MENTAL STATUS EXAMINATION. Outline Operational definition Purposes Components –Behavior...

MENTAL STATUS EXAMINATION

Outline• Operational definition

• Purposes

• Components– Behavior– Cognition– Emotion

• Cognitive examination

• Mini Mental Status

MENTAL STATUS EXAMINATION: What is it?

ASSESSMENT of the:• Behavior (see it all)• Emotion (see some of it)• Cognition (see none of it)Exhibited by the patient during the

entire medical encounter

PURPOSES• Detect• Describe• Neuroanatomical localization• Assess functional implications of

Abnormalities/deficits in:• Behavior• Emotion• Cognition

ABNORMALITIES & DEFICITS

Require diagnostic explanation

May compromise capacity • to coherently and reliably describe

medical state• to give informed consent• to adhere to a therapeutic plan

MEDICALENCOUNTER

Comprehensiveglobal assessment

BEHAVIORAppearanceAttitudeActivitySpeechDressGroomingHygiene

BEHAVIORAppearanceAttitudeActivitySpeechDressGroomingHygiene

COGNITIONThought contentThought progressionInsight/judgment

BEHAVIORAppearanceAttitudeActivitySpeechDressGroomingHygiene

COGNITIONThought contentCoherenceGoal directednessInsight/judgment

OperationsArousalAttentionMemoryEmotionLanguageReasoning

BEHAVIORAppearanceAttitudeActivitySpeechDressGroomingHygiene

EMOTIONAffectMoodSuicideHomicide

COGNITIONThought contentCoherenceGoal directednessInsight/judgment

OperationsArousalAttentionMemoryEmotionLanguageReasoning

BEHAVIORAppearance appears stated age, uses a cane to walk

Attitude cooperative, hostile, detached

Activity normal, increased, agitated, subdued

Speech normal rate/rhythm, dysarthric

Dress casual, provocative, dirty

Grooming disheveled, meticulous

Hygiene clean, malodorous

COGNITIVE EXAM (“Mental status”)

REASONING

LANGUAGE

MEMORY

ATTENTION

AROUSAL

COGNITIVE EXAM (“Mental status”)

REASONING

LANGUAGE

MEMORY

ATTENTION

AROUSAL

Must know education Can the

patienthear?

MEMORY

Immediate memory = attentionRecent memory (episodic)

Recall of three words at 5 minutesEnsure that pt has registered the items“Repeat these words after me, I want you to remember them.”

Remote memory (semantic & episodic)Tends to overlap with knowledge, most of what we ask is overlearnedPresidents, date of W.W.II, etc..

REASONING (Higher cognitive fx)Tests problem solving, abstract thinkingFund of knowledge - overlaps with remote memory

How many weeks in a year?Name four presidents since 1940?What causes rust?

CalculationsAdd, subtract, multiple, divideSequences

1, 2, 3, ...1, 4, 9, 16, ....2, 3, 5, 7, 11, ...

REASONING (continued)

SimilaritiesApple - orangeCar - airplanePoem - novel

ProverbsDon’t cry over spilt milkA stitch in time saves ninePeople who live in glass houses shouldn’t throw stones

BEHAVIORAppearanceAttitudeActivitySpeechDressGroomingHygiene

COGNITIONThought contentThought progressionInsight/judgmentArousalAttentionMemoryLanguageReasoning

EMOTIONAffectMoodSuicideHomicide

EMOTIONAFFECT “Affect is to weather as mood is to climate”• predominate sad, euphoric, angry, anxious• intensity unmodulated• range narrow, broad• congruence incongruent with contentMOOD euthymic, dysthymic, elatedSUICIDE Do you ever wish you won’t wake up?

Does it ever seem that life isn’t worth it?

HOMICIDE Is there someone who deserves to be hurt?

MEDICALENCOUNTER

Comprehensiveglobal assessment

Focusedselected assessment

IN PRACTICE, MOST ENCOUNTERSARE FOCUSED

• Accordingly the formal mental status exam is often limited to an assessment of COGNITION

• Further cognition is often assessed solely using:

• ORIENTATION

TO ORIENTTo understand

one’srelationship to the

environment

PersonPlaceTime

Situation

“Oriented X 3”“O X3”

PersonPlaceTime

Situation

“Oriented X 3”“O X3”

“Oriented X 4”“OX4”

PersonPlaceTime

Situation

“Oriented X 3”“O X3”

“Oriented X 4”“OX4”

ORIENTATION ASSESSES:

• language• perception• reasoning • remote memory• recent memory

More preciseMore comprehensiveLonger Statistical norms

Less preciseLess comprehensiveShorterExaminer norms

Orientation Full mentalstatus

Mini Mental Status

NeuropsychologicalTesting

MINI MENTAL STATE EXAMADVANTAGES• brief (10 min), systematic bedside instrument• wide recognition among physicians• since it is standardized, the score it yields is meaningful to

physicians familiar with itDISADVANTAGES• specific deficits may be ignored if the overall score is not low

(less than 25 out of 30)• the global score has no localizing valve• repeated use with intact patients produces a mechanical

transaction

• Examiner uses paper and pencil• Total of 30 points

orientation (10)

recent memory (3)

attention (3)

calculation, spell backward (5)

name, read, repeat (4)

write (1)

constructional ability (1)

ideomotor praxis (3)• Not timed

What is the (year) (season) (date) (day) (month)?Where are we? (state) (county) (city) (hospital) (floor)(10)

Ask pt to repeat three objects - give one per second.Number repeated first trial = score (3). Present till allrepeated or 6 presentations.

Serial 7’s - 5 subtractions (93, 86, 79, 72, 65) (5). Scorenumber of correct answers or spell “world” backward, score is number of letters in correct order. “dlorw” is3 points.

What is the (year) (season) (date) (day) (month)?Where are we? (state) (county) (city) (hospital) (floor)(10)

Ask pt to repeat three objects - give one per second.Number repeated first trial = score (3). Present till allrepeated or 6 presentations.

Serial 7’s - 5 subtractions (93, 86, 79, 72, 65) (5). Scorenumber of correct answers or spell “world” backward, score is number of letters in correct order. “dlorw” is3 points.

Ask the patient to name a watch and a pencil. (2)

Ask the patient to say “No ifs, ands or buts” (1).

Ask the patient to recall the three words (3).

Ask the pt to read and follow the command:“Close your eyes”. Score (1 ) only if closes eyes.

Ask the pt to write a sentence. It must have asubject and a verb and be sensible. Ignore grammar and punctuation (1).

Ask the patient to name a watch and a pencil. (2)

Ask the patient to say “No ifs, ands or buts” (1).

Ask the patient to recall the three words (3).

Ask the pt to read and follow the command:“Close your eyes”. Score (1 ) only if closes eyes.

Ask the pt to write a sentence. It must have asubject and a verb and be sensible. Ignore grammar and punctuation (1).

Place a piece of paper where the patient can reach it with either hand. Ask him/her to:(1) pick it up, (2) fold it in half, (3) lay it on the floor. 1 pt for each step executed correctly (3).

Ask the patient to copy a drawing of intersectingpentagons. All 10 angles must be present and twomust intersect to create a 4 sided figure. Ignoretremor and rotation (1).

Place a piece of paper where the patient can reach it with either hand. Ask him/her to:(1) pick it up, (2) fold it in half, (3) lay it on the floor. 1 pt for each step executed correctly (3).

Ask the patient to copy a drawing of intersectingpentagons. All 10 angles must be present and twomust intersect to create a 4 sided figure. Ignoretremor and rotation (1).

Normals can be expected to score > 25

However, even with > 25, if 0/3 or 1/3 for recentmemory or problems with naming, repeating, writing or reading suggest focal deficits.

It is most sensitive to disturbances which broadly effect function, it may miss subtle,focal problems.

You may not always do a MMS:

•Too little time

•Patient becomes agitated at challenge

However, even without an MMS

Interacting with the patient and obtaining a

history have provided information to write

up a mental status exam

Lesson: YOU DO NOT HAVE TO DO

AN MMS TO THOROUGHLY EXAM A PT