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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

Module 2

Clinical Assessment & Intervention

MANAGING CLIENTS WITH HIV-RELATED NEUROPSYCHIATRIC COMPLICATIONS

objectives
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
outline
Outline
  • The Basics
  • Complaints, Patterns, Symptoms
  • Assessment and Interpretation
  • Intervention
  • Conclusion
the basics5

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
recognize that complaints may involve cns

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
assess mental health change

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
make the appropriate referral

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
provide follow up care

THE BASICS

Provide Follow-up Care
  • Education
  • Teamwork
  • Communicating information to client
  • Client/family work
complaints patterns symptoms11

COMPLAINTS, PATTERNS, SYMPTOMS

Complaints, Patterns, Symptoms
  • Neurologic symptoms
  • Symptoms of affect, behavior, cognition
  • Medication side effects
  • Red flags
classic neurologic symptoms

COMPLAINTS, PATTERNS, SYMPTOMS

Classic Neurologic Symptoms

Blurred vision

Headache

Numbness/pain

Dizziness

Seizures/tremors

Weakness/uncoordination

Incontinence

Difficulty walking

common complaints

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
common side effects of medications
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
red flags

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
possible origins

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
case example 1

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
case example 1 cont

COMPLAINTS, PATTERNS, SYMPTOMS

Case Example 1 (cont.)
  • Psychiatric Condition
    • anxiety, depression, personality disorder, adjustment disorder
  • Neuropsychiatric syndrome:
    • MCMD, HAD or Delirium
case example 2

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
case example 2 cont

COMPLAINTS, PATTERNS, SYMPTOMS

Case Example 2 (cont.)
  • Psychiatric condition: Depression, adjustment disorder
  • Neuropsychiatric syndrome: MCMD
fundamentals

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
fundamentals cont

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
fundamentals cont25

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.
assessment strategy

ASSESSMENT AND INTERPRETATION

Assessment Strategy
  • Client identification and history
  • Mental health status
  • Follow-up assessment
  • Interpreting data
client identification history

ASSESSMENT AND INTERPRETATION

Client Identification/History
  • Identifying data
  • Chief complaint
  • Present illness history
client identification history cont

ASSESSMENT AND INTERPRETATION

Client Identification/History(cont.)
  • Past medical history
  • Substance use/abuse history
  • Developmental or psychosocial history
  • Cultural data
  • Physical environment
mental health status

ASSESSMENT AND INTERPRETATION

Mental Health Status
  • Assess psychological expression
  • Observe behavior and appearance
  • Evaluate cognitive function
mental health status cont

ASSESSMENT AND INTERPRETATION

Mental Health Status (cont.)
  • Mood
  • Cognitive functioning
  • Thought content
  • Thought process
  • Appearance
  • Psychomotor state
  • Interpersonal
  • Speech
what s going on

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?
organizing information

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
follow up assessment

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
options for intervention

INTERVENTION

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

INTERVENTION

Do Nothing
  • Observe/note changes
  • Pay attention to countertransferrence
obtain further data

INTERVENTION

Obtain Further Data
  • Conduct further testing
  • Expand assessment
provide treatment

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)
make a referral

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
prepare the client

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
conclusion
Conclusion
  • Recognize that common complaints may involve CNS
  • Assess mental health change
  • Make a referral if appropriate
  • Provide follow-up care
slide43
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.