Mental Health and Cognition Assessment PDF

Communication Assessment 93 Section 2: Mental Functions INTRODUCTION Fundamental Concepts Impairments in mental function can have a substantial Effective communication between two people requires that effect on the qualit...

Communication Assessment 93 Section 2: Mental Functions INTRODUCTION Fundamental Concepts Impairments in mental function can have a substantial Effective communication between two people requires that effect on the quality, accuracy, and efficiency of an initial messages be expressed in an understandable manner and examination. The primary categories of mental function that those messages are received as they were intended. In that will be considered here are communication, cognition, typical communication, this involves the motor function and emotional status. of speech; the sensory process of hearing; and the cogni- Communication and cognitive deficits will usually tive processes of word comprehension, word interpretation become evident very early in the patient interview and may (associating meaning with the message), and word produc- substantially alter your plan for the initial examination. If tion. Dysfunction in any or all of those processes may have a a patient has a difficult time communicating or processing profoundly negative effect on one’s ability to communicate. simple cognitive tasks, your physical examination may need Communication deficits often result from dysfunc- to be simplified and condensed to the minimum number tion or disease in the neurological system, such as stroke, of tests and measures required to formulate hypotheses traumatic brain injury, Parkinson’s disease, or cerebral palsy. and begin interventions. Emotional or psychological issues Cognitive dysfunction may also accompany some of these may or may not be immediately evident, but these can also conditions, adding another layer of challenge to the patient’s affect the examination or intervention plan. A patient who assessment. Other conditions, such as tumors of the mouth is emotionally distraught or angry may have a difficult time or throat, cleft lip or palate, or trauma, can also lead to tolerating all of the tests and measures appropriate for his communication difficulties.5 Regardless of the source of or her diagnosis. the problem, communication deficits are typically identi- The degree to which communication, cognition, and/or fied and adjustments made during the interview process. emotional concerns may affect the physical therapy encoun- Should you note a rapid or progressive change in a patient’s ter will obviously vary depending on numerous factors. In ability to communicate, consider this to be a red flag6 and addition, although patients may present with dysfunction in address this concern promptly. only one of these categories, it is not uncommon for all three Physical therapists do not formally identify or treat areas to be affected concurrently. One example is a patient communication deficits. However, you should be familiar who has experienced a left hemispheric stroke. The patient with common communication disorders and how they pres- will likely have language deficits, may have difficulty with ent so you are prepared to make adjustments when neces- cognitive processing, and may also have developed clini- sary. Depending on the setting and the acuity of the patient’s cal depression. Therefore, these examination categories are condition, patients who have communication deficits may be presented in the same section. working concurrently with a speech-language pathologist (SLP). Should this be the case, the SLP may provide you with helpful information about how best to communicate with COMMUNICATION your patient. In addition, you may have the opportunity to reinforce therapeutic techniques suggested by the SLP. ASSESSMENT A physical therapist may encounter a number of com- Introduction munication disorders, as well as many variants of those Communication difficulties often can be detected shortly disorders. Three of the most common are dysarthria, dys- after beginning the initial interview. Impaired communica- phonia, and aphasia, each of which will be described briefly. tion may have a minor or a profound effect on the historical Dysarthria indicates speech difficulties resulting from information you are able to gather, as well as on the tests and impaired motor (muscular) control of one or more of measures you are able to perform in the physical exami- the structures that control speech (tongue, palate, lips, nation. Depending on the type of communication deficit, pharynx). Common causes of dysarthria include motor you may need to adjust your questions to those that have lesions of the central or peripheral nervous system only a yes or no answer, pass information back and forth in (such as a cranial nerve lesion), parkinsonism,7 amyo- writing, use body and hand signals, or communicate solely trophic lateral sclerosis (ALS),8 and diseases of the cere- with the patient’s caregiver. Many students are easily flus- bellum.9,10 Words often are slurred, nasal, or indistinct. tered when working with patients who have a communi- Severity can range from occasional speech disturbances cation deficit; learning how to conduct a good interview to speech that is completely unintelligible.11 Because is challenging enough when communication flows easily dysarthria is caused by a motor deficit, patients typi- from both parties, and making the necessary adjustments cally possess normal word comprehension, and they can prove difficult. Realize, however, the level of fear and have an appropriate cognitive response to question- frustration patients must experience on a daily basis being ing. The patient’s difficulty lies in forming the words unable to communicate with family and friends. to actually speak what is being thought. 94 CHAPTER 6 Global Observation, Mental Functions, and Components of Mobility and Function Dysphonia is difficulty in voice production (volume, Broca Wernicke quality, or pitch). This may be caused by local inflam- mation, such as in laryngitis. Other causes that may lead to longer or even permanent impairment include tumors on the larynx or dysfunction of the vagus nerve (cranial nerve X) that supplies the larynx.12 Spasmodic dysphonia is a disorder that causes involuntary spasms of the muscles of the larynx. These spasms occur only when the person attempts to speak and cause the voice to break or to sound strained, tight, or whispery.13 Aphasia is a cognitive neurological disorder that results in difficulty or inability to produce or understand lan- guage. Aphasia is most often the result of a lesion in the dominant cerebral hemisphere, which is typically FIGURE 6-1 Wernicke’s area and Broca’s area in the left the left.9,10 Therefore, individuals who experience a cerebral hemisphere. left-sided stroke (right side of body affected) are much Reproduced from Aphasia. National Institute on Deafness and Other Communication Disorders. Available at: www.nidcd.nih.gov/health/voice/pages/aphasia.aspx. more likely to have aphasia than those who experience a right-sided stroke. Other common causes include traumatic brain injury or brain tumor, although aphasia may also be caused by infection or dementia.5 dysfunction; it is typically the result of a large left- Although a number of different types of aphasia have sided lesion (that includes Broca’s area and Wernicke’s been identified, the two most common are receptive and area) and often leaves the patient completely unable to expressive aphasia, which are compared in TABLE 6-1. communicate.12 Receptive aphasia is often referred to as Wernicke’s aphasia, and expressive aphasia is often referred to as Procedure Broca’s aphasia.9 Early studies of temporal lobe lesions Formal and extensive communication assessment is typi- were conducted by Carl Wernicke and Paul Broca, and cally not performed during physical therapy examinations. these respective areas of the brain are now referred However, informal assessment is made whenever convers- to by these names (see FIGURE 6-1). Global aphasia ing with the patient or while observing a patient engaged refers to a disorder of both receptive and expressive in conversation with another individual. The following TABLE 6-1 Comparison of Receptive and Expressive Aphasia Wernicke’s (receptive) Aphasia Broca’s (expressive) Aphasia Location of lesion Posterior superior temporal lobe Posterior inferior frontal lobe Characteristics of spontaneous May speak in long sentences that May speak in short, meaningful phrases speech have no meaning; may invent new but with great effort to do so. Often words or add unnecessary words omit small words (“is,” “a,” “the,” “and”). when speaking. Speech often is rapid Persons are usually able to comprehend and effortless but frequently out of the speech of others but are aware of context. Persons are often unaware their own difficulties and mistakes and of their own speech mistakes (they are therefore easily frustrated with their do not understand what they hear inability to communicate. out of their own mouth, but in their mind, it may make sense). Fluency Usually good Nonfluent, slow, and with great effort; inflection usually impaired Word comprehension Impaired Usually good; mild deficits possible Repetition Impaired Impaired Object naming Impaired Impaired; recognizes but cannot verbally name objects Reading comprehension Impaired Usually good Writing Impaired Impaired Data from Bickley L. The nervous system. In: Bates’ Guide to Physical Examination and History Taking. 11th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2013:681–762; and American Speech-Language-Hearing Association. Aphasia: Causes and Number. Available at: www.asha.org/public/speech/disorders/aphasia.htm. Accessed January 7, 2016.  Communication Assessment 95 list contains aspects of speech and language you can easily your communication as needed (such as using more closed- assess while performing your initial interview.9 ended questions) so the patient does not have to struggle to respond to your questions. Language spoken: Does the patient have a good under- If the patient presents with aphasia, there are several standing of the English language, or is an interpreter simple tests you can perform that should provide you with needed? a good understanding of the patient’s ability to participate Hearing: Does the patient have a hearing deficit? If so, and interact with you during the examination.9–11 does the patient use sign language? Does he or she read lips? Does the patient wear hearing aids? Do you need Understanding of questions: Ask the patient his or her to speak loudly when communicating? name and address. If the patient answers correctly, Quantity of speech: Is the patient talkative or relatively progress to something more complicated (“Describe silent? Does the patient only respond to direct ques- your home to me”). tioning, or are comments spontaneous? Word comprehension: Ask the patient to follow a one- Rate and volume of speech: Is the patient’s speech fast or stage command (“Open your mouth,” or “Touch your slow? It is soft or loud? chin”). If successful, try a two-stage command (“Touch Word articulation: Are the patient’s words pronounced your ear and then touch your knee”). clearly and distinctly? Are words slurred or syllables » Persons with expressive aphasia can likely do this; blended? those with receptive aphasia cannot. Fluency: Relates to the rate, flow, and melody of speech. Repetition: Ask the patient to repeat a phrase consisting Also considers the content and use of words. Pay atten- of one-syllable words (“The sun is in the sky”). tion to the following: » Persons with receptive aphasia will not be able to » Gaps or hesitancy in the flow of words do this. » Lack of or abnormal inflection (is the speech » Persons with expressive aphasia may be able to monotone?) repeat one or two of the words correctly or may be » Excessive use of “filler” words (“I have uh, trouble unable to do this. uh, with my uh, walking”) Naming: Ask the patient to identify various common » Use of circumlocutions, which are phrases substi- objects (e.g., watch, pen, book, shoe) and progress to tuted for words the person cannot think of (e.g., say- more difficult objects (e.g., candle, paperclip, bracelet). ing “that thing you write with” instead of “pencil”) » Persons with receptive aphasia will be unable to do When patients present with dysarthria or dysphonia, this. you should pay attention to the severity of the condition » Persons with expressive aphasia will be unable to and note any particular characteristics of the patient’s com- come up with the word, but can correctly nod yes munication in your documentation. If cognitive deficits do or no if asked, “Is this a pen?” not accompany these conditions, the patient should be able Writing: Ask the patient to write a short sentence. to understand typical examination questions or follow com- » Persons with either type of aphasia will not be able plex commands. However, you should be prepared to adjust to do this. © Bocos Benedict/ShutterStock, Inc. PRIORITY OR POINTLESS? When communication is a PRIORITY to present, but the patient demonstrates difficulty answer- assess: ing your interview questions, communication (and Assessing a patient’s ability to understand and express cognition) should be formally assessed. The presence verbal language should occur when his or her diagno- of communication difficulties will affect the remainder sis is known to cause communication problems. This of the examination and should be assessed early in the includes a CVA (cerebrovascular accident, or stroke, encounter so the necessary adjustments can be made. especially left-sided), traumatic brain injury, Parkin- son’s disease, brain tumors, amyotrophic lateral sclero- When communication is POINTLESS to sis (ALS), multiple sclerosis (MS), and diseases of any assess: speech apparatus. The purpose of the assessment often If no communication difficulties are encountered dur- is less for diagnosis or classification of impairment but ing the introduction and through the early portions of more for the purpose of optimizing the examination the patient interview, it is unlikely that communication and intervention plan. When these conditions are not requires formal assessment. 96 CHAPTER 6 Global Observation, Mental Functions, and Components of Mobility and Function © Bocos Benedict/ShutterStock, Inc. CASE EXAMPLE You are performing an initial examination on a patient referred Documentation for Case Example to you for Ⓡ knee pain. The patient required extensive help from her spouse to complete the intake form in the waiting Subjective: Pt c– difficulty communicating verbally during room. In the patient’s past medical history, you note two mild initial exam; spouse provided information when pt could not. Ⓛ-hemispheric CVAs. During the patient interview, you ask an Pt able to confirm that Ⓡ knee pain was c/c. open-ended question about the patient’s chief complaint. The Objective: Communication: Pt demonstrates slow speech patient’s words are few, slow, and sometimes slurred; you and difficulty c– word articulation. Impaired repetition; observe that she often mentally searches for the word she wants impaired writing; reading and word comprehension to use. She often points to body areas or to objects as opposed unimpaired. Responds appropriately to verbal commands. Pt to naming them (e.g., when you ask what she has difficulty prefers pointing and physical demonstration to verbal doing at home, she points to her shirt and to her jacket, indicat- communication; prefers yes/no questions. Demonstrates ing she has difficulty putting these items on and/or taking them frustration c– repeated tasks requiring verbal or written off). The patient often looks to her spouse to provide answers responses. to questions requiring more than a few words to answer. You opt to perform a short communication assessment. When asked Assessment: Pt presents c– s/s consistent c– expressive aphasia to repeat a short phrase you have spoken, she gets only two of following 2 Ⓛ CVAs. Is able to communicate c– PT through the five words correct, and when asked to write that phrase, she gestures/pointing; becomes frustrated at times c– does not get any words correct. However, she is able to appro- communication difficulties. PT able to evaluate Ⓡ knee pain priately follow written commands. The patient responds appro- s– difficulty. priately to all verbal commands, but she eventually gets frustrated with the number of questions you have asked because Plan: Will tailor Rx plan for Ⓡ knee to accommodate of her difficulty answering them. She does far better with yes- communication barriers. or-no questions as opposed to open-ended ones.  Procedure 97 Section 3: Cognition Assessment function. Reversible dementia may be caused by thyroid INTRODUCTION disorders,18 vitamin B12 deficiency,19 depression,20 systemic Cognition includes orientation, attention, memory, prob- inflammatory disorders, normal pressure hydrocephalus,21 lem solving (calculation, abstract thought, and judgment), and as a side effect of medications.22,23 Because 9–10% of all and perception (spatial, visual, and body).3,9 As with com- dementias are considered reversible,24 early screening for munication, cognitive difficulties are typically noticed early these potential causes is important. in the patient interview. For example, questions about past The complexities of the brain, including the processes medical history can be a measure of the patient’s long-term involved in cognition, are well outside the scope of this memory. Likewise, the patient’s ability to remain focused text. However, a brief and highly simplistic description on your questioning may indicate his or her level of atten- of the processing that occurs in the regions of the brain tion. Rapid or unexplained changes in cognition may be can be found in TABLE 6-2 and FIGURE 6-2. Some neu- indicative of a medical condition. For example, it is com- rological conditions are known to affect particular areas mon for older individuals (most typically women) with a of the brain (such as Parkinson’s disease), and a patient’s severe urinary tract infection (UTI) to experience confu- presentation may be quite predictable. Presentations with sion or diminished attention. Cognitive deficits are com- other conditions (such as brain tumor, brain injury, or mon in conditions or diseases that affect the brain, whether stroke) are highly dependent upon the region of the brain developmental or acquired, and many also present with affected: the more regions affected, the greater the severity concurrent communication deficits. Therefore, assessment of dysfunction. of communication and cognition often occur together. FUNDAMENTAL CONCEPTS PROCEDURE A number of standardized cognitive assessment tools are Formal, in-depth assessment of cognition is frequently available for clinical use should specific documentation of performed by a neuropsychologist using a battery of stan- cognitive status be warranted. Some of these tools include dardized psychometric tests. Occupational therapists also the Mini-Mental State Exam (MMSE),25 the Short Portable are trained in methods of formal cognitive testing.14 Thus, Mental Status Questionnaire,26 and the General Practitioner the extent to which a physical therapist assesses a patient’s Assessment of Cognition.15 Although the MMSE has long cognition will likely be at the screening level. For patients been considered one of the easiest and most reliable cogni- with known cognitive deficits, simple assessment tests can tive assessment tools,27 its strict copyright protection makes be performed to determine particular difficulties a patient its clinical use somewhat difficult. may have that could influence the physical therapy inter- vention plan. For patients with no known cognitive deficit, assessment would be necessary if a patient demonstrates dif- ficulty answering questions or if there is an observed change in cognitive processing over time. Many times it is a family member or caregiver who first alerts a clinician to concerns about a patient’s cognition. A slow but recognizable onset of cognitive decline may be the first indication of dementia.15 Dementia is a broad term that indicates a global loss of cognitive ability (memory, attention, language, prob- lem solving, and new learning) in a previously unimpaired person, beyond what might be expected from the normal aging process. Causes of dementia are numerous, with Alzheimer’s disease being the most prevalent.16 Neurode- generation (degradation of neurons in the brain) usually leads to a slow, progressive, nonreversible loss of cognitive function. Dementia occurring in persons under the age of 40 is rare but can be caused by psychiatric illness, alcohol abuse, illicit drug use, metabolic disturbances, or as a side effect of some medications.17 In these instances, removing the cause of the dementia may or may not restore cognitive 98 CHAPTER 6 Global Observation, Mental Functions, and Components of Mobility and Function TABLE 6-2 Function and Associated Dysfunction of the Brain by Lobe/Region Lobe/Region Location General Functions Dysfunction Frontal lobe Most anterior Motor memory and function Loss of simple or complex movement aspect of the Self-awareness Loss of ability to sequence movement or brain Planning process multiple steps Reasoning Loss of focus or attention Word association and meaning Mood changes Judgment and attention Personality or social behavior changes Response to activity in the Lack of ability to solve problems and make environment decisions Control of emotion and impulse Lack of ability to express language Expressive language Depression or euphoria Production of nonverbal Apathy language Disinhibition Parietal lobe Posterior to the Conscious awareness of Inability to attend to more than one object frontal lobe environment at a time Visual attention Inability to name an object Touch perception Reading problems Object manipulation (requires Difficulty distinguishing left from right communication with the frontal Difficulty with mathematics lobe) Lack of awareness of certain body areas Spatial awareness and Difficulty with eye–hand coordination orientation Difficulty drawing objects Sensory integration Goal-directed voluntary movement Occipital lobe Most posterior Vision Visual field cuts lobe Difficulty identifying colors Difficulty recognizing written words or drawn objects Difficulty locating objects in the environment Temporal lobe Sides of head Hearing Difficulty recognizing faces Memory acquisition Difficulty understanding spoken words Some visual perceptions Inability to categorize objects Object categorization Difficulty with selective attention to things seen and heard Difficulty verbalizing information about objects Brain stem Deep in brain; Regulates breathing, heart Impaired swallowing inferior aspect rate, blood pressure, digestion, Difficulty organizing/perceiving swallowing, temperature environment Affects alertness Difficulties with balance Affects sleep Dizziness and nausea Affects balance Difficulties sleeping All cranial nerve function Decreased vital capacity of breathing Serves as a conduit for Sensory and motor deficits all ascending sensory and Eye movements (diplopia) descending motor information Chewing, facial expression, talking (specific to each cranial nerve) Cerebellum Base of skull Coordination of voluntary Loss of coordination of fine movements movement Decreased ability to walk Balance and equilibrium Tremors Memory for reflex motor acts Slurred speech Inability to make rapid movements Difficulty learning novel tasks Data from Nolte J. The Human Brain: An Introduction to Its Functional Anatomy. 5th ed. St. Louis, MO: Mosby; 1999; and Siegel A, Sapru H. Essential Neuroscience. Revised 1st ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006.  Procedure 99 Primary Motor Cortex Primary Somato Central Sensory Cortex Frontal Lobe Generalized and Sulcus Coordination Skilled Adversive Movements Movements Parietal Tactile Movements Lobe Sensation Activation Verbal (Speech and Creative Thought Interpretation) Writing Sensory Combination Intellect and Interpretation Judgment Reflection Emotional Reaction Visual Occipital Bodily Reaction Lobe Musical Reading Visual Memories Auditory Memories Memories Temporal Lobe Cerebellum FIGURE 6-2 Primary lobes of the brain and their key functions. Other screening methods can be useful and easy to per- to itch. Although apraxia is most commonly caused by left- form if concerns about a patient’s cognitive status are present. hemispheric stroke or dementia,29,30 it can be present in any These are outlined in TABLE 6-3. Not all categories of assess- disease that affects the posterior frontal or left inferior pari- ment are required in all cases. However, patients who dem- etal lobes.29,31,32 There are several different types of apraxia onstrate difficulties in multiple categories, especially patients that can be screened with simple tests.9,28 who do not have a previously identified condition known to affect cognition, should be further evaluated by a physician. Buccofacial apraxia is loss of ability to perform move- Assessment of praxis may also be conducted if the patient ments of the lips, mouth, and tongue on command. A is observed having difficulty completing simple motor tasks. patient who is asked to whistle or pretend to blow out Although the impairment is demonstrated via motor perfor- a candle may be unable to do so. mance of tasks, apraxia is actually an impairment of cogni- Ideomotor apraxia is loss of ability to perform learned tive processing. Apraxia is characterized by loss of ability to tasks when provided with the necessary objects. A initiate or carry out learned purposeful tasks on command, patient given a pair of scissors and a piece of paper even though the individual understands the task and has the may try to write with the scissors. If given a comb, the desire and physical ability to perform the task.28 What is quite patient may try to brush his or her teeth. interesting is that many times patients can carry out these Ideational apraxia is loss of ability to carry out learned tasks involuntarily without difficulty. For example, a patient tasks in the correct order. When asked to dress the may not be able to demonstrate the motion of scratching her lower quarter, a patient may first attempt to put on nose on command, but could easily do so if her nose began shoes, then socks, then pants. 100 CHAPTER 6 Global Observation, Mental Functions, and Components of Mobility and Function TABLE 6-3 Tests to Assess Aspects of Cognitive Function Cognitive Function Description Task to Give Patient Examples Attention Ability to attend to a Repetition of a series of 148, 1092, 46142 specific stimulus or task numbers or letters. ZYX, BMOC, UOIEA Begin with three letters or numbers; increase until several mistakes are made. Tip: use numbers/letters you are familiar with but the patient is not (portions of your phone number, initials of family/ friends). Orientation Ability to orient to Ask the following from the Person: ask the patient’s name person, place, and time patient: and age (or address/occupation) (Documented as “Alert & Own name (identity) Place: ask the name of the clinic/ Oriented x 3 [A&O x 3]”) Current location hospital or the name of the city May also see A&Ox4, Knowledge of day/ Time: ask the current day, date, where the 4th element is month/year month, season, and/or year “event” or “situation” Knowledge of Event/situation: Ask if the patient current situation or knows why he or she is at the circumstance clinic/hospital or to describe a recent event. Memory Immediate recall Recount three words after a Apple, book, car Short-term memory few seconds’ delay. Use the same words from Long-term memory Recount words after a 3- to immediate recall 5-minute delay. Job history, children’s birthdays, Recount past events (that make and model of first car you can confirm). Thought processes Demonstration of logic, Complete “if-then” Ask the patient the following: coherence, relevance statements using concrete “If your car has a flat tire, then (how the patient thinks) topics. you would __.” “If it starts to rain when you’re outside, then you would ___.” Calculation Ability to perform verbal Add, subtract, multiply, or Simple math problems or written mathematical divide whole numbers. Serial 7s: starting at 100, subtract 7 problems and keep doing this until you reach 50 (100 – 7 = 93 – 7 = 86 – 7 = 79 – 7 = 72 …). Doubling 3s: What is 2 × 3? What is double that? Double that? Abstract thinking Ability to reason in an Ask for the meaning of a What is the meaning of the abstract vs. a concrete proverb. following: fashion Ask how two objects are “A squeaky wheel gets the similar or different. grease.” “Don’t count your chickens before they’re hatched.” What are the similarities and the differences between these common objects: Pen and pencil Orange and apple Church and theater Judgment Ability to reason in a Demonstrate common sense Ask questions such as the following: concrete fashion and safety (the questions “If you smelled smoke in your may not have a right and house, what would you do?” wrong answer but can be “If you got on the wrong bus, judged as appropriate or what would you do?” inappropriate).  Procedure 101 TABLE 6-3 Tests to Assess Aspects of Cognitive Function (continued) Cognitive Function Description Task to Give Patient Examples Spatial perception Ability to construct or Draw a two- or three- Ask the patient to draw the face draw an object with a dimensional figure that has of a clock with the numbers filled specific orientation or particular characteristics. in: characteristic Ask the patient to draw the hands on the clock representing a certain time (e.g., 7:20). Ask the patient to draw a five- pointed star. Body perception Self-awareness of own Ask the patient to point to Ask the patient to raise the right body or identify specific body hand in the air; then the left hand. parts on his or her own Ask the patient to point to the left body. knee using the right index finger (and vice versa). Point to a body part on a patient and ask the patient to name it. Object perception Ability to recognize The patient attempts to With the patient’s eyes closed, hand objects through touch identify an object only the patient a common object and through touch. ask for its name: Paperclip Key Coin Can identify simply “coin” Can identify which coin Sensory perception Ability to recognize a The patient attempts to With the patient’s eyes closed, number, letter, or shape identify a number, letter, draw a number, letter, or shape on “drawn” on the skin or shape drawn on the the patient’s palm; ask him or her palm (or elsewhere) by the to identify what you have drawn. clinician. Tell the patient if you are drawing a letter, number, or shape (“8” can feel like a “B”). Data from Bickley L. The nervous system. In: Bates’ Guide to Physical Examination and History Taking. 11th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2013:681–762; Fuller G. Mental state and higher function. In: Neurological Examination Made Easy. 4th ed. Philadelphia, PA: Elsevier Health Sciences; 2008:25–38; and Swartz M. The nervous system. In: Textbook of Physical Diagnosis: History and Examination. 7th ed. Philadelphia, PA: Saunders Elsevier; 2014:583–649. © Bocos Benedict/ShutterStock, Inc. PRIORITY OR POINTLESS? When cognition is a PRIORITY to assess: the remainder of the examination and should be assessed Assessing a patient’s cognitive abilities should occur early in the encounter so necessary adjustments can be when his or her diagnosis is known to cause cognitive made. problems (any disorder affecting the brain). The purpose of the assessment may be less for diagnosis or classifica- When cognition assessment is POINTLESS tion of impairment but more for the purpose of opti- to assess: mizing the examination and intervention plan. When If no cognition difficulties are encountered during the a known disorder of the brain is not present but the introduction and through the early portions of the patient demonstrates confusion or difficulty answering patient interview, it is unlikely that cognition requires your interview questions, cognition should be formally formal assessment. assessed. The presence of cognitive difficulties may affect 102 CHAPTER 6 Global Observation, Mental Functions, and Components of Mobility and Function © Bocos Benedict/ShutterStock, Inc. CASE EXAMPLE During an initial interview with a 54-year-old patient referred taking indomethacin, which was prescribed by her physician to your clinic for severe hip pain, you notice that she has diffi- one week ago for her hip pain. A potential side effect of indo- culty answering several questions that you feel should be rela- methacin is confusion (and hallucinations). This prompts you tively easy for her. For example, when asked if she has steps in to call the patient’s primary care physician, relay your findings, or outside of her home, she hesitates and then states, “I think and together determine the most beneficial course of action. so, but I don’t know.” When asked what her daily activity con- sists of, she appears distressed, turns toward her daughter and Documentation for Case Example asks, “What do I do?” She is able to state her name (person) and the year and season (time) but cannot remember the county or Subjective: Pt’s daughter reports recently (past wk) noticing city she lives in (orientation to place, long-term memory) or that the pt is occasionally confused. Daughter reports pt got the name of your clinic (orientation to place, short-term mem- lost during a familiar walk in her own neighborhood in past ory). When asked if she knows how she got to your clinic today, wk. Denies observing this in the past. she responds, “I walked here with my daughter” (but the daugh- Objective: Cognition: Pt A&O × 2 (not oriented to place or ter drove her). She is unable to recall three words several min- event); demonstrates some confusion c– simple questions; utes after you have given her those words to remember impaired STM and LTM; impaired abstraction, advanced (short-term memory). She is able to perform simple, but not calculation, and thought processing. Simple calculation and complex, mathematical calculations in her head (calculation). construction are unimpaired. She also is able to reproduce a three-dimensional drawing (construction). She cannot tell you the similarities or differ- Assessment: Pt experiencing recent onset of confusion, which ences between a pen and a pencil (abstraction), and she strug- seems to coincide c– beginning indomethacin for pain. PT gled with the question “If your car had a flat tire, then you concerned about pharmacological side effect based on recent would ____” (thought process). Further questioning of her and sudden onset of confusion and no hx of similar daughter reveals that the patient has experienced some confu- problems. sion in the past week for no apparent reason, even getting lost during a typical walk in her neighborhood. However, the Plan: PT consulted MD and pt to be seen in MD office within patient has no past medical history that includes confusion. 24 hrs. Will continue c– Rx for hip pain at next PT visit in 2 d. When reviewing her medications, you note that the patient is