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Folstein Mini M ental S tatus Examination
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Folstein Mini M ental S tatus Examination Task Instructions Scoring Date
Orientation "Tell m e the date?" One point each for year, season, date, day of week, and m onth 5 Place
Orientation "Where are you?" One point each for state, county, town, building, and floor o r room 5
Objects Name three objects slowly and clearly. Ask the patient to repeat them. One point for each item correctly repeated 3 Serial
Sevens Ask the patient to count backwards from 100 by 7. Stop after five answers. (Or ask them to spell "world" backwards.) One point for each correct answer (or letter)
5 Recall 3
Objects Ask the patient to recall the objects mentioned above. One point for each item correctly remembered 3 Naming Point to your w atch and ask the patient "what is this?" Repeat w ith a pencil. One point for each correct answer 2 Repeating a Phrase Ask the patient to say "no ifs, ands, or buts." One point if successful on first try 1 Verbal
Commands Give the patient a p lain piece of paper and say "Take this paper in your right hand, fold it in half, and put it on the floor." One point for each correct action 3 Written
Commands Show the patient a piece of paper w ith "CLOSE YOUR EYES" printed on it. One point if the patient's eyes close 1 Writing Ask the patient to w rite a sentence. One point if sentence has a subject, a verb, and m akes sense 1 Drawing Ask the patient to copy a pair of intersecting pentagons onto a piece of paper. One point if the figure has ten corners and two intersecting lines 1
On Death and Dying Grieving One’s Own Impending Death Elisabeth Kubler-Ross, MD • Swiss Born Psychiatrist • Attacked by colleagues for interviewing dying patients (considered taboo) • Prior to her contributions, American and Western doctors never directly told patients that they were dying Five Stages of Grief • Kubler-Ross described five stages of grief in her 1969 bestseller, Death and Dying • Stages do not strictly follow one another, but can ebb and flow depending on the type of personality or situation • In the elderly, the grief process may be associated with the “loss of youth” or function
Ross
• Kubler-Ross was a pioneer of the hospice movement of the early 70’s, which pushed patient palliative care to the forefront • Her work on death removed the taboo and allowed patients, doctors, and families to talk about death • Patients were given autonomy and dignity with death Five Stages of Grief: DABDA • Denial • Anger • Bargaining • Depression • Acceptance KUBLER ROSS: STAGES OF DYING (5): • Dying person may experience several intense emotions. DENIAL: • "No, not me!" • patient rejects the news • initial positive defense mechanism but can become a problem if reinforced by family and friends, leading to poor coping. 13 Stage One: Denial (D) and Shock • Patients may appear dazed, or confused about the diagnosis or deny that anything is wrong • Resistance to accepting the diagnosis is usually an unconscious phenomenon • Physician’s tasks: – Respect patient’s denial while still communicating information clearly about the diagnosis, prognosis, and options for treatment – Decrease patient’s fears of abandonment by clarifying that they will continue to care for them Stage One: Denial (D) • Can be adaptive or maladaptive • This stage usually resolves within hours or days, but… • Some patients never pass beyond this stage
• "Why me?" • resentment and rage over impending death; • may be directed outwards at loved ones.
Stage Two: Anger (A) • Anger, irritability, frustration • “Why me!” • Anger can be directed at God, family, even self • Anger may be displaced onto hospital staff or physicians • May reflect frustration at lack of control over situation • Physician’s task: – Maintain a non-defensive, empathic manner 14
Stage Three: Bargaining (B) • Bargain or barter with doctors, family, or God
• Bargaining may involve keeping pledges- – i.e. giving to charity, attending church, or becoming a non-questioning, compliant patient
• Physicians task: – Encourage patients to be partners in their care – Be honest and straightforward with their symptoms and care DEPRESSION: • gradual realization of consequences • difficult time - persons needs to be watched and supported • a period of grieving must be allowed to work through this stage • trying to cheer up isn’t an asset now! Stage Four: Depression (D) • Patients may show clinical signs of depression such as apathy, withdrawal/social isolation, sleeplessness, hopelessness, suicidal ideation • Signs of sadness over impending death are normal…but, • Major depressive symptoms and
may warrant treatment with medications, etc.
• “I’m m scared but, I'm ready." • These stages may overlap and repeat. Stage Five: Acceptance (A) • Patients come to accept the inevitability and universality of death • Able to use/enjoy remaining time • Moods may range from neutral to euphoric • Resolution of discomfort with thoughts of death
• Patients may gain comfort talking about death
• Belief in an afterlife is comforting to many For most, transition thru the 5 stages takes time...but not for
Kubler-Ross: “Dying with Dignity” • Kubler-Ross died in August, 2004 • “What does it mean to die with dignity?“ – "To die with dignity to me means to die within your character. That means there are people who have used denial all their life long; they will most likely die in a stage of denial. There are people who have been fighters and rebels all their life long, and by golly they want to die that way. And to those patients we have to help them, to say it's OK." – Kubler-Ross 1975 DEFINITION OF DEATH: Spiritual death: • death of meaningful life • including responsiveness to others, with activity of the brain and consciousness ALSO: Unreceptive and unresponsive to painful stimuli - CPR • No movement for an hour • No breathing for 3 minutes • No reflexes • Pupils fixed and dilated - flat EEG • LIFE SIGNS……………….. DEFINITION OF DEATH: Traditional legal definition: • failure of heart and lungs = functional death.
• brain death = absence of electrical impulse activity in the brain (EEG).
• Cells die- e.g., heart, brain, muscle CIRCUMSTANCES OF DEATH • Death at/or before 50 years of age or younger emotional trauma – unexpected • Religious belief = less fear • Pain and physical distress. • Immediately prior to death there is often an increased in vitality • People often "hold on" for a specific life event or person EUTHANASIA: Mercy killing. INDIRECT INVOLUNTARY (PASSIVE) - remove life support DIRECT VOLUNTARY administer fatal drug as condition worsens DIRECT INVOLUNTARYdrug once a patient is in a coma. ILLEGAL / ETHICAL ISSUES • Who will you disclose to someone that he has terminal carcinoma pancreas. how you would differnetiatewhether they are grieve or major depression and focus on the class i.e.major depression i.e. committing suicide and different between grieve and major depression. Differentiate between major depression, grief or bereavement` Normal grief is characterized by shock, denial and perhaps illusion. It normally subsides after 1 to 2 years. There is usually minor weight loss, minor sleep disturbances and some guilty feelings, cries and expresses sadness…. Anything more than this is Abnormal grief (DEPRESSION). In major depressive disorder, there is recurrent episodes of depression, each continuing for at least 2 weeks. The hallmark of this is that patient feels sadness, hopelessness, helplessness, low self esteem and excessive guilt. Postnatal blue, bereavement, grieve: Baby blue which starts a few days following post partum lasts up to 2 weeks after childbirth. This is as a result of stress of childbirth and change in hormonal level. Treatment includes emotional support from physician. Characterised by exaggerated emotions and good grooming. Major depression and brief psychotic disorder which starts 4 weeks and 2 weeks (respectively) following postpartum onset are treated with antidepressant and antipsychotic medications. In major depression, mother develops poor self care, lacks pleasure or interest and feels hopeless. In brief psychotic disorder, mother becomes psychotic and may harm infant. The Grieving Process Grief and Bereavement • Grief and bereavement are finely differentiated • Essentially describe the process and feelings following loss (death) of family, friends, and others significant in the individual’s life • Can also grieve losses of function, status, occupation, etc. “Normal” Grief • No “normal” way to grieve • Grieving process may vary widely between individuals AND within the same individual: – Same person may grieve different losses in different ways “Normal Grief” • Grieving process varies widely between cultures and individuals • Not abnormal to experience shock, disbelief, numbness initially • Feelings of guilt are common, vary in intensity (may become overwhelming in pathological grief) • May experience Survivor Guilt “Normal” Grief • Dreams about the deceased or actual hallucinations-auditory or visual are not uncommon
• These “mis-perceptions” are not pathologic if the patient has insight that they are not real Grief versus Depression • Many of the symptoms of grief are similar to clinical depression – Ex. Sadness, poor sleep, diminished interests, feelings of weakness, decreased appetite, weight loss, trouble concentrating – Certain elements, including time-course/ duration help distinguish grief from clinical depression Fine Details: Grief vs. Major Depression • GRIEF – Bereaved rarely have intense feelings of guilt or worthlessness – Active suicidal ideation is uncommon; passive thoughts are common • DEPRESSION: – Guilt and feelings of worthlessness are common and often excessive – Suicidal ideation is common in severe depression Grief vs. Major Depression • GRIEF – Onset is usually within the first two months of the loss – Acute symptoms of grief usually resolve within two months of the loss. (upto 2 years) • DEPRESSION – Onset at any time – Depression is chronic, intermittent or episodic Grief vs. Major Depression • GRIEF – Impairment in daily living is mild and transient – There is no loss of hope for return to normal function – Psychosis limited to brief hallucinations • DEPRESSION – Impairment in daily living is significant – A loss of hope for the future is common – More prominent psychotic symptoms possible How you manage a person or person: loved one died in family: what support you can provide for those circumstances MAKE IT IN SMALL packets: and we have ordered investigation nd they are suggesting and you are not hundred percent, porstate, if you think that it’s the last stage and they’re not going to live for more than 2 years: then first stage: you are diagnosed with: just tell him, he’s diagnosed with a cancer, don’t use medical jargon: then if PT asks: am I going to die: how much time and I going to live: am I going to die? If survie one month: investigation suggest that you’re cancer is not at the prime and ivnovled more organs: most people don’t live for more than 2 months: statis say this: A B and C. and I’ll be ale to reply to this: and so that they know what’s going on: and if they want to make a will or do some traveling: and they have some time to do what they want. Never GIVE THEM FALSE HOPE!! If they’re suricidal don’t disclose the information Inform family that they’re loved ones died and it’s difficult information has disclosed: first stament should not be: he’s dead: It depends: after accident and he was bleeding and family member and mentally and made up their mind: so it’s not necessary very detailed: b/c they were the one that brought them, bu first of all: show sympathy that you feel sorry and you did everything but unforutnaly and unforutatnly they have died… don’t show smiling… And if they’re cyring and denial again, it’s your duty to provide them and maybe they’re refered to to a pyschiatriast… If someone died: 85 yeard old expiered, family members: and on the other hand: if they were 3 years of age, it would be difficult to accept this… and how close was the relationship and whether who was belonged is anelderly: and it’s bad and it’s acceptable… Under supervision: and you screw up: they will never allow you to do this: chances of accident they’re not large: but it can happen: and there’s two answer: -if you go to lawyer: they wil tell them something else: but ethical aspect: you have to inform first of them and b/c of that mistake someone has died: most of the time: they won’t ask you: they’ll inform this through family member that the person has expired: depends on hospital will not disclose information: if you want to disclose: and you will also be scared and never disclose it… screw up your career… Gorss anatomy and biochemistr y and behaviour: focus on anaomtical difference based on gender: in CNS: if you do a CT scan: anatomically differences: Anatomy & Biochemistry of Behavior Chapter 4 NEUROANATOMY
BOTH HEMISPHERE ARE CONNECTED BY CORPUS CALLOSUM, ANTERIOR COMMISURE, HIPPOCAMPAL COMMISURE AND HABENULAR COMMISURE.
MEN HAVE BETTER DEVELOPED RIGHT HEMISPHERE AND APPEARS TO BE BETTER AT SPATIAL TASKS THAN WOMEN. Maybe few neurotransmitters that play an important rule in psychiatry -role of neurotransmitter NEUROTRANSMISSIONS
BIOGENC AMINES DOPAMINE
NOREPINEPHRINE SEROTONIN DOPAMINE
Dopamine Pathways 4 Main Pathways:
Nigrostriatal Pathway
MESOLIMBIC MESOCORTICAL PATHWAY
NOREPINEPHRINE (NE)
Symptoms of pheos
SEROTONIN (5-HT)
ACETYLCHOLINE
AMINOACID NT’S GABA
GLYCINE GLUTAMATE
NEUROPEPTIDES
brain lesion: depending on portion of scar and cerebral hemisphere: i.e. frontal lobe lesion, parietal, or occipital lesion, what are the findings. lesions of CNS and psychiatric manifestations:
BRAIN LESIONS FRONTAL CORTEX
TEMPORAL LOBE
PARIETAL CORTEX
OCCIPITAL LOBE
LIMBIC SYSTEM
BASAL GANGLIA
APHASIA
LABORED TELEGRAPHIC SPEECH WITH POOR COMPREHENSION Mini mental status examination: Mental status examination: What is the significance of a MMSE: why do we do it? And what is the significance if it’s impaired…!!! How do you differentiate between dementia and pseudodementia Pseudodementia disorder – When depression mimics depression e.g. 78 yr old woman who lost her daughter and now has difficulty sleeping, poor appetite and lost weight. Causes of dementia:
Then sleep: EEG is very important: asked what are the finding in different cases of sleep: REM, nonREM sleep what are the phases, what are the EEG finding? What are th changes that do occur that correspond to the phases of the sleep: i.e. REM, PT may move eyelids: i.e. excitation of body, palpitations, bodily changes that occur Chap 10: Know the sleep patterns of an elderly person versus that of a young person Elderly: Elderly often have poor sleep quality bcos aging is associated with reduced REM sleep, delta sleep (stage 3-4 or slow wave) and increased night time awakenings…..more than 3 per night. Normal young adult: 25% REM, increased REM toward morning Awake……..Alpha and Beta waves Stage 1- lightest stage of sleep, decreased b.p, slow pulse….(Theta waves) Stage 2- largest % of sleep time, tooth grinding. (Spindle) Stage 3 and 4 – deepest, most relaxed stage of sleep, sleep disorders e.g. night terrors, sleep walking, bed wetting etc. (Delta waves) REM- penile erection, dreaming, increased pulse and respiration, skeletal muscle movement. (alpha, beta, theta). Know the sleep disorders: Table 10.3 Normal Sleep. SLEEP
•Circadian •Humans spend 1/3 of life sleeping (well over 175,000 hrs) •typically 8 hours/day…so - 3/day = extra 21 hrs/week �� 10,952 hrs/decade!!! Natural cycle • Circadian rhythm – the biological clock – regular bodily rhythms that occur on a 24 hour cycle – wakefulness – body temperature SLEEP
•Amount of sleep changes with age – younger ages sleep more 
Role of sleep • Essential for survival. • Total sleep deprivation fatal. • Restorative function. R and R. • Activation of cortex. • Dreaming as a result of activity. • Important that cycle be preserved. • Sleeping pills and alcohol disrupt cycle.
Sleep Deprivation • Effects of Sleep Loss – fatigue – impaired concentration – immune suppression – irritability – slowed performance • accidents – planes
– autos and trucks Do we need sleep? Repair & Rest 1965 – Randy Gardner Science fair project…break world record of No sleep (260 hrs) �� 264 hr 12 min = 11 days!!! “mind over matter” First night: 15 hrs Next night: 9 hrs too bad randy, Mrs. Maureen Weston (1977) 18 days!!!! Rocking chair marathon Sleep deprivation (3 to 4 hrs) Humans
1. Increase in sleepiness 2. Mood test 3. Perform poorly on test of vigilance (ex: tones) 2 to 3 days (continuous sleep deprivation) “Microsleeps” (2 to 3 sec long) 1. Eye lids droop 2. Less responsive to stimuli 3. Still standing Performance on complex cognitive tasks????? Performance in motor tests??????? 1929, a German psychiatrist: Hans Berger, Found the it was possible to record the feeble electric currents generated on the brain, without opening the skull, and to depict them graphically onto a strip of paper. Berger named this new form of recording as the electroencephalogram (EEG, for short)
EEG (electroencephalograph) records electrical activity of the brain via electrodes attached to the scalp •Gross measurement of neuronal activity takes an average of the whole population of cells in the area under the electrode •Output of the electrodes are amplified and recorded ��EEGs tell you whether a person is asleep, awake or excited EEG lingo: Measurement of Brain Waves Amplitude: index of voltage = larger the voltage the higher the amplitude (Height)
Frequency: index of waves across time, cycles per second (hertz, Hz) (how often they occur) 2 Basic EEG Patterns: 1. Desynchronized: neurons in the brain firing at many different times �� produces EEG patterns of low amplitude & high frequency (wakefulness) 2 Basic EEG Patterns: 2. Synchronized: neurons are firing at the same time – produces well defined waves of low frequency high amplitude (characteristic of deep sleep) EEG/EMG/EOG 
EMG: Electromyogram - Leg EOG: Electroculogram - Eye muscle There are two divisions of sleep 1. non-rapid eye movement (NREM) 2. rapid eye movement (REM) Non-Rapid Eye Movement Sleep About 80% of adult sleep is NREM sleep. NREM sleep is divided into four stages: •Stage 1—the drowsy transition from waking to sleeping •Stage 2—intermediate sleep, when arousal is more difficult •Stage 3—the beginning of "deep," or slow-wave, sleep •Stage 4—the deepest sleep, when there is little contact with external sensations During NREM: breathing, heart rates, body temperature, blood pressure decrease.  
Stage EEG Rate (Frequency) EEG Size (Amplitude) Awake 8-25 Hz Low 1 6-8 Hz Low 2 4-7 Hz Occasional "sleep spindles" Occasional "K" complexes Medium 3 1-3 Hz High 4 Less than 2 Hz High REM More than 10 Hz Low Note that as sleep progresses from awake to sleep, brain activity becomes more synchronized (low frequency hi amplitude) Resting quietly Eyes closed Arousal & awake Transition btw wakefulness & sleep Short burst of waves 2 to 5 tx a min 1-4 (aging) Only here – pre to delta Sleeping soundly – but report Not asleep at all! REM sleep resembles stage 1 “Saw Tooth” Dreaming
• Are external stimuli incorporated into dreams?
– Water was sprayed on dreaming subjects; 14 of 33 dreamed of water. 
90 minutes to our first bout of REM – average of 5 cycles – REM lasts 10- 20 min then we fall back to stage 2 and so on…
* somnambolism REM SLEEP PGO spiking : Pontine-Geniculate-Occipital Triggers the onset of REM 1. Waves of neural activity first in the pons 2. Then in the lateral geniculate 3. Then in the occipital cortex - Wave is synchronized with eye movement - At this time Pons is also sending inhibitory messages to the spinal cord �� motor neurons Neurochemistry: Pons releases ACh stimulate LGN (inject carbachol=Ach agonist=REM)   
Locus Coeruleus: Noradrenergic neurons: destroy this area you get NO REM but SWS (stage 3 & 4)
Raphe Nucleus: Serontonergic neurons: destroy this area you get NO SLEEP = insomnia…agonist=increase in SWS
- sleeping disorder (1 of 2000) characterized by periods of irresistible sleepiness - "sleep attacks" happen without warning and can occur even after a good night's rest - normally last about 20 minutes - after waking up, the person feels refreshed, only to feel sleepy again a few hours later - There is no known cause of this chronic sleep disorder
Antidepressants tend to suppress REM sleep So need more 5HT Gene found in dogs
Apnea is a Greek word meaning "want of breath” disorder characterized by periods of time when the sleeper stops breathing (apnea) or experiences a sharp reduction in breathing (hypopnea) These periods normally last between 10 and 30 seconds, but can last longer �� males, overweight & elderly (SIDs) The person wakes up shortly and falls back asleep, usually not knowing there had been any interruption in sleep at all. These "apneic events" can occur as many as 20 or 30 times an hour. Sleep apnea (Muscle atonia) Sleep Disorders ��Insomnia ��Excessive Daytime
��Narcolepsy ��Sleep Apnea ��Nightmare/Night terror ��Sleepwalking ��Restless leg
Sleep disorders: Classification:
Dyssomnias:
Parasomnias:
Insomnia: Difficulty falling asleep or staying asleep.
Psychological causes of insomnia
Bipolar disorder:
Anxiety:
Physical Causes:
Sleep Apnea:
Sleep apnea occurs in 1% - 10% of population
Central Sleep Apnea:
Narcolepsy:
Other characteristics of Narcolepsy:
Narcolepsy is uncommon:
Other sleep disorders:
Nocturnal myoclonus:
Restless leg syndrome:
Primary hypersomnias:
Menstrual associated syndrome:
Sleep drunkenness:
REM sleep behavior disorder:
Treatment of Major Sleep Disorders:
Question: A Pt reports that he is sleepy all day despite having 8 hours of sleep each night. His wife reports that his loud snoring keeps her awake Of the following, the best Rx for this Pt is?
You can leave CFS and Neurostamia: Chronic Fatigue Syndrome: Also named: CEBV: chronic Epstein-barr syndrome Duncan syndrome: CFS resembles and mimics in the same way and may complain of weight lost and fatigue CFIDS: Chornic fatigue immune dysfunction syndrome: ME : myalgic encephalitis Yuppie flux :
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