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Mental status

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A person's emotional (feeling) and cognitive (knowing) function

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Optimal mental status functioning

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- simultaneous life satisfaction in work, caring relationships, and within the self.

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Mental disorder

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- Apparent when a person's response is much greater than the expected reaction to a traumatic life event. - A significant behavioral or psychological pattern that is associated with distress (a painful symptom) or disability (impaired functioning) and has a significant risk of pain, disability, or death or loss of freedom.

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Two types of mental disorders

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1. Organic mental disorder 2. Psychiatric mental illness

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Organic mental disorder

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- Due to brain disease of known specific organic cause, such as delerium, dementia, alcohol and drug intoxication and withdrawal, physical insult)

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Psychiatric mental illnesss

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Where an organic etiology has not yet been established, such as anxiety, schizophrenia

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Mental status is inferred through what?

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Mental status is inferred through individual's behaviors o Consciousness o Language o Mood and affect o Orientation o Attention o Memory o Abstract reasoning o Thought process o Thought content o Perceptions

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Consciousness

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Being aware of one's own existence, feelings and thoughts and aware of the environment. - This is the most elementary of mental status functions

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Language

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Using the voice to communicate one's thoughts and feelings

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Mood & affect

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Feelings - Affect: temporary expression of feelings or state or mind - Mood: More durable, a prolonged display of feelings

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Orientation

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Awareness of the objective world in relation to the self

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Attention

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The power of concentration, the ability to focus on one specific thing without being distracted by many environmental stimuli

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Memory

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Ability to lay down and store experiences and perceptions for later recall - Recent memory: evokes day to day events - Remote memory: brings up years worth of experiences

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Abstract reasoning

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Pondering a deeper meaning beyond the concrete and literal

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Thought process

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The way a person thinks, the logical train of thought

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Thought content

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What the person thinks - specific ideas, beliefs, use of words

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Perceptions

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An awareness of objects through the 5 senses

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Developmental: infants and children

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- 18-24 months: distinguish self from other objects - 4 weeks: crying - 6 weeks: cooing - 1 year: one word sentences - 2 years: multi-word sentences - 4-5 years; language as social tool of communication - 7 years: logical thinking - 12-15: hypothetical situation

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The aging adult

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- Aging process leaves mental status mostly intact - No decrease in general knowledge and little/no loss in vocabulary - Response time is slower- effects new learning - Recent memory decreases (names, 24 hr diet) - Vision loss, hearing loss

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When To Perform a Mental Status Exam

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- Behavior changes (memory loss, inappropriate interaction) - Brain lesions (trauma, tumor, brain attack) - Aphasia (impaired language ability caused by brain damage) - Symptoms of psychiatric mental illness (anxiety, depression) esp. with acute onset

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Contributions from the Health History - these factors can affect interpretation of the findings

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- Known illness or health problem - Current medications known to affect mood or cognition - Baseline educational and behavioral level - Personal history; current stress, social habits, sleep habits, drug and alcohol use

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Components of the mental status examination

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- Systematic check of emotional and cognitive functioning

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4 main headings of mental status examination

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ABCT 1. Appearance 2. Behavior 3. Cognition 4. Thought processes

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1. Appearance

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- Posture - Body movements - Dress - Grooming and hygiene

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Posture - normal findings

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- Posture is erect - Position is relaxed

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Posture- abnormal findings

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Anxiety & hyperthyroidism - Sitting on edge of chair or curled in bed - Tense muscles - Frowning - Darting watchful eyes - Restless pacing Depression & organic brain disease - Slumped in chair - Slow walking - Dragging feet

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Body movements - normal findings

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- Voluntary - Deliberate - Coordinated - Smooth and even

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Body movements- abnormal findings

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Anxiety - restless, fidgety movements or hyperkinetic appearance Depression & dementia - Apathy and psychomotor slowing Schizophrenia - Abnormal posturing and bizarre gestures - facial grimaces

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Dress- normal findings

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- Appropriate for setting, age, gender, season, social group - Clothing fits and is put on appropriately

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Dress- abnormal findings

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Organic brain syndrome - Inappropriate dress Schizophrenia or manic syndrome - Eccentric dress with bizarre make up

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Grooming and Hygiene - Normal findings

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- Clean & well groomed - Neat and clean hair - Moderate or no make up - Men are shaved or well groomed - Nails are clean * A disheveled appearance in a previously well groomed person is important!

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Grooming and Hygiene - Abnormal findings

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Cerebrovascular accidents - unilateral neglect Depression and severe alzheimers - Inappropriate dress, poor hygiene, lack of concern with appearance OCD - perfectly dressed and groomed

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2. Behavior

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- Level of consciousness - Facial expression - Speech - Mood and affect

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Level of consciousness- Normal findings

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- Awake, alert and aware of stimuli from the environment and within the self and responds appropriately

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Level of consciousness- Abnormal findings

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- Lethargic (or solmnolent): not fully alert, drifts off to sleep when not stimulated, can be aroused by name in normal voice but looks drowsy, mumbled speech - Obtunded: Sleeps most of time, needs loud shake or shout, confused when aroused - Stupor or semi-coma: spontaneously unconscious, responds only to persistent and vigorous shake or pain, appropriate motor responses otherwise can only groan and mumble - Coma: completely unconscious, no response to pain or external or internal stimuli - Acute confusional state (deririum): clouding of consciousness, inattentive, incoherent convo, impaired recent memory, hallucinations, disoriented, worse at night!

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Facial expression - normal findings

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- Appropriate to situation and changes with topic - Comfortable eye contact unless cultural norm

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Facial expression - abnormal findings

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Depression & Parkinsons - Flat, masklike

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Speech - normal findings

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- Laryngeal sounds effortlessly and shares convo appropriately - Pace is moderate, stream is fluent - Articulation is clear and understandable - Word choice is effortless and appropriate to educational level - Complete sentences

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Speech - abnormal findings

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Speech Disorders - Dysphonia: voice disorder, abnormal pitch or volume due to laryngeal disease, hoarse or whispered but articulation and language in tact - Dysarthria: Articulation disorder, distorted speech sounds, misuses words or omits letters, may sound unintelligible, basic language in tact - Aphasia: language comprehension and production secondary to brain damage, defect in word choice and grammar or defect in comprehension (broca - expressive, wernicke's - receptive) Parkinsons - slow, monotonous speech Manic syndrome - rapid-fire, pressured, loud

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Aphasia - Additional testing

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- Word comprehension: point to things at ask them to name them - Reading: ask to read available print (think educational level) - Writing: ask person to make up and write sentence

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Mood & affect- normal findings

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- Body language and facial expression appropriate to place and condition and changes with topics - Cooperative

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Mood & affects- abnormal findings

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- Flat: lack of emotional response, face immobile, topic varies, expression doesnt) - Depression: sad, gloomy - Depersonalized: lack of ego boundaries, loss of identity, confused about meaning of existence - Elation: Joy and optimism, overconfidence - Euphoria: Excessive well-being, unusually cheerful that is inappropriate given condition - Anxiety: worried of anticipated danger of unknown source - Fear: worried, external danger is known and identified - Irritability: Annoyed, impatient - Rage: Furious, loss of control - Ambivalence: Existence of opposing emotions toward an idea, object, person (love+hate) - Lability: Rapid shift of emotions - Inappropriate affect: Affect clearly discordant with content of the person's speech (laughs while talking ab liver biopsy)

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3. Cognitive functions

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- Orientation - Attention span - Recent memory - Remote memory - New learning—the four unrelated words test - Judgment

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Orientation- normal findings

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- Ask time (day, date, year, season), place (lives, location, city), person (name, age, examiner)

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Orientation - abnormal findings

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- Disorientation occurs with delerium and dementia - Orientation is usually lost in order: 1. time, 2. place, 3. person

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Attention span - normal findings

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- Completes thought without wandering - Give series of directions to follow and note correct sequence

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Attention span - abnormal findings

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- Digression from initial thought - Irrelevant replies to questions - Easily distracted "stimulus bound" - Confusion, negativism

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Recent memory - normal findings

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- 24 hour diet recall or asking time person arrived at agency

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Recent memory - abnormal findings

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- Occurs in delerium, dementia, amnestic syndrome, or Korsakoff's syndrome in chronic alcoholism

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Remote memory- normal findings

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- Ask verifiable past events- describe past health, first job, bday, anniversary dates, historical events

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Remote memory - abnormal findings

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- Lost when cortical storage area for that memory is damaged (alzheimers, dementia or any damage to cerebral cortex )

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New learning- normal findings

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4 unrelated words test: tests persons ability to lay dow new memories, highly sensitive and valid memory test (5, 10, 30 min recall) - normal is 3 or 4 word recall younger than 60

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New learning- abnormal findings

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Alzheimers dementia score 0 or 1 word recall Impaired new learning ability occurs with anxiety (inattention and distraction) and depression (lack of effort)

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Judgement - normal findings

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- Ability to compare and evaluate alternatives in a situation and reach appropriate course of action - Long term or daily goals rather than hypothetical situations - Ask about job plans, social obligations, future plans

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Judgement- abnormal findings

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Mental retardation, emotional dysfunction, schizophrenia, and organic brain disease - Unrealistic, impulsive decisions, or wish fulfillment

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4. Thought processes and perceptions

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- Thought processes - Thought content - Perceptions - Screen for suicidal thoughts

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Thought processes - normal findings

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- does it make sense, follow it? - The way the person thinks should be logical, goal directed, coherent, and relevant. - Complete thoughts

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Thought processes - abnormal findings

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- Illogical, unrealistic thought processes - Digression from initial thought - Ideas run together - Blocking (stops in middle of thought, forgets what saying) - Confabulation (fabricates events to fill memory gaps) - Neologism (inventing new words with no meaning other than to person, condensing words) - Circumlocution (round-about expression, substituting a phrase when cannot think of name of object) - Circumstantiality (talks with unnecessary detail, delays reaching point) - Loosening associations (shifting from one topic to unrelated topic) - Flight of ideas (abrupt change, skipping from topic to topic- associated thoughts) - Word salad (incoherent mixture of words, phrases, and sentences) - Perseveration (persistent repeating of verbal or motor response - lock the door, walk and lock the door) - Echolalia (Imitation, mocking) - Clanging (word choice based on sound, not meaning. my feet are cold, cold, bold, told.)

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Thought content - normal findings

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- Consistent and logical

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Thought content - abnormal findings

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- Phobia (strong, irrational fear of something) - Hypochodriasis (morbid worrying about own health, feels sick with no basis for that assumption) - Obsession (unwanted, persistent thoughts or impulses) - Compulsion (unwanted repetitve, purposeful act; driven to do it, behavior thought to neutralize or prevent discomfort or some dreaded event) - Delusions (firm, false beliefs; irrational)

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Perceptions - normal findings

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- Aware of reality - "how do people treat you" - "Do other people talk about you"

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Perceptions - abnormal findings

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- Auditory and visual hallucinations occur with psychiatric and organic brain disease and psychedelic drugs - Tactile hallucinations - alcohol withdrawal - Hallucination: sensory perception for which there are no external stimuli, may strike any sense (visual, auditory, tactile, olfactory, gustatory) - Illusion: misperception of actual existing stimulus, by any sense

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Anxiety screening

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- two most common mental health problems seen in ppl seeking general medical care - Screen for core anxiety symptoms by asking the first two questions from the 7-item GAD scale: 1. Feeling nervous, anxious, or on edge? 2. Not being able to stop or control worrying? - scores on this GAD subscale range from 0-6, 0 suggest no anxiety disorder.

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4 most common anxiety disorders

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1. Generalized anxiety disorder (GAD) 2. panic disorder 3. social anxiety disorder 4. PTSD **score of 10 on GAD-7 identifies GAD; scores of 5, 10 and 15 signify mild, moderate and severe levels of anxiety

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Depression screening

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- shorter method, asking two simple questions about depressed mood and anhedonia will detect majority of depressed patients. 1. Over the past 2 weeks, have you felt down, depressed or hopeless? 2. Over the past 2 weeks, have you felt little interest or pleasure in doing things?

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Suicidal screening

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- feelings of sadness, hopelessness, despair, grief - Assess risk of harm to self Ages 10-24 3rd leading cause of death

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Suicidal abnormal findings

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- Prior suicide attempts - Depression - Firearms - Family history of suicide - Incarceration - Family violence (harm and sexual abuse) - Self mutilation - Anorexia - Verbal suicidal messages Death themes in art, jokes - Saying goodbye

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What is the MMSE?

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- Simplified version of the MSE - The Mini Mental State Examination (MMSE) or Folstein test is a brief 30-point questionnaire test that is used to assess cognition . It is commonly used to screen for dementia. - It is an 11-question measure that tests five areas of cognitive function

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Cognitive impairment in older adults

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Cognitive impairment is no longer considered normal or an expected change of aging.

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Older adults risk compared to population in terms of cognitive function

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Older adults are at higher risk than the rest of the population, changes in cognitive function often call for prompt assessment

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In older adults, when is cognitive functioning especially likely to decline?

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In older patients, cognitive functioning is especially likely to decline during illness or injury.

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Why is the nurse's assessment of an older adult's cognitive status important for older adults?

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The nurses' assessment of an older adult's cognitive status is instrumental in identifying early changes in physiological status, ability to learn, and evaluating responses to treatment.

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When should MMSE be performed?

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A reasonable time to begin is age 70, unless suspicions are high in the younger patient

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Dementia % at age 60

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Dementia is present in about 1% people at age 60

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Prevalence of dementia every 5 years

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Prevalence doubles every 5 years

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By age 85, what happens?

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By age 85, prevalence of dementia is about 30-50%

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Supplemental Mental Status Examination

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MiniMental State - Orientation—what is the year, season, date, day, month? - Registration—name 3 objects, then repeat them - Attention/calculation—spell "world" backwards, do serial 7s - Recall—name previous 3 objects - Language—point and name to a pencil, follow simple instructions, repetition, writing, drawing

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MMSE - used to detect what?

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Cognitive functioning - Dementia and delerium and to differentiate them from mental illness

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MMSE- normal findings

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Max score on test is 30 Normal = avg 27, 24-30 indicate no cognitive impairment

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MMSE - abnormal findings

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- Demential and delirium 18-23 - Severe cognitive impairment 0-7

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Infants & children mental status assessment cover what?

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Behavioral, cognitive, and psychosocial development

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Infants & children mental status assessment

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A-B-C-T - appearance - behavior - cognition - thought process Also, developmental milestones

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Infants & children mental status abnormalities

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- Omission: child does not achieve a milestone you would expect.

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What test do you use with infants & children for mental status?

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Denver II screening - looks at interactions with young child to assess mental status: detects developmental delays within 4 functions 1. Gross motor 2. Language 3. Fine motor- adaptive 4. Personal-social skills

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Denver II screening test

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125 items arranged in chronological order and displayed in groupings corresponding to recommended ages for health maintenance visits.

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Which of the following is the most basic function and therefore should be tested first in an assessment of mental status? • Behavior • Consciousness • Judgment • Language

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• Consciousness

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Which of the following is not a significant contributor to the assessment of mental status? A. Known illness or health problem B. Current medications known to affect mood or cognition C. Racial background D. Personal history; current stress, social habits, sleep habits, drug and alcohol use

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C. Racial background

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Before administering MMSE:

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- Examine medical and psychiatric patient history - Examine patient's occupation, level of education, right vs. left handedness

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After administration of MMSE

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The patient may need additional tests for follow up: - Blood (toxicology, anemia, diabetes, vit or thyroid deficiencies, etc) - Urine (toxicology subst. use screen) - CT/MRI (seizures, strokes, head trauma, brain tumors, etc) - Spinal tap (if suspecting CNS infection)

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Abnormal results may include evidence of:

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- Indication of organic brain damage - Evidence of thought disorders - Inappropriate mood/affect to its context - Thoughts of suicide - Disturbed speech patterns - Dissociative symptoms - Delusions (belief thats not real) or hallucinations

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MMSE abnormal results

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- Mid to low 20s—mild impairment - Between 10 and 20—moderate impairment - Less than 9—severe impairment

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MMSE Mini cog test consists of what tests?

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- 3-item recall test - Clock drawing test

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The Clock Drawing Test (CDT)

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- Widely used to screen patients with cognitive impairment and memory loss. - Simple test that can be used as part of a neurological examination or as a screening tool for Alzheimer's Disease and other types of dementia

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Advantages of the CDT

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- takes less than 2 min to administer - Accepted by patients - Simple to score - Independent of educational/cultural background - Reliable

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What does the CDT test?

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o Comprehension o Planning o Visual memory o Visual-spatial ability o Motor programming o Motor execution o Reconstruction o Numerical knowledge o Interpreting commands

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CDT technique

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- Give patient blank sheet of paper - Patient is told to draw a clock - Draw the clock face - Draw the numbers in correct position - Draw clock hands to show time of 11:10

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CDT interpretation of results

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- Drawing a closed circle: 1 point - Drawing 12 numbers: 1 point - Positioning numbers correctly: 1 point - Place clock hands at designated time: 1 point

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MMSE Mini cog test abnormalities

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Only recalling 1 or 2 words indicates possible dementia No words = dementia Drawing an abnormal clock indicates cognitive impairement

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CDT contraindications

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Can not be given to: - Patients unable to speak/understand - Comatose/semi conscious state

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What of the following questions is most likely to help the nurse assess visuospatial ability? A. "How often does your loved one get lost? B. What would be the first thing you would do if your wallet got lost in an airport? C. Subtract serials of 7 from 100 D. What does a rolling stone gathers no moss mean?

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C. Subtract serials of 7 from 100

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During your nursing assessment, you want to test the client's ability to abstract a proverb. What is the most important information needed before testing the client's ability to abstract? A. Is the client familiar with the proverb? B. What is the client's educational level? C. Is the client cooperative enough to respond to the question? D. Is the proverb consistent with the client's culture?

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A. Is the client familiar with the proverb?

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