mental status assessment

care ABCT framework

appearance

behavior

cognition

thought processes

appearance

posture

• erect and position relaxed

body movements

• voluntary, deliberate, coordinated, and smooth/even

dress

• appropriate for setting, season, age, gender, and social group

grooming and hygiene

• congruence between grooming and age

pupils

• note pupil size and reaction to light

behavior

level of consciousness

facial expression

speech

mood and affect

level of consciousness

person is awake, alert, and fully aware of self and environment

responds appropriately and in timely manner to environmental stimuli

differentiates lethargy, obtundation, stupor, and coma

• lethargy - very tired; easily arousable but sleepy

• obtundation - can wake with open eyes but disinterested

• stupor - aroused with strong stimuli and open eyes, but cannot answer questions

facial expression

expression matches current situation and conversation topic

maintains comfortable, culturally appropriate eye contact

symmetrical facial movement without mask-like rigidity

speech

clear, effortless, and appropriate conversational flow

normal pacing, clear articulation, and accurate word choice

absence of dysarthria, pressure speech, or word-finding hesitation

mood and affect

mood

• stated by patient

• subjective

affect

• seen upon assessment

• objective

judged by body language, facial expression, and direct questioning

cognition

orientation

attention

memory

orientation

time: day, date, year, season

place: address, city, building, location

person: name, age, who examiner is

situation: in hospital or medical treatment

hosputalized patients may miss exact date but still be oriented

attention

ability to stay focused and complete a thought

often reduced in anxiety, fatigue, or intoxication

memory

recent memory

• ask about events from past 24 hours that you can verify

remote memory

• ask about verifiable past events

• loss of remote memory may occur in Alzheimer’s, dementia, or brain disease

new learning

• sensitive test of new memory

• give four unrelated words and ask for recall at 5, 10, and 30 minutes

thought

thought processes

• way person thinks should be logical, goal oriented, coherent, and relevant

• should complete thoughts

thought content

• what person says should be consistent and logical

perceptions

• person should be consistently aware of reality

• perceptions should be congruent with yours

mental health screening

screen for anxiety disorders

• GAD-2 - initial screen

  • generalized anxiety disorder scale

  • score ≥3 if positive

• GAD-7 identifies probably anxiety and severity

screen for depression disorders

• PHQ-2

  • patent health questionnaire

  • asks 2 questions about depressed mood and anhedonia

  • screening tool for PHQ-9

• PHQ-9

  • provides severity

  • 5-9: minimal depressive symptoms

  • 10-14: minor depressive symptoms

  • 15-19 major depression, moderate

  • ≥20: major depression, severe

screening for suicidal thoughts

• ask-suicide screening (ASQ)

  • if yes to any → positive screening

cognitive screening

mini-mental state exam (MMSE)

• 11 questions

• focuses on cognitive function

• used to detect dementia or delirium

• score 24-30 = normal

montreal cognitive assessment (MoCA)

• requires certification to administer

• total score 30

  • ≥26 normal

  • <26 mild cognitive impairment

• broader, more sensitive to mild impairment

denver 11 test → birth to six years

• screens for delays in behavior, language, cognition, and psychosocial development

behavioral checklist → 7-11 years

• parent-completed tool

• mood, play, school, family, and friends

aging adult

ABCT guidelines, same as other age groups

glasgow coma scale (GCS) to test level of consciousness in older adults

confusion is common and may be misdiagnosed

• check sensory status first

delirium is an acute condition

• appears suddenly

• often linked to illness or medication

• can have serious consequences

dementia is a chronic, progressive condition

• less common

• new learning is affect through loss of memory storage

  • normal aging slows new learning, but dementia is worse and unimproved even with cues