygiene. For some patients, simply correcting their sleep habits by following these tips will correct their quality of sleep.”
You review the handout.
TEACHING POINT
Good Sleep Hygiene
Your Personal Habits
- Fix a bedtime and an awakening time. The body “gets used to” falling asleep at a certain time, but only if this is relatively fixed. Even if you are retired or not working, this is an essential component of good sleeping habits.
- Avoid napping during the day. If you nap throughout the day, it is no wonder that you will not be able to sleep at night. The late afternoon for most people is a “sleepy time.” Many people will take a nap at that time. This is generally not a bad thing to do, provided you limit the nap to 30 to 45 minutes and can sleep well at night.
- Avoid alcohol four to six hours before bedtime. Many people believe that alcohol helps them sleep. While alcohol has an immediate sleep-inducing effect, a few hours later as the alcohol levels in the blood start to fall, there is a stimulant or wake-up effect.
- Avoid caffeine four to six hours before bedtime. This includes caffeinated beverages such as coffee, tea and many sodas, as well as chocolate, so be careful.
- Avoid heavy, spicy, or sugary foods four to six hours before bedtime. These can affect your ability to stay asleep.
- Exercise regularly, but not right before bed. Regular exercise, particularly in the afternoon, can help deepen sleep. Strenuous exercise within the two hours before bedtime, however, can decrease your ability to fall asleep.
Your Sleeping Environment
- Use comfortable bedding. Uncomfortable bedding can prevent good sleep. Evaluate whether or not this is a source of your problem, and make appropriate changes.
- Find a comfortable temperature setting for sleeping and keep the room well ventilated. If your bedroom is too cold or too hot, it can keep you awake. A cool (not cold) bedroom is often the most conducive to sleep.
- Block out all distracting noise, and eliminate as much light as possible.
- Reserve the bed for sleep and sex. Don’t use the bed as an office, workroom or recreation room. Let your body “know” that the bed is associated with sleeping.
Getting Ready For Bed
- Try a light snack before bed. Warm milk and foods high in the amino acid tryptophan, such as bananas, may help you to sleep.
- Practice relaxation techniques before bed. Relaxation techniques such as yoga, deep breathing and others may help relieve anxiety and reduce muscle tension.
- Don’t take your worries to bed. Leave your worries about job, school, daily life, etc., behind when you go to bed. Some people find it useful to assign a “worry period” during the evening or late afternoon to deal with these issues.
- Establish a pre-sleep ritual. Pre-sleep rituals, such as a warm bath or a few minutes of reading, can help you sleep.
- Get into your favorite sleeping position. If you don’t fall asleep within 15 to 30 minutes, get up, go into another room, and read until sleepy.
Getting Up in the Middle of the Night
Most people wake up one or two times per night for various reasons. If you find that you get up in the middle of night and cannot get back to sleep within 15 to 20 minutes, then do not remain in the bed “trying hard” to sleep. Get out of bed. Leave the bedroom. Read, have a light snack, do some quiet activity, or take a bath. You will generally find that you can get back to sleep 20 minutes or so later. Do not perform challenging or engaging activity such as office work, housework, etc. Do not watch television.
A Word About Television
Many people fall asleep with the television on in their room. This is often a bad idea. Television is a very engaging medium that tends to keep people up. We generally recommend that the television not be in the bedroom. At the appropriate bedtime, the TV should be turned off and the patient should go to bed. This also applies to computers, tablets and smart phones. Some people find that the radio helps them go to sleep. Since radio is a less engaging medium than TV, this is probably a good idea.
Which treatments are recommended in the elderly? Select all that apply.
The best options are indicated below. Your selections are indicated by the shaded boxes.
- Benzodiazepines
- B. Cognitive behavioral therapy
- Antihistamines
- Antidepressants
- Zolpidem
Submit
Answer Comment
The correct answers are B, E.
TEACHING POINT
Treatments for Primary Insomnia in the Elderly
Of the behavioral treatments, many of which may be of some assistance in the elderly, only sleep restriction/sleep compression therapy and multi-component cognitive-behavioral therapy have met evidence-based criteria for efficacy.
Cognitive Behavioral Therapy for Insomnia (CBT-I)
CBT-I is recommended as the first choice for most patients with insomnia. CBT-I combines different behavioral treatments, resulting in improvements lasting up to two years. Recent guidelines recommend CBT-I as the first-line therapy for insomnia in adults. Examples include:
- Sleep restriction therapy: The patient is told to reduce his or her sleep/in-bed time to the average number of hours the patient has actually been able to sleep over the last two weeks (as opposed to the number of hours spent in bed (awake plus asleep)). As sleep efficiency increases, time allowed in bed is increased gradually by 15- to 20-minute increments approximately once every five days (if improvement is sustained) until the individual’s optimal sleep time is obtained.
- Sleep compression therapy: The patient is counseled to decrease the amount of time spent in bed gradually to match total sleep time rather than making an immediate substantial change.
Pharmacological Therapy
All drugs for the treatment of insomnia can be associated with side effects – particularly prolonged sedation and dizziness – that can result in the risk of injuries and confusion.
Preferred agents:
Preferred agents:
Class Agents Comments Benzodiazepine Receptor Agonists zolpidem (Ambien) eszopiclone (Lunesta)
Improved sleep onset latency, total sleep time, and wake after sleep onset Tricyclic Antidepressants doxepin 3-6 mg Doxepin only suggested agent in this class Orexin Receptor Antagonist suvorexant (Belsomra) Improved sleep-onset and/or sleep-maintenance insomnia. Benzodiazepines can be effective but have more complications and the additional risk of addiction.
Antihistamines, antidepressants (in the absence of depression), anticonvulsants, and antipsychotics are associated with more risks than benefits in older adults.
Combining CBT-I and pharmacological therapy can be helpful in some patients.
The evidence base for exercise as a treatment for insomnia is less extensive. Despite this, there are many other reasons to encourage regular physical activity in the elderly, assuming there are no other contraindications to such activity.
After discussing these potential causes of insomnia with Dr. Lee, you feel prepared to talk with Mrs. Gomez. You knock on the exam room door and enter to find Mrs. Gomez, who is accompanied by her daughter, Silvia. You introduce yourself and ask if you may ask her a few questions, to which she agrees.
“What brings you to the clinic today?”
“I’m just so tired lately. I just can’t seem to sleep.”
“Tell me more about this.”
“Well, for the last six months I can’t sleep for more than a couple of hours before I wake up,” Mrs. Gomez tells you.
On further questioning, Mrs. Gomez denies any discomfort such as pain or breathing problems disturbing her sleep. She denies any snoring, apneic spells (a period of time during which breathing stops or is markedly reduced), or physical restlessness during sleep. Her daughter agrees that she has not seen these problems. She rarely consumes alcohol or caffeine.
When you ask if anything like noise or an uncomfortable sleeping environment might be bothering her, she replies that this is not a problem – but her daughter interjects: “Yes, in fact Mom’s waking up the rest of us, walking around and turning on the TV. My husband and I both work. So we all need our rest. Mom came to live with us last year after Dad passed away. We’re her only family around here and we thought we should help her.”
You tell Mrs. Gomez,
“I’m sorry to hear about your husband.”
“Yes, we were married for 30 years. This has been a difficult time for me.”
“Do you find that you feel sad most of the time?”
“Of course I am sad when I think about my husband and how much I miss him. But I wouldn’t say that I’m sad most of the time.”
Silvia states, “But Mom, you spend most of your time just moping around the house.” Turning to you she elaborates, “She seems to be in slow motion most of the time. She doesn’t even go to church anymore. She used to go three to four times a week. She used to read all the time, and she doesn’t do that anymore either.”
Mrs. Gomez explains, “I haven’t been reading as much as I used to because I can’t seem to focus and I end up reading the same page over and over.” She goes on to say, “And I don’t seem to have any energy to do anything. I’m not even able to help out around the house. I feel bad about that; I should be helping out more. I seem to spend a lot of time just watching TV and eating junk food.”
You ask,
“Have you tried anything to help you sleep?”
“Well, I tried Tylenol PM (acetaminophen and diphenhydramine), which didn’t help and gave me a dry mouth. I also tried zapoteblanco, a kind of Mexican herbal tea. But it didn’t help me sleep either.”
“I’m not familiar with that product, but I’ll mention it to Dr. Lee. I’m glad you brought it up. It’s important that your doctors know about everything you are taking, whether it’s prescription medication or not. I’m sorry nothing seems to be helping you sleep. We’ll get to the bottom of this together.”
You turn your attention to taking Mrs. Gomez’s past medical history. You learn:
Problem list:
- Hypercholesterolemia
- Type 2 diabetes
- Hypertension
Surgical history:
- Cholecystectomy
- Hysterectomy (due to fibroids)
Medications:
For diabetes:
- Glyburide (10 mg daily)
- Metformin (1,000 mg bid)
For blood pressure:
- Methyldopa (250 mg bid)
- Lisinopril (10 mg daily)
For cholesterol:
- Atorvastatin (80 mg daily)
For CHD prophylaxis:
- Aspirin 81 mg daily
For osteoporosis prevention:
- Calcium citrate with vitamin D (600mg/400 IU bid)
Diphenhydramine is her only over-the-counter medication, and she is taking no traditional or herbal medications beyond the zapote tea.
Social History
She does not smoke, and drinks only small amounts of alcohol on holidays.
Given what you have heard from Mrs. Gomez and her daughter, especially
- her inability to focus,
- her lack of energy,
- the sense that she is in slow motion,
- she has stopped doing activities she previously enjoyed,
You are concerned that her insomnia may be due to depression. Depression may stem from environmental stressors such as her husband’s death and her loss of independence along with a primary neurochemical imbalance. Her depression also could be caused by another medical condition.
Question
Which of the following medical conditions is associated with depression? Select all that apply.
The best options are indicated below. Your selections are indicated by the shaded boxes.
- Hypothyroidism
- Parkinson disease
- Hypertension
- Dementia
- Asthma
Submit
Answer Comment
The correct answers are A, B, D.
TEACHING POINT
Medical Conditions Associated with Depression
A number of diseases either cause depressive symptoms or have depression as a comorbidity at higher rates than would be normally expected.
In looking for the causes and associations of depression, first consider the common conditions. Then think about the very serious diseases that you don’t want to miss. Beyond that, there’s a very wide range of diagnoses that can look like depression:
Hypothyroidism:
About 5% of the U.S. population has hypothyroidism. Checking the level of thyroid stimulating hormone (TSH) would help make the diagnosis. Hypothyroidism can be treated with thyroid-replacement medications such as triiodothyronine (T3) and/or levothyroxine (T4). Once TSH levels are returned to the normal range, the symptoms of depression often subside.
Parkinson disease:
Up to 60% of people with this disorder experience mild or moderate depressive symptoms. Although several reports have shown a link between depressive symptoms and Parkinson disease, it is unclear whether one causes the other or if both may arise from some common mechanism. A recent study has indicated that depressive symptoms are an early feature of Parkinson disease, preceding the characteristic movement problems seen in Parkinson such as tremor and rigid muscles. Therefore, people with signs of depression who start to develop movement problems should be promptly evaluated to rule out a diagnosis of Parkinson disease.
Dementia:
Dementia and depression may be difficult to differentiate, as people with either disorder are frequently passive or unresponsive, and they may appear slow, confused, or forgetful. The Mini-Mental State Examination (MMSE) is useful to assess cognitive skills in people with suspected dementia. (The MMSE examines orientation, memory, and attention, as well as the ability to name objects, follow verbal and written commands, write a sentence spontaneously, and copy a complex shape.) Early and accurate diagnosis of dementia is important for patients and their families because it allows early treatment of symptoms. For people with other progressive dementia, early diagnosis may allow them to plan for the future while they can still help to make decisions. These people also may benefit from drug treatment.
Hypertension (C) and asthma (E) have not been specifically linked to higher rates of depression.
Some other diseases that have been linked to depression include:
- Endocrine disease (Addison disease, diabetes, Cushing syndrome, hypoglycemia, hyperparathyroidism)
- Acquired immunodeficiency syndrome
- Cardiovascular disease (myocardial infarction, angina)
- Cancer (particularly of the pancreas)
- Cerebral arteriosclerosis, cerebral infarction
- Electrolyte and renal abnormalities
- Folate, cobalamin and thiamine deficiencies
- Hepatitis
- Intracranial tumors
- Multiple sclerosis
- Porphyria
- Rheumatologic disease (rheumatoid arthritis, systemic lupus erythematosus, temporal arteritis)
- Syphilis
- Temporal lobe epilepsy
- Huntington disease
- Chronic pain
- Keeping in mind the disorders associated with depression, you elicit a review of systems from Mrs. Gomez to help discover what these indicate regarding her underlying illness.
- Constitutional: Gomez has gained about 10 lbs in the last six months. She denies fevers or dizziness. This makes you less concerned about cancer or other systemic illness.
- Respiratory: No shortness of breath, making cardio-respiratory disease less likely.
- Cardiac: No chest pains, palpitations or edema, decreasing the likelihood of cardiovascular disease.
- Gastrointestinal: No nausea, changes in bowel habits, hematochezia or melena. This makes you less concerned about gastrointestinal cancer or occult blood loss leading to anemia.
- Endocrinologic: No polydipsia or polyuria, decreasing the likelihood of poorly controlled diabetes.
- Neurologic: No acute neurologic changes or tremors. Her daughter confirms that patient has been alert, oriented and has had no episodes of confusion. So you are now less concerned about cerebral infarction, intracranial tumors, multiple sclerosis, and Parkinson disease.
- Urologic: Normally urinates one to two times at night.
- Once you have completed your review of systems, you excuse yourself from the room for a moment while Mrs. Gomez changes into a gown.
When you return to the exam room, after washing your hands, you perform a physical exam on Mrs. Gomez.
Vital signs:
- Heart rate: 60 beats/minute and regular
- Respiratory rate: 16 breaths/minute
- Blood pressure: 128/78 mm Hg
- Weight: 186 pounds (up 10 pounds since last year)
- Height: 64 in
Head, eyes, ears, nose and throat (HEENT): No thyromegaly, adenopathy, or masses.
Cardiac: Regular rate and rhythm, no murmur or gallops. No edema.
Respiratory: Clear to auscultation.
Abdominal: Soft, nontender, without organomegaly or masses.
Neurologic: Cranial nerves 3-12 intact. Normal strength and light touch sensation in extremities. No tremors. Normal gait.
You are afraid your next question may upset Mrs. Gomez, but you know it is important to ask: “Mrs. Gomez, I have one more question: When people are down, sometimes they wish they would fall asleep and never wake up.
“Have you had any thoughts of dying or causing harm to yourself?”
“Well it has been hard and I would like to see my husband, but I could never hurt myself because of my religion,” she tells you.
“Okay, thank you for your openness with me,” you tell Mrs. Gomez. “I would like to bring in Dr. Lee so she can also perform a physical exam before you get dressed. We’ll be back in just a minute. Do you have any questions for me before I go?”
Mrs. Gomez indicates she doesn’t have any concerns, so you exit the room.
Question
What factors increase a patient’s risk for completed suicide? Select all that apply.
The best options are indicated below. Your selections are indicated by the shaded boxes.
- Having served in the military.
- Male sex.
- Older age.
- Living in poverty.
- Having a previous suicide attempt.
Submit
Answer Comment
The correct answers are A, B, C, E.
TEACHING POINT
Risk Factors for Completed Suicide
Sex: The person most likely to succeed in a suicidal attempt is an adult male. While females are more likely to attempt suicide, males are more likely to complete one.
Age: Although overall suicidal behaviors do not increase with age, rates of completed suicide do increase with age.
- Elderly persons attempting suicide are also more likely to be widows/widowers, live alone, perceive their health status to be poor, experience poor sleep quality, lack a confidante, and experience stressful life events.
- Importantly, approximately 75% of elderly persons who commit suicide had visited a primary care physician within the preceding month, but their symptoms were not recognized or treated, underscoring that physicians must be tuned in to the signs and symptoms of depression and risks for suicide. Drug overdose is the most common means of suicide on the elderly, making the safety of medications chosen to treat the condition important.
Previous attempts: Having previously attempted suicide is a risk factor for completed suicide.
Military Service: The suicide rate of military veterans in the United States is higher than that of the general population.
Poverty by itself has not been found to be a risk factor for completed suicide, though it can contribute to psychosocial stress and the development of depressive symptoms.
You locate Dr. Lee and present the case to her, expressing your concern that Mrs. Gomez is depressed. She suggests discussing the evidence you found that Mrs. Gomez may have depression.
You tell Dr. Lee, “Mrs. Gomez has depressed mood and seven of the nine criteria.”
TEACHING POINT
Major Depression Diagnostic Criteria
- For a diagnosis of major depression, the patient must have at least five of the following nine criteria for a minimum of two weeks.
- A least one of the symptoms must be either (1) depressed mood or (2) loss of interest or pleasure.
Depressed Mood
(The eight remaining criteria can be remembered using the mnemonic SIG E CAPS):
Sleep: Insomnia or hypersomnia nearly every day.
Interest (loss of): Anhedonia (loss of interest or enjoyment) in usual activities.
Guilt: Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
Energy (decreased): Fatigue or loss of energy nearly every day.
Concentration (decreased, or crying): Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
Appetite (increased or decreased): or significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month).
Psychomotor retardation: Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
Suicidal ideation: Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
“You seem to have established that Mrs. Gomez meets the criteria for a major clinical depression,” says Dr. Lee, and goes on to explain:
TEACHING POINT
Major Depressive Disorder vs. Bereavement
The presence of certain symptoms that are not characteristic of a “normal” grief reaction may be helpful in differentiating bereavement from a Major Depressive Episode. The table below adapted from the DSM V discusses some potential differences:
Major Depressive Episode Bereavement (Grief) Persistent depressed mood and inability to anticipate happiness or pleasure Feelings of emptiness and loss Depression persistent, not tied to specific thoughts or preoccupations Depressed feelings often decrease in intensity over days to weeks and occurs in waves, associated with thoughts of the deceased Pervasive unhappiness and misery Grief may be accompanied by positive emotions and humor Self-critical or pessimistic ruminations Preoccupation with thoughts and memories of the deceased Feelings of worthlessness and self-loathing Self-esteem is generally preserved. May be self-deprecating—feeling they should have done more or told the deceased how much he or she was loved Suicidal ideation because of feeling worthless, undeserving of life, or unable to cope with the pain of depression Individual thinks about death and dying, generally focused on the deceased and possibly about joining the deceased TEACHING POINT
Risk factors for Late-life depression
Risk factors for late-life depression include:
- Female sex
- Social isolation
- Widowed, divorced, or separated marital status
- Lower socioeconomic status
- Comorbid general medical conditions, e.g. stroke, heart disease and cancer
- Uncontrolled pain
- Insomnia
- Functional impairment
- Cognitive impairment
TEACHING POINT
Depression in the Elderly
Depression is a very serious disease in the elderly:
- Depression increases the risk of disabilities in mobility and the activities of daily living by about 70% over the course of six years.
- Alcohol and drug abuse are very common comorbidities complicating depression.
- Completed suicide is more common in older depressed patients.
- Risk assessment
- CARE DISCUSSION
- You express to Dr. Lee your concern that by asking about suicide you may have made the situation worse.
- Lee reassures you: “Many people worry that bringing up the subject of suicide will cause the patient to commit suicide. On the contrary, talking about it allows the opportunity to intervene and prevent a completed suicide.”
- TEACHING POINT
- Suicide assessment five-step evaluation and triage (SAFE-T)
- SAFE-T (Suicide Assessment Five-Step Evaluation and Triage) Copyright 2009 by Education Development Center, Inc. and Screening for Mental Health, Inc.
- RISK FACTORS
- Suicidal behavior: history of prior suicide attempts, aborted suicide attempts, or self-injurious behavior
- Current/past psychiatric disorders: especially mood disorders, psychotic disorders, alcohol/substance abuse, ADHD, TBI, PTSD, Cluster B personality disorders, conduct disorders (antisocial behavior, aggression, impulsivity) Co-morbidity and recent onset of illness increase risk
- Key symptoms: anhedonia, impulsivity, hopelessness, anxiety/panic, global insomnia, command hallucinations
- Family history: of suicide, attempts, or psychiatric disorders requiring hospitalization
- Precipitants/stressors/Interpersonal: triggering events leading to humiliation, shame, or despair (e.g, loss of relationship, financial or health status—real or anticipated). Ongoing medical illness (esp. CNS disorders, pain). Intoxication. Family turmoil/chaos. History of physical or sexual abuse. Social isolation
- change in treatment: discharge from psychiatric hospital, provider or treatment change
- Access to firearms
- PROTECTIVE FACTORSProtective factors, even if present, may not counteract significant acute risk
- Internal: ability to cope with stress, religious beliefs, frustration tolerance
- external: responsibility to children or beloved pets, positive therapeutic relationships, social supports
- SUICIDE INQUIRYSpecific questioning about thoughts, plans, behaviors, intent
- Ideation: frequency, intensity, duration—in last 48 hours, past month, and worst ever
- Plan: timing, location, lethality, availability, preparatory acts
- Behaviors: past attempts, aborted attempts, rehearsals (tying noose, loading gun) vs. non-suicidal self injurious actions
- Intent: extent to which the patient (1) expects to carry out the plan and (2) believes the plan/act to be lethal vs. self-injurious.
- Explore ambivalence: reasons to die vs. reasons to live
- ›For Youths: ask parent/guardian about evidence of suicidal thoughts, plans, or behaviors, and changes in mood, behaviors, or disposition
- ›Homicide Inquiry: when indicated, esp. in character disordered or paranoid males dealing with loss or humiliation. Inquire in four areas listed above
- RISK LEVEL/INTERVENTION
- Assessment of risk level is based on clinical judgment, after completing steps 1–3
- Reassess as patient or environmental circumstances change
- DOCUMENT Risk level and rationale; treatment plan to address/reduce current risk (e.g., medication, setting, psychotherapy, E.C.T., contact with significant others, consultation); firearms instructions, if relevant; follow-up plan. For youths, treatment plan should include roles for parent/guardian.
Entering the room with you, Dr. Lee greets Mrs. Gomez and her daughter, and thanks them for allowing you to interview them.
She tells Mrs. Gomez, “I understand that you’ve been having trouble sleeping – not unusual given your recent stresses. These can also lead to feelings of depression. I’d like to look into this by going over a short questionnaire with you.”
Dr. Lee goes over the questions on the Geriatric Depression Scale – Short Form (GDS-SF) with Mrs. Gomez. Her score equals 9. This confirms depression, as a score of > 5 is consistent with the diagnosis of depression.
Dr. Lee then performs a Mini-Cog exam to screen for dementia, explaining to Mrs. Gomez that in cases like this, checking out the patient’s memory and concentration can help to rule out other disorders and can assist in planning treatment. She scores in the normal range.
TEACHING POINT
Screening for Depression
The U.S. Preventive Services Task Force (USPSTF) recommends screening all adults for depression, but especially patients with chronic diseases like diabetes, as they are at high risk for depression.
The PHQ-2 is a simple screen that is 97% sensitive and 59% specific as a depression screen:
“Over the past two weeks, have you often been bothered by either of the following problems?”
- Little interest or pleasure in doing things.
- Feeling down, depressed, or hopeless.
If positive, it should be followed up by a diagnostic instrument such as:
TEACHING POINT
Screening for Dementia in Geriatric Patients with Depression
Screening for dementia is important in geriatric patients with depression because the Geriatric Depression Scale is less sensitive in demented patients.
Two dementia screening tools are:
- The Mini-Cog exam
- The Mini-Mental State Exam (MMSE)
The Mini-Cog exam is faster and more sensitive and specific than the MMSE.
Sensitivity Specificity Mini-Cog 99% 93% MMSE 91% 92% Medications and mechanisms of action
TEACHING
“Now that we know Mrs. Gomez is depressed,” states Dr. Lee, “Let’s talk about the different groups of antidepressant medications and how they work.”
TEACHING POINT
Antidepressant Medications
Most antidepressants work by improving the levels of the neurotransmitters norepinephrine (NE), serotonin (5HT), and dopamine (DA). There are four major classes of antidepressants:
Others
Class Mechanism Examples Selective serotonin reuptake inhibitors (SSRIs) Selectively block reuptake of serotonin, potentiating serotonin’s effect on the post-synaptic neuron Citalopram (Celexa) Fluoxetine (Prozac)
Fluvoxamine (Luvox)
Paroxetine (Paxil)
Sertraline (Zoloft)
Escitalopram (Lexapro)
Tricyclic antidepressants (TCAs) Block reuptake of norepinephrine and serotonin, potentiating their effects on the post-synaptic neuron Nortriptyline (Pamelor) Amitriptyline
Clomipramine (Anafranil)
Doxepin (Sinequan)
Monoamine oxidase (MAO) inhibitors Block pre-synaptic catabolism of norepinephrine and serotonin (rarely used today) Phenelzine (Nardil) Tranylcypromine (Parnate)
Serotonin and norepinephrine reuptake inhibitors Block reuptake of norepinephrine and serotonin, increasing their concentration/availability Venlafaxine (Effexor) and Duloxetine (Cymbalta) Others Norepinephrine and dopamine reuptake inhibitors Bupropion (Wellbutrin) Serotonin antagonist and reuptake inhibitors Nefazodone (Serzone) and Trazodone (Desyrel) Norepinephrine and serotonin antagonist, antihistaminic effects Mirtazapine (Remeron) Serotonin partial agonist and reuptake inhibitor Vilazodone (Viibryd) What are common side effects associated with selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs)? Select all that apply.
The best options are indicated below. Your selections are indicated by the shaded boxes.
- Cardiac arrhythmias
- Headaches
- Insomnia
- Nausea
- Arthralgias
Submit
Answer Comment
The correct answers are B, C, D.
TEACHING POINT
Side Effects of SSRI/SNRIs
Common side effects of SSRI/SNRIs include:
- Headaches
- Sleep disturbances (drowsiness and, less frequently, insomnia)
- Gastrointestinal problems such as nausea and diarrhea
- Sexual dysfunction
They can also cause:
- Hyponatremia, due to the syndrome of inappropriate secretion of antidiuretic hormone (SIADH)
- Serotonin syndrome (lethargy, restlessness, hypertonicity, rhabdomyolysis, renal failure, and possible death)
- Increased risk of gastrointestinal bleeding
In the elderly you also have to be concerned about an increased risk for falls with these medications, and recent studies show that they might have adverse effects on bone density.
Older antidepressants such as TCAs can cause arrhythmias. Citalopram and Escitalopram can cause QT interval prolongation at higher doses, especially in the face of hypokalemia and hypomagnesemia or when combined with other medication that have this same effect. Reports of symptomatcarrythmia is uncommon.
Often patients with depression will present with arthralgias and myalgias, but SSRI/SNRIs do not cause arthralgias.
Treatment of choice 1
CLINICAL REASONING
Question
Which of the following would be considered treatment(s) of choice in this clinical scenario? Select all that apply.
The best options are indicated below. Your selections are indicated by the shaded boxes.
- Amitriptyline – a tricyclic antidepressant
- Sertraline – a selective serotonergic reuptake inhibitor (SSRI)
- Cognitive-behavioral therapy
- Electroconvulsive therapy (ECT)
- Exercise
Submit
Answer Comment
The correct answers are B, C, E.
Dr. Lee concludes, “In the elderly, the chance of spontaneous remission of depression is much lower than in younger patients, so it’s best we start some form of therapy. I agree that an SSRI and/or psychotherapy would be a good choice for Mrs. Gomez. Also, the death of her husband and moving into a new environment proved to be stressful for her. Cognitive therapy can help her cope with these life changes.”
TEACHING POINT
Management of Depression
When treating patients with major depression disorder, a biopsychosocial approach should be considered. “Bio” refers to pharmacotherapy; “psycho” refers to psychotherapy; and “social” refers to the identification of life stressors.
While either medication or counseling can be effective when used alone, using the two treatment modalities concurrently offers the patient the most beneficial and comprehensive therapy, and is associated with the highest rates of remission.
Medication:
In a first episode of depression, it’s usually recommended that the patient take the medication for nine to 12 months, as stopping any sooner runs a high risk for recurrence. Recurrent episodes of depression are treated for two to three years. With multiple recurrences and – in the elderly, who experience increased rates of recurrence – continuous therapy should be considered.
SSRIs, such as sertraline, and SNRIs are generally considered safe and effective drugs for depression. They have lower rates of side effects compared to the older tricyclics and, unlike the tricyclics, have little risk in overdose. A tricyclic such as amitriptyline would not be a first-line approach.
Psychotherapy:
Psychotherapy, most notably cognitive behavior therapy and interpersonal therapy, have been found as effective as psychotropic medications. It can be especially useful for patients who want to avoid medication.
Exercise:
Trials of mixed exercise indicated a small but statistically significant positive effect favoring exercise for the treatment of mild to moderate depression and, similarly to combining psychotherapy and medication, may have an additive effect when used in combination simultaneously with other modalities.
Avoidance of other substances:
Additionally, avoidance of recreational drug and excessive alcohol use is a necessary part of any treatment regimen.
ECT:
While ECT is not an appropriate treatment for an initial episode of major depression, it is a safe and effective therapy that can be useful in patients with psychotic depression or severe nonpsychotic depression unresponsive to medications or psychotherapy.
Treatment of choice 2
THERAPEUTICS
“What are the differences between the various SSRIs, and how do I choose which to use?” you ask Dr. Lee.
TEACHING POINT
Antidepressant Profiles
Effectiveness:
The selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are all about equally effective in both adult and geriatric patients. While matching the patient’s symptoms with the drug’s profile, keep in mind that each patient’s reaction to a medication is different and the final selection needs to be individualized.
Cost:
Cost is another strong consideration. There are now generic preparations of many antidepressants, making them more affordable.
Drug-drug interactions:
Also, antidepressants have a wide variety of drug-drug interactions, most prominently through the P450 system.
Side effects
While antidepressants are relatively safe, there are potential side effects that vary in frequency and intensity between medications and the individual patient.
Safety during pregnancy:
Most SSRIs are categorized by the U.S. Food and Drug Administration as Pregnancy Category C, but trimester-specific or population-specific risks exist. Paxil is Pregnancy Category D.
Profiles
Drug Comments Fluoxetine (Prozac) · Unusually long half life (two to four days), so effects can last for weeks after discontinuation. · Most problematic (but uncommon) side effects include agitation, motor restlessness, decreased libido in women, and insomnia.
Sertraline (Zoloft) · In addition to being a frequently used SSRI in pregnancy and breastfeeding, approved specifically for obsessive-compulsive, panic, and posttraumatic stress disorders. · More gastrointestinal side effects than the other SSRIs.
Paroxetine (Paxil) · Side effects can include significant weight gain, impotence, sedation, and constipation. · Due to its short half-life, paroxetine is most likely of all the SSRIs to cause antidepressant discontinuation syndrome.
· Paxil is Pregnancy Category D
Fluvoxamine (Luvox) · Particularly useful in obsessive-compulsive disorder. · Greater frequency of emesis compared to other SSRIs.
Citalopram (Celexa) · Most common side effects include nausea, dry mouth, and somnolence. · Maximum recommended dose: 20 mg per day for patients 60 years of age due to concerns of QT interval prolongation.
Escitalopram (Lexapro) · Approved specifically for Generalized Anxiety Disorder. · Overall, fewer side effects than citalopram.
“I’m glad Mrs. Gomez mentioned trying out a traditional herbal treatment,” Dr. Lee tells you, “This is the sort of thing you don’t want to miss. Do you know anything about zapote?”
You quickly search a drug program on your PDA and an online database and identify a couple of websites that discuss zapote and its suggested uses, but not much else.
TEACHING POINT
Complementary and Alternative Therapies
When obtaining a medication history, health care providers should ask routinely about herbal and other supplements – as well as over-the-counter medications and nutritional supplements. Patients frequently will not mention the use of complementary and alternative medical treatment unless they are asked about them. Be respectful when patients discuss alternative therapies, even if you are unfamiliar or skeptical about a particular treatment.
Herbs and similar supplements are a concern because of their potential to interact with conventional medications or produce side effects, just like conventional drugs. Even where they were obtained is important, as supplements have repeatedly been found to be contaminated with other herbs, heavy metals, and even prescription drugs. Only a few herbs have been scientifically studied, so information on their effectiveness is limited. St. John’s Wort has been shown to be effective for short-term treatment of mild to moderate depression.
Choosing lab tests
TESTING
Question
Which tests would you order to rule out other causes for symptoms of insomnia, fatigue, and a depressed mood? Select all that apply.
The best options are indicated below. Your selections are indicated by the shaded boxes.
- Complete metabolic panel
- Urinalysis
- Brain CT scan
- TSH
- Chest x-ray
- CBC
Submit
Answer Comment
The correct answers are A, D, F.
TEACHING POINT
Evaluation of Fatigue or Depression
- A complete metabolic panel (A) screens for electrolyte, renal, and hepatic problems
- A TSH (D) can detect hypothyroidism
- A CBC (F) will show anemia and vitamin deficiencies
- A urinalysis (B) is unlikely to be useful unless the depression or fatigue is of recent onset and there is suspicion of infection.
- A brain CT scan (C) is unlikely to yield results in the absence of obvious neurologic changes.
- A chest x-ray (E) is unlikely to add anything in the absence of specific symptoms such as cough or shortness of breath.
· Discussing the plan
· CARE DISCUSSION
- When you re-enter the exam room, Dr. Lee sits down to talk with Mrs. Gomez, “I would like to do a few tests to rule out any medical problem that might be causing your symptoms. But it looks as though you may be suffering from depression, which is completely understandable given the recent changes in your life.
- “This may also explain the increases in your blood sugar: Depression takes away your energy and motivation, so it’s hard to summon the effort to stick to a diet or even remember to take your medication regularly.”
- After discussing the options for treatment and the various SSRIs, Mrs. Gomez agrees to try sertraline (Zoloft). Dr. Lee writes a prescription for sertraline 25 mg daily, which is well tolerated and available in a generic form. She tells Mrs. Gomez, “Possible side effects include headache, nausea, diarrhea, sleepiness, and (infrequently) insomnia. Because of your age and other medical problems, I’m starting with a moderate dose, but we may increase it later if you don’t have an adequate response.”
- Lee is also worried that Mrs. Gomez’s methyldopa may be aggravating her depression, so she substitutes amlodipine 5 mg daily. This would also be in line with current blood pressure research.
- Next, she suggests,
· “Mrs. Gomez, another treatment that is very effective for depression is talking with a therapist.”
- You recommend Mrs. Gomez try to get some exercise, possibly walking at the local mall. She agrees to try this. And you give Mrs. Gomez and her daughter a handout about the diagnosis of depression and a list of community resources for people struggling with depression.
- Lee reviews the plan with Mrs. Gomez and her daughter: “We will order the blood tests to make sure there are no other medical conditions causing your symptoms. I will order a hemoglobin A1c to see how your diabetes is doing. We may need to adjust your diabetes medicine.”
- “Do you have any other questions?” Dr. Lee asks Mrs. Gomez and her daughter. They shake their heads no.
- Lee then concludes the visit: “It will probably take four to six weeks before the medication is fully effective, but it is best if I see you before then – let’s say in two weeks – to monitor your progress and discuss any problems or side effects; we will also review your tests and see if anything else needs to be done. Please feel free to call or come in sooner than that if you have concerns, feel worse, or experience side effects that prevent you from continuing to take your medication.”
Follow-up visit 1
HISTORY
At a return visit to Dr. Lee’s office two months later, you see Mrs. Gomez is on the schedule. It is her first visit to the clinic since your previous encounter. Her daughter is in the waiting room.
When you ask how she’s been doing, she says, “Just terrible. I still can’t sleep and now I find that I’m crying all the time.” She admits that she never started her sertraline and didn’t get the lab tests. She was worried that people would think she’s crazy. She also felt that she should be able to handle her feelings without using drugs.
You ask her what she thinks is wrong with her. She replies she simply thinks she is grieving the loss of her husband. She’s been trying to use prayer to overcome it, but this hasn’t worked so far.
Question
Which of the following are true about depression among minority populations in the U.S.? Select all that apply.
The best options are indicated below. Your selections are indicated by the shaded boxes.
- Hispanics have higher rates of depression than non-Hispanic whites.
- Hispanic patients are less likely to be diagnosed than non-Hispanic whites.
- Asian, black and Hispanic patients with depression are less likely than whites to perceive a need for mental health treatment.
- Minority populations are more likely to suffer from psychotic depression.
- Racial, ethnic and economic minorities receive evidence-based treatments at the same rates as white Americans.
Submit
Answer Comment
The correct answers are B and C.
TEACHING POINT
Depression in minority populations
U.S.-born Hispanics experience depression at similar rates to other ethnic groups. Rates of depression in immigrant Hispanics are up to 50 percent lower than U.S.-born Hispanics.
Due to factors such as economics, culture, and language barriers, Hispanics have their depression identified less frequently than non-Hispanic whites. This holds true in some other ethnic groups as well, such as African Americans.
Psychotic features in depression are no more common in minority populations than non-Hispanic whites.
Research shows that Asian Americans, blacks, and Hispanics with depression are less likely than whites to perceive a need for mental health treatment. This was particularly true for Hispanics interviewed in Spanish (as opposed to those interviewed in English), suggesting acculturation may play a role in this disparity.
Hispanics and other ethnic and economic minorities are less likely to receive adequate therapies. It is important for clinicians to recognize that there are disparities in outcomes for minority patients with depression and to take steps to mitigate them. Such steps could include patient-centered communication, addressing social determinants of health, and reflection about implicit biases.
“I worry about my daughter,” Mrs. Gomez says tearfully through the interpreter. “She’s just so angry all the time.” At this point, Mrs. Gomez starts to cry. You attempt to comfort her for a moment, and then retrieve Dr. Lee for assistance.
Dr. Lee offers Mrs. Gomez a tissue and holds her hand. After a moment, she asks,
“Mrs. Gomez, can you tell me why you are worried about your daughter?”
She replies, “It’s just that Silvia is so short tempered and she cries a lot. I feel bad because I know I’m a terrible burden on the family and it’s causing Silvia a lot of stress.”
Dr. Lee responds,
“I have to ask, has your daughter ever hurt you or threatened you?”
Mrs. Gomez denies this.
A quick exam finds no bruises or other signs of abuse.
Dr. Lee explains to Mrs. Gomez that you and she are going to talk with Silvia and will be back in a moment.
You and Dr. Lee interview Sylvia alone. She admits finding the demands of caring for her mother increasingly draining.
Assuring her that it is common for adult children to find themselves caring for both their parents and their own children (a situation sometimes referred to as the “Sandwich Generation”), Dr. Lee directs Silvia to a web site (http://www.familyaware.org/) for families dealing with depression. The website includes:
- Lay-oriented educational materials on depression;
- Resources on how to deal with their own emotional reactions to the illness; and
- Lists of support groups.
When you have answered all of her questions, you excuse yourselves from the room.
Dr. Lee states that she doesn’t feel that there is much risk for abuse in this case, although it’s something a provider should keep an eye open for in such taxing situations.
TEACHING POINT
Elder Abuse
Early research indicates the following risk factors for abuse:
- Shared living situation of elder and abuser (except in financial abuse).
- Caregiver substance abuse or mental illness.
- Heavy dependence of caregiver on elder. Surprisingly, the degree of an elder’s dependency and the resulting stress has not been found to predict abuse.
- Social isolation of the elder from people other than the abuser.
6.Pharmaceutical treatment
7. THERAPEUTICS
- You and Dr. Lee return to speak with Mrs. Gomez about her depression.
- “I can appreciate your concern about the diagnosis of depression,” says Dr. Lee. “I hope it will help to know that these feelings you are having are very common: More than 14 million Americans experience depression in any given year. I see lots of people who are depressed in this clinic, and they are not ‘crazy.’ Depression is not a weakness of character that you should try to deal with on your own. It’s a medical condition just like your diabetes. And just like you take medication to help control your diabetes, we have medication to help with depression. This can be a severe problem, and is unlikely to clear up anytime soon without appropriate help.”
- “But I am afraid I won’t have the same feelings if I take medication,” Mrs. Gomez interjects, “I don’t want to change who I am.”
- Lee explains, “I am glad you shared your concern with me. I want to assure you that the medication won’t change who you are; in fact, I believe that this medication will be helpful in allowing you to be more like you normally are. I also know you are concerned about Silvia and how she’s dealing with her own stress. This is the best thing you can do, not only for yourself, but also for your family.”
- Gomez replies, “Well, I suppose it can’t hurt to give the medicine a try. I don’t seem to be getting better on my own.”
- Lee then replies, “Great. I know this is hard for you to do, but I think you will find it helpful. Once you start taking the medication, you may start feeling better as quickly as within a week. But you probably won’t feel the full effects for about two months. Try not to get discouraged. Depression can be very frustrating. It will take time for your depression to go away.”
- Lee re-prescribes the sertraline and Mrs. Gomez gives her assurance that she will try it this time. Dr. Lee also reorders the lab tests and refers Mrs. Gomez to the local government Department of Aging to see if there are any support services they might provide.
herapeutic challenges
TEACHING
After Mrs. Gomez and her daughter leave, Dr. Lee advises you, “It is common to have difficulty getting an older adult to adhere to an antidepressant regimen.”
TEACHING POINT
Adherence to Antidepressant Medication in the Elderly
Providers note adherence to depression treatment in older adults occurs only about half the time. The reasons are understandable and include:
- Inability to afford the medication
- Concerns about side effects
- Worry about the stigma of the diagnosis
- Not understanding how to take the medication properly
The important thing is to not blame the patient, but to educate her/him about the recommendations, allowing the patient to ask questions and fully express any concerns.
You see Mrs. Gomez and her daughter again about two months later when you return to Dr. Lee’s clinic.
“So nice to see you, Mrs. Gomez!”
“How are you feeling?“
“It’s good to see you also. I’m feeling so much better. I sleep all night, I have more energy, and my mood is lighter. The medicine Dr. Lee gave me made me a little nauseous at first, but when I talked with her about it, she told me it was normal and would subside. So, I continued the sertraline and after a couple of weeks, the nausea did go away. I tried to exercise like you suggested, but my arthritis just bothered me too much.”
Today her score on the Geriatric Depression Scale is 4, which is in the normal range.
Silvia adds, “Mom has made new friends at church and has become involved with a group of women there that she spends time with several days a week. It’s nice to see her taking an interest in things again. It actually takes a huge weight off my shoulders, as well. Thank you for all of your help.”
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Week 10 The Nervous System Discussion
Assignment
Complete only the History, Physical Exam, and Assessment sections of the Aquifer virtual case: Family Medicine 03: 65-year-old female with insomnia.
Discussion Question 1
Based on your performance and the expert feedback in your HISTORY collection, describe two missed questions and your understanding of why they were important to collect for this case history. Use specific references from your text to explain.
Discussion Question 2
Based on your performance and the expert feedback in your PHYSICAL EXAM collection, describe two errors in your exam performance or documentation. Use specific references from your text to explain the importance of these findings in correct assessment of this client.
Discussion Question 3
Based on your performance on the PHYSICAL EXAM collection, describe one key finding that you included in your list and describe a specific physical exam that you can perform at the point-of-care to further evaluate the finding. Use specific references from your text.
Discussion Question 4
Based on your performance and the expert feedback in your ASSESSMENT identification of problem categories, choose one missed/incorrect category and use specific references from your text to explain the importance of this category in arriving at correct differential diagnoses for this client.
Discussion Question 5
Based on your performance and the expert feedback in your ASSESSMENT of differential diagnoses, describe one incorrect/missed differential diagnosis and use specific references from your text to support the inclusion of the diagnosis for this client.
Bookshelf
bookshelf.vitalsource.com
Username: Dayinthelife4@yahoo.com
Password: Williams21!
References
Bickley, L. (2016). Bates’ Guide to Physical Examination and History Taking (12th Ed.). Philadelphia, PA: Lippincott, William & Wilkins. ISBN: 9781469893419
Bickley, L.S. (2016). Bates’ Pocket Guide to Physical Examination and History Taking (8th Ed.). Philadephia, PA: Lippincott, Williams & Wilkins. ISBN: 9781496338488
Goolsby, M. J. & Grubbs, L. (2015). Advanced Assessment: Interpreting Findings and Formulating Differential Diagnoses (3rd ed.). Philadelphia, PA: F. A. Davis Company. ISBN: 9780803643635
Perrin, R. (2017). Pocket Guide to APA Style (6th ed.). Stamford, CT; Cengage Learning. ISBN: 9781305969698
RUBRIC
Quality of Initial Posting:
Exemplary:
The information provided is accurate, providing an in-depth, well thought-out understanding of the topic(s) covered. An in-depth understanding provides an analysis of the information, synthesizing what is learned from the course/assigned readings.
Participation in Discussion
Exemplary:
Comments to two or more classmates’ initial posts and to the instructor’s comment (if applicable) on two or more days. Responses demonstrate an analysis of peers’ comments, building on previous posts. Comments extend and deepen meaningful conversation and may include a follow-up question.
Writing Mechanics (Spelling, Grammar, Citation Style) and Information Literacy
Exemplary:
Minor to no errors exist in grammar, mechanics, or spelling in both the initial post and comments to others. Formatting of citations and references is correct. If required for the assignment, utilizes sources to support work for both the initial post and the comments to other students. Sources include course and text readings as well as outside sources (when relevant) that are academic and authoritative (e.g., journal articles, other text books, .gov Web sites, professional organization Web sites, cases, statutes, or administrative rules).
Lecture notes The Nervous System
As a brief review, the nervous system may be viewed as two distinctive parts: the central nervous system (CNS) and the peripheral nervous systems (PNS). The CNS includes the brain and spinal cord, whereas the PNS encompasses the cranial nerves, the 31 pairs of spinal nerves, and branches. The PNS is responsible for carrying sensory messages to the CNS from sensory receptors, motor messages from the CNS to muscles and glands, and autonomic messages that control the internal organs and blood vessels.
The cranial nerves leave from and return to the brain instead of the spinal cord. The vagus nerve is the only nerve that does not serve the head and neck. The vagus nerve manages the heart, respiratory muscles, stomach, and gallbladder.
The spinal nerves branch out in a ladder like fashion from the spinal column. Each spinal nerve has a dermatome or particular area of skin that it supplies sensation for. There is some overlap for each dermatome so that if one nerve is injured, another may help supply sensation for the affected area.
Reflexes serve as a defense mechanism for the nervous system. The reflexes assist in maintaining balance and muscle tone. The four types of reflexes are: deep tendon (myotatic), superficial, visceral (organic), and pathologic (abnormal).
- An example of a deep tendon reflex would be the patellar or knee jerk
- An example of a superficial reflex would be the corneal reflex
- An example of the visceral reflex would be pupillary light reflex
- An example of the pathologic reflex would be the positive Babinski in an adult
History of Present Illness – The Nervous System
Subjective Questions to ask about headaches
Have you had any frequent or unusual headaches? When did the headaches start? How severe are the headaches? Rate the headaches on a scale of 1 to 10, with 1 being the least pain ever and 10 being the worst pain ever. Point to the area for me. What does the pain feel like? Dull, aching, throbbing, stabbing, etc. Do you notice any other symptoms with the headache such as blurred vision, or loss of sensation in your face or other parts of the body?
Dizziness/Vertigo
Do you ever feel lightheaded or faint? Perhaps a swimming sensation in your head? When have you noticed this sensation? How long does it last? Is it only with position change or activity? What makes it better? How often do you experience this problem?
Have you ever been diagnosed or thought you had vertigo? This is more of a rotational, spinning sensation instead of just being dizzy. The patient may describe vertigo as being dizzy but try to clarify the differences for them.
- Objective vertigo: Sensation as though the room spins
- Subjective vertigo: Sensation as if you yourself are spinning
Did this problem come on slowly or abruptly? Have you taken any over-the-counter or prescription medications for the symptoms? Have these medicines helped?
Seizures
Have you ever had or been diagnosed with seizures or convulsions? How about epilepsy? If yes, when did the seizures start? How long do they typically last? Do you lose consciousness? How often do you have the seizures? What medicines (if any) do you take for the seizures? When have you had blood tests or other tests?
Physical Exam – Nervous System
A screening of the cranial nerves is a brief evaluation to be conducted during a wellness visit, whereas a person with a complaint of headaches, gait instability, weakness, or other neurological problems will need a complete neurological exam. For ease of examination and for the comfort of the patient, the nervous system exam should be conducted along with the appropriate system check. For example, if you are examining the head, check the cranial nerves then. If you are examining the musculoskeletal system, check the deep tendon reflexes then.
Position the patient in an upright sitting position, with the head at your eye level. You should be comfortable with the height of the person in contrast to your height.
Assess the following:
- The Cranial Nerves
- Cranial Nerve I: Olfactory
- Cranial Nerve II: Optic Nerve
- Cranial Nerves III, IV, and VI: Oculomotor, Trochlear, and Abducens
- Cranial Nerve VII: Facial
- Cranial Nerves IX and X: Glossopharyngeal and Vagus Nerves
- Cranial Nerve XI: Spinal Accessory Nerve
- Cranial Nerve XII: Hypoglossal Nerve
- The Motor System
- The Sensory System
Deep tendion reflexes (DTRs) are graded on a 4-point scale as follows:
- 4+ very brisk, hyperactive with clonus, indicative of disease
- 3+ brisker than average, may indicate disease
- 2+ average, normal
- 1+ diminished, low normal
- 0 no response
· Mental Health
- Depression, anxiety, and addiction may be present in children, adolescents, young adults, and older adults. When collecting the history ask specific questions related to these points. For example, you can ask about alcohol intake, prescription drug use, illicit drug use, or thoughts related to suicide.
- When it comes to alcohol ask about the intake. Quantitative intake is important as is type. Note by day, week, or month. When was the last drink? Be mindful of delirium tremens (DTs) risk. Has the patient ever been told they have a drinking problem? If yes, has the patient cut back or tried to quit drinking? Was the attempt successful? Make note of current prescription and OTC medications. Ask about street drugs.
- In the older population, keep in mind the possibility of dementia and altered cognition: The mental status examination of the older adult should include at least a short cognitive screening exam such as the Mini-Cog. If the Mini-Cog is positive, a more thorough examination such as the mini mental state exam (MMSE) or Montreal cognitive assessment tool should be conducted.
The Nervous System As a brief review, the nervous system may be viewed as two distinctive parts: the central nervous system (CNS) and the peripheral nervous systems (PNS). The CNS includes the brain and spinal cord, whereas the PNS encompasses the cranial nerves, the 31 pairs of spinal nerves, and branches. The PNS is responsible for carrying sensory messages to the CNS from sensory receptors, motor messages from the CNS to muscles and glands, and autonomic messages that control the internal organs and blood vessels. A nerve is a bundle of fibers found outside the CNS. Think of the nerve as a fiber-optic cable. It can carry messages to the CNS via the sensory afferent fibers and from the CNS via efferent fibers. The cranial nerves leave from and return to the brain instead of the spinal cord. The vagus nerve is the only nerve that does not serve the head and neck. The vagus nerve manages the heart, respiratory muscles, stomach, and gallbladder. The spinal nerves branch out in a ladder like fashion from the spinal column. Each spinal nerve has a dermatome or particular area of skin that it supplies sensation for. There is some overlap for each dermatome so that if one nerve is injured, another may help supply sensation for the affected area. Reflexes serve as a defense mechanism for the nervous system. The reflexes assist in maintaining balance and muscle tone. The four types of reflexes are: deep tendon (myotatic), superficial, visceral (organic), and pathologic (abnormal). · An example of a deep tendon reflex would be the patellar or knee jerk · An example of a superficial reflex would be the corneal reflex · An example of the visceral reflex would be pupillary light reflex · An example of the pathologic reflex would be the positive Babinski in an adult History of Present Illness – The Nervous System Headache Have you had any frequent or unusual headaches? When did the headaches start? How severe are the headaches? Rate the headaches on a scale of 1 to 10, with 1 being the least pain ever and 10 being the worst pain ever. How often do you experience these headaches? Where do the headaches usually occur? Point to the area for me. What does the pain feel like? Dull, aching, throbbing, stabbing, etc. Do you notice any other symptoms with the headache such as blurred vision, or loss of sensation in your face or other parts of the body? Does anything seem to trigger the headache, such as stress, foods, smells or odors, weather changes, or hormonal changes? Head Injury Have you ever had a head injury? Where on your head were you injured? Did you lose consciousness? How long were you unconscious? Did you receive treatment? If so, what kind of treatment? Were X-rays taken? Dizziness/Vertigo Do you ever feel lightheaded or faint? Perhaps a swimming sensation in your head? When have you noticed this sensation? How long does it last? Is it only with position change or activity? What makes it better? How often do you experience this problem? Have you ever been diagnosed or thought you had vertigo? This is more of a rotational, spinning sensation instead of just being dizzy. The patient may describe vertigo as being dizzy but try to clarify the differences for them. · Objective vertigo: Sensation as though the room spins · Subjective vertigo: Sensation as if you yourself are spinning Did this problem come on slowly or abruptly? Have you taken any over-the-counter or prescription medications for the symptoms? Have these medicines helped? Seizures Have you ever had or been diagnosed with seizures or convulsions? How about epilepsy? If yes, when did the seizures start? How long do they typically last? Do you lose consciousness? How often do you have the seizures? What medicines (if any) do you take for the seizures? When have you had blood tests or other tests? Do you have any warning signs or auras before the seizure? Auras may be auditory, visual, or motor, including the sense of smell. Where do the seizures begin? Are the seizures always in one certain area of the body? Do the seizures travel or migrate to other areas of the body or remain localized? Does your muscle tone seem limp or taut? Do you have seizures on both sides of your body? Do you note, or has anyone noted about you, any associated symptoms, such as change in the color of your face or lips, lip smacking, eye rolling, or eyelid fluttering? Have you lost consciousness, and if so, for how long? Postictal Has anyone told you that you are confused, forgetful, or disoriented after a seizure? How about lethargic or that you sleep a lot afterwards? How long do they say these symptoms last? Does anything seem to trigger the seizures, such as stress, emotional upset, activity, fatigue, lack of medications, or addition of new medications? What medications do you take? Include any over-the- counter medications even if the medicines are vitamins or “natural” medicines. When was the last time you took these medications? How often do you take the medications? How do you try to prevent the seizures? How do the seizures affect your daily activities? Are you able to drive? Tremors Have you had any tremors or shaking in your hands or face? When did these start? Are the tremors continuous or intermittent? Are the tremors or shaking worse when you are anxious? How about with intention? Or do you notice them more when you are resting? What seems to make the tremors lessen? What effect does rest, alcohol, or activity have on the tremors? Do the tremors interfere with your activities of daily living? Weakness and Coordination Have you noticed any weakness or difficulty in moving a body part? Does this seem to be on either side or just one? Have you noticed any other symptoms with this problem? Anything make the symptoms better or worse? How long have you had this difficulty? Any problems with coordination? Do you feel that your balance is off when walking? Do you feel that you are pulling to one side? Have you experienced any falls recently? Which side or way do you fall? Do your legs seem to give way for no reason? Paresthesias Do you have a sensation of numbness or tingling of any part of your body? What does it feel like—pins and needles? When did you notice this sensation? Is it constant or intermittent? Does anything make the symptoms better or worse? How does activity affect the numbness or tingling? Dysphagia Do you have any problems with swallowing? What foods seem to trigger the difficulty in swallowing? Do you have problems more with liquids or with solids? Have you noticed any drooling or excess saliva? Aphasia Have you noticed any difficulty with your speech? Give me an example. Do you have difficulty in forming words or with saying the words that you meant to say? How long ago did this start? Is it worse with stress? Does anything make the problem better or worse? Past History Do you have a history of stroke, transient ischemic attacks (TIAs), cerebral aneurysm, head injury, seizure activity, spinal cord injury, meningitis, encephalitis, brain tumors, congenital defect, alcoholism, syphilis, or herpes? Is there any family history of stroke, TIAs, cerebral aneurysm, or brain tumors? Other Information Are there any environmental hazards that you are aware of at your work or at home? How old is your home? Some homes may still have lead-based paint that may be a hazard. What medicines, prescription and over-the-counter, are you currently taking? Are you using natural or herbal products? How much alcohol do you drink? How much alcohol do you drink daily, or weekly? Do you use any type of drugs, such as marijuana, cocaine, barbiturates, tranquilizers, etc.? Developmental Notes – Infants and Children Infants and Children Ask the mother if she had any health problems during her pregnancy such as infections or illnesses. What medications did she take and why? Did she have toxemia, preeclampsia, hypertension, or diabetes? Did the mother use tobacco products, alcohol, or drugs before or during the pregnancy? Ask the mother to tell you about the baby’s birth. Did she deliver at term, late, or early? How much did the baby weigh at birth? Was the delivery difficult? Did the delivery require forceps or other intervention? Did the baby breathe immediately or require oxygen after birth? Does she know the baby’s Apgar score? Were there any congenital defects? What has the mother noticed about her baby’s behaviors? Does she have any questions? Does the baby seem to coordinate its sucking and swallowing? Are the startle and Moro reflex present? Ask about reflexes in words that the mother will understand. Ask if she has noticed the child having problems with balance. Are there unexplained falls, unsteady gait, muscle weakness that seems to be progressive, difficulty with stairs, or difficulty with position change? Has the mother ever noticed seizure activity in the child? Ask her to describe the activity to you. Was the seizure associated with a high fever? How long did it last? Did the child lose consciousness with the seizure? If so, for how long? Have there been recurrent seizures? Are the seizures always associated with fever? Does it seem that the child is reaching developmental milestones as compared to other children his or her age? Does the child seem to be growing and maturing as he or she should? How does the child’s development compare to siblings’ growth and development? Do you know of any lead exposure? Has anyone mentioned learning disorders for this child, such as problem with attention span, focusing or concentrating, or being hyperactive? Is there a family history of seizures, cerebral palsy, muscular dystrophy, or other neurological disorders? Developmental Notes – The Older Adult The Older Adult Do you have any problems with feeling dizzy? How often does this occur? Do you notice the dizziness when sitting, standing, or lying down? Is there a difference when you change positions, such as moving from lying down to sitting up, or sitting up to standing? Do you feel faint or light-headed when you get up at night to urinate? Does dizziness affect your daily activities? How? Do you feel safe driving? Are you able to get around the house safely? What changes have you made at home to improve your safety? Have you noticed any memory changes? Describe the memory changes. Are the problems with your short-term or your long-term memory? Have you felt confused? Was this a sudden problem, or was the onset more gradual? Have any of your friends or family said something to you about your memory? Have you had any recent problems with tremors? Do you notice the tremor in your face or hands? Is the tremor worse with activity, rest, or anxiety? Does the tremor seem to lessen with alcohol, activity, or rest? Does the tremor interfere with your daily activities? Does it interfere with social activities? Have you had any recent vision changes or any transient loss of vision? Did you feel weak when this vision loss occurred? Did you faint or pass out during this episode? Physical Exam – Nervous System Physical Exam of the Cranial Nerves: A screening of the cranial nerves is a brief evaluation to be conducted during a wellness visit, whereas a person with a complaint of headaches, gait instability, weakness, or other neurological problems will need a complete neurological exam. For ease of examination and for the comfort of the patient, the nervous system exam should be conducted along with the appropriate system check. For example, if you are examining the head, check the cranial nerves then. If you are examining the musculoskeletal system, check the deep tendon reflexes then. Position the patient in an upright sitting position, with the head at your eye level. You should be comfortable with the height of the person in contrast to your height. The Cranial Nerves · Cranial Nerve I: Olfactory Do not test the olfactory nerve routinely, only in those with a loss of sense of smell who have experienced a head injury, when an intracranial lesion is suspected or in altered mental status. You must first check patency of the nostrils: ask the patient to close one eye while you occlude one nostril and then ask the patient to identify an aromatic odor. It is best to choose something familiar, not noxious. Alcohol swabs may be irritating to the nose. Coffee, vanilla, peppermint, and oranges are good examples. The patient should be able to identify the odor on both sides of the nose. Any other finding is abnormal as the loss of smell in older patients should occur bilaterally. · Cranial Nerve II: Optic Nerve Vision screening and visual field testing were discussed when in the lecture on eyes. Review the Week 2 material for a refresher. · Cranial Nerves III, IV, and VI: Oculomotor, Trochlear, and Abducens Use direct and indirect light to assess pupil response. You should document size, equality, regularity, and direct and consensual light reaction, as well as for accommodation. Cardinal field of gaze was discussed under eyes in the Week 2 lectures. Note nystagmus findings in one or both eyes. Use the following terms to describe nystagmus: Pendular movement: The movement of the eye left to right in an equal pattern. Jerk: A quick movement in one direction followed by a slow movement in the opposite direction. Document the direction of the eye in the quick phase. For example, if the eye jerks to the right quickly with a slow return to the left, nystagmus is to the right. Amplitude: Do you consider the movement to be fine, medium, or coarse? Frequency: Does the movement remain constant or fade and stop after a few beats? Plane of motion: Is the nystagmus movement vertical, horizontal, rotary (rotates), or a combination of two or three of these? Keep in mind that endpoint nystagmus or a few beats at the end of extreme lateral gaze is a normal finding. Cranial Nerve V: Trigeminal Palpate the temporal and masseter muscles while the patient clenches their teeth. The muscles should feel equal on both sides without pain. Attempt to open the jaws while pushing down on the chin—you should not be able to, provided the patient is attempting to resist you. Ask the patient to close their eyes. Use a soft material such as a cotton ball to evaluate the ophthalmic, maxillary, and mandibular portions of the trigeminal nerve. Instruct the patient to say “now” when they feel you touching the cotton ball to the skin. You should assess the forehead, chin, and cheeks with a light touch. Corneal reflex: Please do not perform this test unless there is abnormality of facial movement or sensation. Ask the patient to remove any contact lenses and glasses. Have the patient look forward while you bring a cotton ball or small, light piece of gauze in from the side of the eye. Lightly touch the cornea but not the conjunctiva. The proper response is for the patient to blink bilaterally. If the patient has worn contact lenses in the past, this reflex may not be present. The corneal reflex provides information for the sensory afferent in cranial nerve V and the motor efferent for cranial nerve VII. Cranial Nerve VI: Abducens The abducens or cranial nerve VI enervates intraocular lateral rectus muscle thereby controlling lateral eye movement. Cranial nerve VI is assessed through the cardinal fields of gaze (see lecture content from Week 2). Cranial Nerve VII: Facial Ask the patient to perform the following movements and assess the mobility and symmetry of the facial response: smile, frown, and close your eyes tightly while I try to force them open, lift your eyebrows, smile while showing your teeth, and puff your cheeks out. Press on the puffed cheeks and make sure that the air leaves each cheek equally. If facial nerve injury is suspected, perform the taste test. Apply sweet, salty, and sour drops of liquid to the tongue and ask the patient to identify the types of taste, not necessarily the food item. Do not test as a routine part of the exam. Cranial Nerve VIII: Acoustic or Vestibulocochlear Nerve Assess cranial nerve VIII through the whisper test as well as Weber and Rinne tests (see lecture content for Week 2). Cranial Nerves IX and X: Glossopharyngeal and Vagus Nerves Use a tongue blade to depress the tongue and note movement as the word “ahhh” is said or the patient yawns. The uvula and soft palate should rise while remaining midline. A gag reflex may be elicited. Vocal sounds should be smooth not hoarse or strained. Cranial Nerve XI: Spinal Accessory Nerve Ask the patient to turn his or her head to the right while you apply resistance. Repeat the movement to the opposite side, against resistance. Ask the patient to shrug the shoulders while you apply resistance. Note any muscle weakness or atrophy. Cranial Nerve XII: Hypoglossal Nerve Note any tremors or atrophy of the tongue. Ask the patient to push the tongue out then side to side. Ask the patient to say “light, tight, and dynamite” to verify the pronunciation of the L, T, D, and N are clear. A lesion on the hypoglossal nerve will result in slurred speech and deviation of the tongue towards the side of the lesion. Physical Exam of the Motor System The Motor System Note the size and strength of the major muscle systems during the assessment. Document strength and motility of muscle groups (see lecture material for Week 9 for further assessment and documentation details). Tone should be present as a mild resistance to a passive stretch. Evaluate through passive range of motion. Note any involuntary movements, paying attention to location, frequency, rate, and amplitude. Can the patient control these involuntary movements at all? Cerebellar Function Balance tests include gait, tandem walking, and the Romberg test. Note the patient’s gait as you ask him or her to walk 10 to 20 feet, turn, and return to the starting point. Is the gait smooth and rhythmic, with the arms swinging in opposite directions from each other and the steps approximately 15 inches apart? The tandem toe walk will evaluate upper motor neuron lesions such as multiple sclerosis. Ask the patient to walk heel to toe in a straight line. The patient should be able to remain balanced and walk the straight line. The Romberg test evaluates for cerebellar ataxia which is often seen in multiple sclerosis and alcohol intoxication. Ask the patient to stand with feet together and arms at their sides. Wait for approximately 20 seconds and watch for staggering. A slight sway is normal. A positive Romberg test is noted with a loss of balance when the eyes are closed. Rapid alternating movements: Ask the patient to place the hands on the knees, palms down. Then instruct the patient to pat the hands on the knees once, lift the hands up, turn them over, and pat the knees with the dorsal side of the hands. Once the pattern is set, encourage the patient to move faster and faster, demonstrating rapid alternating hand movements. Ask the patient to demonstrate fine motor movements by touching thumb to fingers rapidly, first the thumb to index finger on through the fifth finger, then in the opposite direction. Repeat with the opposite hand. This should be a smooth, easy process. The finger-to-finger test is conducted with the patient’s eyes open. Ask the patient to touch your extended finger then place the patient’s finger on his or her nose, and then repeat the movement. The movement should be smooth and accurate even when you move your finger to a different location. Past pointing is a continuous deviation to one side. The finger-to-nose test evaluates coordination by having the patient close his or her eyes, touch the tip of the nose with their first finger, and then touch it with the other finger. The eyes must remain closed while the patient alternates finger to nose rapidly. The movements should be smooth as well as accurate. Inability to match finger to nose with the eyes closed indicates cerebellar dysfunction. The heel-to-shin test evaluates lower extremity coordination. The patient should be in a supine position. Ask the patient to place the heel of one foot on the opposite leg just below the knee. The patient should run the heel down the shin to the ankle; ask him or her to repeat this on the other leg. If the heel falls off or the movement is not fluent, this indicates cerebellar dysfunction. Physical Exam of the Sensory System The Sensory System The patient should be able to identify different sensory stimuli to evaluate the peripheral nerve fibers, the sensory tracts, and higher cortical discrimination. The patient must be awake, alert, and cooperative in order for these tests to be valid. The patient should be comfortable in the setting and not fatigued. Spinothalamic Tract Test for the patient’s ability to sense pain by simulating a pinprick sensation. You may use a tongue blade that has been broken, leaving a sharp-pointed end and a rounded end. Lightly press the sharp or dull end on the person’s body, making the application random. Ask the patient to identify the sensation as “sharp,” “dull,” or “don’t know.” The dull end is for documenting the response in general, whereas the sharp end is to evaluate response for pain. Allow at least a 2-second gap between applications to avoid summation or the perception of frequent stimuli as one strong event. An alternative to the broken tongue blade would be cotton-tipped applicator—first identify the cotton-tipped end as dull and the rounded wooden end as sharp. Another option is to use a monofilament fiber for sharp and the rubber end of the reflex hammer as dull. Hypalgesia is a decreased sensation to painful stimuli. Hyperalgesia is an increased pain sensation to stimuli. Analgesia is the absence of pain sensation. Test for temperature sensation only if painful stimulus test fails. You may use two tubes of water, one hot and the other cold. Apply the ends of the tubes to the person’s skin, using a random order. Ask them to tell you if it feels hot or cold. Another option is to use the flat side of a tuning fork. The metal of the tuning fork always feels cool. Light touch can be evaluated by using a cotton ball stretched out into a thicker and thinner shape, a cotton-tipped applicator, or a 2×2 gauze. Ask the patient to identify when he or she feels the application of the cotton. Use a very light touch and in random order, brush the skin lightly with the cotton. Allow for some downtime between applications so the patient will not respond by repetition only. Check the arms, forearms, hands, feet, lower and upper legs, and the chest. Note symmetry between the two sides of the body. Hypoesthesia is the decreased sensation to touch. Hyperesthesia is the increased sensation to touch. Anesthesia is the absence of sensation to touch. Posterior Column Tract Vibration may be evaluated by the use of a tuning fork applied to a bony surface. Strike the tuning fork and apply it to the fingers or the toes. Ask the patient to identify when the vibration starts and stops. If a normal response is elicited, stop there. If an abnormal or no sensation is noted, move proximal to the body until a response is elicited. Compare both sides and the responses. If a problem is noted, is it gradual or abrupt? The inability to feel the vibratory sensation is associated with peripheral neuropathy. Peripheral neuropathy usually begins at the feet and gradually moves upwards. A specific nerve lesion would follow its dermatome only. Peripheral neuropathy is associated with alcoholism and diabetes, and can be a symptom of prolonged B12 deficiency. Physical Exam of Sensory Activities Kinesthesia or position evaluates the person’s ability to sense passive movement of the extremities. Move the great toe or the first finger up or down. Ask the patient to tell you which way the digit moved. Do a few trials with the patient’s eyes open in order to make sure they understand the test and the appropriate response. The test should be conducted with the patient’s eyes closed and with you holding the digit by the sides. The patient may be able to sense the direction if you are touching the top or bottom of the digit. Tactile discrimination or fine touch may be evaluated through stereognosis, graphesthesia, two-point discrimination, extinction, and point location. Stereognosis requires the patient to identify a common object by feeling the size, shape, and weight of the object. Ask the patient to close their eyes then place a familiar object in their hand. The patient should be able to identify the object by exploring it with their fingers. Test the right and left hands separately. Common objects would be a paper clip, a key, a coin, a pencil, etc. Astereognosis is the inability to correctly identify an object. This is a common problem poststroke. Graphesthesia is the ability to “read” a number or letter when it is traced in the palm. Use a blunt tipped object, not your finger, to trace a single digit or letter in the patient’s palm. The patient’s eyes should be closed. Make your tracing movements steady but not rapid or too slow. Ask the patient to identify the tracing. If the patient cannot perform stereognosis, graphesthesia is another option. The two-point discrimination requires the use of two small sterile needles or an opened paper clip. Ask the patient to identify the point at which the two separate points become one. Begin with the points at least 3 inches apart and apply a light pressure with both simultaneously. Gradually move inwards, continuing the simultaneous stimuli until the patient can no longer identify the two separate stimuli. The fingertips are the most sensitive and should have a range of 2 to 8 millimeters whereas the back, thighs, and upper arms are the least sensitive with a range of 40 to 75 millimeters. Extinction is the ability to feel a stimulus when it is applied to both sides of the body at the same location at the same time. The inability to identify one of the stimuli indicates a cortical lesion. The lesion is on the opposite side of the body that does not respond. For example, if the right side does not elicit a response, suspect a lesion on the left side of the cerebral cortex. Point location requires the patient to close their eyes; you touch them on the skin, and then ask the patient to identify the location you touched. “Put your finger on the spot that I touched.” This may be conducted with light touch sensation evaluation. A sensory cortex lesion will prevent the patient from identifying the location of the touch although light touch sensation can be intact. Physical Exam of Sensory Losses Patterns of Sensory Loss Peripheral neuropathy: Loss of sensation typically in the extremities such as feet and hands. Suspect metabolic disease or nutritional deficiency. Individual nerves: A decrease in or loss of all sensory ability. The affected area should be limited to the involved nerve. Consider source to be a result of trauma or vascular occlusion. Another example would be herpes zoster. Spinal cord hemisection or Brown-sequard syndrome: Loss of pain and temperature regulation on the contralateral side from the insult. The symptoms begin one to two segments (vertebrae) below the lesion or insult. The patient will experience loss of vibration and position discrimination on the ipsilateral side, below the lesion. Possible sources are meningioma, neurofibroma, cervical spondylosis, or multiple sclerosis. Complete transection of the spinal cord: A complete loss of all sensation below the level of transection. The patient will have paralysis and loss of sphincter control below the level of transection. There may be partial transection or impingement that is severe enough to cause partial paralysis. Possible sources are trauma, demyelinating disorders, and tumors. Thalamus: complete loss of all sensation on the face, arm, and leg on the side contralateral to the lesion. Source may be vascular occlusion or stroke. Cortex: A cortex lesion is more likely to appear with loss of discrimination on the contralateral side. This would include loss of graphesthesia, stereognosis, recognition of shapes and weights, as well as finger finding or fine motor movements. Suspect parietal lobe lesion or cerebral cortex lesion. Reflexes The limbs should be relaxed and the muscle partially stretched for deep tendon reflex (DTR) evaluation. Hold the reflex hammer easily but not too firmly, allowing your wrist to flex quickly. Use a short snappy movement to elicit the reflex. Use the pointed end for a smaller location such as your thumb over a tendon site and the flat end when a larger area is the target. Use only enough force to elicit a response. The response should be equal bilaterally. You should grade reflexes on a 4-point scale as follows: · 4+ very brisk, hyperactive with clonus, indicative of disease · 3+ brisker than average, may indicate disease · 2+ average, normal · 1+ diminished, low normal · 0 no response As with other scales, this evaluation is somewhat subjective. Clinical practice helps with determining the proper result. Only use DTR response as part of the neurological examination; not as a single determination of a disease process. If the expected response is not elicited, reposition the patient and try again. A stronger strike may be needed or additional encouragement of relaxation Physical Exam of the Muscles Clonus: Short jerking contractions of a particular muscle. Hyperreflexia: Exaggeration of the muscle reflex. Found in upper motor lesions such as a stroke. Hyporeflexia: The absence of a muscle reflex. This is a lower motor neuron problem found with interruption of sensory afferents or destruction of motor efferents and anterior horn cells. An example would be a spinal cord injury. The following list provides the DTR, the spinal level that enervates the DTR, and the normal response: · Biceps: C5 to C6. Support the patient’s arm, place your thumb on the bicep tendon; strike a sharp blow to your thumb with the reflex hammer. The expected response is the contraction of the bicep muscle and the forearm should flex. · Triceps: C7 to C8. Ask the patient to let the arm be limp while you hold the upper arm just above the elbow, forming a 45-degree angle. Place a sharp blow to the triceps tendon just above the posterior elbow. The forearm should extend slightly. · Brachioradialis: C5 to C6. Ask the patient to form an open triangle with their thumbs and fingertips touching each other; the hands may rest on the patient’s lap or thighs for support. Grasp the patient’s thumbs together and hold gently while striking the forearm just above the radial process. The forearm should flex and supinate in response. · Quadriceps: L2 to L4. Allow the patient’s lower legs to dangle and the knee to be slightly flexed. Make sure the feet are not resting on a step or the floor. Use the wide end of the reflex hammer to make a strike just below the patella. The lower leg should extend, creating the “knee jerk” response. If the patient is supine, lift the patient’s right leg and bend it slightly, allowing it to rest on your left arm while your left hand is on the patient’s left thigh. This provides flexion of the knee and uses your arm as a lever to support the weight of the leg. Perform the rapid strike below the patella to elicit the desired DTR. · Achilles reflex: L5 to S2. The patient’s knee should be flexed and the hip externally rotated. Dorsiflex the foot and apply a firm strike to the Achilles tendon. The foot should flex against your hand, plantar side first. If the patient is supine, bend the knee and place the bent leg over the opposite leg, just above the ankle, providing relaxation and support. Move the foot into a dorsiflexed position and strike the Achilles tendon. · Clonus: If the reflexes appear hyperactive, be certain to test for clonus. Support the lower leg in one hand while stretching the foot and muscles of the leg with the opposite hand. Stretch the muscles several times to encourage relaxation. Briskly dorsiflex the foot and hold the stretch. You should not feel any further movement of the muscles after the dorsiflexion. If clonus is present, you will see and feel rapid contractions of the calf muscles and the foot. The contractions will be rhythmic in nature. The clonus should last only as long as you hold the foot in dorsiflexion. Physical Exam of Various Reflexes Superficial Reflexes The receptors for superficial reflexes are in the skin instead of the muscles. Abdominal Reflexes · Upper abdomen: T8 to T10 · Lower abdomen: T10 to T12 The patient should be in a supine position with knees slightly flexed. Use the end of the reflex hammer handle to lightly stroke the skin of the abdomen from each side toward the midline. Test upper and lower quadrants, checking both upper quadrants then both lower quadrants. The abdominal muscles should contract toward the stroke. Cremasteric reflex: L1 to L2. For the male patient, use the handle tip of the reflex hammer to lightly stroke the inner thigh. There should be elevation of the ipsilateral testicle. Plantar reflex: L4 to S2. Position the patient with the thighs in slight external rotation. Use the handle tip of the reflex hammer to stroke upwards on the lateral side of the plantar fascia. The movement should follow the pattern of an upside-down letter J. The toes should flex along with inversion and flexion of the forefoot. A positive Babinski is known as “upgoing toes” and is abnormal in the adult but a normal finding in the infant. Pathological Reflexes Babinski: Discussed in plantar reflex. A positive Babinski is found with corticospinal or pyramidal tract disease. Oppenheim: Stroke the anterior medial tibial muscle with the tip of the reflex hammer. A positive response is the extension of the great toe and fanning of the other four toes. This is indicative of pyramidal tract disease. Gordon: Firmly squeeze the calf muscles with your fingers. A positive response is the extension of the great toe and fanning of the other four toes. This is indicative of pyramidal tract disease. Hoffman: Flick the distal phalanx of the middle or index finger with your fingers. The positive response is clawing of the fingers and thumb. This is indicative of pyramidal tract disease. Kernig: Straight leg raise or flex the thigh onto the abdomen then extend the knee out. A resistance to straightening of the knee and or pain down the posterior thigh is a positive response. This reflex is found with meningeal irritation. Brudzinski: Flex the chin to the chest while observing the hips and knees. The presence of resistance and pain in the neck along with flexion of the hips and knees is indicative of meningeal irritation. Physical Exam of the Cranial Nerves – Infants Infants The first twelve months of life is a continuous period of growth and development especially for the nervous system. You should ask about attainment of milestones and the fact that the primitive reflexes have disappeared at the appropriate times. The newborn should have a loud, strong cry along with an excellent sucking reflex. The presence of a high-pitched, shrill, or cat-like cry should be a concern for central nervous system damage. The groaning or weak cry may be found with respiratory distress. Note the interaction or bonding between parent(s) and infant. Is the baby responding to environmental stimuli; does he or she wake spontaneously and sleep the same? Does the parent interact with the baby and experience a response from the baby? A lethargic baby with little response along with a report from the parents regarding significant behavioral changes are warning signs that require further workup and urgent referral. The 2-month-old baby should smile and recognize the parents’ faces. Cooing and babbling should be present by 4 months while early words begin around 9 months of age (“ma ma,” “da da”). You may perform a brief evaluation of the cranial nerves in an infant as follows: · CN II, III, IV, VI: Optical blink reflex elicited by shining a light in the infant’s open eyes. There should be rapid closure of the eyes along with equal size, shape, pupil response. The infant should look at your face or close object. The eyes should track an object. · CN V: The rooting reflex and sucking reflex should be present. · CN VII: When crying or smiling, the forehead and nasolabial folds should wrinkle (facial movements present). · CN VIII: Moro reflex present up to age 4 months. The acoustic blink reflex is noted in response to a loud clap performed approximately 12 inches from the infant’s head. The eyes should then follow the direction of the sound. · CN IX and X: The gag reflex and swallowing reflex. The baby should be able to coordinate sucking and swallowing. · CN XII: Close the nose by gently pinching the infant’s nose shut. The mouth should open and the tongue should move up in the midline
Physical Exam of Motor System – Infants The Motor System The infant’s movements should be spontaneous, smooth, and symmetric. The Denver Developmental Screening Test II (DDSE II) can be used for age-specific milestone documentation. The newborn should be in a flexed position, hips slightly abducted, fists clenched. Breech-delivery infants do not have as much flexion in the lower extremities. The frog position with hips abducted to the point of being almost flat against the table with external rotation is found with breech delivery. This is an abnormal finding in other infants. Opisthotonos: Head and back arched, neck is stiff, arms and legs extended. This posture is found with meningeal or brain stem irritation and kernicterus. The extension of the legs may occur with an intracranial bleed. At the end of two months, the flexion becomes more relaxed; extension begins at the head and moves down in a cephalocaudal direction. Spasticity should not be present. Flex the knees upwards to the abdomen and quickly release the knees. The legs should unfold gently but not rapidly. The baby should allow the head to be pushed gently forwards without resistance. The fists begin to relax around age 3 months with purposeful grasp being noted at 4 months. The transfer of an object from hand to hand is present by 7 months, and pincer grasp at 9 months with purposeful release by 10 months. Babies are ambidextrous for the first 18 months of life. The supine infant should be pulled to a sitting position by the wrists to evaluate head control. The head should move forward with the body, balance very briefly as a sitting position is achieved, then flop forward. The forward flop of the head should disappear by age 4 months. Head lag is an early sign of brain damage. Any baby who has persistent inability to hold the head midline in a sitting position by age 6 months or later should have an immediate referral. You may further evaluate head lag by lifting the baby in a prone position, supporting the chest with one of your hands. The newborn should hold the head at 45 degrees or less from the horizontal while the back is slightly arched or straight. The elbows and knees should be slightly flexed. The 3-month-old will lift the head and arch the back. The head lift and arching of the back are known as the Landau reflex. Lack of the Landau reflex is indicative of motor weakness, upper motor neuron disease, or mental retardation. This reflex disappears after 18 months of age. The Sensory System The newborn typically has hypoesthesia and a strong stimulus is necessary to elicit a response. Crying along with inwards movement of all limbs is the response to pain. The localization of a stimulus begins between 7 and 9 months of age. Hyperesthesia or very rapid withdrawal is found with spinal cord lesions, CNS infections, increased intracranial pressure, and peritonitis. If the infant does not withdraw to stimulus, there is decreased sensation. The decreased sensation is found with lower levels of consciousness, mental deficiency, and spinal cord or peripheral nerve lesions. Physical Exam of Reflexes – The Infant Reflexes Infant reflexes are predictable and have a fairly set timetable of onset and cessation. A screening examination can include the rooting, grasp, tonic neck, and Moro reflexes. Rooting: Gently brush the cheek near the mouth. The infant should turn towards the touch and open the mouth to feed. This reflex is present at birth and disappears between 3 to 4 months of age. Sucking reflex: Use a gloved hand and touch the infant’s lips with your smallest fingertip. The infant should have a strong sucking reflex up to 10 to 12 months of age. Palmar grasp: The baby should be supine with head at the midline. Offer your finger to the baby, coming at the ulnar aspect, away from the thumb. The baby should grasp your finger with its fingers. The grasp should be firm and tight. The baby can often be pulled to a sitting position from the supine position with the palmar grasp reflex. This reflex is strongest at 1 to 2 months and disappears after 3 or 4 months. The palmar reflex is absent in the presence of brain damage and with local muscle or nerve injuries. If the palmar reflex remains after age 4 months, consider frontal lobe lesion. Plantar grasp: Place your thumb at the ball of the baby’s foot. The toes should curl downwards over the thumb. The plantar reflex should disappear between ages 8 to 10 months. Babinski’s reflex: Gently stroke your finger up the lateral edge of the infant’s foot. The toes should fan for a positive Babinski’s reflex. This is normal in the infant from birth up to 24 months of age. Tonic neck reflex: The infant should be supine, relaxed, or asleep. Turn the infant’s head to one side with the chin facing over the shoulder. The ipsilateral extension of the arm and leg while the opposite arm and leg flex. This is also known as the fencing position. The turning of the infant’s head to the other side will elicit a reversal of the position. This reflex appears between 2 to 3 months and disappears by 4 to 6 months of age. Moro reflex: This is also known as the startle reflex. Make a loud noise, gently bump the crib, or move the infant to a semi sitting position then rapidly lower to 30 degrees. The baby should abduct and extend the arms and legs, fan the fingers, and create a C shape with the index finger and thumb. The appearance is that of “tree hugging” as the arms and legs are brought inward towards the body. This reflex disappears between 1 to 4 months of age. The absence of Moro reflex at birth or the persistence of the Moro reflex past 5 months of age is indicative of severe CNS injury. Placing reflex: Hold the infant under the arms and in an upright position. Allow the dorsal aspect of the foot to touch the underside of the exam table. The hips and knees should flex then extend to put the foot up on the table. This reflex begins at 4 days after birth. Stepping reflex: The infant should be held upright with your hands under the arms. The feet should be on a flat surface. The infant should have regular, rhythmic steps. This reflex will disappear before the infant begins to actually walk. Crossing of the legs (scissoring) or extensor thrusts of the legs are abnormal. Physical Evaluation of Children Preschool and School-Age Children Assess general demeanor and behavior of the child while playing and interacting with you and the parent(s), as well as the level of cooperation exhibited by the child. Ask the child to show you how to use buttons appropriately as well as to dress and undress. This will allow for evaluation of gross and fine motor movements, range of motion, symmetry, and muscle strength. If you must assess smell, use familiar scents that the child will recognize. Apply gentle immobilization of the head for cardinal fields of gaze and other visual field assessments so the child will not turn the head to follow the test. Make a game out of the assessment techniques and the child will be more likely to cooperate. Assess gait while walking and running. Remember that the toddler will have a wide-based gait and the preschooler may be “knock kneed.” A 4-year-old should be able to balance on one foot for approximately 5 seconds as well as hop on one foot. The 5-year-old should be able to balance for 8 to 10 seconds. Ask the child to move from a supine to standing position. The supine position should begin on the floor, then curl up to the midline to sit up, then push off with both hands from the floor to achieve a standing position. Children with weak pelvic muscles should be evaluated for muscular dystrophy. The child will roll to one side, bend forward to all four extremities, plant the hands on the legs, and then literally “climb up” to a standing position. This movement is known as Gowers’ sign. You may evaluate fine motor coordination by asking the child to perform the finger to nose test. Give credit if the child is able to come within 1 to 2 inches of the nose. The ability to perform this test does not usually develop until age 4 years or older. Evaluation of sensation in a child is not a reliable test and should be performed only if absolutely necessary. Avoid needles in children as they may have a fear of the needle; substitute another object if superficial pain response is necessary. Children under 5 years of age seldom need DTR evaluation. Young children often do not understand and are not as cooperative as needed for this assessment. If DTRs are assessed in a young child, use your finger to elicit the DTR instead of the reflex hammer. The patella reflex is present from birth onwards. The Achilles reflex along with the brachial reflex develops later followed by the triceps reflex by 6 months of age Physical Evaluation of the Older Adult The Older Adult Keep in mind that the older adult may respond to requests more slowly than a younger adult. The assessment remains the same for the most part. Taste and smell are not usually assessed as these senses are often decreased in the older adult as part of the aging process rather than a malignant problem. Senile tremors may be present. The senile tremors may be found as an intention tremor of the hands, nodding of the head (think Katherine Hepburn), or tongue protrusion. Dyskinesias are repetitive movements in the jaw, lips, or tongue that may be found in the presence of senile tremors. Rigidity should not be present. Parkinson’s tremors will have rigidity and slowing as well as weakness with intentional or voluntary movement. “Pill rolling” is often found in moderate to advanced Parkinson’s disease. Note any gait changes including the shuffling gait of Parkinson’s. The older patient may be slower and more deliberate but the gait is not shuffling. DTR responses are lower in the older adult. The upper extremity reflexes are present whereas the Achilles reflex is often lost. The Babinski reflex may be difficult to elicit or interpret. Reevaluation of the Patient with Neurologic Impairment A patient with a neurologic impairment will often require a recheck to evaluate their status. The impairment may be from head trauma, a stroke, or other disease process. This may take place in the hospital setting, the office, or other establishment. It is very important to recognize the early symptoms of increased intracranial pressure as urgent intervention. An abbreviated neurological exam is useful. Assess level of consciousness, motor function, pupillary response, and vital signs. Level of Consciousness Note any changes in the level of consciousness. This is the earliest and most sensitive factor in evaluation of neurological status. Document the ease of arousal, orientation, and ability to follow verbal commands. If the patient is unable to speak, adapt the questions to allow for head nods or shakes and motions. Note the amount of stimulus, if any, that is required to elicit a response. Motor Function You may assess voluntary movements of all four extremities by asking the patient to follow specific commands and also assess CN VII. Hand grasps will evaluate the upper extremity strength. Evaluate lower extremity strength by asking the patient to perform leg raises. If the patient is unable to lift the leg, ask them to push down with the feet: “Push down as if you are pushing the gas pedal or brake on your car.” If the patient is not responsive to verbal stimuli, you may use limited noxious stimuli to elicit response. Watch for localization or purposeful movement. Abnormal Postures Decorticate rigidity: Moving to the core of the body. The arms, wrists, and fingers move up and inwards; adduction of the arms is present. The lower extremities extend and rotate internally, with plantar flexion of the feet. This posture is the response to a hemispheric lesion of the cerebral cortex. Decerebrate rigidity: The arms are stiff, rigid, and extended. The wrists are rotated outwards with fingers formed into fists. The lower extremities are rigid, stiff, and extended. The back may be hyperextended; the teeth are clenched. The decerebrate posture indicates brain stem injury or lesion at the midbrain or upper pons. This posture does not bode well for patient recovery. Flaccid quadriplegia: A complete loss of muscle tone. Paralysis of all four extremities indicating a nonfunctional brain stem. Evaluate the pupils for size, shape, and symmetry as well as response to light. Pupillary constriction should be brisk and equal bilaterally. Document the pupil size in millimeters. Vital signs should include the pulse, temperature, respirations, and blood pressure. Check vital signs as often as necessary or indicated in the acute care setting. Keep in mind that heart rate and blood pressure changes are late indicators of increased intracranial pressure. Change in level of consciousness is an early symptom.
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