NRS208: Health Assessment

Comprehensive Mental Status EXAM

The Foundation of the Mental Health Assessment

Teresa Chahine RN, MSN, PMHNP-BCOakland University, School of Nursing

Purpose

Provides an estimate on the quality of client’s functioning

UsesEstimate functioning to determine need for further testing Estimate functioning to determine treatment needsAssess progress when functioning has declined in an emergency situationPeriodically assess insidious decline in functioning (e.g., dementias)

OverviewGeneral Description

Emotion

Lethality

Thought

Cognition

Judgment and Insight

Reliability

What an MSE isn’tAn intelligence test

A detailed memory test

A fully precise measure of cognition, affect, and behavior

Prior to testing . . .

Rapport - building is important in order to obtain the client’s cooperation and best effort in responding to the examination

Factors That May Affect Findings

Illnesses or health problems

Current medications or substance use

Depression

Educational and behavioral level

Sensory Perceptual limitations of the aging process

Ways to Conduct a MSE

These components are assessed while interviewing the client about her concerns, circumstances, and history:

Thought form and contentNature, expression, and appropriateness of affectBehavior strengths and weaknesses (or adaptive behaviors)

Ways to Conduct a MSE

These functions may be assessed informally during the interview, or formally through specific questions and tasks:

Amnestic functionsCognitive processing and intellectual functions

General Description

Appearance

Motor Behavior

Speech

Attitudes

General Description

AppearanceProminent features"such that a portrait…”Eye contactDress and groomingAge/appearance

General Description

Motor BehaviorGaitFreedom of movementFirmness and strength of handshakeAny involuntary or abnormal movementsPace of movementsPurposefulness of movementsDegrees of agitation

General Description

SpeechRateSpontaneityIntonationVolumeDefects

General Description

AttitudesHow the patient related"degree of cooperativeness“Evaluator’s attitude

MoodDefinition

Patient report versus inference

EmotionAffect

Definition

Assessment of Affect

Range of affect:RestrictedDullBlunted versus flatlabile

Predominant Affect

Describes the types of affect exhibited during interview, verbal and nonverbal

Can exhibit more than one emotion during examination

ThoughtProcess

ContentPerceptions

Thought Process

Manner of organization and formulation of thoughtStream of ThoughtGoal directedness/ContinuityOther Abnormalities of Thought ProcessConnectedness/Organization

CircumstantialityTangentialityLoose AssociationWord Salad

Assessing Thought FormBlockingConfusion/deliriumConfabulationPoverty of speechFlat speech

Thought Content

Perceptual disturbancesDelusionsOther

Content of Thought

What are pervasive themes or ideas in client’s thoughts, such as:

Hopeless thinkingHelpless thinkingBlaming/abdication of responsibilityNegativistic thinking(Cleopatra Syndrome (queen of denial)Positive thoughts

Lethality

Self HarmAssaultive BehaviorDestruction to Property

Please give specific examples and quote client’s statements.

ASK EVERY CLIENT IN EVERY INITIAL INTERVIEW ABOUT SUICIDAL THOUGHTS, FEELINGS OR ACTIONS

Acutely suicidal feelings are usually temporary, and it is our job to help get clients through crisis periods.

Suicide

Suicide is the 11th leading cause of death in the U.S., with 11 deaths per 100,000 caused by suicide8-25 attempts take place for each completed suicide4 times as many men complete suicide as women; women attempt more

Men use more certainly lethal methods, particularly firearms

Non-Hispanic whites and Native Americans have the highest suicide ratesBlacks, Asian/Pacific Islanders, and Hispanics have the lowest rates (NIMH, 2009)

Suicide

Talking about suicide WILL NOT incite it

NOT talking about suicide could cause you to miss the chance to prevent it

People who are having suicidal thoughts WILL usually tell someone, especially if asked directly

Directly ask client, “Have you ever had thoughts about hurting yourself?”

Suicide

If you’re concerned a client is suicidal, assess for the following risk factors:

DiagnosisDx that includes depressive or intensely anxious mood (MDD, Bipolar in a depressive episode, PTSD)Dx that includes impulsivity, poor judgment, antisocial or suicidal tendencies (Borderline, substance abuse, Antisocial Personality, binging anorexia, gambling)

Mental Status ExamDo a current, direct assessment: ask directly, but also assess indirect signs

Assessing for Suicide Risk

Predominant MoodDepressedOverly calm, especially if it’s a significant change

HistoryPersonal history of attemptsFamily history of suicide or attemptsHistory of psychotic or dissociative Sx (delusions, hallucinations, depersonalization)

Substance UseCan be disinhibitingCan be a sign of severe distress

Assessing for Suicide Risk

Determine level of risk of near-term attemptWhen did they last have suicidal thoughts?How often do they have suicidal thoughts?Is client comfortable with having these thoughts?Has client attempted before?

If yes, How physically and psychologically serious was client?Why didn’t it succeed?Were substances involved?

Does client have a plan? What is level of premeditation?Does client have means to carry out plan?Why is client suicidal now?

Assessing for Risk of Suicide Attempt

Take clinical steps to prevent attemptAlert your supervisor to your concernsContract: written or verbalIncrease frequency of contact with youAlert someone in client’s life to the potential dangerConsider emergency psychiatric evaluationConsider hospitalization if you feel client won’t be safe under any other circumstances

Document everything you do scrupulously

Managing Suicidality

Content of Thought

Content of thought assessment also includes:

Hallucinations (visual, auditory [including command], various others)Delusions (reference, grandeur, persecution, jealousy, guilt, nihilistic, various others)Poverty of thought contentLow thought complexity

The Cognitive Exam

Consciousness

Orientation

Concentration and attention

Calculations

Memory

Intelligence

The Mini-Mental Status

ExaminationA brief measure of amnestic and cognitive processing functions, used to assess short-term changes in mental functioning in hospitalsassess changes in cognitive functioning in emergencies (e.g., injuries on the ball field)Assess progressive changes in cognitive functioning in long term care settingsObtain a “snapshot” of client’s functioning in outpatient mental health settings

(Folstein, Folstein, & McHugh, 1975)

MMSEMMSE assesses:

OrientationShort, recent, remote, remote memorySustained concentrationExecutive functions

RecognitionRegistrationSequencing and organizationComprehensionPerceptual - motor skills

Mental Status Scores

Simple scoring system (point per item)Scores range from 0 - 30Scores below 24 indicative of dementia or cognitive deficitLower scores indicate greater deficitsScores obtained from small sample of Caucasian males and females from middle US

Appropriateness and

ResponsivenessAssess appropriateness of affect to topics discussed

Is client responsive to encouragement? Levity?

Behaviors and Symptoms

Describe behaviors exhibited during the interviewAssess dominant symptoms described by client, even if you don’t observe themSee “Assessment Report” handout for representative symptomsIf needed, survey adaptive behaviors

InsightPatient’s capacity to

Acknowledge/Appreciate illnessAssociated implicationsConsequences

Insight Drugs/alcohol

Dementia/cognitive problems

Psychosis

Severe mood problems

Somatoform disorders

JudgementThe process of

ConsiderationFormulation

Leading to aDecisionAction

Judgement Requires

InsightCognitive functioningOther abstract abilitiesConceptualizationForward thinkingAppreciation of what “rational people” would do.

ReliabilityIntellect

honesty and motivations

psychosis/organic defects

magnification/understatement

You will probably be able to assess most of the areas covered in the MSE during the natural course of your interview without specifically asking If you have doubts, ask the client Always ask specifically about suicidal/homicidal

ideation

Problems in the areas covered in MSE will usually be fairly obvious: you are looking for the unusual, the remarkable. If you observe something notable, investigate further

Be as objective as possible. Don’t make judgments as to why the client is presenting a certain way

Mental Status Exam

Screening Tools

Screening ToolsDepression- Patient Health Questionnaire-9 (PHQ-9)

Anxiety- Generalized Anxiety Disorder (GAD-7 )

Cognitive- Mini Mental Status Exam (MMSE)

Suicide Risk – SAD PERSONS scale

Alcohol & Substance Use-Alcohol Use Disorders Identification Test (AUDIT) CAGE Questionnaire

Alcohol Withdrawal-Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWA)

CAGE Questionnaire to Assess for Substance Abuse

AUDIT Questionnaire for Alcohol Abuse

CIWA Scale Nausea and Vomiting

Tactile disturbances

Tremor

Auditory Disturbances

Paroxysmal sweats

Visual Disturbances

Anxiety

Headache, Fullness in Head

Agitation

Orientation and clouding of sensorium

ALCOHOL WITHDRAWAL SYNDROME

Acute:Delirium Tremens

ChronicWernicke’s-Korsakoff’s syndrome

WERNICKE’S PSYCHOSIS

Cause: Thiamine deficiencyOnset: ChronicOther s/sx:

ConfusionAtaxiaThiamine deficiency

KORSAKOFF’S PSYCHOSIS

Cause: Thiamine and Niacin deficiency

Onset: Chronic

Feature: Memory disturbances (confabulation)

Other s/sx:Retrograde Amnesia (past)Anterograde Amnesia (recent)Thiamine and Niacin deficiency

Mnemonics

Depression Assessment ToolSIGECAPS- Sleep, Interest, Guilt, Energy, Concentration, Appetite, Psychomotor activity, Suicidal thoughts.SADAFACES- Sleep, Appetite, Dysphoric mood, Anhadonia, Fatigue, Anxiety, Concentration, Esteem, Suicidal thoughts.

Anxiety Assessment–AND I C REST

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