Neuropsychological Assessment of Mental State

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Neuropsychological Assessment of Mental State
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Role of Mental Status Examination

• Any patient who has a known brain lesion from
  tumor, trauma, or cerebrovascular accident, as
  well as those with suspected psychiatric and
  organic disease should have a screening mental
  status evaluation to document any cognitive or
  emotional changes.
• Many patients with mild aphasias or memory
  deficits after craniotomy, increased irritability
  and decreased ability to concentrate after head
  trauma, or marked emotional lability following
  infections neurologic disease are released from
  the hospital without recognition of these
  cognitive and emotional deficits.

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Role of Mental Status Examination

• Such patients frequently become emotionally
  frustrated, have difficulty with social
  readjustment, and are unable to carry out the
  demands of home and vocation.
• Early recognition of the neurobehavioral sequelae
  of a known neurologic disorder will help us
  explain the totality of the patients disability
  to family and possibly employers.

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Role of Mental Status Examination

• Mental status screening is extremely important in
  patients who initially present with or brought by
  their families with vague behavioral complaints
  of memory problems, difficulty in concentration,
  declining interest in family or work to determine
  the possibility of organic brain disease.
• Bedside or office mental status examination is
  very effective in diagnosing organic disease and
  for evaluating major areas of deficit.
• By its nature, the examination is qualitative,
  and is not meant to replace standardized
  quantitative testing for evaluating subtle
  deficits, planning for comprehensive
  rehabilitative efforts, and assessing
  improvements in performance.

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Goal of Mental Status Examination

• Mental status testing should be performed in an
  orderly way, with assessment of basic processes,
  such as the level of consciousness, attention,
  and vigilance first, and the higher-level
  functions such as abstract reasoning and special
  cognitive functions tested last.
• The goal of the mental status examination is to
  determine
• Level of consciousness
• Orientation to person, place, and time
• Attention span
• Concentration
• Memory
• Insight
• Judgment and
• Ability to calculate

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Level of Consciousness

• The level of consciousness or wakefulness can
  range from deep coma to anxious hyperalertness.
• This level can be determined by the intensity of
  the stimulation required to elicit a response
  from the patient.
• In coma or stupor, intense stimulation, often
  noxious in nature, is required to provoke a
  response.
• This contrasts with the normal state of
  wakefulness in which the patient is responsive
  even to the subtlest cues.

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Orientation to Time, Place, and Person

• The formal examination of mental status starts
  with questions related to orientation to time,
  place, and person.
• Orientation to time should progress from year
  through season, month, and date to day of the
  week.
• Orientation to space starts with current actual
  locati0n (e.g., patient room in hospital) and
  city, then goes to county, state, and country.
• The patient should be asked to state his/her full
  name and try to identify any person accompanying
  him/her.

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Memory Evaluation

• Memory evaluation should be divided into tests of
  immediate and recent recall.
• Immediate recall is tested by asking the patient
  to immediately repeat a random sequence of
  numbers (digit span).
• Digits can be presented in groups of increasing
  numbers (from 3 to 6).
• Normal adults can readily repeat sequences of
  five to six numbers without error, and most
  adults are able to reverse the number sequence
  successfully.

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Memory Evaluation

• Great difficulty in reversing the sequence may be
  a subtle sign of cognitive impairment.
• Recent recall is tested by presenting the patient
  with three to four unrelated words, asking the
  patient to remember them, and then proceeding
  with other elements of the mental status
  evaluation.
• After 3 to 5 minutes, the patient should be asked
  to repeat the previously given words.
• Unimpaired patients will be able to recall at
  least two to three words.

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Memory Evaluation

• Impairment of recent recall is often affected
  early in dementing processes and may reflect the
  frequent historical complaint that the patient
  has to be repeatedly told things and does not
  seem to remember events.

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Concentration and Calculating Ability

• Concentration and calculating ability are
  evaluated by the use of serial 7s.
• The patient is asked to subtract 7 in a
  sequential manner from 100.
• Finger gnosis, right-left orientation, and
  ability to perform three-step commands can be
  assessed by asking the patient to take his right
  index finger and touch his right ear and close
  his eyes.

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Speech and Language

• Language can be quickly assessed by evaluating
  spontaneous speech, repetition, comprehension of
  spoken and written material, and the ability to
  write.
• Speech may be fluent or nonfluent.
• The presence of aphasia may prevent adequate
  memory and other cognitive testing.
• Apraxia can be evaluated by asking the patient to
  demonstrate how to comb his/her hair, salute, or
  use a screwdriver.
• The ability to draw a clock and to copy a three
  dimensional representation of a cube can be
  useful in detecting visual field deficits and/or
  left hemispatial neglect.

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The Mini-Mental State Examination

• The Mini-Mental State Examination (MMSE
  Folstein, Folstein, McHugh, 2097) is an 11 item
  tool that can be used to systematically and
  thoroughly assess mental status in five areas of
  cognitive function
• orientation,
• registration,
• attention and calculation,
• recall, and
• language.

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The Mini-Mental State Examination

• The maximum score is 30.
• A score of 23 or lower is indicative of cognitive
  impairment.
• The MMSE takes only 5-10 minutes to administer
  andis therefore practical to use repeatedly and
  routinely.

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Goals of Assessment for Focal Disorders

• The goals of speech and language assessment
  following a mental status examination will depend
  upon the period of time since onset of the
  neurological insult and the questions that need
  to be answered.
• In early stages (acute) following neurological
  onset, the goal of assessment is to make a brief
  assessment of language skills.
• Once the patients physical condition improves
  and stabilizes medically, the goal is to make a
  more thorough assessment of communication skills.

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Goals of Assessment for Focal Disorder

• If one suspects aphasia, assess expressive,
  receptive, and gestural communication, in order
  to identify initial treatment targets.
• If one suspects a right hemisphere disorder,
  evaluate for perceptual and attentional deficits,
  as well as assess communication disorders
  associated with right hemisphere syndrome, in
  order to support or justify a diagnosis of right
  hemisphere disorder and to identify initial
  treatment targets.

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Case History/Interview Focus

• Assessment techniques used across disorders of
  communication include case history, hearing
  screening, interview, orofacial examination, and
  speech and language sampling.
• Using the patients medical chart and interviews
  with family members, obtain information on the
  onset and recovery from stroke or other clinical
  condition.
• Consider the results of medical neurodiagnostic
  techniques.

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Case History/Interview Focus

• Consider the results of available psychological,
  cognitive, physical therapy, and related
  assessment information.
• Consider the clients current medical condition
  and prognosis.
• Collect biographical information, including
  education, occupation, literacy, and premorbid
  intellectual and communication skills, as well as
  current family communication patterns.

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Ethnocultural Considerations

• Factors related in an individuals cultural,
  ethnic, social, and personal variables may affect
  assessment of communication disorders.
• We will discuss ethnocultural perspectives more
  thoroughly later in the course, but during the
  interview process, explore
• how the clients culture views the etiology,
  effects, and social significance of focal
  disorders
• how the clients culture views communication and
  communication disorders

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Ethnocultural Considerations

• how the family views assessment and treatment and
  what expectations they have of clinical services
  and
• the extent to which a member of a cultural group
  is different from the majority group (e.g., an
  African-American who does not speak a Black
  English dialect).
• Select standardized tests that have, in their
  standardization process, sampled the
  ethnocultural group to which the client belongs.

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Ethnocultural Considerations

• If culturally appropriate standardized tests are
  not available, design client-specific assessment
  procedures.
• If client is bilingual/multilingual, use trained
  interpreters in the assessment process and
  determine whether a communication disorder exists
  in the primary language, the secondary language,
  or both.

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Assessing Specific Communication Skills

• Specific communication skills can be assessed
  through clinician-assembled diagnostic protocols,
  or through administration of standardized tests
  of aphasia.
• When selecting a standardized test, consider the
  one that is appropriate for the client,
  practical, or preferred because of your
  experience with it.
• Standardized tests of aphasia and/or
  client-specific assessment protocols usually have
  a common/standard set of procedures for assessing
  receptive and expressive language, as well as
  associated motor speech disorders.

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Assessing Specific Communication Skills

• When selecting or designing an assessment
  protocol to use with left hemisphere focal
  disorders, consider the following
• Obtain a language (discourse) sample.
• Assess auditory comprehension deficits, moving
  from simple to complex tasks.
• Assess verbal fluency, including phrase length,
  speech rate, rhythm and intonation,
  grammaticality, speech articulation.
• Assess repetition skills at single word,
  multisyllabic, and phrase/sentence levels.

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Assessing Specific Communication Skills

• Assess word finding and naming skills.
• Assess the use of sentence structures and types,
  including morphological features.
• Assess understanding or usage of gestures.
• Assess reading problems, including comprehension
  of silently read material and oral reading.
• Assess writing problems, including graphomotor
  skills and written expression.
• Assess pragmatic communication problems.

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Assessing Specific Communication Skills

• When selecting or designing an assessment
  protocol to use with right hemisphere focal
  disorders, consider the following
• left-sided neglect and attentional deficits
• disorientation
• constructional impairment
• affective deficits
• denial of illness
• impaired inference
• impaired reasoning, planning, organizing, and
  problem-solving skills

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Assessing Specific Communication Skills

• problems in logical reasoning and
• other behavioral deficits
• In terms of communication ability, take a
  conversational speech sample and assess
• Prosodic problems
• Inappropriate and anomalous speech
• Problems in distinguishing significant from
  irrelevant information
• Problems in comprehending applied meaning
• Problems in integrating information
• Problems in speech pragmatics

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Assessing Specific Communication Skills

• Auditory comprehension of language
• Word-retrieval problems
• Reading and writing problems and
• Motor speech disorders

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Communicative Cognitive Characteristics

• Analyze the results of your assessment to obtain
  the strengths and limitations of the client.
• Summarize the communication deficits.
• To diagnose aphasia, language disturbance should
  be due to recently acquired cerebral injury,
  except in some rare cases of gradual onset.
• Language disturbances should outweigh any
  intellectual deficits observed.
• To diagnose right hemisphere disorder, history
  and medical evidence should be consistent with
  right hemisphere injury, especially strokes,
  tumors, or head trauma.

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Communicative Cognitive Characteristics

• More pronounced perceptual and affective
  disorders than specific language disorders should
  be evidenced.
• A communication disorder should outweigh specific
  loss of language functions.
• With either left or right hemisphere injuries,
  case history and available medical data
  (including neurological, radiological, and
  related data) should support the diagnosis of
  aphasia or right hemisphere syndrome.
• Patterns of deficit observed should help rule out
  related and similar disorders.

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Aphasia Versus Normal Language
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Aphasia Versus Schizophrenia
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Aphasia Versus Schizophrenia (Cont.)
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Aphasia Versus Right Hemisphere Disorder
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Aphasia Versus RH Disorder (Cont.)
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Aphasia Versus Apraxia of Speech
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Aphasia Versus Dysarthria