1. . Copyright © 2015 by Mosby, an imprint of Elsevier Inc. MENTAL STATUS Chapter 5

2. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. "Knowledge speaks, but wisdom listens" --Jimi Hendrix

3. . Copyright © 2015 by Mosby, an imprint of Elsevier Inc. The total expression of a person’s emotional responses, mood, cognitive functioning, and personality Mental Status 3

4. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Mental Status The total expression of a person’s emotional responses, mood, cognitive functioning, and personality 4

5. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Physical Examination Preview: Mental Status Examination Observe physical appearance and behavior. Investigate cognitive abilities.  State of consciousness  Response to questions  Reasoning  Arithmetic ability  Memory  Attention span

6. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Mental Status Examination Evaluate emotional stability for the following:  Signs of depression or anxiety  Disturbance in thought content  Hallucinations Observe speech and language for the following:  Voice quality  Articulation  Coherence  Comprehension 6

7. . Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Review of Related History 7

8. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. HPI: Disorientation and Confusion Onset Associated health problems Associated symptoms Medications 8

9. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. HPI: Depression Troubling thoughts or feelings Low energy level Recent changes in living situation Feels like hurting self, thoughts about dying or suicide Medications: antidepressants 9

10. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. HPI: Anxiety Sudden unexplained attacks of fear, anxiety, or panic Avoids or feels uncomfortable with people Experienced extremely traumatic event Associated symptoms Medications: antidepressants, steroids, benzodiazepines; alternative or complementary therapies 10

11. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Past Medical History Neurologic disorder, brain surgery, brain injury, residual effects, chronic disease, or debilitating condition Psychiatric therapy or hospitalization 11

12. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Family History Psychiatric disorders, mental illness, alcoholism Alzheimer disease Learning disorders, mental retardation, autism 12

13. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Personal and Social History Emotional status Life goals, attitudes, relationship with family Intellectual level, education Communication pattern Changes in sleeping patterns Use of alcohol or street drugs, especially mood- altering drugs 13

14. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Children Speech and language Behavior Performance of self-care activities Personality and behavior patterns Learning or school difficulties 14

15. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Adolescents Risk-taking behaviors School performance and peer interactions Family interactions, reluctance to communicate and to speak of attitudes and experience 15

16. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Older Adults Changes in cognitive functioning, thought processes, and memory Depression, somatic complaints, hopelessness, helplessness, lack of interest in personal care 16

17. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Examination and Findings Mental status is assessed throughout the physical examination Evaluate:  Physical appearance and behavior  State of consciousness  Cognitive abilities  Speech and language skills  Emotional stability 17

18. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Physical Appearance and Behavior Grooming: poor hygiene, lack of concern, inappropriate appearance Emotional status: carelessness, apathy, insensitivity, docility, rage, irritability Body language: slumped posture, lack of expression or eye contact, excessively energetic, constantly watchful 18

19. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. State of Consciousness Oriented to person, place, and time and makes appropriate responses to questions, as well as physical and environmental stimuli  Person disorientation: cerebral trauma, seizures, or amnesia  Place disorientation: psychiatric disorders, delirium, and cognitive impairment  Time disorientation: anxiety, delirium, depression, and cognitive impairment 19

20. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Cognitive Abilities Evaluate cognitive functions as the patient responds to questions during the history-taking process. Several screening tests are available to assess cognition.  Mini-Mental State Examination (MMSE)  Most studied to date 20

21. 21 Figure 5-03. Sample items from the Mini-Mental State Examination (MMSE). (Reproduced by special permission of the publisher, Psychological Assessment Resources, Inc., 16204 North Florida Avenue, Lutz, Florida 33549, from the Mini-Mental State Examination by Marshal Folstein and Susan Folstein, Copyright 1975, 1998, 2001 by Mini Mental LLC, Inc. Published 2001 by Psychological Assessment Resources, Inc. Further reproduction is prohibited without permission of PAR, Inc. The MMSE can be purchased from PAR, Inc. online at www.parinc.com or by calling [813]968-3003.) Cognitive Abilities (Cont.)

22. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Cognitive Abilities (Cont.) Analogies Abstract reasoning Arithmetic calculation Writing ability Execution of motor skills Memory Attention span Judgment 22

23. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Speech and Language Skills A detailed evaluation of receptive and expressive communication skills should be performed if the patient has difficulty communicating during the history.  Voice quality  Articulation  Comprehension  Coherence  Aphasia 23

24. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Emotional Stability Emotional stability is evaluated when the patient does not seem to be coping well or does not have resources to meet his or her needs.  Mood and feelings  Thought process and content  Perceptual distortions and hallucinations 24

25. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Additional Procedures Glasgow Coma Scale  Used to quantify consciousness in person with head trauma or hypoxic event  Versions are available for adult, infant, and young child  Assesses the function of the cerebral cortex and brainstem through the patient’s verbal, motor, and eye opening responses to specific stimuli  Scores range from 3 to 15, with 15 being the optimal level of consciousness 25

26. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Infants and Children Infants  Levels of activity  Lethargic  Drowsy  Stuporous  Alert  Active  Irritable  Responsiveness to environmental stimuli  Smile  Crying and other vocal sounds 26

27. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Infants and Children (Cont.) Children  Types of words and speech patterns  Mood  Activity level  Preferences  Responsiveness to parent and ability to separate 27

28. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Pregnant Women Prevalence of depression during pregnancy and postpartum is estimated to be 10% to 15%. Postpartum “blues” may be found in 50% to 80% of women. Risk factors for postpartum depression  History of depression  Prior postpartum depression Depression may interfere with the mother’s attachment to the newborn and the infant’s subsequent development. 28

29. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Older Adults Some problem-solving skills deteriorate with age and disease. Skills involving vocabulary and inventories of available information are expected to remain at younger adult levels of performance  Isaac Set Test: name 10 items in each of four groups―fruits, animals, colors, towns Recent memory for important events and conversations usually not impaired  Recent memory is believed to deteriorate before remote memory. 29

30. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Older Adults (Cont.) Review the patient’s ability to perform activities of daily living associated with mental status functioning. Older adults are expected to maintain the same level of interpersonal skills and have no personality changes.  Geriatric Depression Scale Facial expressions and stance  Masklike or dramatic  Stooped and fearful 30

31. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Disorders of Altered Mental Status Concussion  An alteration in mental status resulting from a blow to the head or neck  Sports injuries  Motor vehicle accidents  Falls 31

32. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Disorders of Altered Mental Status (Cont.) Concussion  Signs and symptoms  Dizziness or dazed look  Slurred speech  Slow motor and verbal responses  Irritability  Nausea and vomiting  Loss of consciousness may indicate severe injury  Amnesia  Deficits in coordination, memory, attention 32

33. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Disorders of Mood Depression  Signs and symptoms  Memory loss, poor concentration, lack of motivation, indecisiveness  Slow, sluggish speech  Delusions of worthlessness or paranoid ideation  Disorder may result from grief, reaction to medical or neurologic diseases, or change in lifestyle 33

34. 34 Figure 5-09. Geriatric Depression Scale (short form). (From www.stanford.edu/~yesavage). Disorders of Mood (Cont.)

35. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Disorders of Mood (Cont.) Anxiety disorder  Specific disorders include:  Panic attacks  Generalized anxiety disorder  Specific phobias  Obsessive-compulsive disorder (OCD)  Posttraumatic stress disorder (PTSD) 35

36. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Disorders of Mood (Cont.) Anxiety disorder (Cont.)  Signs and symptoms of panic attacks  Palpitations, tachycardia  Sweating, shaking, trembling, choking  Chest pain or discomfort, nausea, abdominal distress  Dizziness, faintness  Feeling unreal or detached from self, “going crazy”  Paresthesias 36

37. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Infants and Children Mental retardation  Significant subaverage general cognitive functioning and deficits in adaptive behavior manifested during the child’s development  Signs and symptoms  Delayed motor development  Delayed speech and language skills 37

38. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Older Adults Dementia  A chronic, slowly progressive disorder of:  Failing memory  Cognitive impairment  Behavioral abnormalities  Personality changes  Often begins after 60 years of age  Usually related to structural diseases of the brain 38

39. Copyright © 2015 by Mosby, an imprint of Elsevier Inc. Older Adults (Cont.) Dementia (Cont.)  Signs and symptoms  Impaired memory, forgets appointments  Getting lost in familiar areas, wandering  Unable to manage shopping, food preparation, medication, finances, and driving  Behavioral changes, inappropriate dress or conduct, impaired grooming, impulsiveness, disinhibition  Aphasia, agnosia, apraxia  Apathy, withdrawal  Anxiety, irritability  Changes in mood 39