Transcript Cognitive symptoms - York University Psychology

The cognitive-functional needs of the
chronically homeless: Examination of
practice data to inform assessment and
rehabilitation.
Sylvain Roy, Ph.D. C.Psych.
Neuropsychologist, Inner City Family Health Team
Lead clinician, Psychosocial Rehabilitation Assessment
Service, Centre for Addiction and Mental Health (CAMH)
Only a small proportion of the homeless population has schizophrenia.
The lifetime prevalence of schizophrenia is only 6% among Toronto’s
homeless population (higher in the US).
Hwang 2001
My objectives for today
1. Provide you with a glimpse of what frontline clinical
neuropsychology looks likes (In a FHT) and discuss some of
the challenges we face.
2. Discuss the neuropsychology of homelessness
1. Going forward, present my vision on how health care can
do better by intergrading primary health care, community
rehabilitation, intense case management and homecare.
2. Secretly recruit you to come join us in the frontlines.
Frontline neuropsychology (ICFHT)
Who we are:
• Small FHT at Queen/Yonge – linked to Seaton House
Shelter for Men (who has own city staff)
Multidisciplinary team:
• 3 nurses, 1 nurse practitioner, 1 physician assistant,
Chiropodist, 3 admin assistants, 2 social workers, 1
health promoter
• Several ICHA Family doctors
• A neuropsychologist, psychiatrist, internists (all part
time consultants).
Frontline neuropsychology (ICFHT)
What we do:
Provide primary health care (e.g. family medecine)
to homeless men living or previously living at
Seaton House (e.g. Hostel, Annex [alcohol
program], or Long Term care floor).
What makes us unique:
• We serve people turned down by other agencies
• We are a multidisciplinary team (with some
leeway with mental health care delivery).
Frontline neuropsychology (ICFHT)
2012: Hiring of a neuropsychologist
– At the time I was already involved with the homeless at
Fred Victor & Community Head Injury Resource Services.
Told of:
– high prevalence of traumatic brain injury in the population
(above 50%) & neurological dysfunction (e.g. severe
mental illness, addictions, dementia, ABI).
– Homeless people with complex and co-occurring
medical/psychological disorders are included in the 1 to
5% of the population who account for 60-70% of health
care costs.
Frontline neuropsychology (ICFHT)
Challenges:
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Traditional neuropsychology does not work well (e.g. full day Ax).
Most patients can’t tolerate more then 2 hours of testing.
Instability and memory impairments result in missed appointments
Physicians don’t understand the role and scope of practice of
psychology and especially neuropsychology (that’s a little on us)
resulting in unusual referrals.
• 1 part time neuropsychologist in the FHT network dedicated to
homeless men. Unsure about CHC. Some other psychologist do some
work with homeless person (e.g. JVS Toronto, CAMH).
• Little time for education and research
• Little time for psychological interventions
What do we know about the
Neuropsychology of homelessness?
1) Not very much (yet)
2) Very heterogenous profile
Question:
Based on what you know about homelessness what
do you expect to see in terms of brain funtioning?
Does brain functioning affect community
participation, ADLs, indepedent functioning in the
homeless?
Or is more about social determinants of health (e.g.
lacking money, rent to high etc.)?
70%
What might drive poor
neuropsychological performances?
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Addictions?
Mental Illness (e.g. anxiety, depression, psychosis)?
Brain damage?
Dementia?
Poverty?
Psychological Trauma (e.g. PTSD)?
Developmental disorders?
Neglect and abuse in childhood?
Addictions: Alcohol
• Alcohol affects state of membranes and modifies a variety of ion channels
or receptors (no binding like cocaine).
• Up to 2 million alcoholics in the US develop permanent and debilitating
conditions that require lifetime custodial care (Rourke, Loberg, 1996).
• Abstinence will lead to some improvements in brain structure/function in
the first year. Depending on various factors, some cognitive impairments
may be permanent.
• Chronic alcohol use can can affect frontal lobe functions (executive skills)
(e.g. 15-23 % neuronal loss (Harper, 1998)), the cerebellum’s (Vermis)
white matter volume and Purkinje cells (motor function) and subcortical
structures e.g. hypothalamus (mammillary bodies) involved in memory.
Addictions: Alcohol
• Hepatic encephalopathy due to cirrhosis of the liver
– Chronic fluctuating neuropsychiatric symptoms due to Increase in
nitrogenous compounds & Decreases in synthesis of proteins
– Memory, psychomotor speed, executive skills (Catafau et al., 2000)
• Wernicke-Korsakoff’s syndrome:
– Pure amnestic state secondary to server thiamine (B1) depletion.
Poor executive, visual-spatial.
• Alcohol-related dementia:
– Mild minimally progressive dementia syndrome (controversial) which
often affects other cognitive systems.
Addictions: Crack / cocaine
• Approximately 2 million users of cocaine and 567,000 users of
crack in US (USDHHS, 2002).
• Heavy use of cocaine is associated with alterations of
neurotransmitter systems, abnormalities in cerebral blood flow
and cerebral glucose metabolism in the prefrontal cortex and
limbic system. These in turn provide the substrate of the
neurobehavioural effects (cognitive & psychiatric).
• Affects dopamine uptake, Blocks transports resulting in
accumulation of dopamine in synaptic cleft which May be
responsible for reinforcing effects of the drug. Also affects regions
involved in decision making, inhibition of inappropriate responses,
evaluation of saliency of reward
Addictions: Crack / cocaine
• Cerebral blood flow was reduced by up to 30% after cocaine use (Wallace et al.,
1994). Results in increased arterial pressure that persist even after 28 days
abstinence.
• Increases risk of Ischemic/haemorrhagic strokes. The prefrontal cortex appears
to be particularly vulnerable.
Addictions: Crack / cocaine
• Persistent changes with chronic use
– Lower grey matter density in insula, temporal cortex, frontal
lobes (Franklin et al., 2002; Matochik et al., 2003)
– Memory, attention, executive functions, concentration, motor
functions, abstraction
– Dose related and persist even after 6 months.
Schizophrenia & Homelessness
Schizophrenia is (up to) 10x more common in the
homeless population than normal population. Hwang
(2003) suggested that about 6-7% of the homeless had
schizophrenia.
Deficits may include: Cognitive speed, mental flexibility,
memory problems found. See: Stergiopoulos et al. (2011)
for link to function (homeless vs. housed with
schizophrenia)
Symptoms can precede psychosis (as early as age 14),
albeit milder in presentation (Valgimigli et al., 2013)
Acquired brain injury
Stephen Hwang et al (2008)
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904 men and women in shelters surveyed
53% were likely to have a TBI over lifetime
12% of cases having moderate or severe TBI.
70% of cases, TBI occurred prior to homelessness: causal pathway?
Measuring severity of TBI
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Science, vol 341 (2013)
• Field study that used quasi-experimental variation in actual wealth.
Indian sugarcane farmers receive income annually at harvest time.
• As a result, they experience cycles of poverty—Compare cognition in
same farmer when poor (pre) vs. richer (post-harvest). Randomly
selected 464 farmers (India). About 60% of income from sugarcane.
• Tasks:
• Numeric Stroop task, which is appropriate for participants with low
literacy rates. In a typical trial, participants would see “5 5 5” and
have to quickly respond “3,” which is the number of 5s in the
sequence, rather than “5” that comes to mind most naturally.
• The Raven’s test involves a sequence of shapes with one shape
missing. Participants must choose which of several alternatives
best fits in the missing space. Raven’s test is a common component
in IQ tests and is used to measure “fluid intelligence,”
Science, vol 341 (2013)
The effects observed correspond to estimated 13 IQ points variation.
Science, vol 341 (2013)
What happens when you have
co-occuring diagnoses?
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HIV
HEP-C
Diabetes
Hypertension
Traumatic Brain Injury
Stroke
PTSD
Poverty
Neglect/abuse in Childhood
Addictions
Anxiety and depression
Schizophrenia
Dementia
• Precise “neurological” condition (e.g.
stroke in hospital), important, but less
relevant in this sector.
• Can rule-in or rule-out major conditions
affect brain functioning, but evolving
multidisciplinary diagnoses the rule.
Patients often “moving targets”
• Testing current level of cognition, social
cognition, personality, psychopathology
important. E.g. access to services, medical
adherence etc.
• At the end of the day we need to treat
was is treatable. Re-Assess as needed
once housed, medically stabilized,
addictions in check etc.
Brain injury: Where does it fit in?
Mental health
CD
Substance use
• 30% of people with mental illness will have substance use disorder
• 37% of people diagnosed with alcohol disorder will have a mental health disorder
• 53% of people with a substance use disorder will also have a mental health disorder
CAMH link: fb.me/18oduXQv2
CASE STUDY
• I chose the following case because it is not
“neuropsychologically speaking” prototypical
of the homeless guys I see.
• The case is complex and constitute a sobering
reality that measures such as IQ & overall
cognitive skills does not always equate in
functional independence.
Social:
Development:
Him & sister abused by mom,
Dad MIA, Taken by children's
aid at 3. Labeled ADHDOppositional as child.
Bounced from home to home
Left system at age 16
Substance Abuse:
History of alcohol abuse
starting in his 20' s. At his
peak, he drank a "26 oz.
per day", which lasted a
"couple years". He now
drinks approximately 6 beers
per week. He occasionally
smokes marijuana and has
used cocaine on rare
occasions.
Was in relationship & has 5
kids and now grand kids. His
relationship with his kids are
strained and they do not
understand why he is
homeless.
CASE 1 – KM
Male, Right
handed, 50yrs
old, English
speaking, Grade
9 education,
WSIB
Neuro:
1st TBI: 16yrs. Hit in mouth
with 2X4 with LOC.
2nd: mid-20's, he was hit in
the head (left orbital/tempo)
w/ steal pipe.
3rd: 1990's in a fight with 5
men “injured pretty badly".
4th: 2012, hit over head with
fire extinguisher in his sleep.
1987: Fall from building
(spinal inj.)
CASE # 1
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Assaulted with a fire extinguisher at Seaton House while sleeping 2012
– Several bilateral hematomas/contusions, right-frontal drain PTA = 1w
– mTBI reported of file (brief LOC)? GCS=13, intoxicated during assault
– 1 month at St-Mikes, then TRI, (+1 month) then Regent Park
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At (TRI) ambulating independently, but had poor orientation, attention, memory, judgment
and insight. His sleep was also poor. MoCA 23/30 prob. abstract thinking and delayed recall.
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At Regent Park, headaches, fearful about falling asleep. Depressed and irritable. No
Hallucinations/mania. MSE: Calm, cooperative, good eye contact, mood depressed. His
thought content focused on childhood, and feelings of distress and frustration with his
current living and financial status. No active SI or HI. His insight and judgment seemed fair.
CASE # 1
Referral: Problems w/ memory, attention, depression, anxiety and PTSD.
Goals: Move out of the shelter system, maintain contact with his children, return to work.
Income: $700/m WSlB - not sufficient to pay for an apartment in the city of Toronto.
Physical symptoms: Frequent headaches, excessive fatigue, right arm weakness (due to
peripheral injury). Numbness feelings in the right side of his right hand due to nerve damage.
Partial blindness in the left eye. Can 't hear well in his right ear due to the assaults. He can't
smell anything (broken nose). His sense of taste is okay. History of “hearing” music and voices in
the past and was hospitalized for this in the 1990's in Whitby.
Cognitive symptoms: Poor planning and organization, spatial orientation, memory (faces, keys,
remote & what he should be doing). Attention reportedly okay, but tangential. Poor judgment
(don’t assess long term ramifications of behaviours, impulsive. Insight is fair.
Psychiatric symptoms; Severe anxiety associated with trauma. Trouble falling and staying asleep,
experience occasional nightmares about his abuse and assault, gets frustrated more easily, and
has less energy than before. Avoids looking at people, afraid of what "might happen”
CASE # 1
Behavioural observations:
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Pleasant and mild mannered.
Comfortable disclosing his complex history.
His speech was quick and pressured
Frequently interrupted the examiner, though he quickly apologized for the interruptions.
He appeared tired
Very tangential during the interview for which he required cuing and redirection.
Needed frequent smoke breaks, coffee after 35 minutes of testing (sustained attention?).
Gait and posture appeared normal.
Language comprehension and expression also appeared normal.
Appeared motivated to do well,
Rapport was sufficient for testing purposes.
CASE # 1
CASE # 1
Case 1: What went wrong?
• Cognition okay – so why is he homeless?
• Tools lack specificity?
• Should we have looked at something else?
Such as personality? Neurobehavioural
functioning? Executive functions?
• Thoughts?
Question: What roles can
psychologists play in addressing
homelessness?
Eliminating homelessness in Ontario
Moving forward
• Challenges:
– Creating assisted housing environments that are
designed for those with moderate to severe brain
injury, neurobehavioural problems, limited selfawareness, poor social support structures, addictions,
mental illness.
– Who would want to house someone who does not
care for themselves or who could burn the place
down? (e.g. a place like CHIRS in North York).
Moving forward
• Neuropsych screen to assess functional capacity & supports needed in housing
transition (1.5 hours long) For now: Mostly at Seaton House (Annex, LTC,
Hostel), possibly at Sistering
• Tests include:
o Interview, Beck Hopelessness scale, Brief Cognitive Exam Status (WMS-IV)
(abstraction of MoCA), CVLT-II (short form), D-KEFS trails, Practical Problem
Solving (KBNA), Math subtest (KBNA), Word reading(WRAT-IV), Emotion
recognition (ACS), Gait & speech video recorded.
• Benefits: Short, function driven, evaluates level of disability, informs
intervention and need for in-depth assessments.
• Outcome: Simple 1 page report, no lingo, with broad findings with implication
for community functioning and top three recommendations, MRPs get same
date feedback. Can support ODSP applications (and reviews), court diversion,
sufficient to get the person moving forward.
What You See
What You Do
Forgetfulness
Use memory aids, calendars, reminders, signs, easy lists kept in the same place.
Poor concentration,
distractedness
Keep it simple, remove distractions, plan brief activities,
use cues to bring attention back.
Impaired planning and
organization
Encourage routine/structure, break instructions down into
small components.
Slowed response & info.
processing
Allow extra time to process, limit choices, pause 5-7
seconds after a request, do not assume an immediate
response.
Poor initiative, appears to
lack motivation, difficulty
following through.
Structure, routine, limited choice and prompts to start.
What You See
What You Do
Inflexibility of thinking,
difficulty seeing more than
one view.
Write summary of what discussed and give client a carbon
copy.
Impulsivity
Repeat → Stop, Think, Plan.
Encourage awareness of social rules.
Emotional lability –
inappropriate, out of
context.
Identify and avoid triggers. Watch for overstimulation,
stress, fatigue. Shorten episode.
Egocentricity, impatient,
demanding
Set clear limits of what can be done. Give clear feedback
about other’s feelings. Do not take personally.
Irrationality or temper
control.
Employ risk management measures. Remain calm. “Lower
your voice or I will leave.”
Moving forward
• Challenges:
– Assessing chronically homeless across province
– I’m the only neuropsychologist working directly with
the homelessness (to the best of my knowledge)
– OTs in the sector are rare
– Family docs, nurses, and social workers are not
interested in AX and have little time.
– Limited budget to hire postdocs & interns
How can you be aware you’re not aware, when
you’re not aware you’re not aware? (Dr. Proulx)
Applies to patients, clinicians and policy makers!
Is it denial or Anosognosia (A lack of knowledge or unawareness of cognitive impairment)?