Assessment Mental Status

mental status dysfunction

a pattern that is associated with distress or disability (increases risk for pain, loss of autonomy)

causes of mental status

mental illness: anxiety, depression, schizophrenia
organic: brain disease of organic structural problem (stroke, seizure, tumor)

cerebrum

primarily responsible for mental status
cerebral cortex houses the areas that control higher mental function
controls perception and behavior

frontal lobe

contains motor cortex
contains broca’s area (speech formation)
contains area related to emotions, affect, drive, and self awareness
allows for goal oriented behaviors
regulates ability to concentrate
forms short term memory
bipolar, schizophrenia, attention deficit / hyperactivity, MDD, OCD, PTSD, AD

parietal lobe

processes sensory data as it is received
ADHD, OCD, schizophrenia

temporal lobe

responsible for perception and interpretation of sound (schizophrenia)
contains wernicke’s speech area (comprehension of spoken and written language)
involved with integration of behavior, emotion, and personality
associated with long term memory
alzheimer disease, schizophrenia, major depressive disorder, PTSD

limbic system

mediates behavior that determines survival
associated with affection, fear, and aggression
regulates reaction to emotions
schizophrenia, MDD, bipolar, anxiety, PTSD

infants and children mental status evolution

brain cells present at brith take few years to fully develop and myelinize
trauma, infection, and chemical imbalance can cause mental status changes
environment can promote or impair intellectual development

adolescents mental status evolution

intellectual maturation continues
abstract thinking is developing
judgment begins to develop

older adults mental status evolution

overall general intelligence preserved
problem solving skills may decline
slower recall of new data and problems with non verbal memory
remote memory may be more efficient than recent memory
decline in synthesis and metabolism of neurotransmitters
higher incidence of delirium due to acute distress

apperance

actual age and apparent age
attire
grooming and hygiene
physical abnormalities
nutritional status

speech

quantity of speech
rate of speech: slow: common in patients with depression. fast: known as pressured
volume of speech
aphonia loss of voice
accents (being mindful of cultural differences)

echolalia

repetition of words or phrases said by others (may be observed in individuals with mania, schizophrenia, or autism spectrum disorder)

blocking

sudden unanticipated interruption of speech - often resume with new thought (many be observed in individuals with schizophrenia)

perservation

persistent repetition of words, topics, and ideas (mania or schizophrenia)

attriculation

the way words are spoken

articulate

words spoken clearly and distinctly

dysarthria

typically, slurred or slow speech that is hard to understand
can occur secondary to neurological condition (stroke, brain injury, brain tumor) or muscle weakness (diseases that cause facial, throat muscle, or tongue paralysis)

aphasia

disorder of producing or understanding language
usually because of a lesion within the dominant cerebral hemisphere that contorls speech
omission or addition of letters, syllables, or words
misuse of words, transposition of words

aphasia wernicke

reading comprehension is impaired
hears words, but unable to decipher the content
speech is fluent but lacks meaning

aphasia broca

reading comprehension is fine
understands words / questions, but difficulty expressing self with language
speaks few words with much effort
mainly use nouns in speech

testing for aphasia - word comprehension

ask patient to follow one step command: point to your nose, take this pen, write your name

testing for aphasia - repetition

ask patient to repeat a phrase of one syllable words (no ifs ands or buts)

testing for aphasia - naming

ask patient to name parts of a common object (ex: leg of table)
examiner points to different common objects and asks patients to name them

testing for aphasia - reading comprehension

examiner asks patient to read a paragraph aloud then summarize its meaning

testing for aphasia - writing

tell a patient a specific word and ask them to write a sentence using a word and then read it aloud

affect

your observation
observable emotional expression
assessed through facial expression, tone of voice, behavior, and emotional range
may be congruent or incongruent with mood

mood

patient’s report / what they tell you
internal emotional experience
assessed by asking the patient
may be described as sad, anxious, happy, angry, content

constricted affect

moderate reduction in intensity of tone

blunted affect

severe reduction in intensity

flat affect

absence of affect

inappropriate affect

affect that appears inconsistent with the conversation topic or reported emotional experience

labile affect

rapid, abrupt and unexpected changes in affect that are not related to external stimuli

incongruent affect

patient’s affect does not match his / her description of thier mood

alertness (level of consciousness)

person’s state of awareness of his / her environment and relationship with the environment

lethargy

patient arouses to loud voice, answers questions but may fall back to sleep

obtundation

patient awakens to gentle shaking, but remains somewhat confused

stupor

patient awakens only to painful stimuli (sternal rub), but response is slow or absent; once stimulus is removed, lapses back into an unresponsive state

comatose

profound state of unconsciousness regardless of any stimuli

attention / concentration tests

serial 7s: instruct patient “start from a hundred, subtract 7 and keep subtracting 7”
ask the patient to say WORLD and spell it, then spell it backwards

calcuation tests

simple math problems

remote memory

inquire about birthdays, jobs held, culturally appropriate past historical events (only ask information you can verify and is reasonably expected for that individual)
who was the first president of the USA?
what do we celebrate on the 4th of july?

recent memory

inquire about events of a patient’s day (that you can verify - family members can help)

immediate recall or new learning ability

give 3-4 words and ask patient to repeat them right away and then after 3-5 minutes ask patient to repeat the words again (red, table, 69, broadway)

abstract thinking

have patient interpret a common proverb: what does the phrase: don’t cry over spilled milk” mean to you
similarities and differences: provide patient with 2 related objects and ask what is similar / different: describe what is the same and different about an apple and orange

constructural ability

ask patient to draw intersecting pentagon
ask patient to draw the face of a clock that reads a given time ex: 2 o clock

loose associations - thought process

ideas shift from one subject to another in a loose way; a vague connection can be made between concepts, but speaker does not return to the central or original thought (schizophrenia)

flight of ideas - thought process

multiple thoughts and ideas generated spontaneously and rapidly; continuous verbalizations with constant shifting and without clear connections between ideas (may be observed in individuals during manic episodes)

illusion

misinterpretation or misperception of real stimuli
psychosis, PTSD, or schizophrenia

hallucinations

auditory, visual, olfactory, gustatory, or tactile
a sensory perception experienced in the absence of an external stimulus
psychosis, PTSD, schizophrenia

thought process

observe throughout interview
assess patient’s patterns of thinking
is it logical, realistic, goal oriented

thought perception

evaluate for perceptual distortions
determine if patients perceives sensations that are not caused by external stimuli

thought content

evaluated by assessing what the patient says
should be consistent and logical
ask patient about obsessive thoughts, fears, guilt
ask patient about performing ritualistic behaviors
ask patient about reoccurring intrusive thoughts
this is where we assess for suicidal and homicidal thoughts

obsessions

recurrent uncontrollable thoughts

compulsions

repetitive behaviors that are used to prevent a state that would make a patient feel uncomfortable
the actual action

phobias

persistent irrational fears

anxieties

apprehensions, uneasiness, impending doom

delusions

fixed, false beliefs that are not shared by others within the individual’s cultural, social, or religious context
they persist despite contradictory evidence

grandeur / grandiosity

type of delusion
one believes that they possess superior qualities such as genius, fame, omnipotence, or wealth

paranoid

type of delusion
affected individual believes that they are being harmed or persecuted by another individual / group of individuals

feelings of unreality

sense that things in the environment are strange or unreal

feelings of deperosnalization

a feeling that you are observing yourself from outside your body or from a dream like state

insight

what brings you into the hospital
what do you think is wrong
consider factors that may influence insight, including delirium, dementia, mental health conditions, neurological disorders, or limited health literacy

judgement

note patient’s responses to family, job situations and interpersonal relationship conflicts
if you found an addressed letter in the street, what would you do
not the best way to assess judgement

impulsivity

tendency to act without considering potential consequences
aggressive / violent behaviors, financial risks

reliability

the quality and consistency of the information obtained during the encounter
is the patient’s history internally consistent
is the information consistent with available records or collateral sources when appropriate
are there factors that may affect patient’s ability to provide a complete history
an inconsistent history should prompt further assessment rather than assumptions or judgement

cognitive screening assessment

orientation: time, date, where you are
registration: repeating a short list of words right after hearing them
attention and calculation: doing simple math or spelling words backwards
recall: remembering those same words a few minutes later
language: naming objects, repeating phrases, and following verbal or written commands
visuospatial skills: copying a drawing of intersecting shapes

serotonin location and regulatory function

location: brainstem: raphe nuclei
function: helps regulate mood, arousal, and cognition

norepinephrine location and regulatory function

location: brainstem: locus coeruleus
function: regulates mood, arousal, attention, and cognition

Dopamine location and regulatory function

location: brainstem: substantia nigra
function: regulates mood, arousal, cognition, and motor control

acetylcholine location and regulatory function

location: basal forebrain: basal nucleus of Meynert
function: regulate sleep, arousal, and attention

panic disorder

recurrent sudden episodes / spells / attacks of intense fear or discomfort that are unexpected or with intervening periods of living in fear or worrying of having another attack or facing the consequences of the attack

circumlocutions

phrases or sentences are substituted for a word the patient cannot think of, such as “what you write with” instead of “pen”

paraphasias

words are malformed (“I write with a den”), incorrect (“I write with a bar”) or invented (“I write with a dar”)

circumstantiality

speech with unnecessary detail, indirection, and delay in reaching the point
obsessions

clanging

speech with choice of words based on sound rather than meaning, as in rhyming and punning
ex: Look at my eyes and nose, wise eyes and rosy nose. two to one, the ayes have it
schizophrenia and manic episodes

Confabulation

fabrication of facts or events in response to questions, to fill in the gaps from impaired memory
korsakoff syndrome from alcoholism

derailment

tangential speech with shifting topics that are loosely connected or unrelated, patient is unaware of the lack of association
schizophrenia, manic episodes, psychotic disorders

neologisms

invented or distorted words, or words with new and highly idiosyncratic meanings
schizophrenia, psychotic disorders, aphasia

depersonalization

sense that one’s self or identify is different, changed, unreal; lost; or detached from one’s mind or body

derealization

sense that the environment is strange, unreal, or remote

digit span

recite a series of digits, starting with 2 at a time and ask patient to repeat back to you
increase to 3 at a time then 4
if makes a mistake try again, stop after a second failure

age related cognitive decline

mild forgetfulness, difficulty remembering names and mildly reduced concentration
don’t affect daily function

mild cognitive impairment (MCI)

daily function is perserved, but there is evidence of modest cognitive decline in one or more cognitive domains (complex attnetion, exeucutive function, learning and memory, language, perceptual motor, or social cognition) based on objected tasks, as reported

Alzheimer Disease

clear evidence of a decline in memory and learning and at least one other cognitive domain, steady progressive decline in cognition without extended plateaus, no evidence of mixed etiology from other neurodegenerative, cerebrovascular, mental, or systemic disease

vascular dementia

vascular risk factors or cerebrovascular disease associated with cognitive impairment. stepwise decline, especially in executive function, should correlate with the onset of cerebrovascular event, but consider this dementia even if just risk factors are present. may also be gait changes and focal findings

lewy body

evidence of parkinsonism. visual hallucinations, delusions, gait disorder.
fluctuating mental status, sensitivity to antipsychotic medications

frontotemporal dementia

prominent behavior or language disorders at times with personality changes including impulsivity, aggression, and apathy. excessive eating / drinking. relative preservation of memory and visual - spatial skills.

cingulate cortex

mangages attention, emotion, memory
ADHD, OCD, GAD (anxiety), MDD, schizophrenia