Mental Status Exam

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Mental Status Exam

• Pharmacy Practice 741
• October 4, 2004

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Mental Status Exam (MSE)

• Used in every client encounter
• Conducted mostly in interview process, but
  continues throughout exam
• Learn to integrate mental status into the history
  so less like an interrogation/test
• Some overlap with general survey
• Only need to record once
• In episodic write-ups, may use mental status
  section and little or no general survey

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Aspects the facilitate the exam

• This is evaluated throughout the PE
• Patient awareness
• Orientation
• Cognitive abilities
• Affect
• If in doubt interview a family/independent
  observer
• Note variations in responses to ?

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Techniques to assess Mental Status

• Observation of physical appearance
• Cognitive abilities
• How pt responds to your questions
• 6 item cognitive impairment test
• MMSE
• Pt have resources to meet their daily needs
• Listening to pt speech and language skills

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Complete Mental Status Exam

• Appearance and Behavior
• Level of Consciousness
• Posture and Motor Behavior
• Dress, Grooming and Personal Hygiene
• Facial Expression
• Manner, Affect and Relationship to Persons and
  Things
• Speech and Language
• Quantity
• Rate
• Loudness
• Articulation of Words
• Fluency
• Mood
• How are your spirits?

• Thought and Perceptions
• Thought Processes
• Thought Content
• Perceptions
• Insight
• Judgment
• Cognitive Functions
• Orientation
• Attention
• Remote Memory
• Recent Memory
• New Learning Ability
• Higher Cognitive Functions
• Information and Vocabulary
• Calculating Ability
• Abstract Thinking
• Constructional Ability

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Review of Related History History of Present
Illness

• Disorientation and confusion
• Onset
• Duration
• Associated problems
• Medications

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Review of Related History History of Present
Illness

• Depression
• Feelings
• Energy level
• Changes
• Medications

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Medication-Related Causes ofDepression

• Antihypertensive agents (clondine, Methyldopa,
  reserpine)
• Antiparkinsonian agents
• Antipsychotic agents
• Corticosteroids
• Neoplastic agents
• Nonsteroidal anti-inflammatory agents
• Sedative-hypnotic agents
• Stimulant withdrawal

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Review of Related History History of Present
Illness

• Anxiety
• Feelings
• Associated symptoms
• Medications

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Review of Related History Past Medical History

• Neurologic disorder, brain surgery, brain injury,
  residual effects, chronic disease, or
  debilitating condition
• Psychiatric therapy or hospitalization

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Review of Related History Family History

• Psychiatric disorders, mental illness, alcoholism
• Mental retardation, autism
• Alzheimer disease
• Learning disorders

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Review of Related History Personal Social
History

• Emotional status
• Occupation
• Intellectual level
• Home life
• Drug use

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Mental Status Components

• Appearance and Behavior
• Speech and Language
• Mood
• Thought and Perceptions
• Cognitive Functions

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MSE Components

• Appearance and Behavior
• Level of Consciousness
• Posture and Motor Behavior
• Dress, Grooming and Personal Hygiene
• Facial Expression
• Manner, Affect and Relationship to Persons and
  Things

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MSE Components

• Speech and Language
• Quantity
• Rate
• Loudness
• Articulation of Words
• Fluency

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MSE Components

• Mood
• How are your spirits?
• Disorders of Mood
• Depressive
• Bipolar
• Asking about suicide does not implant the idea in
  the patients mind

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MSE Components

• Thought and Perceptions
• Thought Processes
• Thought Content
• Perceptions
• Insight
• Judgement

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MSE Components

• Cognitive Functions
• Orientation
• Attention
• Remote Memory
• Recent Memory
• New Learning Ability

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MSE Components

• Cognitive Functions (cont.)
• Higher Cognitive Functions
• Information and Vocabulary
• Calculating Ability
• Abstract Thinking
• Constructional Ability

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Mental Status Exam (MSE)

• Screening
• LOC (Level of Consciousness)
• Judgments
• Abstract reasoning
• Memory
• Concentration Attention
• Orientation

• Complete
• Appearance Behavior
• Speech Language
• Mood
• Thought Perceptions
• Cognitive Functions

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Mini-Mental State Exam (MMSE)

• A brief test of mental status/cognitive functions
• Useful in screening for dementia
• Scoring system helpful in following progress of
  dementia over time
• Results should be interpreted cautiously
• Mild dementia ---gt significant false negatives
• Low scores ---gt psychiatric illness?
  uncooperative? first language not English?

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Mini-Mental State Exam(Folstein et al.)

• Max Score Pt. Score
• 5 ( )
• 5 ( )

• Questions
• What is the (year) (season) (month) (day of the
  week) (date)
• Where are we (state) (country) (town) (hospital)
  (floor)

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Mini-Mental State Exam(Folstein et al.)

• Max Score Pt. Score
• 3 ( )

• Questions
• Name 3 objects slowly. Ask the patient to repeat
  them

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Mini-Mental State Exam(Folstein et al.)

• Max Score Pt. Score
• 5 ( )

• Questions
• Do serial 7s (count backward from 100 subtracting
  7 each time) Stop after 5 subtractions
  (93,86,79,72,65)
• If the patient cannot or will not perform this
  task, ask them to spell the word WORLD backwards.
  The score is the number of letters in the
  correct order (e.g. dlrow5 dlorw3)

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Mini-Mental State Exam(Folstein et al.)

• Max Score Pt. Score
• 3 ( )

• Questions
• Ask patient to name the 3 objects previously
  memorized.

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Mini-Mental State Exam(Folstein et al.)

• Max Score Pt. Score
• 2 ( )
• 1 ( )

• Questions
• Show patient a wristwatch and ask her/him what it
  is. Repeat using a pencil/pen
• Have the patient repeat the sentence No ifs ands
  or buts

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Mini-Mental State Exam(Folstein et al.)

• Max Score Pt. Score
• 3 ( )
• 1 ( )

• Questions
• Put a blank sheet of paper in front of the
  patient and tell them to pick it up in their
  right hand fold it in half and place it on the
  floor
• On a blank piece of paper write CLOSE YOUR EYES
  in large letters. Ask the patient to read it and
  do what it says

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Mini-Mental State Exam(Folstein et al.)

• Max Score Pt. Score
• 1 ( )
• 1 ( )

• Questions
• Have the patient write a sentence on a blank
  piece of paper of his or her own
• Have the patient copy a pair of intersecting
  pentagons onto a piece of blank paper

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Mental Status Exam

• What/where to document
• Can be documented in several places
• General
• you would state patients mood, ability to answer
  questions, how they are dressed, hair, and
  overall appearance

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Mental Status Exam

• What/where to document
• Neurologic
• Mental Status -
• Appearance and behavior. (Tense but alert and
  cooperative).
• Speech and Language
• Mood
• Cognitive functions
• Orientation time, space, person, situation
• Attention
• Remote memory
• Recent memory

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Mental Status Exam

• What/where to document
• Neurologic
• Cognitive functions
• New learning ability
• Higher Cognitive Functions
• Information and Vocabulary
• Calculating ability
• Construction Ability

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Mental Status Exam

• What/where to document
• Neurologic
• NAD, alert and cooperative. Thought coherent.
  Oriented. Intelligence as expected for age. MMSE
  administered, scored 24 out of 30. Patient had
  difficulty with serial 7s, day of the week and
  repeating the names of 3 objects.

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Complete Mental Status Exam

• Appearance and Behavior
• Level of Consciousness
• Posture and Motor Behavior
• Dress, Grooming and Personal Hygiene
• Facial Expression
• Manner, Affect and Relationship to Persons and
  Things
• Speech and Language
• Quantity
• Rate
• Loudness
• Articulation of Words
• Fluency
• Mood
• How are your spirits?

• Thought and Perceptions
• Thought Processes
• Thought Content
• Perceptions
• Insight
• Judgment
• Cognitive Functions
• Orientation
• Attention
• Remote Memory
• Recent Memory
• New Learning Ability
• Higher Cognitive Functions
• Information and Vocabulary
• Calculating Ability
• Abstract Thinking
• Constructional Ability

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Symptoms of Delirium

• Disorientation
• Confusion
• Rambling speech
• Delusions
• Hallucinations
• Irritability
• Reduced attention, concentration and memory
• Tremors and abnormal reflexes
• Behavior disinhibition

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Medication-Related Causes ofDelirium

• Stimulant (cocaine, methamphetamine, caffeine,
  pseudoephedrine, ephedrine)
• Digoxin
• Anti-asthma agents (theophylline, albuterol)
• Anticholinergics
• Withdrawal from Medications
• ETOH
• Opoids
• Anti-anxiety agents
• Sedative-hypnotics

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Delirium

• Onset is acute and rapid
• Duration is usually short
• Worse at night
• Cognitive impairment
• Memory, attentiveness, consciousness,
  calculations
• Speech/language
• Slurred or rapid and manic, rambling, incoherent

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Delirium

• Mood and affect
• Rapid mood swings fearful, suspicious
• Delusions/hallucinations
• Visual, auditory, tactile, hallucinations,
  delusions
• Associated factors or triggers
• Physical condition, drug toxicity, brain injury,
  change in environment, vision or hearing problems
• Reversibility
• Potential

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Disease Related Causes ofDelirium

• Elderly with general medical conditions
• CHF
• Pneumonia
• UTIs
• Electrolyte imbalances
• Cancer

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Dementia

• Onset is insidious, relentless, or sporadic
• Duration is persistent
• Time of day no change
• Cognitive impairment
• Abstract thinking, judgment, memory, thought
  patterns, calculations, agnosia, permanent and
  progressive
• Speech/language
• Disordered, rambling, incoherent struggles to
  find words

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Dementia

• Delusions/hallucinations
• Delusions, no hallucinations
• Associated factors or triggers
• Chronic ETOH, vitamin B-12 deficiency, Huntington
  chorea, arterial disease, HIV infection,
  Alzheimer disease
• This is a progressive disease that is usually not
  reversible.

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Medication-Related Causes ofDementia

• Antiarrhythmics
• Antibiotics
• Anticholinergics
• Antidepressants
• Anticonvulsants
• Antiemetics
• Antihypertensives
• Antineoplastics
• Sedative-hypnotic agents

• Antiparkinsonian agents
• Cardiac agents (Dig)
• Corticosteroids
• Histamine-receptor antagonists
• Immunosuppressive agents
• Narcotic analgesics
• Muscle relaxants
• Nonsteroidal anti-inflammatory agents

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Non Medication Causes ofDementia

• Age
• Head trauma
• Metabolic/endocrine disorders
• Anemia
• Electrolyte abnormalities
• Hyper\hypothryoidism
• Heavy Metal poisoning (lead)
• Hypoglycemia
• Infections
• Psychiatric Disorders (depression, schizophrenic
  decompensation)

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