# mental status assessment --- **mental status assessment** ABSCAT Appearance behavior /affect (often thought of as the same as behavior, but for remembering it can be it's own thing) speech cognition affect/mood thought content Always check vision and hearing before proceeding with mental status exam. (especially with older aduts!) Unknown sensory deficits could result in an inaccurate finding in MSE ## Level of Consciousness (technically part of behavior, move down?) [[level of consciousness]] ## Appearance - Dress / grooming / hygiene - Congruent to age - Appropriate for occasion - Culture may influence dress - Older adults may wear more clothes due to cold intolerance - Posture - should be erect and relaxed - Body movements - Voluntary / deliberate / coordinated / smooth ## Behavior - Awake & alert (LOC) - Aware of environment - Responds appropriately to questions - Responds appropriately to environmental stimuli - Eye contact / adjust for culture - Facial expressions appropriate to situation / changes with context ## Speech - Tone, clarity pace - May be slower in older adults but should be clear and moderately paced - If having difficulty, ask client to name objects in room or read something or write a sentence - Quality of speech - Able to articulate - Makes sound effortlessly - No dysphonia (like, hoarsness), dysphasia ## Cognition - Orientation - To person, place, time and events (time is usually lost first & person last) - Aware of self and others / family at home - Older adults may be confused in acute care / most know who they are and current month & year - Attention span / able to concentrate - May be impaired if anxious or fatigued - Abstract reasoning - Ask them to compare and contrast two objects - Recent & remote memory ## Affect / Mood - Observe body language - Observe facial expression - Appropriate and congruent to condition and situation or topic discussed - if they just had bad news, it's normal that they'd have a sad affect - Ask, "how are you feeling today?" and 'What are your plans for the future?" - May use additional tools such as the geriatric depression scale or - Normal for people to be cooperative Terms: ## Though Content & Process - Observe for content and clarity - Perception congruency - "Tell me what your understanding is of. - Identify self-injurious or suicidal thoughts - Must not be ignored, and must be taken seriously - Judgement ## Assessment Tools - Confusion Assessment Method (CAM) Weber & Kelley p.92 - Geriatric Depression Scale (Weber & Kelley p. 824) - Short Blessed Test (Weber & Kelley p.824) ___