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started 9-14 after break, ended 9-21

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Lecture 4 Lecture 4 Presentation Transcript

  • V550 Mental Status Richard E. Meetz, OD, MS 2009v3
  • Mental Status
    • After the Hx is recorded, you will need to make an assessment of the patient’s mental status.
    • NOTE: The mental status is actually part of the Objective examination and not part of the history, but the status is assessed as the history is conducted.
  • Mental Status
    • By evaluating the patient’s
      • Appearance and behavior
      • Speech and language
      • Affect and mood
      • Orientation
        • To person, place and time
      • Thought and perceptions
        • Cognitive functions
  • Appearance and Behavior
    • A patient’s appearance and behavior are important indicators of general level of function.
      • A well-dressed, well-organized patient is “probably” functioning at a higher level than one who is disheveled and unkempt.
      • Important to note “is the dress appropriate for the situation and weather.”
  • Appearance and Behavior
    • Posture
        • (see earlier lecture on patient types)
    • Grooming and personal hygiene
        • Deteriorate in some disorders
          • Depression, schizophrenia & dementia
        • Excessive care in obsessive-compulsive disorder (OCD)
        • One sided neglect seen in some strokes or lesions of the non-dominate parietal cortex
  • Speech and Language
    • The character of the patient’s speech provides insight into the patient’s mental state.
    • Aspects of speech;
      • Amplitude or loudness
      • Volume or amount
      • Prosody or fluidity
  • Speech and Language
    • Language can be assessed by evaluating:
      • Spontaneous speech
      • Repetition
      • Comprehension of spoken & written material
      • The ability to write
  • Speech and Language
    • Language and vocabulary are fairly good indicators of intelligence.
    • They are relatively unaffected by any but the most severe disorders.
      • Can help distinguish between a mentally retarded adult (limited vocabulary) from those with mild or moderate dementia and a fairly well preserved vocabulary.
  • Speech and Language
    • Disorders of Speech
      • Fall into 3 groups
      • The voice
      • The articulation of words
      • The production & understanding of language
  • Speech and Language
    • Disorders of Speech: the voice
      • Aphonia : loss of voice 2° to nerve or larynx disease or it’s nerve supply (CN X)
      • - cancers
      • - stroke
      • Dysphonia: less severe impairment in volume, quality or pitch (hoarseness)
      • - laryngitis
      • - local damage (intubation, strain, smoking)
  • Speech and Language
    • Disorders of Speech: articulation
      • Dysarthia : defect in muscular control 2° to motor lesions, (lips, tongue, palate, ect)
      • Words maybe:
      • - nasal, slurred or indistinct
      • But language remains intact
      • Causes:
      • - parkinsons
      • - cerebellar Dz
      • - both CNS & perpheral NS defects
  • Speech and Language
    • Disorders of Speech: language
      • Aphasia : central NS defect in producing or understanding language.
      • Types:
      • Receptive (fluent)
      • Expressive (non fluent)
  • Speech and Language
    • Disorders of Speech: language
      • Aphasia : Receptive (fluent)
        • Speech is rapid without effort
        • Speech may lack meaning, made-up
        • Reading, writing and Word comprehension are impaired
        • Naming objects is impaired
        • Repetition is impaired
  • Speech and Language
    • Disorders of Speech: language
      • Aphasia : Expressive (non fluent)
        • Speech is slow, few words, laborious
        • Inflection & articulation are impaired
        • Speech is meaningful with good construction
          • Nouns & verbs
        • Word comprehension & reading is fair to good
          • But writing is impaired
        • Naming objects is impaired
          • But are recognized
        • Repetition is impaired
  • Speech and Language
    • Speech and Language pathology:
      • Parkinson’s Dz patients will speak with a hypophonic, hushed quality.
    • Note:Facial features:
    - Masklike face with decreased blinking. (2-3/min) -Classic stare with chin down and fixation peering upwards
  • Speech and Language
    • Speech and Language pathology:
      • A Parkinson’s patient will also write extremely small “micrographia” that becomes progressively smaller over time.
  • Speech and Language
    • Speech and Language pathology;
      • In strokes the type of speech pattern will help localized the lesion
        • In frontal lobe lesions, the patient will have non-fluent speech,
          • “ Broca’s aphasia,” with hemiparesis
        • In temporal lobe lesions, the speech will be fluent but makes little to no sense
          • Wernicke’s Aphasia
  • Thought and perceptions
    • Assess the logic the patient uses in words and speech throughout the history taking.
    • Does the speech/thinking progress in a logical manner?
    • Is the content of their answers relevant to the question asked?
  • Thought and perceptions
    • Assess the patients insights and judgment
      • Insights
        • After the RFV ask what they think might be causing their complaint
          • Pts with psychotic disorders often lack insight into their problems
          • Pts with neurologic disorders often are in denial of their problems
  • Thought and perceptions
    • Assess the patients insights and judgment
      • Judgment
        • Note pts response to “How did you…” type of questions
          • Use of money, conflicts, job or family situations
          • Pts with disorders often lack good judgment
        • Note whether decisions and actions are based on reality
          • Impulse, wish fulfillment, values
            • Note there are some cultural variations
  • Thought and perceptions
    • Variations & abnormalities of speech
      • Circumstantiality (delay 2° to detail)
      • Derailment (Loosening of associations)
      • Flight of ideas (accelerated flow)
      • Neologisms (invented or distorted words)
      • Incoherence (lack of connections disordered grammar or words)
      • Blocking (sudden stop before end of thought)
      • Confabulation (fabrications of facts)
      • Perseveration (persistent repetition of words)
      • Clanging (using rhyming & punning speech)
  • Thought and perceptions
    • Abnormalities in content
      • Neurotic disorders
      • Compulsion (repetitive behaviors or mental acts)
      • Obsessions (recurrent, uncontrollable thoughts)
      • Phobias (persistent, irrational fears)
      • Anxieties (apprehensions, fears & tensions)
        • Focused = phobia
        • Free floating = ill-defined dread or doom
  • Thought and perceptions
    • Abnormalities in content
      • Psychotic disorders
      • Feeling of unreality (feeling that all is unreal or remote)
      • Feeling of depersonalization (detached from self)
      • Delusions (false fixed beliefs)
  • Thought and perceptions
    • Abnormalities in perception
      • Illusions
      • Hallucinations
  • Thought and perceptions
    • Abnormalities in perception
      • Illusions
      • Misinterpretations of real external stimuli
      • Can occur in grief reactions, delirium, traumatic stress disorders & schizophrenia
  • Thought and perceptions
    • Abnormalities in perception
      • Hallucinations
      • Sensory perceptions in the absence of relevant external stimuli
      • May be auditory, visual, olfactory, tactile, ect
      • May occur in delirium, dementia, alcoholism, traumatic stress disorders & schizophrenia
      • Perceptions associated with dreaming are not classified as hallucinations
  • Affect
    • How a person reacts to various topics.
    • The “affect” is not the assessment of mood but the observation of voice, facial expression or demeanor in response to topics .
  • Mood
    • Mood is a more sustained emotion.
    • Refers to a person’s persistent emotional state.
        • Includes sadness, melancholy, contentment, joy, euphoria,anger & rage, anxiety & worry.
    • Abnormality of mood fall into either depression or mania (bipolar).
  • Mood
    • Depression is seen in a number of neurological Dz.
      • Parkinson’s Dz
      • Huntington’s Dz
      • Strokes affecting the dominant hemisphere
    • Mania may be seen occasionally in cerebral lesions.
  • Mood
    • Evaluation of Depression & risk of suicide
      • Ask:
        • Do you get pretty discouraged?
        • How do you feel?
        • Do you think your depressed?
        • Do you feel like you want to end it?
        • Do you have a plan?
          • If yes think: SAL
          • 1. Is the method specific ?
          • 2. Is it available ?
          • 3. Is it lethal ?
  • Affect Assessment
    • You need to observe if the affect varies appropriately with the topic under discussion.
    • Does the patient look sad as they talk of the death in their family or do they laugh?
  • Affect Descriptors:
    • Normal
      • “ Appropriate” (for the situation)
      • “ Full range”
    • Abnormal
      • Apathy
      • Blunted
      • Flat
      • Labile (fluctuating more than “normal”)
  • Orientation
    • Is the patient oriented to person, place and time?
      • Person: Who they are and who you are, relatives?
      • Place: Where they are now, residence?
      • Time: Approximate date, time of day, year, season?
  • Orientation
    • For normal patients we use:
    • ‘ Patient Oriented X3’
    • as the recorded observation.
    • Abnormal orientation would be recorded as:
    • ‘ Patient Oriented X2, confused for time/day’
    • … with the missing component noted.
  • Recording Mental Status:
    • In the patient’s chart both affect and orientation are recorded.
    • Examples :
      • “ Appropriate & Oriented X3” for normal patients
      • “ Inappropriate & Oriented X3” for a patient who laughs at all our questions
  • Recording Abnormal Mental Status:
    • Examples (cont’d):
      • “ Flat & Oriented X3” - might be seen in a patient with early Parkinson’s.
      • “ Apathetic & Oriented X2” – confused for time or date, might be seen in dementia.
      • “ Labile & Oriented X3” - might be seen in a patient with grief.
  • Abnormal Mental Status:
    • Evaluation of abnormal mental status
      • Assessment of cognitive functions
        • Attention
        • Remote memory
        • Recent memory
        • Learning ability
        • Vocabulary
        • Math ability / calculation
        • Abstract thinking
        • Construction ability
  • Abnormal Mental Status:
    • Evaluation of abnormal mental status
      • Assessment of cognitive functions
        • Attention
          • Digit span
            • Give the patient a series of numbers two at a time, asking the patient to repeat them back to you.
            • After several correct try again with three then four.
          • Serial 7s
            • Have the patient count backwards in 7s from 100
          • Spelling backwards
            • Have the patient spell a word backward
            • Typically most use the word “world”
  • Abnormal Mental Status:
    • Evaluation of abnormal mental status
      • Assessment of cognitive functions
        • Remote memory
          • Long term memories; family birthdays, grade schools, jobs, events relevant to patients past
          • May be impaired in late stage dementia
        • Recent memory
          • Events of the day, meals, weather, ect
          • Impaired in Anxiety, dementia, delirium
        • Learning ability
          • Tell the patient you are going to give them 3 unrelated words to remember, then after 3 to 5 min ask the patient to recall the words
  • Abnormal Mental Status:
    • Evaluation of abnormal mental status
      • Assessment of cognitive functions
        • Vocabulary
          • Estimate of patients intelligence
        • Math ability / calculation
          • Ask simple addition & multiplication
          • Ask example of change making problem
            • “ You pay for a 78 cent item how much change should you get?”
  • Abnormal Mental Status:
    • Evaluation of abnormal mental status; other tests: abstract thinking
      • Tests the capacity to think beyond the Q
      • Proverbs
        • Ask the patient what people mean when they use the a saying or proverb such as:
          • “ The squeaking wheel gets the grease”
          • “ A stitch in time saves nine”
        • A concrete response is often given by people with MMR, delirium, schizophrenia or dementia
          • A schizophrenic may also give a normal or odd ans
  • Abnormal Mental Status:
    • Evaluation of abnormal mental status; other tests: abstract thinking
      • Tests the capacity to think beyond the Q
      • Similarities:
        • Ask the patient how the following are alike:
          • An orange and an apple
          • Wood and coal
          • A cat and a mouse
        • An abstract response would be both are animals
        • A concrete response would be both have tails
  • Abnormal Mental Status:
    • Evaluation of abnormal mental status; other tests: Constructional ability
      • Clock test
        • Patient draws a clock face
        • If poor suggests dementia or parietal damage
  • Abnormal Mental Status:
    • Evaluation of abnormal mental status
      • Mini-mental status examination (MMSE)
        • Highly reliable & validated 30-pt test
          • Check orientation
          • Repeat the names of 3 objects
          • Concentration “spell WORLD backward” or serial 7s
          • Name 2 objects
          • Repeat: “No ifs, ands, or buts”
          • Write a sentence
          • Read and enact a sentence “close your eyes”
          • Copy a figure (two interlocking pentagons)
          • Recall the 3 names of object repeated earlier
        • However, Insensitive in detecting dementia
  • Abnormal Mental Status:
    • Evaluation of abnormal mental status; other tests
      • Cognitive Impairment Test (CIT)
        • Shorter 6 item test
        • Correlates well with the MMSE
        • Sensitive in detecting dementia
  • Mental Status Exam; CIT
  • Abnormal Mental Status:
    • Mental Health Disorders in 1° care
  • Abnormal Mental Status:
    • Mental Health Disorders in 1° care
      • Est. 20% of 1° care patients
        • > 50% undiagnosed
      • Prevalence:
        • Anxiety 20%
        • Mood Disorders 25%
        • Depression 10%
        • Somatoform Disorders 10 to 15%
        • Alcohol & substance abuse 15 to 20%
  • Abnormal Mental Status:
    • Mental Health Disorders in 1° care
      • Unexplained symptoms
        • 1/3 of patients medical patients
        • 20 to 25% chronic Sx
        • 50% assoc with depression or anxiety
        • Co-occurrence of functional Sx reach 30 to 90%
          • IBS, TMJ, fibromyalgia, chronic fatigue, Mult Chem Sen
        • Near 80 to 90% Sx overlap with: fatigue, sleep disturbance, HA, GI Sx
  • Abnormal Mental Status:
    • Types of Disorders
      • Somatoform Disorders
      • Character Disorders
      • Disorders of Mood
      • Anxiety Disorders
      • Psychotic Disorders
      • Temporal lobe epilepsy
      • Dementias & Alzheimer’s
  • Abnormal Mental Status:
    • Types of Disorders
      • Somatoform Disorders
        • Defn: Chronic, multisystem complaints lacking an adequate medical or physical explanation
        • Sx include pain, GI, sexual dysfunction and neurologic symptoms
        • Onset early in life, psychosocial & vocational achievements are limited
  • Abnormal Mental Status:
    • Types of Disorders
      • Somatoform Disorders
        • Pain disorder
          • 1° Sx is pain of psychological origin
        • Conversion disorder
          • Mimics neurologic disorder in which psychological factors are etiologic, patients may not realize stress factor
            • Sx: HA, pain, paralysis
        • Hypochondria
          • Preoccupation with idea of having a serious Dz
        • Body dysmorphic disorder
          • Preoccupation with imagined or exaggerated defect in physical appearance
  • Abnormal Mental Status:
    • Types of Disorders
      • Other Somatoform-like Disorders
        • Factitous disorder
          • Intentional production or feigning of physical signs without external reinforcers
          • Munchausen syndrome; inflict physical harm on themselves or inflict / provoke symptoms in a child
        • Malingering
          • Intentional production or feigning of physical signs with external reinforcers /gain clearly present
          • Most common Opt Presentation: 6 - 8 yo Fe wanting glasses
  • Abnormal Mental Status:
    • Other Somatoform-like Disorders
      • Dissociative disorder
        • Disruptions of consciousness, memory, identity or perception judged to be due to psychological factors
          • Dissociative amnesia
            • Unable to remember traumatic events
          • Dissociative fugue
            • Acting in complex ways, travel with out memory of
          • Dissociative identity
            • AKA: multiple personality disorder
            • Switching from one coherent personality to another
          • Depersonalization disorder
            • Recurrent episodes of feeling outside of ones body
  • Abnormal Mental Status:
    • Types of Disorders
      • Character Disorders
        • AKA: “personality disorders” “difficult patients”
        • 6% of population
          • Assoc with alcohol & substance abuse (30-59%)
        • Dysfunctional interpersonal coping skills
        • Early onset, not due to substance abuse, long term
          • Behavioral traits formed in early childhood
          • 30% sexual abused
        • Impulsive
          • 50% attempt suicide or self mutilation
  • Abnormal Mental Status:
    • Types of Character Disorders
        • Paranoid - distrust & suspicious
        • Schizoid – detached, restricted range of emotions
        • Schizotypal – eccentric with cognitive distortions
        • Antisocial – disregard for others, no remorse
        • Borderline – instability in relations & self-image
        • Histrionic – emotional overreactions, theatrical
        • Narcissistic – grandiosity, need for admiration
        • Avoidant – social inhibition, hypersensitivity
        • Dependant – submission, clinging behavior
        • Obsessive-compulsive –rigid, detailed, repetitive
  • Abnormal Mental Status:
    • Types of Disorders
      • Disorders of Mood
          • 30% of pop
        • Major depressive episode
        • Manic episode
        • Mixed episode
        • Hypomanic episode
        • Bipolar I and II
        • Dysthymic and Cyclothymic disorders
  • Abnormal Mental Status:
    • Disorders of Mood
        • Major depressive episode
          • 10 to 15% of pop
          • More common in females 2:1
          • Peck onset; 30 to 40 yo,
          • 13% of postpartum Fe, 5% of adolescents, 30 - 40% in elderly
          • 20 - 40% in pts with comorbid medical Dz
          • Genetic links
            • 2-3X risk with Dx 1° relatives
            • 50% in twins
          • Relapse > 60%
  • Abnormal Mental Status:
    • Disorders of Mood
      • Major depressive episode
        • Diagnosis
          • Must have a change from their normal state with either:
            • Depressed mood most of the day nearly every day
            • Sig wt gain or loss, change in appetite nearly every day
          • Plus: 3 or 4 of the following nearly every day
            • Insomnia, agitation, fatigue, feeling of worthlessness or guilt, loss of concentration, recurrent thoughts of death or suicide
  • Abnormal Mental Status:
    • Disorders of Mood
        • Manic episode
          • Dx period of persistently elevated, expansive or irritable mood X 1week with 3 of the following Sx
            • Inflated self-esteem or grandiosity
            • Decreased need for sleep (< 3 hrs)
            • More talkative than usual or pressure to keep talking
            • Flight of ideas or racing thoughts
            • Distractibility
            • Increased agitation
            • Excessive involvement in high-risk activities
          • Severe enough to impair function
  • Abnormal Mental Status:
    • Disorders of Mood
        • Mixed episode
          • Having both major and manic depressive episodes
          • Each episode last at least a week each
        • Hypomanic episode
          • The mood and Sx similar to a manic episode
          • Less impairing, do not require hospitalization
          • No hallucination or delusions
          • Sx are shorter, minimum in duration - min 4 days
  • Abnormal Mental Status:
    • Disorders of Mood
        • Bipolar Disorders
          • Gen pop ≈ 2%, genetic linked Pos Hx 5-10% risk, Male /Female 1:1, rapid cycling freq in females
        • Bipolar I
          • Includes one or more manic or mixed episodes, accompanied by major depressive episodes
        • Bipolar II
          • Includes one or more major depressive episodes accompanied by at least one hypomanic episodes
  • Abnormal Mental Status:
    • Disorders of Mood
        • Dysthymic disorders
          • Minor depressed mood & Sx for most of the day, for more days than not, over at least 2 years
          • Freedom from Sx last no more than 2 months at a time
        • Cyclothymic disorders
          • Noted for numerous periods of hypomanic and minor depressive symptoms that last for at least 2 years
          • Freedom from Sx last no more than 2 months at a time
  • Abnormal Mental Status:
    • Types of Disorders
      • Anxiety Disorders
        • Panic disorder
        • Agoraphobia
        • Phobias
        • Social phobia
        • Obsessive-compulsive disorder
        • Acute Stress disorder
        • Posttraumatic Stress disorder
        • General Anxiety disorder
  • Abnormal Mental Status:
    • Types of Disorders
      • Psychotic Disorders
        • Schizophrenia
        • Schizophreniform Disorder
        • Schizoaffective Disorder
        • Delusional Disorder
        • Brief Psychotic Disorder
        • Substance-induced Psychotic Disorder
  • Abnormal Mental Status:
    • Types of Disorders
      • Temporal lobe epilepsy
        • Abnormal electrical discharge most often 2° to old temporal lobe trauma
        • Most common in the elderly
        • Must DDx from other Disorders
        • Sx: sudden unprovoked change in behavior
          • Temporal pattern of “spells”
          • “ Aura” ; feeling or sensation (odor)
          • Automatisms; lip smacking, eye blinking, pilling
          • Change in level of consciousness
  • Abnormal Mental Status:
    • Types of Disorders
      • Dementias & Alzheimer’s
        • Dementia – 30% of those > 85yo
          • Alzheimer’s (AD) – 70% of Dementias
        • Vascular Dementia
        • Parkinson’s – Lewy Body Dz
          • Parkinson’s Plus – with dementia
        • Hydrocephlic Dementia
        • Delirium
        • Metabolic & Hematologic Disorders
  • Abnormal Mental Status:
    • Types of Disorders
      • Dementias & Alzheimer’s
        • Dementia – 30% of pop> 85yo
          • Alzheimer’s (AD) – 70% of Dementias
        • Early onset vs late onset
          • Early onset – 30- 60yo rare 2%, genetic #21
          • Late onset - >65yo common 98%
        • Clinical presentation:
          • Gradually progressive decline in multiple functions; memory, orientation, judgment, insight, language
          • Depression frequently early
          • Psychosis, agitation, behavioral disinhibition late
  • Abnormal Mental Status:
    • Types of Dementias
        • Vascular Dementia –
          • 10% of dementias, 2° strokes
          • Onset after CVD Sx stepwise
          • Early incontinence, gait disturbances, flatted affect
        • Parkinson’s – Lewy Body Dz
          • 2 nd most common dementias
          • Parkinson’s – brain stem findings of Lewy bodies
            • Slow movement, tremors, rigidity, balance problems
          • Parkinson’s Plus – with dementia, diffuse Lewy bodies
            • Above Sx and visual hallucinations, cognitive fluctuations
            • Death ≈ 1 year after Dx
  • Abnormal Mental Status:
    • Types of Dementias
        • Hydrocephalic Dementia
          • Late onset hydrocephalic > 85 yo
          • Sx: motor slowing, impaired affect & mood, gait instability, urinary incontinence
          • Gait is wide with shuffling walk
          • Sx evolve slowly over weeks
        • Delirium
          • AKA: Acute confusional state, toxic encephalopathy
          • Acute onset, hours to days, fluctuates
          • 2° to medical condition; 10% of hospitalized pts
            • Drugs, anesthesia, infections, stress, endocrine
          • Sx: disorientation, excitement, defective perceptions with illusions and hallucinations
  • Abnormal Mental Status:
    • Types of Disorders
      • Substance-Related disorders
      • 15% of pop, males > females, Onset 25 -30 yo
      • Types
        • Sedatives: alcohol, barbiturates, benzodiazepines
          • Sx: acute lethargy, disorientation stupor, memory loss, apathy
        • Hallucinogens:cannabis, opioids, mescaline, phencyclidine
          • Sx: defective perceptions with illusions and hallucinations
        • Stimulants: amphetamine, caffeine, cocaine
          • Sx: agitation and paranoia
        • Substance-induced Psychotic Disorder
          • Sx can be induced with intoxication or withdrawal
            • More common with alcohol, cocaine and opioids
          • Sx: Delusions & hallucinations, seizures
  • Mental Status
    • Reference & readings
    • Bates’ Guide to Physical Examination and History Taking , 7th Ed. (Red) Lippincott,
      • Chap 3; pgs 107-122 & 123-127
    • Or
    • Bates’ Guide to Physical Examination and History Taking 8th or 9 th Ed. (both black)
      • Chap 16
  •