Mental status NSG 464 Spring 2012 J Hansen APN

General Survey Apparent state of health Acute or chronically ill, frail Level of consciousness Awake, alert, responsive or lethargic, obtunded, comatose Signs of distress Cardiac or respiratory; pain; anxiety/depression Skin color and obvious lesions Dress, grooming, and personal hygiene Appropriate to weather and temperature Clean, properly buttoned/zipped Facial expression Eye contact, appropriate changes in facial expression Odors of body and breath Posture, gait, and motor activity

General survey (cont’d) Height Measure in stocking feet Short or tall Build: slender and lanky, muscular, or stocky Body symmetry Note general body proportions and any deformities Weight Emaciated, slender, plump, obese If obese, is fat distributed evenly or concentrated over trunk, upper torso, or around the hips? Calculate the body mass index (BMI)

Behavior History Focus is on insight, judgment and assessment for thought disorders, disorders of perception. Vocabulary is key

Level of Consciousness Level of consciousness: how aware the person is of his environment Attention: the ability to focus or concentrate Alert: the patient is awake and aware Lethargic: you must speak to the patient in a loud forceful manner to get a response Obtunded: you must shake a patient to get a response Stuporous: the patient is unarousable except by painful stimuli (sternal rub) Coma: the patient is completely unarousable

Memory Memory: the process of recording and retrieving information Short-term memory covers events or memories that occurred minutes to days before Long-term memory covers events or memories that occurred months to years before Orientation: aware of person (who they are), place (where they are), and time (when is it); this requires memory and attention

Mental Status Examination Consists of the following components: Appearance and behavior Speech and language Mood Thoughts and perceptions Cognitive function: memory, attention, information and vocabulary, calculations, abstract thinking, and constructional ability

Mental status exam (cont’d) Perceptions: awareness of the objects in the environment to the five senses and their interrelationships Thought processes: the logic, coherence, and relevance of a patient’s thoughts as they lead to thoughts and goals; HOW people think Insight: awareness that thought, symptoms, or behaviors are normal or abnormal; e.g., distinguishing that a daydream or hallucination is not real Judgment: process of comparing and evaluating different possible courses of action

Appearance and Behavior Assess the level of consciousness Is the patient awake and alert? Does the patient understand your questions? Does the patient respond appropriately and reasonably quickly or lose track of the topic and fall silent or even asleep? If the patient does not respond to your questions, escalate the stimulus in steps: Speak to the patient by name and in a loud voice Gently shake the patient

Appearance and Behavior (cont.) Assess the patient’s manner, affect, and relationship to people and things Does the affect reflect the mood? Is the affect stable or labile (mood changing from happiness to tears and back quickly)? Does the patient seem to see or hear things you do not?

Appearance and Behavior (cont.) Posture and motor behavior Does the patient lie in bed or prefer to walk around? Is the patient sitting or lying comfortably? Is the patient agitated with repetitive movements? Assess the patient’s dress, grooming, and personal hygiene Generally, grooming and hygiene deteriorate in depression or schizophrenia Assess the patient’s facial expressions A flat affect (lack of facial movement) can be seen due to a physical reason such as Parkinson’s disease or a psychological reason such as profound depression

Affect: the observable mood of a person expressed through facial expression, body movements, and voice Mood: the sustained emotion of the patient Euthymic: normal Dysthymic: depressed Manic: elated Language: the complex symbolic system for expressing written and verbal thoughts, emotion, attention, and memory Higher cognitive functions: level of intelligence assessed by vocabulary, knowledge base, calculations, and abstract thinking

Affect Based on your observations Use words like Expansive Euthymic (i.e. normal) Constricted (i.e. limited variation) Blunted (i.e. minimal variation) Flat (i.e. no variation)

Speech and Language Quantity: Is the patient talkative or silent? Rate: Is the speech fast or slow? Loud: Is speech loud or soft? Articulation of words: Does the patient speak clearly and distinctly? Is there nasal quality to the speech?

Speech Assess quality, rate, volume Use descriptors like Quality: clear, fluent, monotonous, mumbled, laborious Abnormals Dysarthria – defective articulation. Words are slurred, indistinct but central symbolic value is intact Aphasia Fluent (receptive) aphasia – speech fluent, comprehension impaired Non-fluent (expressive aphasia) – speech labored, slow, comprehension is at least fair to good Paraphasias – sentences or phrases that lack meaning Neologisms – made up words

Speech and Language (cont.) Fluency: involves the rate, flow, and melody of speech Hesitancies in speech (as seen in patients with aphasia from strokes) Monotone inflections (schizophrenia or severe depression) Circumlocutions: words or phrases are substituted for the word a person cannot remember; e.g., “the thing you block out your writing with” for an eraser Paraphasias: words are malformed (“I write with a den”), wrong (“I write with a branch”), or invented (“I write with a dar”)

Assessing Mood Use open-ended questions “How do you feel about that?” “How are you feeling?” How long has the patient’s mood been this way How good or bad has the patient felt Sometimes you have to ask friends or family of the patient to help you assess the patient’s mood Do not be afraid to ask the patient about thoughts of self-harm or suicide

Mood Sustained emotion that the patient is experiencing Ask: How do you feel most days? Helpful Depressed Anxious Good Tired Not helpful and must be clarified OK Rough Don’t know

Mood Disorders Depression Common – and undertreated Often treated in primary care Important to screen At risk for depression Stressed – chronic pain, illness, psychosocial stress, lack of social support, caregiver burden, meds, substance/ETOH abuse, genetics Situational – post-partum, post-stroke, vascular dementia, other Rates highest among 25-44 (F>M) but pay attention to elders! If mood is low, consider use of specific screening tool

Mood Disorders Anxiety Common Look for excessive anxiety, worry, restlessness, irritability, muscle tension, sleep disturbance Panic disorder is an extreme manifestation PTSD, OCD, social phobias, agoraphobia are somewhat common Assessments include Appearance Mood/affect Suicidal ideation Orientation/recall May see physical manifestations – tachycardia, diaphoresis, tremors, insomnia, tics, hair pulling, etc

Thought and Perceptions: Thought Processes Assess thought processes: logic, relevance, organization, and coherence Abnormalities in the thought process Circumstantiality: speech characterized by indirection and delay due to the patient’s excessive use of details that have no connection to the point Derailment: speech in which a person shifts topics with no apparent relation between the topics Flight of ideas: accelerated change of topics in a very fast but generally coherent manner Neologisms: invented or distorted words

Thought and Perceptions: Thought Processes (cont.) Incoherence: speech that is incomprehensible because it is illogical Blocking: sudden interruption of speech, before the completion of an idea, occurs in normal people Confabulation: fabrication of facts to hide memory impairment Perseveration: persistent repetition of words or ideas Echolalia: repetition of the words or phrases of others Clanging: choosing a word on the basis of sound rather than meaning

Thought and Perceptions: Thought Content Assess thought content during the interview by following appropriate leads as they occur Abnormalities of thought content Compulsions: repetitive behaviors that a person feels driven to perform to prevent or produce some future state of affairs Obsessions: recurrent, uncontrollable thoughts, images, or impulses that a patient considers unacceptable Phobias: persistent fear of a stimuli the patient feels is irrational (spiders, snakes, the dark) Anxiety: apprehension or fear that may be focused (phobia) or free floating (general sense of dread)

Thought and Perceptions: Thought Content (cont.) Abnormal thought content continued Delusions: false, fixed beliefs that are not shared by other members of the person’s culture Delusion of persecution, grandeur, or jealousy Delusion of reference: a person believes an outside event or object has an unusual personal reference to them; i.e., a comet passing earth means the patient should buy a car Delusion of being controlled by outside forces Somatic delusion: believing one has a disease or defect that he does not Systematized delusion: a single delusion with many elaborations around a single theme all systematized into a complex network; i.e., the KGB is after the patient

Abnormalities of Perception Delusions – false beliefs not shared by others The TV news announcer told me to speak to NATO Illusion – misinterpretation of real external stimuli Johnny smiled at me and I know he loves me Hallucinations – selective sensory perceptions in the absence of relevant external stimuli. May be auditory, visual, olfactory, gustatory, tactile, or somatic. NOT related to dreaming, falling asleep, awakening. The little green men are coming through the window right now.

Thought Content Assess for suicidal ideation Do you have any thoughts of wanting to harm or kill yourself? Do you have any thoughts that you would be better off dead? If yes, then assess for plan, access to means. May need to intervene to protect pt safety If indicated, assess for homicidal ideation

Question Is the following statement true or false? When assessing the patient’s thought content, it is important to always follow specific questions to keep the patient on task.

Answer False. When assessing the patient’s thought content, follow appropriate leads as they occur rather than using stereotyped lists of specific questions.

Thought and Perceptions: Perceptions Inquire about false perceptions Do you hear voices other people don’t hear? Do you see things other people don’t see? Do you know things other people don’t know? Abnormalities of perception Illusions: misinterpretations of real stimuli; e.g., the postman leaves mail, therefore there is a plot to poison the patient Hallucinations: a subjective external stimuli the patient hears or sees that others do not hear or see and that the patient may not recognize as false; these can be auditory, visual, olfactory, gustatory, or tactile Abe Lincoln speaks to the patient from the back of a penny Do not include false perceptions associated with dreaming/falling asleep

Question Which of the following is true about hallucinations? Experiences may or may not be recognized by the person as false Hallucinations may be auditory, visual, olfactory, gustatory, tactile, or somatic Do not include false perceptions associated with dreaming and falling asleep All of the above

Answer All of the above Experiences may or may not be recognized by the person as false Hallucinations may be auditory, visual, olfactory, gustatory, tactile, or somatic Do not include false perceptions associated with dreaming and falling asleep

Thought and Perceptions: Insight and Judgment Ask the patient about the reasons behind his clinic or hospital visit; patients with psychological disorders often lack insight into their disease You can usually assess judgment by noting the patients’ responses to stressors on their relationships, job, and finances

Cognitive Functions Assess orientation to person, place, and time Assess attention Digital span: give the patient a string of numbers to recite back to you Serial 7s: ask the patient to subtract serial “7s” from 100 Spelling backward: ask the patient to spell W-O-R-L-D backwards Assess remote memory by asking about past historical events Assess recent memory by asking about something recent (weather, national event, etc.) Assess new learning ability by giving the patient three or four words to remember; then ask him to repeat the words after several minutes

Higher Cognitive Functions Through your conversation, you can often assess the patient’s higher cognitive functions Information and vocabulary Calculating ability: ask the patient to perform more difficult calculations such as making change (e.g., if you had a dollar’s worth of nickels and someone needed 65 cents how many nickels would you have left?) Abstract thinking Interpreting proverbs: “A stitch in time saves nine” Similarity exercises: What do a ball and an orange have in common?

Higher Cognitive Functions (cont.) Constructional ability Ask a patient to copy a geometric figure onto a sheet of paper Ask a patient to draw a clock face indicating 5:00

MMSE Brief, 30 point exam to screen for cognitive impairment Scores above 25 are considered normal 21-24 indicates mild impairment 10-20 indicates moderate impairment Useful in identifying dementia Can track status over time Easy to administer Exists in 10 foreign languages Some adaptations for physical impairments (e.g. intubated, blind) exist Copyright issues in play. Alternatives exist.

MMSE

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