Download Mental state assessment - Wk 1-2

Mental state assessment
1. Recognise the possibility of an organic mental disorder (organic brain syndrome) in a
confused or delirious patient.
An organic brain syndrome is a delirium, dementia or other mental disorder (anxiety,
depression, personality change and psychosis) that is caused by physical illnesses or by drugs
and other substances.
A patients’ medical Hx, previous admissions, and family/carer input will be useful in
recognizing dementia in a confused patient. More acute symptoms (detailed below) will be
necessary in recognizing delirium in a confused patient.
In either instance the point is that practitioners need to be constantly aware that a patient’s
behaviour may be demonstrating delirium/dementia, and they are not trying to specifically
annoy/anger/make life difficult for the doctor. Conversly their appearance of ‘confusion’ may
be masking an underlying acute delirium that needs urgent attention.
2. Identify the features of dementia, and distinguish from delirium.
Dementia: Dementia is characterised by a decline in cognitive functioning that is severe
enough to produce significant disability and handicap. In contrast to delirium, which involves
an acute derangement of brain function, dementia is associated with progressive neuronal
loss.
Dementia always involves some loss of memory. Associated features include spatial
disorientation, impaired judgement and insight, and disinhibition. Dementia may be
complicated by the development of depression (especially early in the course when a person
retains insight into his or her condition), anxiety, delusions (especially persecutory),
hallucinations (most commonly visual) and delirium. The risk of suicide is highest early in the
course. People with dementia may occasionally be violent. Dementia is sometimes associated
with motor disturbances of gait and slurred speech. People with early dementia may
experience intense anxiety upon having their declining intellectual function made evident
Delirium: Delirium is a syndrome caused by a reversible and global derangement of brain
metabolism that includes behavioural, psychological and physical symptoms. Any medical
condition or substance that directly or indirectly affects the central nervous system can cause
delirium. There is usually a relatively rapid onset of symptoms and signs in delirium. The
critical clinical feature is an altered level of consciousness that can vary from mild inattention
(especially whilst taking the history!) and clouding through to coma, and the condition may
fluctuate during waking hours.
Other signs include disorientation in time, place and person; hallucinations, especially visual
and tactile; reversal of the sleep-wake cycle; fleeting persecutory ideation; disorganisation of
thinking and behaviour; and either psychomotor agitation or reduced activity and awareness.
Important causes to keep in mind include alcohol and benzodiazepine withdrawal, infection
(e.g. pneumonia, urinary tract infection and meningitis), drug toxicity (e.g. lithium,
benztropine, carbamazepine, digoxin) subdural haematoma, subarachnoid haemorrhage,
congestive cardiac failure and Wernicke's encephalopathy. Drugs with anticholinergic side
effects are particularly prone to cause delirium.
3. Outline the components of the mental state examination and the use of mental state
examination in the assessment of higher functioning in the confused patient.
The Mental State Examination (MSE) is a screening test that tests similar faculties as the
mini-MSE but is far more comprehensive and time consuming. It is an orderly assessment of
the important cognitive and emotional functions that are commonly and characteristically
disturbed in patients with organic brain disease lesions or psychiatric conditions. The process
involves taking the patient’s history and while doing so assessing the following key stimulus
from the patient:
BACPAC: Behaviour, affect, cognition, perception, appearance, communication

Behaviour: Gait, mannerisms, tics, gestures, overly affectionate

Affect: (mood) - How does the patient describe how they feel? Depth, duration and
fluctuations in mood – depressed, anxious, despairing, angry, euphoric, guilty.

Cognition: Stream of thought, paucity of ideas, rapid thinking, memory. Do the
patient’s replies really answer questions?, ability to think abstractly, level of
education, concentration.

Perceptual Disturbances: Hallucinations and illusions: Does patient see visions or
hear voices? Extreme feelings of detachment from one’s self or the environment.

Appearance: Posture, clothes, grooming, sickly, angry, frightened.

Communication: Rapid, slow, pressured, hesitant, emotional, loud
These parameters provide the practitioner a measure to assess function and mental capacity in
a patient, and the degree to which they may be related to acute causes of confusion.
Mini Mental State Examination:
This instrument can be used to give a quantitative estimate of the severity of a person's
cognitive impairment, or to serially document cognitive change. A score of less than 20
suggests a diagnosis of dementia, delirium, schizophrenia or affective disorder. Such a score
is not found in normal elderly people or in those with a primary diagnosis of neurosis or
personality disorder. The test is not expected to replace a complete clinical appraisal
described above (in brief), in reaching a final diagnosis.