Mental Status Evaluation
Compenents of Mental Function
Level of Consciousness= alertness, awareness of environment
Attention = ability to focus or concentrate on task
Recent (Short-term) Memory = memory in minutes, hours, days
Remote (Long-term) Memory = memory in years
Orientation = awareness of who person is in relation to time, place, other people
Depends on memory + attention
Sensory perception = awareness of environment – initiated by external stimuli
Thought processes = sequence, logic, coherence of thought –>leads to goals
Thought content = what people think about
Insight = aware that symptoms/behaviors are abnormal
Judgement = compare + evaluate alternatives to decide on course of action
Affect = immediately observable, episodic feeling tone
Expressed through voice, facial expression
Mood = sustained emotion
Language = symbolic system of expressing, receiving, comprehending words
Higher cognitive functions:
Vocabulary, fund of information, abstract thinking, calculation, copy
objects
Changes with Age
Adolescence
continuing intellectual maturation, increase in vocab. + fund of info.
12 yrs old – abstract thinking àgeneralizations, hypotheses, logical reasoning
development of judgement, set of values
Psychological Problems:
Concerns over bodily changes
Panic attacks
Rage
Depression
Suicide
Psychotic –>Schizophrenia
Aging
Deaths of loved ones, retirement, decreased physical capacities
Biological Changes :
Decreased brain volume + # of brain cells
Memory Loss –>”Benign forgetfulness” = name recall, objects, details
Dementia = 1/3 of those > 85 y.o.
Depression = 15% > 65 y.o.
Delirium
Techniques of Examination
Assess level of consciousness, appearance + affect, attention, memory, speech
Appearance and Behavior
Level of Consciousness
Awake, alertness
Respond to question? If no –>say patient’s name in loud voice, shake
gently
Lethargic = drowsy, can open eyes, responds to questions, then fall asleep
Obtunded = open eyes, look at you, responds slowly, somewhat confused
No response –>assess for stupor, coma
Posture and Motor Behavior
Note bodily posture, ability to relax
Tense posture, restlessness, fidgetiness –>Anxiety
Crying, pacing, handwringing –>Agitated depression
Hopeless, slumped posture, slowed movements –>Depression
Singing, dancing, expansive movements –>Manic Episode
Dress, Grooming, and Personal Hygiene
Deteriorates –>depression, schizophrenia, dementia
Excessive fastidiousness –>obsessive-compulsive
One-sided neglect –>lesion in contralateral parietal cortex (nondominant side)
Facial Expression
Anxiety, depression, apathy, anger, elation
Facial immobility –>Parkinsonism
Manner, Affect, and Relationship to Persons and Things
Anger, hostility, suspiciousness, evasiveness –>Paranoid
Elation, euphoria –>Manic
Flat affect, remoteness –>Schizophrenic
Apathy (dull affect, detachment, indifference) –>Dementia
Speech and Language
Quantity
Rate
Slow –>Depression
Rapid, loud –>Manic
Loudness
Articulation
Dysarthria = defective articulation
Aphasia = disorder of language
Fluency
Rate, flow, melody of speech, content of words
Gaps in flow, rhythm of words
Disturbed inflections – monotone
Circumlocution = phrases/sentences substituted for word person can’t think of
“what you write w/ ” = “pen”
Paraphrasias = words malformed “I write w/ den”
Words wrong “I write w/ bar”
Words invented “I write with dar”
These suggest aphasia –>can falsely suspect psychotic disorder
If speech lack meaning/fluency, proceed w/:
Test for Aphasia
Word Comprehension = ask patient to follow one-stage command (“Point to Nose”)
Repetition = repeat “No ifs, ands, or buts ”
Naming = name parts of watch
Reading Comprehension = read aloud
Writing = write sentence
Test allows determining aphasia –>Broca’s or Wernicke’s If can write correct sentence –>doesn’t have aphasia
Mood
Get patients perception of their mood
Suicidal thoughts
Includes sadness, deep melacholy, contentment, joy, euphoria, elation, anger, rage,
Anxiety, worry, detachment, indifference
Depressive and Bipolar Disorders
Thoughts and Perception
Thought Processes
Assess logic, relevance, organization, coherence
Variations/Abnormalities in Thought Processes:
Circumstantiality = delay in reaching point b/c of unnecessary detail
In obsessional people
Derailment (Loosening of Associations) = shifts from one subject to other
Unrelated subjects, ideas slip off track in between clauses
In schizophrenia, mania
Flight of Ideas = continuous flow of accelerated speech, abrupt change in
Subjects, changes based on play of words, understandable
Associations.
In manic patients
Neologisms = invented words –>schizophrenia, aphasia
Incoherence = illogic, incomprehensible speech, disorder word use, shifts in
Meaning w/in words. Severe flight of ideas –>incoherence
Severely disturbed psychotic patients (schizophrenic)
Blocking = interruption of speech in mid-sentence before idea is complete
Schizophrenia
Confabulation = make up facts to fill up gaps in memory
Amnesia
Perseveration = persistent repetition of words, ideas
Schizophrenia
Echolalia = repetition of other people’s words
Manic, schizophrenia
Clanging = speech where words based on sounds, rhyming
Manic, schizophrenia
Thought Content
Abnormalities of Thought Content
Compulsions = person feels driven to repeat behaviors
Obsessions = recurrent, uncontrollable thoughts, images that is
unacceptable
To person
Phobias= persistent, irrational fears, desire to avoid stimulus
Anxieties = apprehension, fears, tension
Focused (phobia) or free-floating (generalized)
Above abnormalities associated w/ neurotic disorders
Feelings of Unreality = environment strange, unreal
Feelings of Depersonalization = self is different, changed, unreal,
detached from one’s body
Delusions = False, fixed beliefs not shared by others in one’s culture
Delusions of persecution
Grandiose delusions
Delusional jealousy
Delusions of reference = something in environment has personal
Significance (TV gives instruction to person)
Delusions of being controlled by outside force
Somatic delusions = having disease, defect
Systematized delusions = single delusion w/ cluster of related
delusions around single theme
Delusions, feelings of unreality/depersonalization –>psychotic disorders
Delusions also in delirium, severe mood disorders, dementia
Perception
Abnormalities of Perception
Illusions = misinterpretations of real external stimuli
In grief reactions, delirium, acute/posttraumatic stress disorders,
schizophrenia
Hallucinations = subjective sensory perception, no external stimuli
Auditory, visual, olfactory, gustatory, tactile, somatic
Delirium, dementia, posttraumatic stress disorder, schizophrenia
Insight and Judgement
Patients w/ psychotic disorders lack insight into illness
Denial of impairment –>neurologic disorders
Poor judgment –>delirium, mental retardation, psychotic , anxiety disorders.
Judgement also affected by mood disorders, intelligence, education,
Socioeconomic background, cultural values
Cognitive Functions
Orientation: Time, Place, Person
Disorientation (w/ impaired memory or attention) –>delirium
Attention: Tests
Digit Span = Ask patient to repeat numbers
Repeat numbers backward
Normally able to repeat correctly at least five digits forward, back
Poor performance –>delirium, dementia, mental retardation,
Performance anxiety
Serial 7′s = Subtract 7 from 100
Normally able to complete in 1.5 minutes w/ less than 4 errors
Poor performance –>delirium, late stage dementia, mental
retardation,
Loss of calculating ability, anxiety, depression
Spell Backward = “W-O-R-L-D”
Remote Memory = Ask about birthdays, anniversaries
Impaired in late stage dementia
Recent Memory = Ask about events of day (weather, medication)
Impaired in delirium, dementia Amnestic Disorders –>impaired memory and new learning, but don’t have global features of delirium, anxiety
Also affected by anxiety, depression, mental retardation
New Learning Ability = Give patient three words (apple, car, shoe), ask patient to remember, and ask patient to repeat it later
Higher Cognitive Functions
Information and Vocabulary
Ask about specific facts (presidents, cities)
Good indicator of intelligence
Unaffected by any but most severe psychiatric disorders
Help in distinguishing mentally retarded (information limited) from those w/ mild dementia (information and vocabulary preserved)
Calculating Ability
Start w/ addition, multiplication
Poor performance –>dementia, aphasia
Assessed in terms of patient’s intelligence, education
Abstract Thinking
Proverbs (“rolling stone gathers no moss”)
Concrete responses –>mental retardation, dementia, or little education
Schizophrenic –>concrete response or w/ bizarre interpretation
Similarities (apple vs. orange)
Constructional Ability = Ask patient to copy figures of increasing complexity
(Circle, cross, diamond, cube)
Ask patient to draw clock
Poor constructional ability (vision and motor intact) –>dementia, parietal lobe damage, mental retardation
Special Technique (Mini-Mental State Examination)
To screen dementia-max score in parentheses
Tell me date? Ask for year, season, day, month (5)
Subtract 1 for each part not given
Where are you? Ask for state, county, town, hospital, floor (5)
Subtract 1 for each not given
Name three objects-ask patient to repeat (3)
Ask patient to do serial 7s. Stop after 5 answers. Or spell WORLD backward (5)
Ask for the three objects in #3 (3)
Show patient watch, ask for its name. Repeat w/ pencil (2)
Ask patient to repeat “No ifs, ands, or buts” (1)
Give piece of paper and ask patient to put in right hand, fold in ½, put on floor (3)
Show paper w/ word CLOSE YOUR EYES. Ask patient to read and do it (1)
Ask patient to write own sentence (1)
Ask patient to copy pair of intersecting pentagons on paper (1)
Max score = 30 Normal = 23-30 Dementia < 24
Tags: Agitated depression, anger, anxiety, apathy, contralateral parietal cortex, dementia, depression, elation, Lethargic, Manic Episode, mental function, Obtunded, schizophrenia, Schizophrenic
