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Module 2. Clinical Assessment & Intervention. MANAGING CLIENTS WITH HIV-RELATED NEUROPSYCHIATRIC COMPLICATIONS. Objectives. To review how CNS involvement may present as common client complaints To review various causes of CNS complaints To provide strategies for evaluating mental status

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Clinical Assessment & Intervention

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    2. Objectives • To review how CNS involvement may present as common client complaints • To review various causes of CNS complaints • To provide strategies for evaluating mental status • To discuss treatment intervention and referral • To understand your role on the treatment team

    3. Outline • The Basics • Complaints, Patterns, Symptoms • Assessment and Interpretation • Intervention • Conclusion

    4. The Basics

    5. THE BASICS The Basics • Recognize that common complaints may involve CNS • Organize mental history and assess mental status change • Refer to appropriate resource or consultation as needed • Provide follow-up care

    6. THE BASICS Recognize That Complaints May Involve CNS • Neuropsychiatric disturbances can occur with HIV • HIV-CNS involvement can masquerade as psychiatric disorders • Symptoms can represent disorders of mind or brain, or the effects of physical illness on mental functioning • The more serious the symptoms, the more important it is to rule out biologic cause

    7. THE BASICS Assess Mental Health Change • Evaluate clients to your level of expertise • Conduct a thorough history • Do a mental status exam • Consult with treatment team • Assess within context of age, gender, and culture • Note: Acute change may require immediate attention

    8. THE BASICS Make the Appropriate Referral • Ask for help when problem is beyond scope of practice • Ask for help if a biological origin is suspected • Refer to primary care physician, psychiatrist, or neurologist for comprehensive work-up • Refer acute problems to primary care physician or admit to hospital

    9. THE BASICS Provide Follow-up Care • Education • Teamwork • Communicating information to client • Client/family work

    10. Complaints, Patterns, Symptoms

    11. COMPLAINTS, PATTERNS, SYMPTOMS Complaints, Patterns, Symptoms • Neurologic symptoms • Symptoms of affect, behavior, cognition • Medication side effects • Red flags

    12. COMPLAINTS, PATTERNS, SYMPTOMS Classic Neurologic Symptoms Blurred vision Headache Numbness/pain Dizziness Seizures/tremors Weakness/uncoordination Incontinence Difficulty walking

    13. COMPLAINTS, PATTERNS, SYMPTOMS Common Complaints CHANGES IN AFFECT, BEHAVIOR, COGNITION • Sadness/grief • Nervousness • Anger/irritability • Relapse (or fear) • Agitation/hallucinations • Impulsive behavior • Euphoria • Distractibility/confusion • Fatigued/lethargic/slow • Sleep problems • Sexual problems • Pain/somatic complaints • Memory problems • Adherence problems

    14. Headache Gastrointestinal problems Fatigue Loss of appetite Depression Sensory change Sleep problems Anxiety Hallucinations Pain Nightmares Paranoia Delusions Mania COMPLAINTS, PATTERNS, SYMPTOMS Common Side Effects of Medications

    15. COMPLAINTS, PATTERNS, SYMPTOMS Red Flags • Acute changes that endanger client • Sudden changes in cognitive capacity • Acute onset of pain • Acute disorientation • Acute change in personality • Destructive behavior • Change in level of consciousness

    16. COMPLAINTS, PATTERNS, SYMPTOMS Possible Origins • Situational stressor • HIV-related illnesses • Medical problems (not HIV) • Substances: over the counter, illicit, prescribed, alcohol, herbal, caffeine • Any new medications/drug interaction • Psychiatric disorders • Neuropsychiatric manifestation

    17. COMPLAINTS, PATTERNS, SYMPTOMS Case Example 1 • Client complaint: “ I feel anxious”- “I can’t think”- “I can’t keep track of things” • Situational stressors:A friend died in methadone treatment • HIV-related illness: Toxoplasmosis • Medical problems (not HIV): Diabetes • Substances: Alcohol, herbs, caffeine • Medication: Zidovudine

    18. COMPLAINTS, PATTERNS, SYMPTOMS Case Example 1 (cont.) • Psychiatric Condition • anxiety, depression, personality disorder, adjustment disorder • Neuropsychiatric syndrome: • MCMD, HAD or Delirium

    19. COMPLAINTS, PATTERNS, SYMPTOMS Case Example 2 • Client complaint: “I’m sad”; “I’m tired” • Situational stressors: Lost housing • HIV-related illness: Low testosterone • Medical problems (not HIV):Anemia, diabetes • Substances: Alcohol • Medication: Efaviren

    20. COMPLAINTS, PATTERNS, SYMPTOMS Case Example 2 (cont.) • Psychiatric condition: Depression, adjustment disorder • Neuropsychiatric syndrome: MCMD

    21. COMPLAINTS, PATTERNS, SYMPTOMS Don’t Panic!!! Edvard Munch “The Scream”

    22. Assessment and Interpretation

    23. ASSESSMENT AND INTERPRETATION Fundamentals • Establish a reasonable evaluation of presenting symptoms and critical issues • Incorporate your knowledge, skills, and experience • Recognize your limits. Consult with care team if/when appropriate

    24. ASSESSMENT AND INTERPRETATION Fundamentals (cont.) • Choose appropriate assessment tool(s) • Use them consistently • Assess problems specific to CNS • Diagnose by exclusion • Recognize assessment as a continuous process

    25. ASSESSMENT AND INTERPRETATION Fundamentals (cont.) • Recognize cultural differences in symptom expression • Be cautious not to misinterpret symptoms • Cultural compatibility between MHP and client can be important for creating an atmosphere of trust • MHPs should assess their personal attitudes and comfort levels when working with clients of different demographic or cultural background.

    26. ASSESSMENT AND INTERPRETATION Assessment Strategy • Client identification and history • Mental health status • Follow-up assessment • Interpreting data

    27. ASSESSMENT AND INTERPRETATION Client Identification/History • Identifying data • Chief complaint • Present illness history

    28. ASSESSMENT AND INTERPRETATION Client Identification/History(cont.) • Past medical history • Substance use/abuse history • Developmental or psychosocial history • Cultural data • Physical environment

    29. ASSESSMENT AND INTERPRETATION Client Identification/History (cont.) • Neuropsychiatric checklist

    30. ASSESSMENT AND INTERPRETATION Mental Health Status • Assess psychological expression • Observe behavior and appearance • Evaluate cognitive function

    31. ASSESSMENT AND INTERPRETATION Mental Health Status (cont.) • Mood • Cognitive functioning • Thought content • Thought process • Appearance • Psychomotor state • Interpersonal • Speech

    32. ASSESSMENT AND INTERPRETATION What’s Going On? • What do you know? • How do you know what you know? • What do you do with what you know? • I am worried because . . . • What are the next steps?

    33. ASSESSMENT AND INTERPRETATION Organizing Information • Provide demographic information • Organize symptom presentation • Offer findings of mental status exam • Pose a specific question • Ask if there is missing information

    34. ASSESSMENT AND INTERPRETATION Follow-up Assessment Inquire about changes in: • Medical problems (HIV and non-HIV) • Medications and other substances • Affect, behavior, cognition • Situation stressors

    35. Intervention

    36. INTERVENTION Options for Intervention • Do nothing. Watch for change. • Obtain further data. • Provide appropriate treatment. • Make a referral. • Prepare/educate client.

    37. INTERVENTION Do Nothing • Observe/note changes • Pay attention to countertransferrence

    38. INTERVENTION Obtain Further Data • Conduct further testing • Expand assessment

    39. INTERVENTION Provide Treatment • Goals (what will be accomplished) • Objectives (interventions to reach goal) • Methods (e.g., psychotherapy, client/family education, support groups, cognitive skill building) • Players (primary care providers, social worker, psychiatrists, psychologists, neurologists)

    40. INTERVENTION Make a Referral Refer for consultation if: • problem is beyond scope of practice • problem is beyond scope of expertise • problem is beyond control (psychiatric emergency) • problem presents as Red Flag

    41. INTERVENTION Prepare the Client • Explain your level of concern • Explain who you want to have help with the current concerns • Emphasize this is to diagnose the problem to implement appropriate treatment. • State you will follow through the evaluation and help the client manage the process of tests, consults, etc. • Find out as much as possible about the actual procedures and tests which might be done, and provide support for coping with the process

    42. Conclusion • Recognize that common complaints may involve CNS • Assess mental health change • Make a referral if appropriate • Provide follow-up care

    43. By remaining vigilant to the signs of CNS disruption, and exercising caution when making diagnoses, MHPs can increase the quality of care for all HIV clients.