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206 PHYSICAL EXAMINATION
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UNIT 2
Dysarthria, a disturbance in muscular control of speech, is abnormal.
A
Dysarthria is due to ischaemia affecting motor nuclei of CN X and CN XII,
P
defects in the premotor or motor cortex that provide motor input for the face
throat and mouth, or cerebellar disease.
Dysphonia, difculty making laryngeal sounds, is abnormal and can progress
A
aphonia (total loss of voice).
to
Dysphonia is usually caused by lesions of CN X or swelling and inammation
P
ofthe larynx.
URGENT FINDING
The consumer with dysphonia
Consumers with signs of dysphonia (impaired laryngeal speech) are at high risk for
dysphagia (difculty with swallowing) and therefore aspiration. A thorough assessment of
swallowing is warranted before the consumer may eat unassisted, otherwise this consumer
may not be able to protect their airways. Depending on your resources and scope, you may
need to refer to a speech therapist to have swallowing comprehensively assessed.
Apraxia, the inability to convert the intended speech into the motor act of
A
speech, is abnormal.
P
Apraxia is due to dysfunction in the precentral gyrus of the frontal lobe.
Agraphia, the loss of the ability to write, is abnormal.
A
Agraphia is caused by lesions of Broca’s and Wernicke’s areas in the dominant
P
side of the brain.
Alexia, the inability to grasp the meaning of written words and sentences
A
(wordblindness), is abnormal.
P
Alexia is usually due to a lesion of the angular gyrus and the occipital lobe.
TABLE 7.7 Classication of aphasias
APHASIA PATHOPHYSIOLOGY CHARACTERISTICS
Broca’s aphasia Motor cortex lesion, Broca’s area Speech slow and hesitant, the consumer has difculty in selecting
and organising words. Naming, word and phrase repetition, and
writing impaired. Subtle defects in comprehension.
Wernicke’s aphasia Left hemisphere lesion in Wernicke’s area Auditory comprehension impaired, as is content of speech.
Consumer unaware of decits. Naming severely impaired.
Anomic aphasia Left hemisphere lesion in Wernicke’s area Consumer unable to name objects or places. Comprehension and
repetition of words and phrases intact.
Conduction aphasia Lesion in the arcuate fasciculus, which connects and transports
messages between Broca’s and Wernicke’s areas
Global aphasia Lesions in the frontal-temporal area Both oral and written comprehension severely impaired; naming,
Transcortical
sensory aphasia
Transcortical
motor aphasia
Lesion in the periphery of Broca’s and Wernicke’s areas
(watershed zone)
Lesion anterior, superior or lateral to Broca’s area Comprehension intact. Naming and ability to write impaired.
Consumer has difculty repeating words, substitutes incorrect
sound for another sound (e.g. dork for fork).
repetition of words and phrases, ability to write impaired.
Impairment in comprehension, naming and writing. Word and
phrase repetition intact.
Word and phrase repetition intact.
Cognitive abilities and mentation
Assessment of cognitive function includes testing for attention, memory,
judgement, insight, spatial perception, calculation, abstraction, thought processes
and thought content.
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
MENTAL STATUS AND NEUROLOGICAL TECHNIQUES 207
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Attention
1. Pronounce a list of numbers slowly (approximately 1 second apart), starting
E
with a list of two numbers and progressing to a series of ve or six numbers.
For example: 2, 5; 3, 7, 8; 1, 9, 4, 3; 1, 5, 4, 9, 0.
2. Ask the consumer to repeat the numbers in correct order, both forwards
andbackwards.
3. Give the consumer a different series of the same number of digits, if the
consumer is unable to repeat the rst series correctly. Stop after two misses
ofany length series.
4. Serial 7s is another way of assessing attention and concentration. Instruct
the consumer to begin with the number 100 and to count backwards by
subtracting 7 each time: 100, 93, 86, 79, 72, 65, etc.
5. The consumer may also try serial 3s (counting backwards from 100 by 3s)
ifunable to perform serial 7s.
The consumer should be able to correctly repeat the series of numbers up to a
N
series of ve numbers. The consumer should be able to recite serial 7s or serial 3s
accurately to at least the 40s or 50s from 100 within 1 minute. (Be aware this test
will not be appropriate for people who have issues with numeracy.)
If the consumer has a short attention span, the consumer will not be able to
A
repeat the numbers in sequence or perform serial 7s or 3s.
Dementia, neurological injury or disease, and intellectual disability may
P
impairattention.
CHAPTER 7
CLINICAL REASONING
Preparing for cognitive mental status screening
The Mini Mental State Exam (MMSE) is a widely used tool for assessing cognitive mental status,
detecting impairment following the course of an illness, and monitoring response to treatment;
however, this needs to be contextually appropriate. The MMSE is most useful in screening
for the cognitive decits seen in syndromes of dementia and delirium. The MMSE has been
adapted to many contexts; some are available online or through your healthcare organisation.
A mental status examination usually assesses appearance, behaviour, affect, mood, cognition,
speech and thought form, thought content, perception, history obtained from family/carers,
orientation, concentration, short-term and long-term memory, and cortical function.
Assessment of cognitive function
You should have on hand:
> pre-printed lists of objects, phrases and numbers for consumer recall and explanation
> answers to long-term memory questions to accurately assess recall
> alternative tests prepared for consumers with language barriers, aphasia, deafness,
blindness, etc.
> paper and pencils for consumer to use to respond.
One version is accessible via https://oxfordmedicaleducation.com/geriatrics/minimental-state-examination-mmse/
Content specic for children can be found at https://www.rch.org.au/clinicalguide/
guideline_index/Mental_state_examination/
Cultural differences will need to be considered. Some examples include:
• A medical practitioner’s example of working in Australian Aboriginal communities:
http://www.aams.org.au/mark_sheldon/ch8/ch8_mental_state_exam.htm
• Transcultural mental health centre: https://www.dhi.health.nsw.gov.au/transcultural-
mental-health-centre-tmhc/health-professionals/cross-cultural-mental-health-care-aresource-kit-for-gps-and-health-professionals/cross-cultural-mental-health-assessment
• The Centre of Best Practice in Aboriginal & Torres Strait Islander Suicide Prevention:
https://cbpatsisp.com.au/clearing-house/best-practice-screening-assessment/
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
208 PHYSICAL EXAMINATION
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UNIT 2
Memory
1. Assess immediate recall in conjunction with attention span as
E
discussedpreviously.
2. Give a list of three items that the consumer is to remember and repeat
in 5minutes. Have the consumer repeat the items to check initial
understanding. During the 5 minutes, carry on conversation as usual.
Asktheconsumer to repeat the items again after the 5-minute time frame.
3. If the consumer is unable to remember one or more of the objects, show a
listcontaining the objects along with others, and check recognition.
4. Record the number of objects remembered over the number of objects given.
5. Long-term memory is memory that is retained for at least 24 hours.
Commonly asked questions for testing long-term memory include name
of spouse, spouse’s birthday, mother’s maiden name, name of the Prime
Minister and the consumer’s birthday.
The consumer should be able to correctly respond to questions and to identify
N
all the objects as requested.
Memory loss is abnormal.
A
Memory loss may be caused by pathologies such as nervous system infection,
P
trauma, stroke, tumours, Alzheimer’s disease, seizure disorders, alcohol and
drugtoxicity. Memory is located in the temporal lobe and the hippocampus.
Damage to these areas, in the form of haemorrhage, ischaemia, compression or
herniation, will cause memory impairment. See Table 7.4 for neurological signs
ofdrug ingestion.
Judgement
1. During the interview, assess whether the consumer is responding
E
appropriately to social, family and work situations that are discussed.
2. Note whether the consumer’s decisions are based on sound reasoning and
decision making.
3. Present hypothetical situations and ask the consumer to make decisions as
towhat his or her responses would be. For example: ‘What would you do if
you were driving and noticed a police car with ashing lights behind you?’
or ‘What would you do if you saw smoke in your house?’
4. Interview the consumer’s family or directly observe the consumer to assess
judgement more carefully.
The consumer should be able to evaluate and act appropriately in situations
N
requiring judgement.
Impaired judgement, the inability to act appropriately in situations, is abnormal.
A
Frontal lobe damage, dementia, psychotic states and an intellectual disability
P
may cause the consumer to exhibit lack of appropriate judgement.
Insight
Insight is the ability to realistically understand oneself.
1. Ask the consumer to describe personal health status, reason for seeking
E
health care, symptoms, current life situation and general coping behaviours.
2. If the consumer describes symptoms, ask what life was like prior to the
appearance of the symptoms, what life changes the illness has introduced,
and whether the consumer feels a need for help.
The consumer should demonstrate a realistic awareness and understanding
N
ofself.
Unrealistic perceptions of self are abnormal.
A
Lack of insight may occur in the euphoric stages of bipolar affective disorders,
P
endogenous anxiety states or depressed states.
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
MENTAL STATUS AND NEUROLOGICAL TECHNIQUES 209
Diamond Patient’s drawing
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Spatial perception
(May be considered advanced practice depending on context)
Spatial perception is the ability to recognise the relationships of objects in space.
1. Ask the consumer to copy gures that you have previously drawn, such as
E
acircle, triangle, square, cross, and a three-dimensional cube.
2. Ask the consumer to draw the face of a clock, including the numbers around
the dial.
3. Ask the consumer to identify a familiar sound while keeping their eyes closed;
for example, a closing door, running water or a nger
4. Have the consumer identify right from left body parts.
The consumer should be able to draw the objects without difculty and as
N
closely as possible to the original drawing, and to identify familiar sounds and
left and right body parts.
Agnosia, the inability to recognise the form and nature of objects or persons,
A
isabnormal. It may be visual, auditory or somatosensory. For example, the
consumer may be unable to name or recognise objects, faces or familiar objects
by touch, or to identify the meaning of nonverbal sounds.
Lesions in the nondominant parietal lobe impair the consumer’s ability to
P
appreciate self in relation to the environment and to conceive three-dimensional
objects. Lesions in the occipital lobe will cause visual agnosia, and temporal
lesions will cause auditory agnosia.
Apraxia, the inability to perform purposeful movements despite the preservation
A
of motor ability and sensation, is abnormal.
inability to reproduce gures on paper (
P
Apraxia is usually associated with lesions of the precentral gyrus of the frontal lobe.
Constructional apraxia is the
Figure 7.11).
snap.
FIGURE 7.11 Constructional apraxia
CHAPTER 7
Calculation
The consumer’s ability to perform serial 7s was discussed in the section on
attentionand is also an assessment of calculation (note: be aware of consumer’s
abilities innumeracy).
1. Ask the consumer to add 3 to 100, then 3 to that number, until numbers
E
greater than 150 are reached.
2. Note the amount of time and difculty associated with the calculations.
The consumer should be able to calculate the correct numbers upon subtraction
N
or addition within educational abilities and with fewer than four errors in less
than 1½ minutes.
Dyscalculia, the inability to perform calculations, is abnormal (unless low level
A
of schooling or issues are identied with numeracy).
Dyscalculia may be caused by depression or anxiety, dementia or an intellectual
P
disability. The most common cause of dyscalculia is focal lesions in the
dominant parietal lobe; however, calculation decits have also been ascribed to
focal lesions in the frontal, temporal and occipital lobes.
Abstract reasoning
1. Ask the consumer to describe the meaning of a familiar fable, proverb or
E
metaphor. Use examples that are meaningful within the context of the
consumer’s culture and language. Some examples from Australian and
NewZealand culture are:
• A storm in a tea cup
• Opening a can of worms
• Don’t let the cat out of the bag
• You shouldn’t look a gift horse in the mouth
• It’s raining cats and dogs
2. Note the degree of concreteness versus abstraction in the answers.
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
210 PHYSICAL EXAMINATION
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UNIT 2
Consumers should be able to give the abstract meanings of proverbs, fables or
N
metaphors within their cultural understanding.
Conceptual concreteness, the inability to describe in abstractions, to generalise
A
from specics, and to apply general principles, is abnormal.
Alterations of cognitive processes causing concreteness in thought may occur in
P
consumers with dementia, frontal tumours or schizophrenia. Concreteness in
thought processes may also indicate low intelligence.
Thought process and content
1. Observe the consumer’s pattern of thought for relevance, consistency,
E
coherence, logic and organisation.
2. Listen throughout the interview for aws in content of conversation.
Thought processes should be logical, coherent and goal-oriented. Thought
N
content should be based on reality.
Unrealistic, illogical thought processes and interruptions of the thinking processes,
A
such as blocking, are abnormal. Blocking is demonstrated when an extended pause
occurs during a sentence due to a repressed or painful subject matter. Sometimes,
the thoughts following are unrelated to what the consumer was discussing.
P
Abnormal thought processes are often due to psychotic symptoms.
Flight of ideas, demonstrated when the consumer changes from subject to
A
subject within a sentence, is abnormal. This is frequently due to distractions or
word associations with a resultant lack of sense of purpose of the conversation.
Consumers suffering from manic episodes of bipolar affective disorder often
P
demonstrate ight of ideas.
Confabulation, the making up of answers unrelated to facts, is abnormal.
A
Confabulation is often related to ageing, memory loss, disorientation, Korsakoff’s
P
psychosis or psychopathic disorders.
Echolalia, the involuntary repetition of a word or sentence that was uttered by
A
another person, is abnormal.
P
Consumers suffering from dementia or schizophrenia often demonstrate echolalia.
Neologism, a word coined by the consumer that is meaningful only to the
A
consumer, is an abnormal nding.
P
Consumers with delirium or schizophrenia may exhibit neologism.
Delusions of persecution, grandiose delusions, hallucinations, illusions,
A
obsessive-compulsiveness and paranoia are examples of abnormal thoughts.
Abnormal thought content is demonstrated in consumers suffering from
P
schizophrenia or dementia and in people who may be affected by substances.
Suicidal ideation
If the consumer has expressed feelings of sadness, hopelessness, despair, worthlessness
or grief, explore his or her feelings further with more specic questions such as:
1. Have you ever felt so bad that you wanted to hurt yourself?
E
2. Do you ever feel that life isn’t worth living?
3. Do you feel like hurting yourself now?
The consumer should provide a negative response and be able to verbalise his or
N
her self-worth.
An afrmative response is abnormal and requires probing such as:
A
> Do you have a plan to hurt yourself?
> What would happen if you were dead?
Continued afrmative responses and expressions of worthlessness and
hopelessness should be interpreted as suicidal ideation, a psychiatric emergency
that requires immediate referral to a specialist.
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
MENTAL STATUS AND NEUROLOGICAL TECHNIQUES 211
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Suicidal ideation is associated with mental disorders, particularly depression,
P
substance abuse and personality disorders.
CLINICAL REASONING
Suicide risk factors and clinical decision making
Suicide was the fteenth leading cause of all deaths in Australia in 2020. In the 15–44-year-old
age group it was the leading cause of death. In 2020, there were 3139 deaths from suicide in
Australia (Australian Bureau of Statistics, 2021). As in most states in Australia, in Queensland
males remain overrepresented for death rates by suicide and there were higher percentages
of deaths by suicide related to remoteness (Leske, Adam, Catakovic, Weir & Kolves, 2022).
Consider the following risk factors for suicide when undertaking a health history and
deciding where to focus attention:
> Living with a mental illness diagnosis
> Female (more non-fatal suicide behaviour)
> Male (more fatal suicide behaviour)
> Prior non-fatal suicide behaviour
> Family member with suicide behaviour (both fatal and non-fatal) history
> Substance use and overuse
> Unwillingness to seek help because of stigma
> Barriers to accessing mental health treatment
> Stressful life events or loss
> Easy access to lethal methods such as guns and poisons
> Is thinking about suicide, with or without a plan
> Have a history of living with post-traumatic stress disorder
Risk factors identied should prompt the health practitioner to explicitly explore any
self-harm plans, means and opportunity, and refer to emergency mental health services as
outlined in your mental health legislation if a positive plan and risk are identied.
Be aware of your language around suicide when assessing consumers. As a health
professional you need to be sure that your language does not present suicide as a desired
outcome (e.g. ‘successful suicide’ or ‘unsuccessful suicide’; try ‘died by suicide’ or ‘took their
own life’) or add to the stigma, such as associating suicide with a crime or a sin (e.g. saying
‘commit/ed suicide’; try ‘took their own life’, or ‘suicide death’ instead) (Everymind, 2022).
CHAPTER 7
Table 7.8 compares and contrasts the various clinical parameters that distinguish
dementia, depression, delirium and acute confusion.
TABLE 7.8 Distinguishing dementia, depression, delirium and acute confusion
PARAMETER DEMENTIA DEPRESSION DELIRIUM ACUTE CONFUSION
Denition Deterioration of all cognitive
function with little or no
disturbance of consciousness
or perception
Onset Gradual Variable Sudden Variable
Pathophysiology
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
> Alzheimer’s disease
> Metabolic disorders
> Stroke
> Head injury
An abnormal emotional
statecharacterised by
feelings of sadness, despair
and discouragement
> Inherited: neurochemical
abnormalities
> Situational: acute loss of
signicant person
> Stroke
> Parkinson’s disease
> Alzheimer’s disease
> Medications (e.g. steroids)
A disorder of perception
with heightened awareness,
hallucinations, vivid dreams and
intense emotional disturbances
> Withdrawal from alcohol and
other drugs
> Drug intoxication
> Encephalitis
> Traumatic injury
> Febrile states
> Hypoxia
> Fluid and electrolyte imbalance
An inability to think with
customary speed, clarity
and coherence
> Metabolic disorders
> Drug intoxication
> Traumatic injury
> Febrile states
>>
212 PHYSICAL EXAMINATION
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TABLE 7.8 continued>>
PARAMETER DEMENTIA DEPRESSION DELIRIUM ACUTE CONFUSION
Attention Impaired Intact Impaired: heightened or dulled Impaired: dulled
UNIT 2
> Short-term: impaired rst
Intact
> Long-term: intact for
> Short-term: impaired
> Long-term: intact
a while
Judgement Impaired Intact
> Grossly impaired
> Impulsive
> Volatile
Insight Impaired May be intact Impaired Impaired
Spatial perception Impaired Intact Intact May be impaired
Calculation Impaired May be intact May be intact Impaired
Abstract reasoning Impaired Intact Impaired Impaired
Thought process
Impaired Intact Impaired, hallucinations present Impaired, incoherent
and content
CLINICAL REASONING
Practice tip: Depression acronym
An easy way to remember the symptoms of clinical depression is to use the acronyms
CAPS or SIG-E-CAPS
C Concentration impaired or decreased
A Appetite changes
> Short-term: impaired
> Long-term: may be intact
Impaired
P Psychomotor function decreased
S Suicidal ideations and sleep disturbances
SOURCED FROM HTTPS://W WW.NURSEBUFF.COM/NURSING-ASSESSMENT-MNEMONICS/
S Sleep changes – increased during day or decreased at night
I Interest loss in activities that used to interest them
G Guilt or worthlessness – depressed elderly tend to devalue themselves
E Energy reduction/lack of – fatigue is a common presenting symptom
C Cognition/Concentration – reduced cognition and/or difculty concentrating
A Appetite change – loss (common) or gain of weight (sometimes)
P Psychomotor – agitation, anxiety or lethargy
S Suicide – suicidal thoughts or preoccupation with death (elderly consumers with higher risk
factors for this include living alone, male, alcoholism, comorbid physical illness)
ADAPTED FROM HTT P://WEBMEDIA.UNMC.EDU/INTMED/GERIATRICS/REY NOLDS/PEARLCARDS/DEP RESSION/SIGECAPS.HTM
MENTAL STATUS AND NEUROLOGICAL TECHNIQUES 213
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CLINICAL REASONING
Mental state examination
An easy way to remember the categories of a mental state examination is to use the
acronym ‘I AM A STAR’:
> I: Introduce yourself. For example: Hello my name is …
> A: Appearance and behaviour
> M: Movement and gait
> A: Affect and mood
> S: Speech
> T: Thought pattern
> A: Attention and concentration
> R: Respond and record
ADAP TED FRO M GIBSON, H. ( 2009). U SING MNEMO NICS TO INCR EASE KN OWLEDG E OF AN ORGA NIZING CU RRICULU M FRAME WORK. TEACHING AND LEARNING IN NU RSING,
4(2 ), 56–6 2.
Mental health
Findings during the cognitive functioning examination may indicate the need for
further mental health screening.
illness that may lead the practitioner to refer the consumer for further diagnostic study.
Table 7.9 summarises ndings common to mental
CHAPTER 7
TABLE 7.9 Mental illnesses
DISORDER DEFINING CHARACTERISTICS POPULATION CHARACTERISTICS
Anxiety disorders
> Panic
> Phobias
> Generalised anxiety disorder
> Obsessive-compulsive disorder
> Trauma and stressor-related
disorders
Panic disorder
> Panic attack
> Panic disorder
Phobias
> Agoraphobia
> Social phobia
> Specic phobias
Generalised anxiety disorder Protracted period of anxiety and worry accompanied by
A group of conditions that share extreme or pathological
anxiety as the principal disturbance of mood or
emotionaltone
The consumer has experienced recurrent unexpected
panic attacks and develops persistent concern over
having recurring attacks or changes behaviour to avoid or
minimise such attacks
Panic attacks are abrupt surges of intense fear or intense
discomfort that reach a peak within minutes accompanied
by physical and or cognitive symptoms
Marked fear of specic objects or situations
Fear and anxiety to the specic phobias must be intense
and severe
The amount of fear experienced may vary with proximity to
the feared object and may occur in anticipation of or in the
actual presence of the object or situation
multiple associated physical and cognitive symptoms
Persistent and excessive worry about various domains that
the individual nds difcult to control
> Common across cultures
> Early age onset
> Relapsing or recurrent episodes
> Periods of disability
> Signicant overlap with mood and substance
abuse disorders
> Twice as common in women as men
> Onset most common between adolescence and
mid-adult life
> Signicant overlap with mood, substance abuse,
psychotic disorders
> Panic attacks can be used as a descriptive specier for
any anxiety disorder
> Experienced by approximately 8% of the population
> Typically begin in childhood
> There is a second peak in the middle 20s of adulthood
> Animal, natural environment and situational-specic
phobias are predominantly experienced by females,
whereas blood injection-injury phobia is experienced
by both sexes
> Twice as common in women as men
> Half of cases begin in childhood or adolescence
> Symptoms increase with life stress or difculties
Obsessive-compulsive disorder Obsessions are recurrent; intrusive thoughts, impulses or
images that are perceived as inappropriate, grotesque
or forbidden
Compulsions are repetitive behaviours or mental acts that
reduce the anxiety that accompanies an obsession
> Equally common among the sexes
> Begins in adolescence to young adult life in males
> Males have an earlier onset than females
> Female onset typically is young adult life
> Familial pattern
> Strongly associated with Tourette disorder
> Signicant overlap with other anxiety disorders and
major depressive disorder
>>
214 PHYSICAL EXAMINATION
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TABLE 7.9 continued>>
DISORDER DEFINING CHARACTERISTICS POPULATION CHARACTERISTICS
Acute and post-traumatic
stress disorders
UNIT 2
Mood disorders
> Major depressive disorder
> Persistent depressive
disorder – dysthymia
> Bipolar disorder
> Cyclothymia
Major depressive disorder Five or more of the following symptoms have been present
Acute: the anxiety and behavioural disturbances that
develop within the rst month after exposure to an
extreme trauma
If the symptoms persist for more than 1 month and are
associated with functional impairment, the diagnosis is
changed to post-traumatic stress disorder
A cluster of mental disorders best recognised by
depression or mania
Common feature of depressive disorders is the presence of
sad, empty or irritable mood accompanied by somatic and
cognitive changes that signicantly affect the individual’s
capacity to function
for the same 2-week period and represent a change from
previous functioning; at least one symptom is either
depressed mood or loss of interest or pleasure:
> Depressed mood
> Loss of interest or pleasure
> Signicant weight loss when not dieting
> Insomnia or hypersomnia
> Psychomotor agitation or retardation
> Fatigue or loss of energy
> Feeling of worthlessness
> Diminished ability to think or concentrate; indecisiveness
> Recurrent thoughts of death or suicidal ideation
> Twice as prevalent in females as males
> Develop in approximately 9% of those exposed to
extreme trauma
> Rape
> Physical assault
> Near-death experience
> Witnessing murder and combat
> Rank among the top 10 causes of worldwide disability
> More prevalent in women
> Leading cause of absenteeism and diminished
productivity at work
> Common comorbidities include anxiety disorder,
personality disorders, and chronic medical conditions
> May be caused by:
• Dominant hemispheric strokes
• Hyperthyroidism
• Antihypertensives
• Cushing disease
• Oral contraceptives
• Pancreatic cancer
• Alcohol withdrawal
> More common among females
> Most severe depressions more common among
the elderly
> At least 50% will recur
Dysthymia – persistent
depressive disorder
Bipolar disorder
> Type I (manic episode
may have been preceded
by hypomanic or major
depressive episodes)
> Type II (hypomanic
episodes only)
Cyclothymic disorder Chronic uctuating mood disturbance involving numerous
A chronic form of depression; symptoms are constant for a
2-year period (1 year for children)
Recurrent mood disorder featuring one or more episodes
of mania or mixed episodes of mania/hypomania
anddepression
periods of hypomanic symptoms and periods of depressive
symptoms that are distinct from each other
Manic and depressive states of insufcient intensity or
duration to merit a diagnosis of bipolar disorder or major
depressive disorder
> Twice as many females as males are diagnosed
> Early onset (childhood, adolescence or early adult life)
> Affects about 2% of adults each year
> If onset in childhood before 21 years old, associated
strongly with subsequent substance abuse and
comorbid personality disorders
> Susceptible to major depression episode superimposed
on dysthymia
> Equally common in males and females
> Affects about 2% of adult population
> Lifetime risk of suicide in individuals with bipolar
disorder is estimated to be at least 15 times that of the
general population. A past history of suicide behaviour
and days spent depressed in the past years are
associated with greater risk of suicide behaviour
> 33% higher risk than general population to develop
bipolar disorder I or II
> Cyclothymic disorder onset is usually adolescence or
early adult life
>>
MENTAL STATUS AND NEUROLOGICAL TECHNIQUES 215
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TABLE 7.9 continued>>
DISORDER DEFINING CHARACTERISTICS POPULATION CHARACTERISTICS
Schizophrenia Profound disruption in cognition and emotion. Two or more
of the following symptoms persist for a signicant portion
of time during a 1-month period:
> Delusions
> Hallucinations
> Disorganised speech
> Grossly disorganised or catatonic behaviour
> Negative symptoms: affective attening, alogia
(inability to express oneself through speech) or
avolition (lack of motivation for work or other
goal-directed activity)
SOURC E: INFORM ATION CON DENSED FR OM HARRIS ON, C., CHA RLES, J. & BR ITT, H. (2015 ). COMORB IDITIES A ND RISK FACT ORS AMON G PATIENTS W ITH SCHI ZOPHREN IA. AUSTRALIAN FAMILY PHYSICIAN, 44(11), 20 15 PAGES 781–3 .
> Onset during young adulthood
> Women experience later onset than men
> One-year prevalence in adults is estimated to be 1.3%
> Associated with signicantly higher mortality rate than
the general population
> Suicide
> Comorbid medical illness: visual and dental problems,
hypertension, diabetes, hyperlipidaemia and sexually
transmitted diseases
CLINICAL REASONING
The elderly depressed consumer
It is often difcult to differentiate between depression and early dementia in the elderly.
The clinical presentation of apathy, difculty concentrating, memory loss, and general
inability to keep up with the demands of everyday life is common to both depression and
early dementia. It is imperative to also remember that the elderly may have other aetiologies
that may account for their behaviour, such as thyroid disease, altered glucose metabolism,
electrolyte imbalance and polypharmacy. A complete health history and physical
examination are warranted, and referral if abnormal ndings are present.
CHAPTER 7
Sensory examination
Sensation should be tested early in the neurological assessment because of the detail
involved and because the cooperation of the consumer is required. The conclusions
of the assessment may be unreliable if the consumer becomes fatigued.
The sensory examination is divided into three sections. First, the exteroceptive
sensations (supercial sensations that originate in the sensory receptors in the
skin and mucous membranes) are tested. These are the sensations of light touch,
supercial pain and temperature.
Next, the proprioceptive sensations (deep sensations, with sensory receptors in
the muscles, joints, tendons and ligaments) are assessed. Proprioception is tested
with the modalities of motion and position, and vibration sense.
Finally, the cortical sensations (those that require cerebral integrative and
discriminative abilities) are assessed.
discrimination, and extinction are tested.
Exteroceptive sensation
1. Explain the procedure to the consumer before starting the examination.
2. The sensory examination is carried out with the consumer’s eyes closed.
3. For a thorough sensory examination, the consumer should be in a
supineposition.
4. The consumer should be cooperative and reliable, although the pain
examination may be performed on comatose consumers.
5. Note the consumer’s ability to perceive the sensation.
6. Much of the sensory component of the neurological examination is
subjective; observe the reactions of the consumer by watching their face for
grimacing, or for withdrawal of the stimulated extremity.
7. Compare the consumer’s sensation on the corresponding areas bilaterally.
8. Note whether any sensory decits follow a dermatome distribution.
9. The borders of any area exhibiting changes in sensation should be mapped
by dermatomes (see Figure 7.7).
Stereognosis, graphaesthesia, two-point
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