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Cognitive impairment associated with acute or chronic disease
Brief Reports This section will carry communications of work in progress, preliminary research reports, or interesting and unusual vignettes. Such reports will be considered for their practical clinical relevance or heuristic value.
Cognitive Impairment Associated with Acute or Chronic Disease Louis A. Gottschalk, Professorand Co-Scientific
M.D.
Director, National Alcoholism
Research Center, Department
of Psychiatry
and Human
College of Medicine, University of California, Irvine, California Consultation and Liaison Service, Psychiatry Department, University of Cakfornia, Irvine Aliedical Center, Orange, California Behavior,
Abstract: Cognitive impairment in connection with acute or chronic disease may complicate the diagnosis, management, and treatment of general hospital inpatients. Consulting psychiatrists may be called upon to evaluate cognitive and intellectual impairment associated with organic brain syndromes versus psychiatric disorders due to other causes. To assist the psychiatrist informulatinga differential diagnosis, thestandard mental status examination and various objective neuropsychologic tests can be used. In addition, the author suggests a method of cognitive measurement using content and form analysis of five-minute speech samples, lmpaired cognitivefunction may be caused or exacerbated by conditions such as alcohol abuse or psychoactive drug abuse which may not be revealed by the patient during the histoy taking. This report calls attention to the high frequency of cognitive impairment found associated with acute or chronic disease, and alerts psychiatrists that this impairment may confound or obscure the diagnosis or management of these acute or chronic diseases. Presented at the Annual Meeting of the American Psychiatric Association, Chicago, Illinois, May 2979. Supported, in part, by AAAO5024 and NIA-76-32(P) from the National Institute on Alcohol Abuse and Alcoholism.
344 ISSN 0163~8343/79/040344-03%02.25
A psychiatrist actively engaged on a psychiatric consultation and liaison service in a general hospital is likely to be involved in the differential diagnosis of various degrees of cognitive and intellectual impairment associated with organic brain syndromes versus psychiatric disorders due to other causes. For these diagnostic evaluative efforts the Law of Parsimony (that is, the simplest explanation of the factors leading to the pathological processes being observed) will often not be sufficient to explain the phenomena observed. Instead of a psychiatric disorder caused by either organic cerebral malfunction or a mental condition not caused by brain impairment, both an organic or functional disorder may account for the psychiatric problems. The mental problems may have a psychosomatic or somatopsychic pathogenesis, or may not involve either of these routes of pathogenesis. The clinical psychiatrist customarily uses the mental status examination to assist in making these differential diagnoses. Simple but useful rule-ofthumb tests are employed as a basis for making diagnostic opinions. For example, the patient may be requested to recite serial subtraction of sevens General Hospital Psychiatry @ Elsevier North Holland, Inc., 1979
Cognitive
from 100, digit span forwards and backwards, simple mathematical calculations, or the short-term remembrance of three objects. He may also be asked to copy simple designs, such as a cross. The psychiatrist may ask the patient to name recent presidents of the United States. The patient may be asked to give the meaning of various proverbs to test abstract and concrete thinking. When in doubt about the degree of contribution of organic cerebral factors, the psychiatrist may request the administration of various objective neuropsychologic tests such as the Halstead-Reitan neuropsychologic test battery. The author has been involved in the development of a neuropsychologic test, the data for which are.quickly and easily obtained. Although the data analysis of this neuropsychologic test is relatively slow at this stage of its development, the test results are quite objective and valid. This method uses the content and form analysis of five-minute samples of speech that have been tape recorded. The frequency of use of certain categories of verbal behavior are scored according to methods that have been developed over the past six years. This cognitive measurement procedure has been well validated by previous studies, and it is being validated by more extensive studies in the present (l-5). At least 50% of patients seen on the medical and surgical services of the University of California, Irvine Medical Center, have some degree of cognitive impairment associated with the acute or chronic disease. This points to the necessity for consulting psychiatrists to be familiar with the various methods used to assess cognitive functioning.
Alcohol Abuse as it Contributes to the Complexity of Problems Seen on a Psychiatric Consultation Service Psychiatric consultation is often requested for patients on the medical or surgical services when peculiar behavior has led to development of a medical condition that resulted in hospitalization. Although the patient may not volunteer the information, a careful history can indicate a recent, if not chronic, excessive use of alcohol. The psychiatrist may discover a chain of events in which the patient’s personal difficulties led to abuse of alcohol; impairment of cognitive functioning developed from excessive intake of alcohol; and both the alcohol abuse and the cognitive impairment caused or aggravated the medical condition that necessitated hospitalization.
lmpairment
and Illness
Case 1 A 33-year-old vocational nurse was hospitalized for arteritis of a radial artery and a localized hematoma. The patient explained that she had been suffering from a severe migraine headache that aspirin did not allay. She injected 10 cc of Paregoric not into a vein but into an artery, “so it would have a rapid effect.” Especially because the patient was a currently practicing nurse, this foolish action was difficult to understand; and some cognitive impairment was suspected. A clinical mental status examination suggested this was true, on the basis of very poor serial subtraction of sevens from 100. Cognitive impairment scores derived from a five-minute speech sample definitely corroborated this suspicion. Although the patient had previously denied excessive alcohol use to the medical staff, she acknowledged during the psychiatric consultation that she had been drinking a pint of whiskey daily for four to five weeks because she and her ex-husband had been involved in serious arguments. Further history revealed that she periodically drank exessively, sometimes as much as a quart or a quart and-a-half of whiskey when things were going poorly in her social or domestic life. Although the patient was reasonably cooperative in the treatment of her severe arteritis, she continually requested analgesic medication. Her emotional, domestic, and alcohol problems and the associated cognitive impairment were necessary data to care for her properly during and following the period of hospitalization.
Anticholinergic Psychoactive Drug Effects on Cognitive Function Nonpsychiatrists as well as psychiatrists are liberally administering antidepressant medication to their medical patients who complain of feelings of depression. Quite often these medications, in the form of the tricyclic amines or other antidepressant drugs, are administered with a variety of other drugs, including antiinflammatory drugs, antihypertensive agents, antacids, corticosteroids, and so forth. Psychiatric consultants on the medical and surgical services see patients of this type: They may have stopped following their prescribed medical regimen; some may appear to have been unresponsive to the antidepressant medication; or they may appear to have worsened emotionally. In many instances the problem is found to be an acute or chronic brain syndrome, that is, some degree of cognitive impairment associated with the adverse anticholinergic effects of the antidepressant medication. Either the patient’s depression did not respond to the tricyclics, or the drug dose was too high, or the other medication that the patient was 345
L. A.
Gottschalk
receiving increased or contributed to the anticholinergic intoxication of the patient, The differential diagnosis between a depressive reaction and primary or secondary cognitive impairment is not easy to determine, but can often be made by a standard mental status examination or, if necessary, by using more objective neuropsychologic testing. The distinction can be made relatively easily by the five-minute verbal sample procedure being developed by Gottschalk and coworkers, except in cases of very depressed patients who will not talk at all. The blood levels of tricyclic amines are considered helpful, in some circumstances, to determine whether or not the patient has sufficient antidepressant medication, for example, between 200 and 300 mg of imipramine. But this procedure is not foolproof for a number of reasons, including the fact that the patient might not be a favorable drug responder to this medication; or, other medication taken by the patient may have an adverse interaction effect on drug absorption, metabolism, or excretion. Each case must be carefully studied, analyzed, and, in particular, examined for evidence of cognitive impairment before any clear diagnosis or management becomes evident.
Case 2 A %-year-old woman on the Physical Medicine and Rehabilitation Service, who had fractured her leg, was bedridden and uncooperative in making efforts to learn to walk again under the regimens recommended by the physical therapist. The patient’s family said she had had a schizophrenic episode in her 40s. The psychiatrist had prescribed a tricyclic amine, assuming the patient was uncooperative and remaining in bed because she was depressed. On the mental status examination the patient was confused and her sensorium was clouded. When asked why she was not cooperative in participating in graded exercises to help her regain her walking skills, she replied simply, “I cannot.” The psychiatric consultant discontinued the tricyclic amine (namely, Amitryptyline) and, after a week’s washout, recommended low doses of a major tranquilizer if her state of confusion and impaired sensorium cleared.
and treatment of acute or chronic medical disease. Obtaining a history of such drug abuse or alcoholism is of course useful, if not essential. Refreshing the psychiatrist’s acquaintance with and use of that portion of the mental status examination diagnostic of organic brain dysfunction is important to the detection of these conditions. A cognitive impairment scale applicable to five-minute speech samples obtained in response to standardized instructions can now be used to provide cognitive impairment scores, and cut-off scores are indicative to brain function impairment. Furthermore, scores can be derived from these five-minute speech samples that give very close approximations to most of the subtests of the Halstead-Reitan neuropsychologic test battery. Unfortunately, scoring these speech samples with satisfactory reliability requires a fair amount of training. Computer analysis of the typescripts of these speech samples for cognitive impairment scores is being developed and should be available in one or two years.
References 1. Gottschalk LA, Kunkel RL: Changes in emotional and intellectual functioning after total body radiation. In Saenger EL, Friedman BJ, Keriakis JG, Perry H (eds). Metabolic Changes in Humans Following Total Body Radiation. Cincinnati, Ohio, University of Cincinnati, College of Medicine, Cincinnati General Hospital, 1966 of 2. Gottschalk LA, Gleser GC: The Measurement Psychological States Through the Content Analysis of Verbal Behavior. Berkeley and Los Angeles, University of California Press, 1969 3. Gottschalk LA: Cognitive defect in the schizophrenic syndrome as assessed by speech patterns. In Serban G (ed). Cognitive Defects in the Development of Mental Illness. New York, BrunnerlMazel, Inc., 1978 4. Gottschalk LA, Eckardt M, Feldman D: Further validation studies of a cognitive-intellectual impairment scale applicable to verbal samples. In Gottschalk, Louis A (ed). The Content Analysis of Verbal Behavior: Further Studies. New York, Spectrum Publication, Inc., 1979 5. Gottschalk LA, Cohn JB: Studies of cognitive function as influenced by administration of Haloperidol or Diazepam in detoxification of acute alcoholics. Methods Findings Experi Clin Pharmacol (Barcelona) 1:51-61, 1979
Discussion and Summary Alcohol
abuse may not
and/or psychoactive drug abuse, which be volunteered by the patient during history taking by the physician, may lead to the impairment of cognitive and intellectual function and hence complicate the diagnosis, management,
346
Direct reprint requests to: Louis A. Gottschalk, M.D. Department of Psychiatry and Human Behavior University of California College of Medicine Irvine, CA 92717
Cognitive Impairment Associated with Acute or Chronic Disease Louis A. Gottschalk, Professorand Co-Scientific
M.D.
Director, National Alcoholism
Research Center, Department
of Psychiatry
and Human
College of Medicine, University of California, Irvine, California Consultation and Liaison Service, Psychiatry Department, University of Cakfornia, Irvine Aliedical Center, Orange, California Behavior,
Abstract: Cognitive impairment in connection with acute or chronic disease may complicate the diagnosis, management, and treatment of general hospital inpatients. Consulting psychiatrists may be called upon to evaluate cognitive and intellectual impairment associated with organic brain syndromes versus psychiatric disorders due to other causes. To assist the psychiatrist informulatinga differential diagnosis, thestandard mental status examination and various objective neuropsychologic tests can be used. In addition, the author suggests a method of cognitive measurement using content and form analysis of five-minute speech samples, lmpaired cognitivefunction may be caused or exacerbated by conditions such as alcohol abuse or psychoactive drug abuse which may not be revealed by the patient during the histoy taking. This report calls attention to the high frequency of cognitive impairment found associated with acute or chronic disease, and alerts psychiatrists that this impairment may confound or obscure the diagnosis or management of these acute or chronic diseases. Presented at the Annual Meeting of the American Psychiatric Association, Chicago, Illinois, May 2979. Supported, in part, by AAAO5024 and NIA-76-32(P) from the National Institute on Alcohol Abuse and Alcoholism.
344 ISSN 0163~8343/79/040344-03%02.25
A psychiatrist actively engaged on a psychiatric consultation and liaison service in a general hospital is likely to be involved in the differential diagnosis of various degrees of cognitive and intellectual impairment associated with organic brain syndromes versus psychiatric disorders due to other causes. For these diagnostic evaluative efforts the Law of Parsimony (that is, the simplest explanation of the factors leading to the pathological processes being observed) will often not be sufficient to explain the phenomena observed. Instead of a psychiatric disorder caused by either organic cerebral malfunction or a mental condition not caused by brain impairment, both an organic or functional disorder may account for the psychiatric problems. The mental problems may have a psychosomatic or somatopsychic pathogenesis, or may not involve either of these routes of pathogenesis. The clinical psychiatrist customarily uses the mental status examination to assist in making these differential diagnoses. Simple but useful rule-ofthumb tests are employed as a basis for making diagnostic opinions. For example, the patient may be requested to recite serial subtraction of sevens General Hospital Psychiatry @ Elsevier North Holland, Inc., 1979
Cognitive
from 100, digit span forwards and backwards, simple mathematical calculations, or the short-term remembrance of three objects. He may also be asked to copy simple designs, such as a cross. The psychiatrist may ask the patient to name recent presidents of the United States. The patient may be asked to give the meaning of various proverbs to test abstract and concrete thinking. When in doubt about the degree of contribution of organic cerebral factors, the psychiatrist may request the administration of various objective neuropsychologic tests such as the Halstead-Reitan neuropsychologic test battery. The author has been involved in the development of a neuropsychologic test, the data for which are.quickly and easily obtained. Although the data analysis of this neuropsychologic test is relatively slow at this stage of its development, the test results are quite objective and valid. This method uses the content and form analysis of five-minute samples of speech that have been tape recorded. The frequency of use of certain categories of verbal behavior are scored according to methods that have been developed over the past six years. This cognitive measurement procedure has been well validated by previous studies, and it is being validated by more extensive studies in the present (l-5). At least 50% of patients seen on the medical and surgical services of the University of California, Irvine Medical Center, have some degree of cognitive impairment associated with the acute or chronic disease. This points to the necessity for consulting psychiatrists to be familiar with the various methods used to assess cognitive functioning.
Alcohol Abuse as it Contributes to the Complexity of Problems Seen on a Psychiatric Consultation Service Psychiatric consultation is often requested for patients on the medical or surgical services when peculiar behavior has led to development of a medical condition that resulted in hospitalization. Although the patient may not volunteer the information, a careful history can indicate a recent, if not chronic, excessive use of alcohol. The psychiatrist may discover a chain of events in which the patient’s personal difficulties led to abuse of alcohol; impairment of cognitive functioning developed from excessive intake of alcohol; and both the alcohol abuse and the cognitive impairment caused or aggravated the medical condition that necessitated hospitalization.
lmpairment
and Illness
Case 1 A 33-year-old vocational nurse was hospitalized for arteritis of a radial artery and a localized hematoma. The patient explained that she had been suffering from a severe migraine headache that aspirin did not allay. She injected 10 cc of Paregoric not into a vein but into an artery, “so it would have a rapid effect.” Especially because the patient was a currently practicing nurse, this foolish action was difficult to understand; and some cognitive impairment was suspected. A clinical mental status examination suggested this was true, on the basis of very poor serial subtraction of sevens from 100. Cognitive impairment scores derived from a five-minute speech sample definitely corroborated this suspicion. Although the patient had previously denied excessive alcohol use to the medical staff, she acknowledged during the psychiatric consultation that she had been drinking a pint of whiskey daily for four to five weeks because she and her ex-husband had been involved in serious arguments. Further history revealed that she periodically drank exessively, sometimes as much as a quart or a quart and-a-half of whiskey when things were going poorly in her social or domestic life. Although the patient was reasonably cooperative in the treatment of her severe arteritis, she continually requested analgesic medication. Her emotional, domestic, and alcohol problems and the associated cognitive impairment were necessary data to care for her properly during and following the period of hospitalization.
Anticholinergic Psychoactive Drug Effects on Cognitive Function Nonpsychiatrists as well as psychiatrists are liberally administering antidepressant medication to their medical patients who complain of feelings of depression. Quite often these medications, in the form of the tricyclic amines or other antidepressant drugs, are administered with a variety of other drugs, including antiinflammatory drugs, antihypertensive agents, antacids, corticosteroids, and so forth. Psychiatric consultants on the medical and surgical services see patients of this type: They may have stopped following their prescribed medical regimen; some may appear to have been unresponsive to the antidepressant medication; or they may appear to have worsened emotionally. In many instances the problem is found to be an acute or chronic brain syndrome, that is, some degree of cognitive impairment associated with the adverse anticholinergic effects of the antidepressant medication. Either the patient’s depression did not respond to the tricyclics, or the drug dose was too high, or the other medication that the patient was 345
L. A.
Gottschalk
receiving increased or contributed to the anticholinergic intoxication of the patient, The differential diagnosis between a depressive reaction and primary or secondary cognitive impairment is not easy to determine, but can often be made by a standard mental status examination or, if necessary, by using more objective neuropsychologic testing. The distinction can be made relatively easily by the five-minute verbal sample procedure being developed by Gottschalk and coworkers, except in cases of very depressed patients who will not talk at all. The blood levels of tricyclic amines are considered helpful, in some circumstances, to determine whether or not the patient has sufficient antidepressant medication, for example, between 200 and 300 mg of imipramine. But this procedure is not foolproof for a number of reasons, including the fact that the patient might not be a favorable drug responder to this medication; or, other medication taken by the patient may have an adverse interaction effect on drug absorption, metabolism, or excretion. Each case must be carefully studied, analyzed, and, in particular, examined for evidence of cognitive impairment before any clear diagnosis or management becomes evident.
Case 2 A %-year-old woman on the Physical Medicine and Rehabilitation Service, who had fractured her leg, was bedridden and uncooperative in making efforts to learn to walk again under the regimens recommended by the physical therapist. The patient’s family said she had had a schizophrenic episode in her 40s. The psychiatrist had prescribed a tricyclic amine, assuming the patient was uncooperative and remaining in bed because she was depressed. On the mental status examination the patient was confused and her sensorium was clouded. When asked why she was not cooperative in participating in graded exercises to help her regain her walking skills, she replied simply, “I cannot.” The psychiatric consultant discontinued the tricyclic amine (namely, Amitryptyline) and, after a week’s washout, recommended low doses of a major tranquilizer if her state of confusion and impaired sensorium cleared.
and treatment of acute or chronic medical disease. Obtaining a history of such drug abuse or alcoholism is of course useful, if not essential. Refreshing the psychiatrist’s acquaintance with and use of that portion of the mental status examination diagnostic of organic brain dysfunction is important to the detection of these conditions. A cognitive impairment scale applicable to five-minute speech samples obtained in response to standardized instructions can now be used to provide cognitive impairment scores, and cut-off scores are indicative to brain function impairment. Furthermore, scores can be derived from these five-minute speech samples that give very close approximations to most of the subtests of the Halstead-Reitan neuropsychologic test battery. Unfortunately, scoring these speech samples with satisfactory reliability requires a fair amount of training. Computer analysis of the typescripts of these speech samples for cognitive impairment scores is being developed and should be available in one or two years.
References 1. Gottschalk LA, Kunkel RL: Changes in emotional and intellectual functioning after total body radiation. In Saenger EL, Friedman BJ, Keriakis JG, Perry H (eds). Metabolic Changes in Humans Following Total Body Radiation. Cincinnati, Ohio, University of Cincinnati, College of Medicine, Cincinnati General Hospital, 1966 of 2. Gottschalk LA, Gleser GC: The Measurement Psychological States Through the Content Analysis of Verbal Behavior. Berkeley and Los Angeles, University of California Press, 1969 3. Gottschalk LA: Cognitive defect in the schizophrenic syndrome as assessed by speech patterns. In Serban G (ed). Cognitive Defects in the Development of Mental Illness. New York, BrunnerlMazel, Inc., 1978 4. Gottschalk LA, Eckardt M, Feldman D: Further validation studies of a cognitive-intellectual impairment scale applicable to verbal samples. In Gottschalk, Louis A (ed). The Content Analysis of Verbal Behavior: Further Studies. New York, Spectrum Publication, Inc., 1979 5. Gottschalk LA, Cohn JB: Studies of cognitive function as influenced by administration of Haloperidol or Diazepam in detoxification of acute alcoholics. Methods Findings Experi Clin Pharmacol (Barcelona) 1:51-61, 1979
Discussion and Summary Alcohol
abuse may not
and/or psychoactive drug abuse, which be volunteered by the patient during history taking by the physician, may lead to the impairment of cognitive and intellectual function and hence complicate the diagnosis, management,
346
Direct reprint requests to: Louis A. Gottschalk, M.D. Department of Psychiatry and Human Behavior University of California College of Medicine Irvine, CA 92717