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Mental Status

Mental Status. Neurological assessment. Mental Status: Neurological Assessment. Orientation: “Alert & Oriented x 4” OR: Confusion Dementia Delirium Level of consciousness or LOC Memory Cognition. Assessing Orientation. Person—ask their name Place—do they know where they are?

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Mental Status

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  1. Mental Status Neurological assessment

  2. Mental Status: Neurological Assessment • Orientation: • “Alert & Oriented x 4” OR: • Confusion • Dementia • Delirium • Level of consciousness or LOC • Memory • Cognition

  3. Assessing Orientation • Person—ask their name • Place—do they know where they are? • Country/state/city • Building/floor • Time • Month, day and year • Season • Situation • Current circumstance • General (life/work/family, etc.)

  4. Level of Consciousness • Consciousness is • Awareness of self and the environment • NOT the same as Orientation! • Subtle changes in LOC may be the first sign that something is wrong

  5. LOC Assessment Alert Drowsy Lethargic Obtunded Stuporous Comatose These are terms which are often used but they can be confusing…

  6. Objective Measures of LOC • Glasgow Coma Scale (GCS) • Less confusing than terms requiring definitions • ACDU (Alert, Confused, Drowsy, Unresponsive) • AVPU (Alert, Responds to Voice, Responds to Pain, Unresponsive)

  7. Glasgow Coma Scale

  8. Glasgow Coma Scale-Pediatric

  9. Cognitive Assessment Tools Confusion Assessment Method (CAM) Mini-Mental Status Examination (MMSE) Montreal Cognitive Assessment (MoCA) Sweet 16 IQCODE Clock Drawing Test (CDT) Test Your Memory (TYM)

  10. Delirium vs. Dementia • Delirium • Sudden onset • Causes fluctuations in mental function • Mainly affects attention • Usually reversible • Dementia • Gradual onset • Mental function declines slowly • Mainly affects memory • Usually irreversible

  11. Delirium—Risk Factors Can affect anyone but most common in older patients Dementia Stroke Dehydration Neurodegenerative disorders Illness Sleep deprivation Drugs ICU

  12. Confusion Assessment Method (CAM) • Feature 1: Acute Onset and Fluctuating Course • Evidence of an acute change in mental status from the patient’s baseline • Behavior fluctuates during the day, or increases and decreases in severity • Feature 2: Inattention • Difficulty focusing attention • Distractibility • Trouble keeping track of what was being said

  13. Confusion Assessment Method (CAM) • Feature 3: Disorganized thinking • Rambling or irrelevant conversation • Unclear or illogical flow of ideas • Switching subjects unpredictably • Feature 4: Altered Level of consciousness • Vigilant [hyperalert] • Lethargic • drowsy, easily aroused • stupor [difficult to arouse] • coma [unarousable]

  14. Tests of Cognitive Function • Useful for establishing patient’s baseline • Ongoing periodic assessment • Cognitive decline • Treatment efficacy • Differentiates between subjective vs. objective memory loss/difficulty concentrating • Subjective reports without objective findings • Often indicative of depression or anxiety

  15. Alzheimer’s Dementia Serial MRI brain scans, taken six months apart, show progression from mild cognitive impairment to Alzheimer's disease with significant atrophy (blue)and ventricle enlargement (orange/red).

  16. Mini Mental State Exam (MMSE) • Commonly used to screen for dementia • Advantages • Widely used and recognized • Brief—takes about 10 minutes to complete • Simple enough to be used by non-professionals • Limitations • Somewhat culture-specific • Communication difficulties • Learning disabled or other disabilities

  17. Montreal Cognitive Assessment (MoCA) Similar to the MMSE in terms of what it measures Not as commonly used May be more sensitive in identifying Mild Cognitive Impairment (MCI) than MMSE and other similar tests

  18. Clock Drawing Test Assesses visual/spatial and constructive deficits as well as problems with executive functioning The patient is asked to draw a clock face showing a predetermined time (ex: 10 after 11) Scoring is based on deviations from the norm

  19. Clock Drawing Test (CDT) Scoring

  20. Cognitive Impairment in Younger People Syndromic vs. Non-Syndromic May be discovered in infancy Others when they begin having difficulty in school For adults, it is important to remember that it is not always readily apparent

  21. Mental status can also be affected by: Hypothyroidism Depression/Anxiety Stress Medications Others?

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