The Mental Status Examination in Primary Care by the Natural Medicine Physician (DC/ND) - Alan Korbett

Alan B. Korbett, DC, DO DABCO, DACAN

Adult, Child & Adolescent Psychiatrist [email protected]

The Mental Status Examination in Primary Care by the Natural Medicine Physician (DC/ND)

Altered Mental Status Manifestation of

• Trauma

• Medical Emergencies

• Medication or drug uses

• Exposure to toxins

Altered Mental Status Manifestation of Neurological Disorders:

• posttraumatic syndromes • degenerative processes• organic deliriums • vascular abnormalities • Infections• neoplasm • organic psychoses • toxic states

Neurological Examination: 6 Components

• Mental Status Examination

Cranial NervesMotor SystemReflexesSensationCerebellar System

Mental Status Examination 8 Components Hierarchically arranged:

Behavior Observation

Levels of Consciousness

Attention and Concentration

Language

Memory

Constructional Ability

Higher Cognitive Function

Related Cortical Function

Mental Status Examination Components #1 Behavioral Observation

• Behavioral Observation: Observation of :– Orientation – Appearance– Attire– Hygiene – Attitude– Demeanor– Conduct– Reactions

Mental Status Examination Components #2 Consciousness

• Consciousness is a reflection of :- Arousal (Continuum)- Content of Consciousness (higher cognitive

and emotional function )

5 Principle Levels of Consciousness:

Coma: completely unarousable

Alert : awake and cognizant of stimuli

Lethargic or Somnolent : not fully alert, requires active stimuli to maintain alertness, attention impaired, spontaneous movement decrease

Obtundation: difficult to arouse; requires constant stimuli; confusedStupor or Semicomatose: does not respond

spontaneously

Mental Status Examination Components #3 Attention/Concentration

• Attention : the ability to attend to a specific stimuli without distraction from extraneous internal / external stimuli.

• Complex interaction of limbic, neo-cortical and reticular activating system

Attention presupposes alertness but alertness does not necessarily imply attentiveness

Assessment of Attention:

• Digital Repetition: begin with two digits sequence and continue adding an additional digit until patient fails.

Normal digital span is 6 + 1 pending age and general intellectual abilities Inability to repeat five or ≤ suggest defective attention

Concentration (Vigilance): the ability to sustain attention over an extended period.

• Assessment of Vigilance:– Serial Seven Subtraction: count

backwards from 100 by sevens

– Months of the Year Backwards– Common Words Spelled Backwards:

WORLD - DLROW

Mental Status Examination Components #4 Language

• Handedness and language are closely allied, 90% of population definitely right handed of which 99% are strongly left hemisphere dominate

3 Components of Language: Phonology, Semantic (Lexic), Syntactic

• Phonology: refers to the sound patterns of human speech

• Semantics: refers to the assignment of meaning to words and the production of linguistically appropriate individual words

• Syntax: refers to the assembly of words into sentences using pronouns, prepositions, tenses etc. in complex ways which obey strict grammatical rules

6 Assessment of Language Function:

• Fluency of Speech • Reading• Writing• Comprehension • Repetition• Naming

Assessment of Language Function: # 1 Verbal Fluency: Verbal Fluency: the ability to produce spontaneous speech reflective of word finding efficiency

• Fluency is assessed by noting spontaneous speech:

• Substantive content • Clarity of articulation• Grammatical integrity • Evidence of latency • Paucity / excess of words

Aphasia: loss or impairment of language function

Fluent Speech: speech produced at a normal rate, preserved rhythm, melody, good articulation and normal phrase length vs

Non-Fluent Speech: slow, laborious, abnormal rhythm and melody, poor articulation, shortened phrase length.

• Assessment of Verbal Fluency: – Letter Fluency (FAS)– Category Fluency: Animals, Fruits …

• Animal Naming Test: patient asked to generate as many animal names as possible in 60 seconds.

Assessment of Language Function: #2 Comprehension

• Comprehension the ability to perceive, correctly interpret and understand the meaning of visual, auditory and other sensory stimuli, together with interpretation and grasp of the total situation.

Assessment of Comprehension:

• Single-word Comprehension: using everyday objects of differing familiarity and parts of objects.

• Sentence (syntactic) Comprehension: using 3 common objects, test comprehension using a range of syntactic structures. The Pen - Watch-Key Test

• Conceptual Comprehension: using the same array of objects and asking conceptual questions. i.e.: Point to the item used for writing?

Other more formal test: Token Test, Peabody Picture Vocabulary Test

Assessment of Language Function: #3 Repetition

• Repetition: the ability to reproduce with precision devoid of errors.

Assessment of Repetition: tested with series of words and sentences of progressively increasing complexity.

No ifs, ands or buts

The orchestra played and the audience applauded

Assessment of Language Function: #4 NamingNaming: the ability to identify by name objects or drawings of objects.

• Assessment of Naming:

Confrontational Naming: using items from several categories and varying frequency of common to uncommon items

• Generate a List: items from a particular category or items beginning with a particular letter “t”

Assessment of Language Function: #5 Reading

Reading: Assessed by: Single Letter Identification Single word reading using words with regular and

exceptional spelling to sound correspondence, and

plausible non words Text Reading

Disorders of Reading:

• Peripheral Dyslexias: defect in the early

visual components of decoding written script

Central Dyslexias: defect in the normal linguistic processes involved in the deriving of meaning from words

Assessment of Language Function: #6 Writing

• Writing: depends upon integration of

motor control, visual spacial and

kinaesthetic function and symbolic

aspects of the language system. Angular Gyrus associated with writing ability

• Assessment of Writing:– Copying of words and single letters – Writing words with regular and exceptional spelling to sound correspondence, and plausible non words– Spontaneous writing of sentences

Mental Status Examination Components #5 :Memory

• Memory: mental process to store

experiences and perceptions for recall

at a later time.

Memory is a hierarchi process that may provide clinical and anatomic diagnostic data.

• 3 Stages: Stage I : information received and

registered by particular sensory modalities, held in short term (working)

memory temporarily Stage II: storing or retaining of information on

a more permanent basis Stage III: recall or retrieval of stored information

• Clinical Subdivisions of Memory: – Immediate Memory: recall after an

interval of a few seconds

i.e.: Digital recall

Recent Memory: ability to learn and retrieve new material after an interval of minutes, hours or days

Remote Memory: recollection of very early events

Mental Status Examination Components #5 Memory: Explicit Memory: that which is available to conscious access.Implicit (Procedural) Memory: refers to the forms of memory that do not have conscious access• Explicit Memory:

Short Term (Working) Memory: Verbal Spatial Long Term Memory:

Semantic (Fact) Memory Episodic (Event) Memory

Short Term (Working) Memory: responsible for immediate repetition of words, numbers, melodies (aka phonologic or articular loops)

Mental Status Examination Components #5 Long Term Memory (Explicit Memory):

1. Semantic (Fact) Memory - responsible for the permanent store of representational

knowledge of facts and concepts , words and their meanings

• Disorders of Semantic Memory: – Selective Impairments: (sparing of other

cognitive

abilities) • HSV encephalopathies• Major Head Injures• Vascular Lesions• Focal Temporal lobe atrophy

– As part of more diffuse dementing illnesses

Assessment for Semantic Memory Long Term Memory (Explicit Memory):

• Test of General Knowledge – Information; Similarities and Vocabulary– Category Fluency– Object Naming to Confrontation

Mental Status Examination Components #5 Long Term Memory (Explicit Memory) : 2. Episodic (Event) Memory:

• Disorders of Episodic (Event) Memory: 1. Amnestic Syndromes - restricted to individuals with pure disorders of memory, sparing global intellectual function

a. Anterograde Amnesia - inability to learn new material after the brain insult b. Retrograde Amnesia - amnesia for events that occurred before the brain insult

2. Transient Amnesia

Mental Status Examination Components #5 Long Term Memory: Test for Anterograde Amnesia:

• Verbal: – recall of complex verbal information– Word-List Learning – Three Unrelated Words

Non-Verbal: recall of geometric figures Rey-Osterrieth Figure Test Visual Design Reproduction

Mental Status Examination Components #5 Long Term Memory: Test for Retrograde Amnesia:

1. Personal Autobiographical

2. Public Events: Famous Faces Test, Famous Events Test

Mental Status Examination Components #5 Implicit (Procedural) Memory

Conditioning

Priming

Motor Skills

Mental Status Examination Components #6 Constructional Ability

Constructional Ability: refers to the ability to draw or construct two or three dimensional

figures or shapes• Constructional Ability Impairments:

– Apraxia: inability to execute complex motor tasks despite intact sensory and motor systems, coordination, good comprehension and full co-operation. Parietal lobe posterior to the Rolandic Fissure.

Apraxia Assessment: Drawing to Command: patient is instructed to draw a picture of a clock, flowerpot and a house (in perspective)

Mental Status Examination Components #7 Higher Cognitive Function Higher cognitive Function: are built upon the basic processes of attention, language and memory. • Cognitive Functions attributed to the Frontal lobes:

– Adaptive Behavior – Problem Solving– Abstract Conceptional Ability – Planning– Set Shift / Mental Flexibility – Initiation– Sequencing behavior – Social behavior– Personality (drive, motivation, inhibition) – Temporal order judgements

Related Cortical Function

• Right - Left Disorientation• Agnosia - • Denial & Neglect • Apraxia

Thank YOUThe Mental Status Examination in Primary Care by the Natural Medicine Physician (DC/ND)

Alan B. Korbett, DC, DO

DABCO, DACAN

Adult, Child & Adolescent Psychiatrist

[email protected]