Scales Flashcards by Michael Meehleib

MMSE (0-30)- Normal

25-30

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MMSE (0-30)- mild cognitive impairment/ early stage of alzheimer’s disease

21-24

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MMSE (0-30)- moderate/moderate alzheimers

10-20

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MMSE (0-30)- Late/severe alzheimer’s disease

0-9

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SLUM: 0-30 (Mental Status)
Normal

27-30

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SLUM: 0-30 (Mental Status)
Mild Dementia

21-26

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SLUM: 0-30 (Mental Status)
Dementia

0-20

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What depression scales are there?

HAM D
PHQ-9
Beck

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HAM-D (0-76)
Normal
*hint: HAM-Da Pig lives on 7543 E. Bacon ave.

0-7

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HAM-D (0-76)
Mild

8-13

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*HAM-D (0-76)
Moderate

14-18

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HAM-D (0-76)
Severe

19-22

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HAM-D (0-76)
Very severe

23-76

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PHQ-9 (0-27)
Normal
*Hint: might as well call it PHQ 4)

0-4

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PHQ-9 (0-27)
Mild

5-9

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PHQ-9 (0-27)
Moderate

10-14

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PHQ-9 (0-27)
Mod to severe

15-19

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PHQ-9 (0-27)
Severe

20-27

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Beck (0-63)
Normal
*Hint: Becka lives on 9910 23rd and southern

0-9

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Beck (0-63)
Mild

10-18

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*Beck (0-63)
Moderate

20-28

Beck (0-63)
Severe

30-63

What scales are used for anxiety?

HAM A
GAD

HAM A (0-56)
Mild
*Hint: AAA- Adolescent, Adult, and Anxiety

0-17

*HAM A (0-56) Moderate

18-24

HAM A (0-56) Severe

25 and above

GAD 7 (0-23) Normal

0-4

GAD 7 (0-23) Severe

15-23

GAD 7 (0-23) Mild

5-9

*GAD 7 (0-23) Moderate

10-14

COWS- (0-36) When to start treatment? Hint: normal- young kids don't do drugs but start when they are 7 yo.

No symptoms = 0-4 Start tx when 7 or higher

COWS- (0-36) Mild What to medication should you give? Hint: this medication can also be given at a certain age for impulsively and ADHD.

5-12 Clonidine

*COWS- (0-36) Moderate What meds to give?

13-24 Buprenorphine or Suboxone

COWS- (0-36) Mod to severe Hint: this is when adults will most likely do drugs.

25-35

COWS- (0-36) Severe

36 or higher

CIWA (0-21) When to start treatment?

0-9 no symptoms/minimal symptoms Start treatment higher than 8.

CIWA (0-21) Mild

10-15

*CIWA (0-21) Moderate

16-20

CIWA (0-21) Severe

21 or higher

CIWA- when you can start giving PRN meds

When the patient scores 8 or higher.

CIWA- when to give scheduled meds and PRNs?

15 and above

Main benzos for CIWA?

Diazepam (Valium) and Lorazepam (Ativan)

Diazepam =

Longer half life

Lorazepam =

Shorter half life. Give if liver is compromised

Where to refer patients on ETOH withdrawal to?

Refer to residential tx center

What to do when a pregnant patient is having withdrawals?

Refer to residential TX center *not report to CPS

Scale = Mild anxiety/ depression

Either do therapy or nothing

Scale = moderate anxiety/depression

Medications and/or therapy

Pulse Sweating RestlessNess Pupil size Body aches Running nose Gi upset Yawning Tremors Anxiety/irritability Gooseflesh skin

COWS Scale components

N/V Tremors Sweats Anxiety Agitation Tactile disturbance AH HA Orientation

Signs of CIWA components

What are three medications to treat ETOH Disorder?

1. Acamprosate 2. Dissulfiram 3. Naltrexone

Acamprosate is metabolized by liver: True or false

True