Download Chapter 5 Mental Status The total expression of a person`s

Chapter 5
Mental Status
The total expression of a person’s emotional responses, mood, cognitive functioning, and
personality
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
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
Anatomy and Physiology
The cerebrum of the brain is primarily responsible for a person’s mental status.
Many areas in the cerebrum contribute to the total functioning of a person’s mental processes.
Two cerebral hemispheres, each divided into lobes, comprise the cerebrum.
Gray outer layer, the cerebral cortex, houses the higher mental functions and is responsible for
perception and behavior.
Cerebrum
Frontal lobe, containing the motor cortex, is associated with:
Speech formation (Broca area)
Goal-oriented behavior
Ability to concentrate and short-term memory
Cerebrum (Cont.)
Parietal lobe is responsible for processing sensory data.
Temporal lobe is responsible for perceptions and long-term memory.
Contains the Wernicke speech area, which permits comprehension of spoken and written
language
Involved in the integration of behavior, emotion, and personality
Limbic System
Limbic system mediates certain patterns of behavior that determine survival.
Reactions to emotions originate here.
Expression of emotion and behavior is mediated by connections between the limbic
system and the frontal lobe.
Reticular Activating System (RAS)
Reticular activating system (RAS) in the brainstem regulates the level of wakefulness or arousal.
Disruption of the ascending RAS can lead to altered mental status.
Infants and Children
All brain cells are present at birth but it takes the first years of life for cells to fully develop and
myelinize.
Brain insults, such as infection, trauma, or metabolic imbalance, can damage brain cells, leading
to potentially serious dysfunction in mental status.
Adolescents
Intellectual maturation continues with greater capacity for information and vocabulary
development.
Abstract thinking develops:
Ability to develop theories
Ability to use logical reasoning
Ability to make future plans
Ability to use generalizations
Ability to consider risks and possibilities
Judgment begins to develop with education, intelligence, and experience.
Older Adults
Cognitive functions most sensitive to aging include the speed at which new information is:
Perceived
Encoded
Processed
Retrieved
Minimal decline in cognitive and daily functioning should occur unless systemic or neurologic
disorder develops.
Older Adults (Cont.)
Loss of recent memory, delayed response time, and diminished ability to learn complex
information may occur.
Remote memory may be more efficient than short-term memory.
Some studies suggest that higher education attainment has been associated with better memory
and cognitive function later in life.
Review of Related History
HPI: Disorientation and Confusion
Onset
Associated health problems
Associated symptoms
Medications
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
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
Past Medical History
Neurologic disorder, brain surgery, brain injury, residual effects, chronic disease, or debilitating
condition
Psychiatric therapy or hospitalization
Family History
Psychiatric disorders, mental illness, alcoholism
Alzheimer disease
Learning disorders, mental retardation, autism
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
Children
Speech and language
Behavior
Performance of self-care activities
Personality and behavior patterns
Learning or school difficulties
Adolescents
Risk-taking behaviors
School performance and peer interactions
Family interactions, reluctance to communicate and to speak of attitudes and experience
Older Adults
Changes in cognitive functioning, thought processes, and memory
Depression, somatic complaints, hopelessness, helplessness, lack of interest in personal care
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
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
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
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
Cognitive Abilities (Cont.)
Several screening tests are available to assess cognition.
Mini-Cog
Three unrelated words
Clock face
Cognitive Abilities (Cont.)
Analogies
Abstract reasoning
Arithmetic calculation
Writing ability
Execution of motor skills
Memory
Attention span
Judgment
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
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
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
Infants and Children
Infants
Levels of activity
Lethargic
Drowsy
Stuporous
Alert
Active
Irritable
Responsiveness to environmental stimuli
Smile
Crying and other vocal sounds
Infants and Children (Cont.)
Children
Types of words and speech patterns
Mood
Activity level
Preferences
Responsiveness to parent and ability to separate
Infants and Children (Cont.)
Children (Cont.)
Self-comforting measures
Does the child play and have fun?
Attempt memory testing at about age 4.
Test with familiar objects
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.
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.
Older Adults (Cont.)
Assess close family members’ concern about memory loss.
In patients over 71, one in seven has some form of dementia.
Assess other causes of cerebral dysfunction.
Cardiovascular
Hepatic
Renal
Metabolic
Older Adults (Cont.)
Medications
Slow reaction times
Disorientation
Confusion
Loss of memory
Tremors
Anxiety
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
Common Abnormalities
Disorders of Altered Mental Status
Concussion
An alteration in mental status resulting from a blow to the head or neck
Rotational forces cause a transient disruption in the reticular neurons that maintain
alertness
Sports injuries
Motor vehicle accidents
Falls
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
Disorders of Altered Mental Status (Cont.)
Delirium
Impaired cognition, consciousness, mood, and behavioral dysfunction of Acute onset of
impaired cognition, consciousness, mood, and behavioral dysfunction
Risk factors
Serious illness
Injury
Preexisting cognitive decline
Disorders of Altered Mental Status (Cont.)
Delirium tremens
Brain’s response to withdrawal from alcohol consumed in large quantities over time
Alcohol withdrawal signs include elevated vital signs, irritability, anxiety,
restlessness, and anorexia.
Delirium tremens signs include agitation, confusion, combativeness, panic,
seizures, hallucinations, and illusions.
Disorders of Mood
Depression
Common psychiatric disorder associated with a neurochemical imbalance
Symptoms from mild to major depressive disorder; characterized by feelings of
helplessness and hopelessness and recurrent suicidal thoughts
Mood and affect are altered, with extreme sadness or anxiety and agitation
Somatic complaints: altered appetite, sleep problems, constipation, headache, and
fatigue
Disorders of Mood (Cont.)
Depression (Cont.)
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
Disorders of Mood (Cont.)
Mania
Persistently elevated, expansive, or irritable mood lasting longer than 1 week, one phase
of the bipolar disorder
Associated with a neurochemical imbalance, an increased level of monoamines
Impairments in social, occupational, and interpersonal functioning
Disorders of Mood (Cont.)
Mania (Cont.)
Symptoms
Hyperactivity, overconfidence, exaggerated view of one’s abilities, grandiose or
persecutory delusions, decreased need for sleep, and poor social judgment
Characterized by racing thoughts, flights of ideas, and rapid-fire, loud speech, possibly
involving excessive rhyming or punning
Disorders of Mood (Cont.)
Anxiety disorder
Group of disorders with such marked anxiety or fear that it causes significant interference
with personal, social, and occupational functioning
Associated with abnormalities in the norepinephrine and serotonin systems
These are the most common psychiatric disorders and may persist throughout life
Disorders of Mood (Cont.)
Anxiety disorder (Cont.)
Specific disorders include:
Panic attacks
Generalized anxiety disorder
Specific phobias
Obsessive-compulsive disorder (OCD)
Posttraumatic stress disorder (PTSD)
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
Disorders of Mood (Cont.)
Schizophrenia
A severe, persistent, psychotic disorder with relapses throughout life
May be associated with fetal neurodevelopmental defects:
Viral infection during pregnancy
Prenatal nutritional deficits
Perinatal complications
Inheritable disorder likely involving several genes on different chromosomes
Disorders of Mood (Cont.)
Schizophrenia (Cont.)
Typical adolescent or early adult onset
Affects perceptions, thinking, language, emotions, and social behavior
Major symptoms
Hallucinations
Delusions
Disordered thinking, speech, and behavior
Infants and Children
Mental retardation
Significant subaverage general cognitive functioning and deficits in adaptive behavior
manifested during the child’s development
May be associated with structural brain defects or genetic disorders
Signs and symptoms
Delayed motor development
Delayed speech and language skills
Infants and Children (Cont.)
Attention-deficit/hyperactivity disorder (ADHD)
A neurobehavioral problem of impaired attention and hyperactive behavior affecting 5%
to 10% of school-age children
Theorized that dopamine system disturbances may be associated with ADHD onset
Infants and Children (Cont.)
Attention-deficit/hyperactivity disorder (ADHD) (Cont.)
Signs and symptoms
Short attention span
Easily distracted
Trouble completing assignments
Fidgets and squirms, moving, running, jumping
Disruptive behavior, poor impulse control
Infants and Children (Cont.)
Autistic disorder
Pervasive neurodevelopmental disorder of unknown etiology
Refers to a wide spectrum of disorders typically before 3 years of age
Believed to have multifactorial causes and a strong genetic influence
Infants and Children (Cont.)
Autistic disorder (Cont.)
Signs and symptoms
Does not make eye contact
Resists being held or touched
Odd and repetitive behaviors
Ritualized play, preoccupation with parts of objects
Motor development appropriate for age
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
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
Older Adults (Cont.)
Dementia (Cont.)
Alzheimer type
Approximately 60% of cases
May be caused by abnormal processing or deposition of amyloid
Vascular dementia
Approximately 5% to 10% of cases
Reduced cerebral blood flow such as a brain infarct(s)
Other dementias
Associated with diffuse Lewy bodies in the brain
Parkinson’s disease
Frontal lobe degeneration
Question 1
The Glasgow Coma Scale is used to:
A. Determine the cause of decreased consciousness.
B. Assess a patient’s level of abstract reasoning.
C. Quantify consciousness.
D. Predict response to stimulant medications.
Question 2
Assessing orientation to person, place, and time helps determine:
A. Ability to understand analogies
B. Abstract reasoning
C. Attention span
D. State of consciousness
Question 3
One method to evaluate mental status, cognitive function, and assess for dementia is:
A. Mini-cog
B. Glasgow scale
C. Geriatric depression inventory
D. Coherence testing scale
Question 4
Testing the patient’s arithmetic calculation will assist in determining which of the following:
A. Dementia and Parkinson disease
B. Depression and diffuse brain disease
C. Schizophrenia and brain damage
D. Intellectual disability
Question 5
Mrs. Alred brings her 48-month-old toddler in for an examination. Which of the following
expressive language milestones should he be able to accomplish?
A. Two word combinations
B. Two to three word sentences
C. Sentences may have four or more words
D. Able to spell one syllable words