Chapter 5 - Mental Status Assessment

• Mental status encompasses a person's emotional and cognitive functions.

Components of Mental Status Examination

• Appearance
• Posture: Should be erect and relaxed.
• Body Movements: Voluntary, deliberate, coordinated, smooth, and even.
• Dress: Appropriate for the setting, season, age, gender, culture, and social group.
• Grooming and Hygiene: Clean and well-groomed, noting congruence with age; a sudden change can be significant.
• Pupils: Note size and reaction to light.

Behavior

• Level of Consciousness (LOC): Awake, alert, aware of stimuli, and responds appropriately.
• Facial Expression: Matches the situation and shifts accordingly.
• Speech: Effortless, appropriate, and conversational.
• Mood and Affect: Assessed through body language, expressions, and direct questions, aligning with the person's condition.
• Cooperation: The person should be willing to cooperate.

Cognitive Functions

• Orientation: Assessed through questions about address, phone number, and health history (Time, Place, Person).
• Attention Span: Evaluated by the ability to complete a thought without wandering.
• Recent Memory: Assessed with a 24-hour diet recall or time of arrival.
• Remote Memory: Inquire about verifiable past events.
• New Learning: Use the Four Unrelated Words Test to assess the ability to form new memories; recall should be tested after 5 minutes.

Thought Process and Perceptions

• Thought Process: Logical, goal-directed, coherent, and relevant.
• Thought Content: Consistent and logical.
• Perceptions: Constant awareness of reality. Inquire about experiences such as hearing one's name when alone.
• Anxiety Screening: Use GAD-2 (first 2 questions of GAD-7); a score of 3+ suggests Generalized Anxiety Disorder (GAD).
• Depression Screening: Use PHQ-2 (two questions about depressed mood and anhedonia); a score of 2+ requires the full PHQ-9.
  • PHQ-9 Scores: 5-9 (minimal symptoms), 15-19 (moderately severe major depression), 20+ (severe major depression).
• Suicide Screening: Use Ask-Suicide-Screening Questions (ASQ), consisting of 4 questions. A "yes" or refusal to answer indicates a positive screen.

Objective Data Collection & Supplemental Mental Status Examination

• Mini-Mental State Examination (MMSE): Tests cognitive functions like memory, orientation, naming, reading, writing, and following commands. Requires the person to be able to write and have no vision impairment.
  • Focus: Concentrates on cognitive functioning, not mood, thought processes, or executive function.
  • Scoring:
  • Maximum score is 30 (normal average is 27).
  • 24-30 (no cognitive impairment).
  • 18-23 (mild cognitive impairment).
  • Less than 17 (severe cognitive impairment).

Developmental Considerations

• Infants and Children: Monitor developmental milestones as missing milestones is a late sign of developmental delay. Assess behavioral, cognitive, and psychosocial development and coping mechanisms.
• Adolescents: Use open-ended questions initially, then become more specific about stress, anxiety, and parental perceptions.
• Aging Adults: Brief mental status examination is important upon hospital admission due to the prevalence of misdiagnosed confusion and delirium. Neural processing speed, mental flexibility, and memory may decline, but most adults remain within normal cognitive ranges. Rule out sensory deficits first.

Additional Considerations for Aging Adults

• The Glasgow Coma Scale quantitatively assesses consciousness through eye opening, verbal response, and motor response. A score of 3 indicates severe brain injury or death.
• Many older adults experience social isolation, loss of structure, change in residence, and short-term memory loss.

Delirium vs. Dementia

• Delirium: Acute confusional state with disorientation, disordered thinking, defective memory, agitation, and inattention; potentially preventable in hospitalized individuals.
• Dementia: Chronic, progressive loss of cognitive and intellectual functions with intact perception and consciousness, characterized by disorientation, impaired judgment, and memory loss.