Chapter 7 Mental Status PDF

CHAPTER Mental Status T he mental status portion of the neurologic examination is a complex process. Mental status is the total expression of a person’s emotional responses, mood, cognitive functioning (ability to think, reason, and make judgments), and personality. A major focus of the examination...

CHAPTER Mental Status T he mental status portion of the neurologic examination is a complex process. Mental status is the total expression of a person’s emotional responses, mood, cognitive functioning (ability to think, reason, and make judgments), and personality. A major focus of the examination is the identification of the individual’s strengths and capabilities for interaction with the environment. This chapter focuses on the mental status evaluation of the individual’s overall cognitive state. See Chapter 23 for the assessment of neurologic lesions that cause alterations in mental status. Physical Examination Components 1. Observe physical appearance and behavior 2. Investigate cognitive abilities: State of consciousness Response to analogies Abstract reasoning Arithmetic calculation Memory Attention span 3. Observe speech and language for voice quality, articulation, coherence, and comprehension. 4. Evaluate emotional stability for signs of depression, anxiety, thought content disturbance, and hallucinations.    ANATOMY AND PHYSIOLOGY The cerebrum of the brain is primarily responsible for a person’s mental status. Many areas in the cerebrum contribute to the total functioning of a person’s mental processes. Two cerebral hemispheres, each divided into lobes, comprise the cerebrum. The gray outer layer—the cerebral cortex—houses the higher mental functions and is responsible for perception and behavior (Fig. 7.1). The frontal lobe, containing the motor cortex, is associated with speech formation (in the Broca area). This lobe is responsible for decision making, problem solving, the ability to concentrate, and short-­term memory. Associated areas—related to emotions, affect, drive, and awareness of self and the autonomic responses related to emotional states—also originate in the frontal lobe. The parietal lobe is primarily responsible for receiving and processing sensory data. 7 The temporal lobe is responsible for the perception and interpretation of sounds as well as localizing their source. It contains the Wernicke speech area, which allows a person to understand spoken and written language. The temporal lobe is also involved in the integration of behavior, emotion, and personality, as well as long-­term memory. The limbic system mediates certain patterns of behavior that determine survival (e.g., mating, aggression, fear, and affection). Reactions to emotions such as anger, love, hostility, and envy originate here, but the expression of emotion and behavior is mediated by connections between the limbic system and the frontal lobe. A major function is memory consolidation needed for long-­term memory. The reticular system, a collection of nuclei in the brainstem, regulates vital reflexes such as heart and respiratory functioning. It also maintains wakefulness, which is important for consciousness and for awareness and arousal functions. Disruption of the ascending reticular activating system can lead to altered mental status (e.g., confusion and delirium). Infants and Children All brain neurons are present at birth in a full-­term infant, but brain development continues with the myelinization of nerve cells over several years. Brain insults, such as infection (e.g., Zika virus or rubella), trauma, or metabolic imbalance, can damage brain cells, which may result in serious permanent dysfunction in mental status. Genetic, metabolic, and chromosomal disorders may also affect cognitive development and mental status. Adolescents Intellectual maturation continues, with greater capacity for information and vocabulary development. Abstract thinking (i.e., the ability to develop theories, use logical reasoning, make future plans, use generalizations, and consider risks and possibilities) develops during this period. Judgment begins to develop with education, intelligence, and experience. Older Adults Cognitive function should be intact in healthy older adults but declines in cognitive abilities occur in some older adults after 60 or 70 years of age. Variations in genetics, environment, diet, exercise, and chronic disease have an 93 94 CHAPTER 7 Mental Status Review of Related History Precentral gyrus (motor area) Central sulcus Premotor area (intellectual functions) Postcentral gyrus (sensory area) Primary taste area Somatic sensory association area Prefrontal area (behavioral, ethical, moral, social) Visual association area Visual cortex Broca area (motor speech area) Wernicke area (sensory speech area) Transverse gyrus Auditory association area Primary auditory area impact on the cognitive function of older adults. Decreases in the speed of information processing and psychomotor speed accompanied by less cognitive flexibility are expected with healthy aging. However, cognitive declines in executive functioning (the ability to plan and develop strategies, organize, concentrate and remember details, and manage activities) and memory are associated with cognitive impairment (Wischenka, et al., 2016). An estimated 2.4 to 5.5 million persons in the United States have dementia with increasing prevalence by age (Langa, et al. 2017). REVIEW OF RELATED HISTORY For each of the symptoms or conditions discussed in this section, targeted topics to include in the history of the present illness are listed. Responses to questions about these topics provide clues for focusing the physical examination and the development of an appropriate diagnostic evaluation. Questions regarding medication use (prescription and over-­the-­counter preparations) as well as complementary therapies are relevant for each area. History of Present Illness Disorientation and Confusion Abrupt or insidious onset: intermittent, fluctuating, or persistent; association with time of day or emotional crisis Associated health problems: new hearing or vision impairment; neurologic disorder, vascular occlusion, or brain injury; systemic infection; withdrawal from alcohol; metabolic or electrolyte disorder Associated symptoms: delusions, hallucinations (imaginary perceptions), mood swings, anxiety, sadness, lethargy or agitation, insomnia, change in appetite, drug toxicity Medications: anticholinergics, benzodiazepines, opioid analgesics, tricyclic antidepressants, levodopa or amantadine, diuretics, digoxin, antiarrhythmics, sedatives, FIG. 7.1 Functional subdivisions of the cerebral cortex. (From Patton, 2016.) hypnotics, or complementary therapies such as gingko biloba and St. John’s wort Depression Troubling thoughts or feelings, constant worry; change in outlook on life or change in feelings; feelings of hopelessness; inability to control feelings Low energy level, awakens feeling fatigued, agitation, feels best in the morning or at night Recent changes in living situation, death or relocation of friends or family members, changes in physical health T houghts or plans for hurting self and/or others, thoughts about dying, hopelessness, no plans for the future Medications: antidepressants; medications that may cause or worsen depression (e.g., antihypertensive agents, corticosteroids, beta-­blockers, calcium channel blockers, barbiturates, phenytoin, anabolic steroids) Anxiety Sudden, unexplained episodes of intense fear, worry, anxiousness, or panic for no apparent reason; afraid will be unable to escape or get help in certain situations; cannot control worrying; spends excessive time repeatedly doing or checking things Feels uncomfortable in or avoids situations or events that involve being with people Exposure to frightening or traumatic events Associated symptoms: panic attacks, obsessive thoughts, or compulsive behaviors Medications: antidepressants, steroids, benzodiazepines Past Medical History N  eurologic disorder, brain surgery, brain injury, residual effects, chronic disease, intellectual delay, or debilitating condition Psychiatric disorder or hospitalization CHAPTER 7 P  sychiatric disorders, mental illness, alcoholism A lzheimer disease Learning disorders, intellectual disability, autism Personal and Social History E  motional status: feelings about self; anxious, restless, or irritable; discouraged or frustrated; problems with money, job, legal system, spouse, partner, or children; ability to cope with current stressors in life Life goals, attitudes Relationship with family members Intellectual level: education history, access to information, mental stimulation Communication pattern, able to understand questions, coherent and appropriate speech, change in memory or cognitive thought processes Changes in sleeping or eating patterns; change in appetite or diet, weight loss or gain; decreased sexual activity Use of alcohol or illicit drugs, especially mood-­altering drugs Children S  peech and language: timing of first words, words understood, progression to phrases and sentences Behavior: temper tantrums, ease in separating from family or adjusting to new situations Performance of self-­care activities: dressing, toileting, feeding Personality and behavior patterns: changes related to any specific event, illness, or trauma Learning or school difficulties: associated with interest, hyperactivity, or ability to concentrate Adolescents  isk-­taking behaviors R School performance and peer interactions Family interactions Reluctance to talk about attitudes, behaviors, and experience Older Adults C  hanges in cognitive functioning, thought processes, memory; association with medications prescribed (e.g., opioids, benzodiazepines, antidepressants, corticosteroids, muscle relaxants) Changes in activities of daily living (ADLs), e.g., money management, food preparation Depression: somatic complaints, hopelessness, helplessness, lack of interest in personal care EXAMINATION AND FINDINGS Mental status is assessed continuously during the entire patient interaction by evaluating their alertness, BOX 7.1 95 Procedures of the Mental Status Screening Examination The shorter screening examination is commonly used for health visits when no known mental status problem is apparent. Information is generally obtained during the history by observation of behavior and responses to questions in the following areas. Appearance and Behavior Grooming Emotional status Body language Emotional Stability Mood and feelings Thought processes Cognitive Abilities State of consciousness Memory Attention span Judgment Speech and Language Voice quality Articulation Comprehension Coherence Aphasia FIG. 7.2 During the initial greeting, observe the patient for behavior, emotional status, grooming, and body language. Note the patient’s body posture and ability to make eye contact. orientation, cognitive abilities, and mood (Box 7.1). Observe the patient’s physical appearance, behavior, and responses to questions asked during the history (Fig. 7.2). Note any reliance on an accompanying adult to answer questions. Make a point of asking the patient to provide responses. Note any variations in response to questions of differing complexity. Speech should be clearly articulated. Questions should be answered appropriately, with ideas expressed logically, relating current and past events. Examination and Findings Family History Mental Status 96 CHAPTER 7 Mental Status Examination and Findings Physical Appearance and Behavior Grooming Assess the patient’s hygiene, grooming, and appropriateness of dress for age and season. Poor hygiene, lack of concern with appearance, or inappropriate dress for season or occasion in a previously well-­groomed individual may indicate depression, another psychiatric disorder, or dementia. Emotional Status Note the patient’s behavior. The patient’s manner should demonstrate concern appropriate for the topics discussed. Consider cultural variations when assessing emotional responses. Note patient behavior that conveys carelessness, apathy, loss of sympathetic reactions, unusual docility, hostility, rage reactions, or excessive irritability. Nonverbal Communication (Body Language) Note the patient’s posture, eye contact, and facial expression. Some cultural groups will not maintain eye contact with others. Slumped posture and a lack of facial expression may indicate depression or a neurologic condition such as Parkinson disease. Excessively energetic movements or constantly watchful eyes suggest tension, mania, anxiety, a metabolic disorder, or the effects of illicit or prescription drug use (e.g., methamphetamine, amphetamine salts, opioids, cocaine, and steroids). State of Consciousness Assess the patient’s orientation to person, place, and time with responses to questions, as well as to the physical and environmental stimuli. Person disorientation results from cerebral trauma, seizures, or amnesia. Place disorientation occurs with psychiatric disorders, delirium, and cognitive impairment. Time disorientation is associated with anxiety, delirium, depression, and cognitive impairment. See Table 7.1 for potential causes of unresponsiveness. The TABLE 7.1 Common Causes of Unresponsiveness TYPE OF DISORDER CAUSE Focal lesions of the brain Hemorrhage, hematoma, infarction, tumor, abscess, trauma Diffuse brain disease Drug intoxications Disturbances of glucose, sodium, or calcium metabolism, renal failure, myxedema, pulmonary insufficiency Hypothermia, hyperthermia Hypoxic or anoxic event such as strangulation, drowning, cardiac arrest, pulmonary embolism Encephalitis, meningitis Seizures Psychogenic unresponsiveness Dementia Glasgow Coma Scale is used to quantify the level of consciousness after an acute brain injury or medical condition (see Chapter 26). Cognitive Abilities Evaluate cognitive functions from patient responses to history-­taking questions. Specific questions and tasks can provide a detailed assessment of cognition, the execution of complex mental processes (e.g., learning, perceiving, decision making, and memory). See tools (e.g., Montreal Cognitive Assessment and Mini-­Cog) later in the chapter to assess cognitive function in older adults if quantification of cognitive function is needed. Signs of possible cognitive impairment include the following: significant memory loss, confusion (impaired cognitive function with disorientation, attention and memory deficits, and difficulty answering questions or following multiple-­step directions), impaired communication, inappropriate affect, personal care difficulties, hazardous behavior, agitation, and suspiciousness (see Clinical Pearl, “The Importance of Validation”). CLINICAL PEARL The Importance of Validation Interview a family member or friend of the patient if you have any concerns about a patient’s responses or behavior. Determine whether the patient has any problems remembering appointments or important events, paying bills, shopping independently for food or clothing, preparing meals, taking medication, getting lost while walking or driving, making decisions about daily life, or asking the same thing again and again. Analogies Ask the patient to describe simple analogies first and then more complex analogies: What is similar about these objects: Peaches and lemons? Ocean and lake? Trumpet and flute? Complete this comparison: An engine is to an airplane as an oar is to a ____. What is different about these two objects: A magazine and a cookbook? A bush and a tree? Correct responses should be given when the patient has average intelligence. An inability to describe similarities or differences may indicate a lesion of the left or dominant cerebral hemisphere. Abstract Reasoning Ask the patient to tell you the meaning of a fable, proverb, or metaphor, such as the following: A stitch in time saves nine. A bird in the hand is worth two in the bush. A rolling stone gathers no moss. When the patient has average intelligence, an adequate interpretation should be given. Inability to explain a CHAPTER 7 Arithmetic Calculation Ask the patient to do simple arithmetic, without paper and pencil, such as the following: Subtract 7 from 50, subtract 7 from that answer, and so on, until the answer is 8. Add 8 to 50, add 8 to that total, and so on, until the answer is 98. The calculations should be completed with few errors and within 1 minute when the patient has average intelligence. Impairment of arithmetic skills may be associated with depression, cognitive impairment, and diffuse brain disease. Writing Ability For a comprehensive mental status examination, ask the patient to write his or her name and address or a dictated phrase. Omission or addition of letters, syllables, words, or mirror writing may indicate aphasia (impairment in language function). Alternatively, if poor literacy is a concern, ask the patient to draw simple geometric figures (e.g., a triangle, circle, or square) and then more complex figures such as a clock face, house, or flower. Uncoordinated writing or drawing may indicate dementia, parietal lobe damage, a cerebellar lesion, or peripheral neuropathy. Execution of Motor Skills Ask the patient to unbutton a shirt button or to comb his or her hair. Apraxia (the inability to translate an intention into action that is unrelated to paralysis or lack of comprehension) may indicate a cerebral disorder. Memory Immediate recall or new learning: Ask the patient to listen and then repeat a sentence or a series of numbers. Five to eight numbers or words forward or four to six numbers or words backward can usually be repeated. Recent memory: Give the patient a short time to view four or five test objects, telling them that you will ask about the objects in a few minutes. Ten minutes later, ask the patient to list the objects. All objects should be remembered. (See Clinical Pearl, “Testing Memory in the Visually Impaired.”) Remote memory: Ask the patient about verifiable past events or information such as sibling’s name, high school attended, or a subject of common knowledge. Memory loss may result from disease, infection, or temporal lobe trauma. Impaired memory occurs with various neurologic or psychiatric disorders, such as anxiety and depression. Loss of immediate and recent memory with retention of remote memory suggests dementia. 97 CLINICAL PEARL Testing Memory in the Visually Impaired When a patient is visually impaired, test recent memory with unrelated words rather than observed objects. Pick four unrelated words that sound distinctly different, such as “green,” “daffodil,” “hero,” and “sofa” or “bird,” “carpet,” “treasure,” and “orange.” Tell the patient to remember these words. After 5 minutes, ask the patient to list the four words. Attention Span Ask the patient to follow a short set of commands. Alternatively, ask the patient to say either the days of the week or to spell the word “world” forward or backward. The ability to perform arithmetic calculations is another test of attention span. Appropriate response to directions is expected. Easy distraction, confusion, negativism, and impairment of recent and remote memory may all indicate a decreased attention span. This may be related to fatigue, depression, delirium, or toxic or metabolic causes that result in confusion. Judgment Determine the patient’s judgment and reasoning skills by exploring the following topics: How is the patient meeting social and family obligations? What are the patient’s plans for the future? Do they seem appropriate? Ask the patient to provide solutions to hypothetical situations, such as: “What would you do if you found a stamped envelope?” “What would you do if a police officer gave you a ticket after you drove through a red light?” If the patient is meeting social and family obligations and adequately dealing with financial obligations, judgment is considered intact. The patient should be able to evaluate the situations presented and recognize the consequences of action. Impaired judgment may indicate intellectual disability, emotional disturbance, frontal lobe injury, dementia, or psychosis. Speech and Language Skills Detailed evaluation of the patient’s communication skills, both receptive and expressive, should be performed if the patient has difficulty communicating during the history. The patient’s voice should have inflections, be clear and strong, and be able to increase in volume. Determine whether the patient’s rate of speech is excessively fast or slow, normal, or has hesitations. Speech should be fluent with a clear expression of thoughts. Voice Quality Determine whether there is any difficulty or discomfort in phonation, or if laryngeal speech sounds are present. Examination and Findings phrase may indicate poor cognition, dementia, brain damage, or schizophrenia. Mental Status Examination and Findings 98 CHAPTER 7 Mental Status  IFFERENTIAL DIAGNOSIS D  Distinguishing Characteristics of Aphasias CHARACTERISTICS BROCA APHASIA (EXPRESSIVE) WERNICKE APHASIA (RECEPTIVE) GLOBAL APHASIA (EXPRESSIVE AND RECEPTIVE) Word comprehension Fair to good Can hear words but cannot relate them to previous experiences Absent or reduced to a person’s own name, few select words Spontaneous speech Impaired speech flow; laborious effort to speak; know what they want to say but cannot articulate properly; telegraphic speech (mostly nouns and verbs) Fluent speech but uses words inappropriately, such as neologisms or word substitutions; may be totally incomprehensible Absent or reduced to only a few words or sounds Reading comprehension Intact Impaired Severely impaired Writing Impaired Impaired Severely impaired Dysphonia, a disorder of voice volume, quality (e.g., harsh, nasal, or breathy), or pitch (e.g., monotony of pitch or loudness), suggests a problem with laryngeal innervation or disease of the larynx. Articulation Evaluate spontaneous speech for pronunciation and ease of expression. Abnormal articulation includes imprecise pronunciation of consonants, slurring, difficulty articulating a single speech sound, hesitations, repetitions, and stuttering. Dysarthria, a motor speech disorder, is associated with many conditions of the nervous system such as stroke, inebriation, cerebral palsy, and Parkinson disease. Comprehension Ask the patient to follow simple one-­and two-­step directions during the examination, such as during the attention span assessment. The patient should be able to follow simple instructions. Coherence The patient’s intentions or perceptions should be clearly conveyed to you. Communication characteristics that may be associated with a psychiatric disorder include the following: Circumlocution—pantomime or word substitution to avoid revealing that a word was forgotten Perseveration—repetition of a word, phrase, or gesture Flight of ideas or use of loose associations—disordered words or sentences Word salad—meaningless, disconnected word choices Neologisms—made-­up words that have meaning only to the patient Clang association—word choice based on sound so that words rhyme in a nonsensical way (e.g., The far car mar to the star) Echolalia—Repetition of another person’s words Utterances of unusual sounds Aphasia, a speech disorder that can be receptive (understanding language) or expressive (speaking language), may be indicated by hesitations and other speech rhythm disturbances, omission of syllables or words, word transposition, circumlocutions, and neologisms. Aphasia can result from facial muscle or tongue weakness or from neurologic damage to brain regions controlling speech and language. Characteristics of different types of aphasia are listed in the Differential Diagnosis box following this section. Emotional Stability Emotional stability is evaluated when the patient does not seem to be coping well or does not have the resources to meet their personal needs. Mood and Feelings During the history and physical examination, observe the mood and emotional expression evident from the patient’s verbal and nonverbal behaviors. Note any mood swings or behaviors indicating anxiety, depression, anger, hostility, or hypervigilance. Ask the patient how he or she feels right now, whether feelings are a problem in daily life, and whether any time or experience is particularly difficult for the patient. The U.S. Preventive Health Task Force recommends depression screening of all adults using the self-­ administered Patient Health Questionnaire (PHQ) (Siu and U.S. Preventive Health Task Force, 2016). A two-­ and a nine-­item version of the PHQ exist. The PHQ-­2 questions are: Over the past 2 weeks, have you felt down, depressed, or hopeless? Over the past 2 weeks, have you felt little interest or pleasure in doing things? If the response is positive to both questions, perform the PHQ-­9 or ask more questions about depression symptoms, such as trouble sleeping or sleeping too much, moving too slow or restlessness, poor appetite or overeating, poor concentration, feeling like a failure, or thoughts of hurting yourself. The PHQ-­9 is a valid and sensitive tool for identifying a major depressive disorder in adults (Nandakumar, et al., 2019). This tool has been translated into several languages. See www.phqscreeners.com for full access to the PHQ-­9. Be concerned if the patient does not express appropriate feelings that correspond to the situation. For example, does the patient laugh when talking about a seriously ill family member? Unresponsiveness, hopelessness, agitation, aggression, anger, euphoria, irritability, or wide mood swings indicate disturbances in mood, affect, and feelings. Identify the potential for suicide, particularly if the patient has signs of depression or risk factors for suicide could be present. See Risk Factors: Suicide. Two questions on the Columbia-­Suicide Severity Risk Screener (C-­SSRS) help identify the patient at higher risk for suicide ideation and behavior: Have you wished you were dead or wished you could go to sleep and not wake up? Have you actually had any thoughts of killing yourself? A positive response to the second item places the patient at higher risk, especially if the patient made any recent preparations for how to end his or her life. Implement a patient safety monitoring plan with the patient and family and obtain an immediate psychiatry referral if preparations have occurred within the past two to three weeks. Arrange a more thorough suicide risk assessment for other patients with a positive response (Posner et al, 2016). Full access to the C-­SSRS is available at https://cssrs.columbia.edu/wp-­ content/uploads/C-­SSRS_Pediatric-­SLC_11.14.16.pdf. Mental Status 99 process should be easy to follow with logical and goal-­ directed ideas expressed. Illogical, disorganized, or unrealistic thought processes, flight of ideas (rapid disconnected thoughts), blocking (i.e., an inappropriate pause in the middle of a thought, phrase, or sentence), or an impaired stream of thinking (e.g., repetition of a word, phrase, or behavior) indicates an emotional disturbance or a psychiatric disorder. Evaluate disturbance in thought content by asking about obsessive thoughts related to fears, guilt, or making decisions. Does the patient ever feel like he or she is being watched or followed, is controlled or manipulated, or loses touch with reality? Does the patient compulsively repeat actions or check and recheck to make sure something is done? Obsessive thoughts, compulsive behaviors, phobias, or anxieties that interfere with daily life may indicate mental dysfunction or a psychiatric disorder. Does the patient have delusions (false personal beliefs not shared by others in the same culture), such as delusions of grandeur or of being controlled by an outside force? Does the patient feel unrealistic persecution, jealousy, or paranoia? Delusions are often associated with psychiatric disorders, delirium, and alcohol or drug intoxication. (See Clinical Pearl, “Distorted Thinking.”) CLINICAL PEARL Distorted Thinking A patient who demonstrates an unrealistic sense of persecution, jealousy, grandiose ideas, or ideas of reference (e.g., neutral things in the environment have a special meaning to the person) may be experiencing distorted thinking. Risk Factors Suicide S ocial isolation, older men or women, divorced or widowed, living alone Mental health disorder, depression, hopelessness Serious chronic or terminal health condition (e.g., HIV infection, cancer, renal failure) Family history of suicide or suicide attempt Identifies as LGBTQ in presence of other risk factor Knowing someone who recently attempted or committed suicide Significant personal losses or challenges (e.g., bereavement, financial or legal problems, unemployment, in an abusive relationship, recent breakup with a partner) Adverse childhood experiences Has thought about a plan for suicide; previous suicide attempt Alcohol and substance use disorders Access to firearms or other means of self-­harm    Thought Process and Content Observe the patient’s thought patterns, especially the appropriateness of sequence, logic, coherence, and relevance to the topics discussed. The patient’s thought Perceptual Distortions and Hallucinations Determine whether the patient perceives any sensations that are not caused by external stimuli (e.g., hears voices, sees vivid images or shadowy figures, smells offensive odors, tastes offensive flavors, feels worms crawling on the skin). Find out when these experiences occur. Auditory and visual hallucinations are associated with psychiatric disorders, severe depression, acute intoxication, withdrawal, delirium, and dementia. Tactile hallucinations are most commonly associated with alcohol withdrawal. Infants and Children Evaluate an infant’s general behavior and level of consciousness by observing the level of activity and responsiveness to caregivers and environmental stimuli. Note whether the baby is lethargic, drowsy, stuporous, alert, active, or irritable (Fig. 7.3A). By 2 months of age, the infant should appear alert, quiet, and content and should recognize the face of a primary caregiver (see Fig. 7.3B). The examiner who devotes time to developing a relationship with a 2-­to 3-­month old infant should be able to coax Examination and Findings CHAPTER 7 100 Mental Status Examination and Findings CHAPTER 7 A a smile. When it is difficult or impossible to elicit a social smile in an infant who appears ill, be concerned about a neurologic condition or infection, such as meningitis. Be concerned if the parent or primary caregiver seems detached or depressed. An infant’s social and emotional development is heavily influenced by interaction with the primary caregiver. Crying and other vocal sounds are evaluated when language has not yet developed. The infant’s cry should be loud and angry. A shrill or whiny, high-­pitched cry or catlike screeching cry suggests a central nervous system disorder. Cooing and babbling are expected after 3 and 4 months of age, respectively. Evaluate the types of words and speech patterns used by the child. For example, does the child pronounce most words correctly as expected for age, do persons outside the immediate family understand the child’s speech, and does the child stammer or stutter? What is the child’s voice quality? Does the child’s voice have intonation (e.g., excitement)? Table 7.2 describes expressive language milestones for toddlers. Language development should be appropriate for age and speech should be more clearly understandable as the child ages. Questionnaires completed by parents (e.g., Ages and Stages Questionnaire, see www.agesandstages.com; and Parent’s Evaluation of Developmental Status, see www.pedstest.com) are effective screening tools recommended for developmental assessment during routine well child visits. These questionnaires have good sensitivity and specificity for detecting developmental concerns. Ask children 5 years and older to draw a picture of a person, doing the best job possible. Scores for the detail in 14 TABLE 7.2 AGE (MONTHS) EXPRESSIVE LANGUAGE MILESTONES 4–6 Babbles speech-­like sounds, including p, b, and m 10–12 Imitates different speech sounds, has 1 or 2 words, such as “mama,” “dada,” “bye-­bye,” but sounds may not be clear 12–24 Increases words each month, 2-­word questions or phrases (e.g., “Where baby?” and “Want cookie”) 24–36 Uses two-­ to three-­word sentences to ask for things Large vocabulary, speech understood by family members most of the time 36–48 Answers simple questions, talks about activities Sentences have four or more words, speech understood by most people 48–60 Says most sounds correctly, except l, s, r, v, z, ch, sh, th Uses sentences, gives many details Tells stories and stays on topic B FIG. 7.3 (A) Note this newborn’s irritability and posturing associated with cocaine withdrawal. (B) Note this infant’s level of alertness and interest in various objects and people.  Expressive Language Milestones for Toddlers and Preschoolers Data from National Institutes of Health, National Institute on Deafness and Other Communication Disorders (2017). Mental Status 101 body part attributes are available to assess cognitive development (Kwan, 2018) (Fig. 7.4). Observe the child’s behaviors during the patient history to identify mood, activity level, communication pattern, preferences, responsiveness to the parent, and ability to separate. Does the child have self-­comforting measures? Does the child play and have fun? Attempt memory testing at about 4 years of age if the child pays attention and is not too anxious. Expected memory skills vary with the age of the child. When testing immediate recall, a 4-­year-­old can repeat three digits or words, a 5-­year-­old can repeat four digits or words, and a 6-­year-­old can repeat five digits or words. Test recent memory in a child starting at 5 to 6 years by showing the child familiar objects and waiting no longer than 5 minutes to ask the child to recall the objects (Fig. 7.5). Remote memory is tested by asking the child to recite a nursery rhyme, say what they had for dinner last night, or tell you their address. Concerns about behaviors and mood disorders may be assessed in children 4 to 18 years of age with tools like the Pediatric Symptom Checklist (https://www.massge neral.org/psychiatry/treatments-­a nd-­services/pediatric-­ symptom-­c hecklist). An adolescent version of the Patient Health Questionnaire—9 (PHQ-­9) is also available to screen for depression. Positive responses should prompt questions about school, family, friends, moods, and activities. FIG. 7.4 Ask the child to draw a picture of a man or woman. The presence and form of body parts provide a clue about the child’s development when following the scoring criteria of the Goodenough-­Harris Drawing Test. Older Adults Assess cognitive function to identify mild cognitive impairment that may indicate the onset of dementia or cognitive changes associated with normal aging. As with all adults, assess the patient’s response to questions and directions during the history and physical assessment. Recent memory for important events and conversations is usually not impaired. The older adult may complain about episodic memory loss, but this is not predictive of cognitive decline. The concern of a close family member about the patient’s memory loss or a patient’s report that memory loss interfered with daily activities are indications to use a standardized tool to assess cognition. The Montreal Cognitive Assessment (MoCA) is a tool initially designed to detect mild cognitive impairment that may identify a transition between normal aging and dementia. The MoCA-­Basic is a version for low literacy adults. This tool also helps identify patients needing a more comprehensive cognitive assessment. See Evidence-­ Based Practice in Physical Examination: Montreal Cognitive Assessment Battery. FIG. 7.5 Test a child’s memory recall by using familiar objects. Pregnant Patients An estimated 39% of patients who have depression during pregnancy have postpartum depression. An estimated 13% of patients have postpartum depression, and postpartum psychosis occurs in up to 3% of postpartum patients (Wilkinson, et al. 2017). Risk factors for postpartum depression include a history of depression, prior postpartum depression, and poor social support. Because the depression may interfere with the patient’s health, ability to work, attachment to the newborn, and the infant’s subsequent development, all pregnant patients should be screened for depressive symptoms during pregnancy and then in the postpartum period, including during routine well-­child visits. The two PHQ-­2 depression screening questions listed in the section on Mood and Feeling can be used for screening. Ask additional questions to determine whether depression is present when the response to screening questions is positive. The Edinburgh Postnatal Depression Scale is a 10-­item self-­administered screening test that may be used during pregnancy and the postpartum period. Patients are asked to identify the frequency of feelings (e.g., happiness, anxiety or worry, scared or panicky, and sad or miserable) over the past 7 days. See https://psychology-­tools.com/epds/ for access to this tool. Examination and Findings CHAPTER 7 102 CHAPTER 7 Mental Status Evidence-­Based Practice in Physical Examination Examination and Findings Montreal Cognitive Assessment Battery The Montreal Cognitive Assessment tools (MoCA and low literacy MoCA-­Basic) include items in the following domains providing a broader assessment of cognitive status than the Mini-­Mental State Examination (MMSE): Immediate and delayed memory recall Visuospatial abilities with clock drawing and copying a three-­ dimensional cube Executive functioning with trail-­making, phonemic fluency, and verbal abstraction tasks Attention, concentration, and working memory sustained attention serial subtraction, and digits forward and backward tasks Language with identification of low-­familiarity animals, repetition of two complex sentences Orientation to time and place It has more cognitively demanding tasks related to memory recall and executive functioning than the MMSE. With a cutoff score of 24 in a 30-­point test, the MoCA-­Basic has a sensitivity of 81% and specificity of 86% in the identification of mild cognitive impairment with clinically objective signs of cognitive decline. Scores did not vary significantly by literacy level during tests with more highly educated individuals (Julayanont, et al., 2015). The MoCA was found to better discriminate between patients with mild cognitive impairment at risk for dementia than the MMSE, as well as those patients with multiple domain versus single domain mild cognitive impairment (Dong et al, 2012). For access to the screening tool, visit www.mocatest.org.    The Mini-­Cog is a brief screening tool for measuring cognitive function that takes up to 5 minutes to administer. It involves immediate and delayed recall of three unrelated words and a clock-­d rawing test (see Fig. 7.6 for test administration and scoring guidelines). A score of 0 to 5 points is possible, and a score of 2 or less may be associated with dementia. The Mini-­Cog has a sensitivity of 87% and specificity of 85% for detecting probable dementia (Yang, et al., 2016). It has been used successfully in non-­English-­speaking and culturally diverse populations, as well as those with varying educational levels. The MMSE is a standardized tool to assess cognitive function changes over time. The 11 items—measuring orientation, registration, attention and calculation, recall, ability to follow commands, and language—take approximately 5 to 10 minutes to administer. Fig. 7.7 shows testing of the copying skill under the language portion of the MMSE. The maximum score is 30. A score of 20 or less may be associated with dementia, and a score of 26 or higher is not associated with dementia. The MMSE has been translated into multiple languages and adapted for many cultures; however, age, ethnicity, and education have an impact on scoring (Hwang, et al., 2019). MMSE Version 2 was developed to replace problematic items and to improve item translation (Folstein and Folstein, 2020). For access to the full tool, see https://www.parinc.com/Pr oducts/NEUROPSYCHOLOGY/Dementia. Determine whether any changes in cerebral function could be the result of cardiovascular, hepatic, renal, or metabolic disease. Medications can also impair central nervous system function, causing slowed reaction time, disorientation, confusion, loss of memory, tremors, and anxiety. Problems may develop because of the dosage, number, or interaction of prescribed and over-­the-­counter medications. Review the patient’s ability to perform ADLs associated with mental status. FUNCTIONAL ASSESSMENT Activities of Daily Living Related to Mental Status The ability to perform instrumental ADLs, or the ability to live independently, is an important assessment. When assessing the patient’s mental status, attempt to determine the patient’s ability to perform the following ADLs: Shop, cook, and prepare nutritious meals Use problem-­solving skills Manage medications (purchase, understand, and follow directions) Manage personal finances and business affairs Speak, write, and understand spoken and written language Remember appointments, family occasions, holidays, household tasks Older adults are expected to maintain the same level of interpersonal skills and have no personality changes. Depression, one of the most common conditions in older adults, may contribute to cognitive impairment. Depression can be identified with the Geriatric Depression Scale (Fig. 7.8). Paranoid thought may be a striking alteration in personality. Attempt to determine whether the thought process is accurate or a paranoid ideation, keeping in mind the incidence of elder abuse. Facial expressions that are masklike or overly dramatic, or a stance that is stooped and fearful, may indicate a progressive disease in the older adult. Patient Safety Older Adult’s Living Arrangements When impairment in the ability to perform ADLs is identified, determine safety in the older adult’s living arrangements. Is a caregiver present in the home or does someone check in each day? Is food delivered to the home or are meals provided? Are medication dosages provided or monitored? Has the older adult stopped driving a car? How well can the older adult safely move around the home? If safety is a concern, have a discussion with the older adult’s family member or friend to encourage changes that will improve safety.    CHAPTER 7 Mental Status 103 The Mini-Cog assessment instrument combines an uncued three-item recall test with a clockdrawing test (CDT). The Mini-Cog can be administered in about three minutes, requires no special equipment, and is relatively uninfluenced by level of education or language variations. Administration The test is administered as follows: 1. Instruct the patient to listen carefully to and remember three unrelated words and then to repeat the words. 2. Instruct the patient to draw the face of a clock, either on a blank sheet of paper or on a sheet with the clock circle already drawn on the page. After the patient puts the numbers on the clock face, ask him or her to draw the hands of the clock to read a specific time, such as 11:20. These instructions can be repeated, but no additional instructions should be given. Give the patient as much time as needed to complete the task. The CDT serves as the recall distractor. 3. Ask the patient to repeat the three previously presented words. Scoring Give 1 point for each recalled word after the CDT distractor. Score 1–3. A score of O indicates positive screen for dementia. A score of 1 or 2 with an abnormal CDT indicates positive screen for dementia. A score of 1 or 2 with a normal CDT indicates negative screen for dementia. A score of 3 indicates negative screen for dementia. The CDT is considered normal if all numbers are present in the correct sequence and position, and the hands readably display the requested time. FIG. 7.6 The Mini-­Cog is a brief screening tool for measuring cognitive function. (Reprinted with permission from Borson et al, 2000.) Think About It Mental Status A B FIG. 7.7 (A) Acceptable drawing of a clock with numbers appropriately spaced around the face and the requested time of 10 minutes after the 4 o’clock noted correctly by the long and short hands. (B) Unacceptable drawing that shows poor planning regarding number placement around the clock face, and hands pointing to the 10 and 4, for 10 minutes after the 4 o’clock. (From Stern and Fricchione, 2010.) An older adult expresses concern about forgetfulness, such as not remembering her last appointment to see you. She lives alone, her closest family members live an hour away, and she worries about being a burden to her family. During the history, she responded to all questions indicating good recall, an ability to shop for and prepare healthy meals, and taking her prescribed medications. During the physical examination, she followed two-­step directions correctly. Findings indicate appropriate cognitive functioning at this time. If concerns about cognitive function were revealed, a valid tool such as the MoCA could help reveal mild cognitive impairment.    Examination and Findings The Mini-Cog Assessment Instrument for Dementia