Mental status examination in neurology

1. HISTORY AND BEHAVIOURAL
OBSERVATIONS
S&B Lesson2

2. HISTORY
• 4 Primary areas of clinical concern
• 1) Presence of classic behavioural changes indicative of organic
dysfunction eg memory or language impairement
• 2)Possibility of functional psychiatric disorder considered
• Overlap or mesquarading features
• eg mesquarading conditions: tumor of left frontal lobe, presenting as
major functional illness/depression/mania/schizophrenia

3. • Conditions with overlapping features established organic syndromes
also develop secendary depression or anxiety eg post stroke
depression.
• Schizophrenia presenting with cognitive deficits.
• 3)Establish Pt’s premorbid level of functioning and behaviour.

4. • 4) Pt’s general medical status comorbidities
prescriptions

5. HISTORY OUTLINE
(only important points)
Poor social judgement discarding new clothes in trash or being verbally
abusive at social gatherings without provocation.

6. BEHAVIOURAL OBSERVATION
• Only important/new points
• Physical appearance
Habits of dress
a. Type of clothing
b. Cleanliness of clothing
c. Sloppiness in dressing
d. Excessive fastidiousness in dressing and grooming
e. Indication of unilateral neglect

7. MOOD AND GENERAL
EMOTIONAL STATUS
• Mood (longitudinal)
Normal for situation
Constancy or fluctuations of mood
Inappropriate mood: expressed affect inconsistent with the content
of thought.
Emotional status(crossectional)
Degree of cooperation with examiner

8. Clinical syndromes
• Acute confusional state
• Main crux clouding of consciousness
ie not awake ie not alert
Ie no awareness on many things
dulling of cognitive process
general impairement of alertness
inattentive
incoherent speech
drift from central point

9. • Mild confusion detected by systematic examination
• Difficulty in holding a coherent conversation
• On specific probing admit nocturnal hallucinations
• Confusional behaviour rarely is stable characteristically waxes and
wanes
• Confusion behaviour results from wide spread cortical and subcortical
neuronal dysfunction

10. • Cortical dysfunction presents as ------ deviance in content of
consciousness. (?hyperactive delirium)
• Subcortical dysfunction –ascending reticular activating system leads
to disturbance in basic arousal(hypoactive delirium).
• As changes are biochemical in origin delirium is reversible.

11. • Systematesized delusions and organized paranoid delusions are
infrequent in pt in acute confusion state.

12. • Frontal lobe syndrome
• Frontal related to personality
• Features pointing personality disturbances
Apathy – towards examiner
towards family
in work
Irritability
Inappropriateness in social circumstances

13. • Apathetic patients when consistently stressed become irritable and
argumentative.
• Conversly other pts have inappropriate intrusiveness, loud jocular,
socially aggressive
• Euphoric and energetic behaviour that is non constructive.

14. • Pt with frontal damage loose social drive
loose interest in their environment
fail to maintain job performance, family relations or
even personal cleanliness.
• Other deficits with frontal damage
high order cognitive problems
In attention
Memory disorder
Executive motor deficits

15. Behavioural symptoms depends on location
of leison
• Basal orbital –disinhibited euphoric behaviour.
lack of concern
quick irritability (+ve symptoms)
• Dorsolateral convexities –apathy , reduced drive,
depressed mentation
impaired planning(-ve symptoms)

16. • Case vignette 58yr old decreased interest in caring for home and personal
needs for a year
observed by daughter –lack of interest in conversation
unkempt appearance
lack of concern of family affairs
total neglect of personal and
household cleanliness
stopped attending church

17. • Mr N 65yrs old brought by wife C/o since 4 years
Premorbid behaviour Recent change in behaviour
Jovial and joker with social restrain Loss of restrain with being more open in remarks(noti
ki edi vasthe adi aneyadam)
Outgoing person Flippancy (lacking seriousness)
Well balanced person Aggressive egotism, show off and boast
Loss of personal cleanliness
Falling memory,unable to follow instructions

18. • In later course he became agitated and paranoid.
• He wandered around neighborhood and would tell tales to strangers,
eg of being undercover agent.
• Going through stop sign when drove a car and joked about it with his
wife.
• Last events prompted for medical referral.

19. • On examination
• Appearance uncut nails, uncombed hair(in relevence to his socio
culture background)
• Messy clothes
• Behaviour was trying to leave room often during the
interview(agitated), inappropriate with the doctor
• Speech content whether risperidone was some poison
• Thought process extremely concrete.

20. • CT revealed frontotemporal atrophy.
• Presumptive diagnosis PICKS disease.
• DD for frontal lobe syndrome
SOL- tumor
Injury
Tissue degeneration PICKS disease
Infection- AIDS

21. Clinical tests to assess frontal lobe functioning
• They are primarily alternating motor sequencing tasks.
• Visual pattern completion test
• Motor pattern completion test

22. Test items for visual pattern completion test

23. Instructions Must be able to do
First tell the pt to reproduce the pattern as given
Later tell to continue the pattern with additional
instructions if needed, to ensure pt understands
pattern of test.
Perform without error

24. • Loss of sequence or perservance suggest loss ability to shift sets
• Eg

25. Test items for alternating motor pattern
• 1.Fist-palm-side test

26. • Fist palm side test: Hit the top of the desk repeatedly with fist-palm-
side repeatedly.
• Demonstarate once then tell the pt to perform until told to stop.
• Performance 15-20 secs should be suffice to assess adequacy.

27. • FIST RING TEST:
• Instruct the pt to extend his arm several times, first with hand in a
fist, and then thumb and forefinger opposed to form a ring.
• Demonstrate and then tell to perform.

29. • RECIPROCAL CORDINATION TEST:
• Both hands placed on desk with one hand in a fist and another extend
palm down.
• Tell the pt to alternate position of both hands.

31. • Denial and Neglect:
Clinically spectrum of denial and neglect ranges
From explicit denial of illness as the most severe behavioural
abnormality  mild inability to recognize stimulation on one side
when during bilateral simultaneous stimulation.
Implicit denial can be addressing the illness but not apperiaciating the
situation in areal manner.
Eg was brought to hospital for regular check ups
brought to a rest facility rather than hospital

32. • Clinical presentation can be pt grooming only 1 side of the body eg:
shaving only one side
• Most subtle form of unilateral neglect is inattention to one side when
both sides are stimulated simultaneously.

33. • Leison is located non dominant hemisphere, parietal.
• Vascular etiology
• Gross explicit denial is usually seen in acute stages after a vascular
accident with associated confusion.

34. Examples of neglect on drawing test

35. • APATHY Vs DEPRESSION or DYSTHYMIA
• Characteristic of organic brain lesion– dementia, frontal lobe lesion,
and lesions in non dominant hemisphere.
• Mistaken with depression.
• Apathy in isolation never justifies diagnosis of depression.
• Should fullfill the criteria with associated symptoms.

36. • Diagnostic dilemma is differentiating apathy with ealy dementia.
• To tell a depressed pt that he or she is demented is a devastating
error.
• Also mistake of overlooking a frontal menigioma, while treating a pt
with depression.

37. • Elderly pt presenting with depression do not always manifest an
obviously depressive mood as dramatically as do younger pts.
• Elderly depressive pt also typically demonstrate
fewer crying spells
less expressed sadness
less expressed guilt
less self deprecation

38. • Show subtle cognitive deficits on formal mental status testing.
• No specific pattern of deficits is seen and deficits are mild
• Mild problems with concentration, memory and arthimetics.
• In general impaired performance on any task that requires the
marshaling of significant mental energy.

39. • Many elderly depressive pts are initially diagnosed as having a
dementia.
• Term pseudodementia has been applied to those pts in whom the
initial diagnostic impression is of dementia.
• Yet on careful evaluation and follow up the symptoms prove to be
secondary to depression or another emotional disorder and improve
with appropriate treatment.

40. Wells tabulated major features
Pseudodementia dementia
Clinical course and history Onset fairly well demarcated Onset indistinct
History short (?time period) History quite long (?time period)
Rapidly progressive Early deficits go unnoticed
Past h/o of psychiatric episode
or recent life crisis +nt
Uncommon occurrence of previous
psychiatric problem

41. Pseudodementia Dementia
Clinical behaviour Detailed elaborate complaints of
cognitive dysfunction
Little complaint of cognitive loss
Little effort expended on examination
items
Struggles with cognitive tasks
Affect change often present Usually apathetic with shallow
emotions
Behaviour doesnot reflect cognitive
task
Behaviour compatible with cognitive
loss
Nocturnal exacerbation rare Nocturnal accentuation of dysfunction
common

42. Pseudodementia Dementia
Examination findings Frequently answers I don’t know ,
before even trying
Usually tries items
Inconsistent memory loss for both
recent and remote
Memory loss for recent items
worse than for remote items
May have particular memory gaps No specific memory gaps exist
Generally inconsistent performance Rather consistently impaired
performance

43. • If the examiner takes sufficient time and encourages optimum
performances from the pt…
depressed pt with complaints of memory loss will show near normal
performance that is far better than would be expected from the nature
and severity of complaints.

44. • In some significantly depressed pts, mental status seems to verify
initial impression of dementia, hence pseudodementia.
• Cognitive performance demonstrates impairement that seems
organic probably because of neurotransmitter abnormalities…
• Term depressive dementia or dementia of depression are used.

45. • The problem of pseudodementia is most common in depressed pt,
but…
• Somatoform disorders, manic episode, high levels of anxiety and any
psychotic disorder can all produce picture of dementia on mental
status examination.

46. • Treating pseudodementia id rewarding because with appropriate
treatment pt gets his life back.
• Mental status reverts to normal premorbid levels.