Lecture 4
- 1. V550 Mental Status Richard E. Meetz, OD, MS 2009v3
- 2. Mental Status After the Hx is recorded, you will need to make an assessment of the patient’s mental status. NOTE: The mental status is actually part of the Objective examination and not part of the history, but the status is assessed as the history is conducted.
- 3. Mental Status By evaluating the patient’s Appearance and behavior Speech and language Affect and mood Orientation To person, place and time Thought and perceptions Cognitive functions
- 4. Appearance and Behavior A patient’s appearance and behavior are important indicators of general level of function. A well-dressed, well-organized patient is “probably” functioning at a higher level than one who is disheveled and unkempt. Important to note “is the dress appropriate for the situation and weather.”
- 5. Appearance and Behavior Posture (see earlier lecture on patient types) Grooming and personal hygiene Deteriorate in some disorders Depression, schizophrenia & dementia Excessive care in obsessive-compulsive disorder (OCD) One sided neglect seen in some strokes or lesions of the non-dominate parietal cortex
- 6. Speech and Language The character of the patient’s speech provides insight into the patient’s mental state. Aspects of speech; Amplitude or loudness Volume or amount Prosody or fluidity
- 7. Speech and Language Language can be assessed by evaluating: Spontaneous speech Repetition Comprehension of spoken & written material The ability to write
- 8. Speech and Language Language and vocabulary are fairly good indicators of intelligence. They are relatively unaffected by any but the most severe disorders. Can help distinguish between a mentally retarded adult (limited vocabulary) from those with mild or moderate dementia and a fairly well preserved vocabulary.
- 9. Speech and Language Disorders of Speech Fall into 3 groups The voice The articulation of words The production & understanding of language
- 10. Speech and Language Disorders of Speech: the voice Aphonia : loss of voice 2° to nerve or larynx disease or it’s nerve supply (CN X) - cancers - stroke Dysphonia: less severe impairment in volume, quality or pitch (hoarseness) - laryngitis - local damage (intubation, strain, smoking)
- 11. Speech and Language Disorders of Speech: articulation Dysarthia : defect in muscular control 2° to motor lesions, (lips, tongue, palate, ect) Words maybe: - nasal, slurred or indistinct But language remains intact Causes: - parkinsons - cerebellar Dz - both CNS & perpheral NS defects
- 12. Speech and Language Disorders of Speech: language Aphasia : central NS defect in producing or understanding language. Types: Receptive (fluent) Expressive (non fluent)
- 13. Speech and Language Disorders of Speech: language Aphasia : Receptive (fluent) Speech is rapid without effort Speech may lack meaning, made-up Reading, writing and Word comprehension are impaired Naming objects is impaired Repetition is impaired
- 14. Speech and Language Disorders of Speech: language Aphasia : Expressive (non fluent) Speech is slow, few words, laborious Inflection & articulation are impaired Speech is meaningful with good construction Nouns & verbs Word comprehension & reading is fair to good But writing is impaired Naming objects is impaired But are recognized Repetition is impaired
- 15. Speech and Language Speech and Language pathology: Parkinson’s Dz patients will speak with a hypophonic, hushed quality. Note:Facial features: - Masklike face with decreased blinking. (2-3/min) -Classic stare with chin down and fixation peering upwards
- 16. Speech and Language Speech and Language pathology: A Parkinson’s patient will also write extremely small “micrographia” that becomes progressively smaller over time.
- 17. Speech and Language Speech and Language pathology; In strokes the type of speech pattern will help localized the lesion In frontal lobe lesions, the patient will have non-fluent speech, “ Broca’s aphasia,” with hemiparesis In temporal lobe lesions, the speech will be fluent but makes little to no sense Wernicke’s Aphasia
- 18. Thought and perceptions Assess the logic the patient uses in words and speech throughout the history taking. Does the speech/thinking progress in a logical manner? Is the content of their answers relevant to the question asked?
- 19. Thought and perceptions Assess the patients insights and judgment Insights After the RFV ask what they think might be causing their complaint Pts with psychotic disorders often lack insight into their problems Pts with neurologic disorders often are in denial of their problems
- 20. Thought and perceptions Assess the patients insights and judgment Judgment Note pts response to “How did you…” type of questions Use of money, conflicts, job or family situations Pts with disorders often lack good judgment Note whether decisions and actions are based on reality Impulse, wish fulfillment, values Note there are some cultural variations
- 21. Thought and perceptions Variations & abnormalities of speech Circumstantiality (delay 2° to detail) Derailment (Loosening of associations) Flight of ideas (accelerated flow) Neologisms (invented or distorted words) Incoherence (lack of connections disordered grammar or words) Blocking (sudden stop before end of thought) Confabulation (fabrications of facts) Perseveration (persistent repetition of words) Clanging (using rhyming & punning speech)
- 22. Thought and perceptions Abnormalities in content Neurotic disorders Compulsion (repetitive behaviors or mental acts) Obsessions (recurrent, uncontrollable thoughts) Phobias (persistent, irrational fears) Anxieties (apprehensions, fears & tensions) Focused = phobia Free floating = ill-defined dread or doom
- 23. Thought and perceptions Abnormalities in content Psychotic disorders Feeling of unreality (feeling that all is unreal or remote) Feeling of depersonalization (detached from self) Delusions (false fixed beliefs)
- 24. Thought and perceptions Abnormalities in perception Illusions Hallucinations
- 25. Thought and perceptions Abnormalities in perception Illusions Misinterpretations of real external stimuli Can occur in grief reactions, delirium, traumatic stress disorders & schizophrenia
- 26. Thought and perceptions Abnormalities in perception Hallucinations Sensory perceptions in the absence of relevant external stimuli May be auditory, visual, olfactory, tactile, ect May occur in delirium, dementia, alcoholism, traumatic stress disorders & schizophrenia Perceptions associated with dreaming are not classified as hallucinations
- 27. Affect How a person reacts to various topics. The “affect” is not the assessment of mood but the observation of voice, facial expression or demeanor in response to topics .
- 28. Mood Mood is a more sustained emotion. Refers to a person’s persistent emotional state. Includes sadness, melancholy, contentment, joy, euphoria,anger & rage, anxiety & worry. Abnormality of mood fall into either depression or mania (bipolar).
- 29. Mood Depression is seen in a number of neurological Dz. Parkinson’s Dz Huntington’s Dz Strokes affecting the dominant hemisphere Mania may be seen occasionally in cerebral lesions.
- 30. Mood Evaluation of Depression & risk of suicide Ask: Do you get pretty discouraged? How do you feel? Do you think your depressed? Do you feel like you want to end it? Do you have a plan? If yes think: SAL 1. Is the method specific ? 2. Is it available ? 3. Is it lethal ?
- 31. Affect Assessment You need to observe if the affect varies appropriately with the topic under discussion. Does the patient look sad as they talk of the death in their family or do they laugh?
- 32. Affect Descriptors: Normal “ Appropriate” (for the situation) “ Full range” Abnormal Apathy Blunted Flat Labile (fluctuating more than “normal”)
- 33. Orientation Is the patient oriented to person, place and time? Person: Who they are and who you are, relatives? Place: Where they are now, residence? Time: Approximate date, time of day, year, season?
- 34. Orientation For normal patients we use: ‘ Patient Oriented X3’ as the recorded observation. Abnormal orientation would be recorded as: ‘ Patient Oriented X2, confused for time/day’ … with the missing component noted.
- 35. Recording Mental Status: In the patient’s chart both affect and orientation are recorded. Examples : “ Appropriate & Oriented X3” for normal patients “ Inappropriate & Oriented X3” for a patient who laughs at all our questions
- 36. Recording Abnormal Mental Status: Examples (cont’d): “ Flat & Oriented X3” - might be seen in a patient with early Parkinson’s. “ Apathetic & Oriented X2” – confused for time or date, might be seen in dementia. “ Labile & Oriented X3” - might be seen in a patient with grief.
- 37. Abnormal Mental Status: Evaluation of abnormal mental status Assessment of cognitive functions Attention Remote memory Recent memory Learning ability Vocabulary Math ability / calculation Abstract thinking Construction ability
- 38. Abnormal Mental Status: Evaluation of abnormal mental status Assessment of cognitive functions Attention Digit span Give the patient a series of numbers two at a time, asking the patient to repeat them back to you. After several correct try again with three then four. Serial 7s Have the patient count backwards in 7s from 100 Spelling backwards Have the patient spell a word backward Typically most use the word “world”
- 39. Abnormal Mental Status: Evaluation of abnormal mental status Assessment of cognitive functions Remote memory Long term memories; family birthdays, grade schools, jobs, events relevant to patients past May be impaired in late stage dementia Recent memory Events of the day, meals, weather, ect Impaired in Anxiety, dementia, delirium Learning ability Tell the patient you are going to give them 3 unrelated words to remember, then after 3 to 5 min ask the patient to recall the words
- 40. Abnormal Mental Status: Evaluation of abnormal mental status Assessment of cognitive functions Vocabulary Estimate of patients intelligence Math ability / calculation Ask simple addition & multiplication Ask example of change making problem “ You pay for a 78 cent item how much change should you get?”
- 41. Abnormal Mental Status: Evaluation of abnormal mental status; other tests: abstract thinking Tests the capacity to think beyond the Q Proverbs Ask the patient what people mean when they use the a saying or proverb such as: “ The squeaking wheel gets the grease” “ A stitch in time saves nine” A concrete response is often given by people with MMR, delirium, schizophrenia or dementia A schizophrenic may also give a normal or odd ans
- 42. Abnormal Mental Status: Evaluation of abnormal mental status; other tests: abstract thinking Tests the capacity to think beyond the Q Similarities: Ask the patient how the following are alike: An orange and an apple Wood and coal A cat and a mouse An abstract response would be both are animals A concrete response would be both have tails
- 43. Abnormal Mental Status: Evaluation of abnormal mental status; other tests: Constructional ability Clock test Patient draws a clock face If poor suggests dementia or parietal damage
- 44. Abnormal Mental Status: Evaluation of abnormal mental status Mini-mental status examination (MMSE) Highly reliable & validated 30-pt test Check orientation Repeat the names of 3 objects Concentration “spell WORLD backward” or serial 7s Name 2 objects Repeat: “No ifs, ands, or buts” Write a sentence Read and enact a sentence “close your eyes” Copy a figure (two interlocking pentagons) Recall the 3 names of object repeated earlier However, Insensitive in detecting dementia
- 45. Abnormal Mental Status: Evaluation of abnormal mental status; other tests Cognitive Impairment Test (CIT) Shorter 6 item test Correlates well with the MMSE Sensitive in detecting dementia
- 46. Mental Status Exam; CIT
- 47. Abnormal Mental Status: Mental Health Disorders in 1° care
- 48. Abnormal Mental Status: Mental Health Disorders in 1° care Est. 20% of 1° care patients > 50% undiagnosed Prevalence: Anxiety 20% Mood Disorders 25% Depression 10% Somatoform Disorders 10 to 15% Alcohol & substance abuse 15 to 20%
- 49. Abnormal Mental Status: Mental Health Disorders in 1° care Unexplained symptoms 1/3 of patients medical patients 20 to 25% chronic Sx 50% assoc with depression or anxiety Co-occurrence of functional Sx reach 30 to 90% IBS, TMJ, fibromyalgia, chronic fatigue, Mult Chem Sen Near 80 to 90% Sx overlap with: fatigue, sleep disturbance, HA, GI Sx
- 50. Abnormal Mental Status: Types of Disorders Somatoform Disorders Character Disorders Disorders of Mood Anxiety Disorders Psychotic Disorders Temporal lobe epilepsy Dementias & Alzheimer’s
- 51. Abnormal Mental Status: Types of Disorders Somatoform Disorders Defn: Chronic, multisystem complaints lacking an adequate medical or physical explanation Sx include pain, GI, sexual dysfunction and neurologic symptoms Onset early in life, psychosocial & vocational achievements are limited
- 52. Abnormal Mental Status: Types of Disorders Somatoform Disorders Pain disorder 1° Sx is pain of psychological origin Conversion disorder Mimics neurologic disorder in which psychological factors are etiologic, patients may not realize stress factor Sx: HA, pain, paralysis Hypochondria Preoccupation with idea of having a serious Dz Body dysmorphic disorder Preoccupation with imagined or exaggerated defect in physical appearance
- 53. Abnormal Mental Status: Types of Disorders Other Somatoform-like Disorders Factitous disorder Intentional production or feigning of physical signs without external reinforcers Munchausen syndrome; inflict physical harm on themselves or inflict / provoke symptoms in a child Malingering Intentional production or feigning of physical signs with external reinforcers /gain clearly present Most common Opt Presentation: 6 - 8 yo Fe wanting glasses
- 54. Abnormal Mental Status: Other Somatoform-like Disorders Dissociative disorder Disruptions of consciousness, memory, identity or perception judged to be due to psychological factors Dissociative amnesia Unable to remember traumatic events Dissociative fugue Acting in complex ways, travel with out memory of Dissociative identity AKA: multiple personality disorder Switching from one coherent personality to another Depersonalization disorder Recurrent episodes of feeling outside of ones body
- 55. Abnormal Mental Status: Types of Disorders Character Disorders AKA: “personality disorders” “difficult patients” 6% of population Assoc with alcohol & substance abuse (30-59%) Dysfunctional interpersonal coping skills Early onset, not due to substance abuse, long term Behavioral traits formed in early childhood 30% sexual abused Impulsive 50% attempt suicide or self mutilation
- 56. Abnormal Mental Status: Types of Character Disorders Paranoid - distrust & suspicious Schizoid – detached, restricted range of emotions Schizotypal – eccentric with cognitive distortions Antisocial – disregard for others, no remorse Borderline – instability in relations & self-image Histrionic – emotional overreactions, theatrical Narcissistic – grandiosity, need for admiration Avoidant – social inhibition, hypersensitivity Dependant – submission, clinging behavior Obsessive-compulsive –rigid, detailed, repetitive
- 57. Abnormal Mental Status: Types of Disorders Disorders of Mood 30% of pop Major depressive episode Manic episode Mixed episode Hypomanic episode Bipolar I and II Dysthymic and Cyclothymic disorders
- 58. Abnormal Mental Status: Disorders of Mood Major depressive episode 10 to 15% of pop More common in females 2:1 Peck onset; 30 to 40 yo, 13% of postpartum Fe, 5% of adolescents, 30 - 40% in elderly 20 - 40% in pts with comorbid medical Dz Genetic links 2-3X risk with Dx 1° relatives 50% in twins Relapse > 60%
- 59. Abnormal Mental Status: Disorders of Mood Major depressive episode Diagnosis Must have a change from their normal state with either: Depressed mood most of the day nearly every day Sig wt gain or loss, change in appetite nearly every day Plus: 3 or 4 of the following nearly every day Insomnia, agitation, fatigue, feeling of worthlessness or guilt, loss of concentration, recurrent thoughts of death or suicide
- 60. Abnormal Mental Status: Disorders of Mood Manic episode Dx period of persistently elevated, expansive or irritable mood X 1week with 3 of the following Sx Inflated self-esteem or grandiosity Decreased need for sleep (< 3 hrs) More talkative than usual or pressure to keep talking Flight of ideas or racing thoughts Distractibility Increased agitation Excessive involvement in high-risk activities Severe enough to impair function
- 61. Abnormal Mental Status: Disorders of Mood Mixed episode Having both major and manic depressive episodes Each episode last at least a week each Hypomanic episode The mood and Sx similar to a manic episode Less impairing, do not require hospitalization No hallucination or delusions Sx are shorter, minimum in duration - min 4 days
- 62. Abnormal Mental Status: Disorders of Mood Bipolar Disorders Gen pop ≈ 2%, genetic linked Pos Hx 5-10% risk, Male /Female 1:1, rapid cycling freq in females Bipolar I Includes one or more manic or mixed episodes, accompanied by major depressive episodes Bipolar II Includes one or more major depressive episodes accompanied by at least one hypomanic episodes
- 63. Abnormal Mental Status: Disorders of Mood Dysthymic disorders Minor depressed mood & Sx for most of the day, for more days than not, over at least 2 years Freedom from Sx last no more than 2 months at a time Cyclothymic disorders Noted for numerous periods of hypomanic and minor depressive symptoms that last for at least 2 years Freedom from Sx last no more than 2 months at a time
- 64. Abnormal Mental Status: Types of Disorders Anxiety Disorders Panic disorder Agoraphobia Phobias Social phobia Obsessive-compulsive disorder Acute Stress disorder Posttraumatic Stress disorder General Anxiety disorder
- 65. Abnormal Mental Status: Types of Disorders Psychotic Disorders Schizophrenia Schizophreniform Disorder Schizoaffective Disorder Delusional Disorder Brief Psychotic Disorder Substance-induced Psychotic Disorder
- 66. Abnormal Mental Status: Types of Disorders Temporal lobe epilepsy Abnormal electrical discharge most often 2° to old temporal lobe trauma Most common in the elderly Must DDx from other Disorders Sx: sudden unprovoked change in behavior Temporal pattern of “spells” “ Aura” ; feeling or sensation (odor) Automatisms; lip smacking, eye blinking, pilling Change in level of consciousness
- 67. Abnormal Mental Status: Types of Disorders Dementias & Alzheimer’s Dementia – 30% of those > 85yo Alzheimer’s (AD) – 70% of Dementias Vascular Dementia Parkinson’s – Lewy Body Dz Parkinson’s Plus – with dementia Hydrocephlic Dementia Delirium Metabolic & Hematologic Disorders
- 68. Abnormal Mental Status: Types of Disorders Dementias & Alzheimer’s Dementia – 30% of pop> 85yo Alzheimer’s (AD) – 70% of Dementias Early onset vs late onset Early onset – 30- 60yo rare 2%, genetic #21 Late onset - >65yo common 98% Clinical presentation: Gradually progressive decline in multiple functions; memory, orientation, judgment, insight, language Depression frequently early Psychosis, agitation, behavioral disinhibition late
- 69. Abnormal Mental Status: Types of Dementias Vascular Dementia – 10% of dementias, 2° strokes Onset after CVD Sx stepwise Early incontinence, gait disturbances, flatted affect Parkinson’s – Lewy Body Dz 2 nd most common dementias Parkinson’s – brain stem findings of Lewy bodies Slow movement, tremors, rigidity, balance problems Parkinson’s Plus – with dementia, diffuse Lewy bodies Above Sx and visual hallucinations, cognitive fluctuations Death ≈ 1 year after Dx
- 70. Abnormal Mental Status: Types of Dementias Hydrocephalic Dementia Late onset hydrocephalic > 85 yo Sx: motor slowing, impaired affect & mood, gait instability, urinary incontinence Gait is wide with shuffling walk Sx evolve slowly over weeks Delirium AKA: Acute confusional state, toxic encephalopathy Acute onset, hours to days, fluctuates 2° to medical condition; 10% of hospitalized pts Drugs, anesthesia, infections, stress, endocrine Sx: disorientation, excitement, defective perceptions with illusions and hallucinations
- 71. Abnormal Mental Status: Types of Disorders Substance-Related disorders 15% of pop, males > females, Onset 25 -30 yo Types Sedatives: alcohol, barbiturates, benzodiazepines Sx: acute lethargy, disorientation stupor, memory loss, apathy Hallucinogens:cannabis, opioids, mescaline, phencyclidine Sx: defective perceptions with illusions and hallucinations Stimulants: amphetamine, caffeine, cocaine Sx: agitation and paranoia Substance-induced Psychotic Disorder Sx can be induced with intoxication or withdrawal More common with alcohol, cocaine and opioids Sx: Delusions & hallucinations, seizures
- 72. Mental Status Reference & readings Bates’ Guide to Physical Examination and History Taking , 7th Ed. (Red) Lippincott, Chap 3; pgs 107-122 & 123-127 Or Bates’ Guide to Physical Examination and History Taking 8th or 9 th Ed. (both black) Chap 16