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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