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Chapter 5

Mental Status Assessment

Mental status is a person’s emotional and cognitive functioning.

Optimal functioning aims toward simultaneous life satisfaction in work, caring relationships, and within the self.

Usually, mental status strikes a balance between good and bad days, allowing person to function socially and occupationally.

Defining Mental Status (1 of 2)

Mental status cannot be scrutinized directly like the characteristics of skin or heart sounds.

Its functioning is inferred through assessment of an individual’s behaviors:

Consciousness, language, mood, and affect

Orientation and attention

Memory and abstract reasoning

Thought process, through content, and perception

Defining Mental Status (2 of 2)

Mental disorder

Clinically significant behavioral emotional or cognitive syndrome that is associated with significant distress or disability involving social, occupational, or key activities

Organic disorders

Due to brain disease of known specific organic cause (e.g., delirium, dementia, alcohol and drug intoxication, and withdrawal)

Psychiatric mental illnesses

Organic etiology has not yet been established (e.g., anxiety disorder or schizophrenia)

Mental status assessment documents a dysfunction and determines how that dysfunction affects self-care in everyday life.

Mental Status Structure and Function

Infants and children

Difficult to separate and trace development of just one aspect of mental status in children, because all aspects are interdependent.

Addressing concerns as developmental process associated with aging continues

Critical issues r/t substance abuse, suicide, and impact of mental health issues being diagnosed and/or individuals receiving treatment

Aging adults

Age-related changes in sensory perception can affect mental status along with chronicity of disease process (presence of comorbidity).

Grief and despair surrounding these losses can affect mental status and can result in disability, disorientation, or depression.

Older adulthood contains more potential for losses.

Developmental Competence

Full mental status examination is a systematic check of emotional and cognitive functioning.

Usually, mental status can be integrated within the context of the health history interview.

Four main headings of mental status assessment: A-B-C-T

Appearance

Behavior

Cognition

Thought processes

Components of the Mental Status Examination

Mental Status Examination

It is necessary to perform a full mental status examination when any abnormality in affect or behavior is discovered and in certain situations.

You will collect ample data to be able to assess mental health strengths and coping skills and to screen for any dysfunction.

When a Full Mental Status Examination Is Necessary

Initial screening

Suggests an anxiety disorder or depression

Behavioral changes

Memory loss, inappropriate social interaction

Brain lesions

Trauma, tumor, cerebrovascular accident, or stroke

Aphasia

Impairment of language ability secondary to brain damage

Symptoms of psychiatric mental illness

Especially with acute onset

Factors That Could Affect Interpretation of Findings

Known illnesses or health problems:

Such as alcoholism or chronic renal disease

Medications:

Side effects of confusion or depression

Educational and behavioral level:

Note factor as normal baseline

Stress responses observed in

social interactions, sleep habits, drug and alcohol use

Data Collection

Assess accurately and assure validity

Basic function (consciousness and language)

Sequence of steps forms a hierarchy in which the most basic functions are assessed first

Examination Sequence of Steps

Objective Data: Collection

Addressing key areas:

Appearance, behavior, cognitive functions, and thought processes

Additional screenings as needed based on observations

Determination of normal versus abnormal findings

Documentation of findings

Obtaining baseline and then trending results upon ongoing assessment

Objective Data: Appearance

Posture

Erect and position relaxed

Body movements

Body movements voluntary, deliberate, coordinated, and smooth and even

Dress

Appropriate for setting, season, age, gender, and social group

Grooming and hygiene

Congruence between grooming and age

Objective Data: Behavior (1of 2)

Level of consciousness

Person is awake, alert, aware of stimuli from environment and within self, and responds appropriately and reasonably soon to stimuli.

Facial expression

Appropriate to situation and changes appropriately with topic; comfortable eye contact unless precluded by cultural norm

Objective Data: Behavior (2 of 2)

Speech

Judge the quality of speech, noting that person makes sounds effortlessly and shares conversation appropriately.

Pacing, articulation, and word choice

Mood and affect

Judge by body language and facial expression and by direct questioning.

Mood should be appropriate to person’s place and condition and should change appropriately with topics; person is willing to cooperate.

Objective Data: Cognitive Functions (1 of 2)

Orientation

Discern orientation through course of interview, or use direct questioning to verify

Time: day of week, date, year, season

Place: where person lives, address, phone number, present location, type of building, name of city and state

Person: own name, age, who examiner is, type of worker

Many hospitalized people normally have trouble with exact date but are fully oriented on remaining items.

Attention span

Check person’s ability to concentrate

by noting whether he or she completes a thought without wandering.

Attention span commonly is impaired in people who are anxious, fatigued, or intoxicated.

Objective Data: Cognitive Functions (2 of 2)

Recent memory

Assess in context of interview by 24-hour diet recall or by asking time person arrived at agency.

Ask questions you can corroborate to screen for occasional person who confabulates or makes up answers to fill in gaps of memory loss.

Remote memory

In the context of the interview, ask the person verifiable past events; for example, ask to describe past health, the first job, birthday and anniversary dates, and historical events that are relevant for that person.

Remote memory is lost when cortical storage area for that memory is damaged, such as in Alzheimer disease, dementia, or any disease that damages cerebral cortex.

New Learning: The Four Unrelated Words Test

Highly sensitive and valid memory test

Requires more effort than recall of personal or historic events, and avoids danger of unverifiable recall

Assessment Process

Pick four words with semantic and phonetic diversity; ask person to remember the four words.

To be sure person understood, have him or her repeat the words.

Ask for the recall of four words at 5, 10, and 30 minutes.

Normal response for persons younger than 60 is an accurate 3- or 4-word recall after 5, 10, and 30 minutes.

Additional Testing for Persons with Aphasia

Aphasia: loss of ability to speak or write coherently or to understand speech or writing due to a cerebrovascular accident

Word comprehension: point to articles in the room or articles from pockets and ask person to name them

Reading: ask person to read available print; be aware that reading is r/t educational level

Writing: ask person to make up and write a sentence; note coherence, spelling, and parts of speech

Thought Processes, Content, and Perceptions

Thought processes

Way person thinks should be logical, goal directed, coherent, and relevant; should complete thoughts

Thought content

What person says should be consistent and logical.

Perceptions

Person should be consistently aware of reality; perceptions should be congruent with yours.

Anxiety and depression are the two most common mental health disorders seen in individuals seeking health care.

Generalized anxiety disorder scale (GAD-7)

Consists of 7 itemized scale

Higher the score, greater the likelihood.

First 2 questions relate to core anxiety.

Greater or equal than 3 indicates diagnosis.

Screen for Anxiety Disorders

Series of tools that can be used in clinical setting

Patient Health Questionnaire-2 (PHQ-2)

Asks 2 questions about depressed mood and anhedonia (lack of interest).

Serves as a screening tool to use full PHQ-9 tool

PHQ-9

Series of 9 questions requiring adding column totals that relate to frequency of occurrence of symptoms

Higher the score, the greater the likelihood of functional impairment or clinical diagnosis.

Screen for Depression Disorders

Screening for Suicidal Thoughts

Assess for possible risk for harm if the person expresses feelings of sadness, hopelessness, despair, or grief.

Begin with more general questions and proceed if you hear affirmative answers.

It is very difficult to question people about possible suicidal wishes for fear of invading privacy.

Risk is far greater skipping these questions if you have the slightest clue that they are appropriate; you may be the only health professional to pick up clues of suicide risk.

For people who are ambivalent, you can buy time so the person can be helped to find an alternate remedy.

Share any concerns you have about a person’s suicide ideation with a mental health professional.

Is the ability to compare and evaluate alternatives and reach an appropriate course of action

Test judgment about daily or long-term goals, likelihood of acting in response to hallucinations or delusions, and capacity for violent or suicidal behavior.

In the context of the interaction

Note what person says about job plans, social or family obligations, and plans for the future; job and future plans should be realistic, considering person’s health situation.

Ask for rationale for his or her health care, and how he or she decided about compliance with prescribed health regimens; actions and decisions should be realistic.

Judgment

Supplemental Mental Status Examination

Mini-Mental State Exam (MMSE)

Concentrates only on cognitive functioning

Standard set of 11 questions requires only 5 to 10 minutes to administer.

Useful for both initial and serial measurement

Detect dementia and delirium and to differentiate these from psychiatric mental illness.

Normal mental status average 27; scores between 24 and 30 indicate no cognitive impairment

Montreal Cognitive Assessment (MoCA)

Examines more cognitive domains, more sensitive to mild cognitive impairment

Ten minutes to administer

Total score of 30 with a score of greater to or equal than 26 considered normal

Developmental Competence

Infants and children

Covers behavioral, cognitive, and psychosocial development and examines how child is coping with his or her environment

Follow A-B-C-T guidelines as for adults, with consideration for developmental milestones

Abnormalities often problems of omission; child does not achieve expected milestone

Parent’s health history, especially sections on developmental history and personal history, yields most of mental status data.

Screening Tests

Infants and children

Denver II screening test gives a chance to interact directly with child to assess mental status.

For child from birth to 6 years of age, Denver II helps identify those who may be slow to develop in behavioral, language, cognitive, and psychosocial areas.

An additional language test is the Denver Articulation Screening Examination.

“Behavioral Checklist” for school-age children, ages 7 to 11, is tool given to parent along with the history.

Covers five major areas: mood, play, school, friends, and family relations

It is easy to administer and lasts about 5 minutes.

Adolescents

Follow same A-B-C-T guidelines as for adults.

Developmental Care of Aging Adults

Check sensory status, vision, and hearing before any aspect of mental status.

Confusion is common and is easily misdiagnosed.

Presence of delirium can have serious affects.

Overall presence of dementia has decreased. determination of delirium versus dementia must be evaluated when cognitive impairment is present upon examination of the older adult.

Testing Aging Adults

Follow same A-B-C-T guidelines for the younger adult with these additional considerations.

Behavior: level of consciousness

Glasgow Coma Scale is useful in testing consciousness in aging persons in whom confusion is common.

Gives numerical value to person’s response in eye-opening, best verbal response, and best motor response

Avoids ambiguity when numerous examiners care for same person

Aging Adults: Orientation

Cognitive functions: orientation

Many aging persons experience social isolation, loss of structure without a job, change in residence, or some short-term memory loss.

Aging persons may be considered oriented if they know generally where they are and the present period.

Consider them oriented to time if year and month are correctly stated.

Orientation to place is accepted with correct identification of the type of setting (e.g., the hospital and name of town).

Aging Adults: New Learning

Cognitive functions: new learning

In people of normal cognitive function, age-related decline occurs in performance in the Four Unrelated Words Test.

Persons in the eighth decade average two of four words recalled over 5 minutes and will improve performance at 10 and 30 minutes after being reminded by verbal cues.

The performance of those with Alzheimer disease does not improve on subsequent trials.

Aging Adults: Supplemental Mental Status Testing

Mini-Cog

Reliable and quick instrument to screen for cognitive impairment in healthy adults

Consists of three-item recall test and clock-drawing test

Tests person’s executive function, including ability to plan, manage time, and organize activities, and working memory

Those with no cognitive impairment or dementia can recall the three words and draw a complete, round, closed clock circle with all face numbers in correct position and sequence and hour and minute hands indicating time you requested.

Altered level of consciousness

Speech disorders

Mood and affect abnormalities

Anxiety disorders

Delirium, depression, and dementia

Thought process abnormalities

Thought content abnormalities

Perception abnormalities

Characteristics of eating disorders

Childhood mental disorders

Review Abnormal Findings

A nursing student is learning about the importance of performing a mental status assessment on patients so as to provide an adequate indicator of cognitive status.

1. What information would be included in a mental status assessment for an adult patient?

Case Study Question 1

Answer to Case Study Question 1

See Chapter 5: Defining mental status

From Textbook:

Mental status cannot be scrutinized directly like the characteristics of skin or heart sounds. Its functioning is inferred through assessment of an individual’s behaviors:

Review definition of concepts

Consciousness, language, mood, and affect

Orientation, attention, memory, and abstract reasoning

Thought process, thought content, and perceptions

Case Study Question 2

2. How would the nursing student assess abstract reasoning in an adult patient?

Answer to Case Study Question 2

To test abstract reasoning in an adult patient, the nursing student would use a situation in which the patient would have to apply or interpret a statement. Abstract reasoning involves problem solving and interpretation of analogies. The concept can be applied both verbally and graphically, allowing the adult patient to provide an interpretation and understanding of a process or sequence.

Case Study Question 3

3. How would the nursing student differentiate between recent and remote memory in an adult patient?

To differentiate between recent and remote memory in an adult patient, the nursing student could use probing questions r/t recent/current events versus past family/childhood experiences. The context of how the adult patient frames the information would provide the distinction between the assessment of recent and remote memory.

Answer to Case Study Question 3

Case Study Question 4

4. The nursing student is reviewing the components of a Mini-Mental Status Exam (MMSE) to be used during the assessment process. How would the nursing student interpret the results of an MMSE if the score was noted as 15?

See Cognitive Function in Chapter 5: Mental Status Assessment.

MMSE exam is based on a numeric scale of 1 to 30 with the higher score indicating full cognitive function.

From Textbook:

The maximum score on the test is 30; people with normal mental status average 27. Scores between 24 and 30 indicate no cognitive impairment.

Scores that occur with dementia and delirium are classified as follows: 18 to 23 = mild cognitive impairment; 0 to 7 = severe cognitive impairment.

As the score noted is 15, this would indicate that the patient had more than just mild cognitive impairment.

Answer to Case Study Question 4

Question 5

5. The student nurse is reviewing comparative differences between delirium and dementia. Based on these observations, how would the student nurse characterize the following presentations?

A 78-year-old male presents with new onset confusion in the physician’s office.

A 65-year-old female has been having continued difficulty remembering phone numbers for several months’ duration and comes to the physician’s office out of concern.

An 89-year-old male has a urinary tract infection and is confused on admission to the hospital.

See section The Aging Adult in Chapter 5: Mental Status Assessment.

From Textbook:

Delirium is an acute confusional change or loss of consciousness and perceptual disturbance, may accompany acute illness (e.g., pneumonia, alcohol/drug intoxication), and is usually resolved when the underlying cause is treated.

In contrast, dementia is a gradual progressive process—causing decreased cognitive function even though the person is fully conscious and awake—and is not reversible.

The 78-year-old patient should be evaluated for delirium, as this is a “new onset” confusion.

The 65-year-old patient should be evaluated for dementia, as this is an ongoing problem.

The 89-year-old patient should be evaluated for delirium due to the comorbid condition of a urinary tract infection.

Answer to Case Study Question 5

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