Chapter 13 THE MENTAL STATE EXAMINATION

INTRODUCTION

This chapter is devoted to the mental state examination of older people in the community setting. Mental state examination is often referred to as mental status examination in North America. Accurate mental state examination (MSE) with older people is quite an art and the mental health worker needs to obtain some experience before developing proficiency in this art. As noted in Chapter 12, near the beginning of a clinical interview with an older person, it is necessary to make a tactical decision about how much time and effort to devote to taking the history as opposed to undertaking the MSE. In people with moderate or severe cognitive impairment, most of the history will need to be obtained from other informants. In such instances, the mental health worker should concentrate on the MSE during the clinical encounter with the person. Similarly, in cases where the person is highly suspicious or uncooperative, the mental health worker should concentrate initially on the MSE.

In older people it is essential to conduct a detailed cognitive assessment as part of the MSE. This is covered in Chapter 14. Confusingly, one of the more commonly used cognitive assessment tools is called the Mini-Mental State Examination (MMSE) (Folstein et al 1975). The MMSE must not be confused with the MSE, despite the similarity in their acronyms. The MSE is much broader than the MMSE. Because of the importance of the cognitive component of the MSE in older people, this will be dealt with in detail in the following chapter, after discussing the essential features of the MSE in this chapter.

As was noted in Chapter 12, it is often preferable to see the person alone in case domestic violence or other types of elder abuse have been present. It also eliminates the risk that well-meaning supporters will assist the older person with their responses.

CULTURAL ISSUES

In transcultural situations (see Ch 6), it is preferable not to use family members as translators, as family members sometimes modify what the person says to save face or for other reasons. They also often try to make sense of what the person is saying, making it difficult for the mental health worker to identify formal thought disorder (see below). Thus, it is best to use accredited professional medical translators. However, it is important to ascertain the precise dialect that the person speaks before arranging for the translator to be present. Sometimes, there is no time to arrange this because an urgent situation has developed and the mental health worker will have to make do with family translators. However, in such situations, it is usually worthwhile doing a subsequent interview using a professional translator to check initial findings.

Sometimes, language is not an issue, but cultural issues are. In such circumstances, such as when assessing Australian Aborigines or New Zealand Maori, it is prudent to involve a transcultural mental health worker who is familiar with the cultural background of the person.

SENSORY IMPAIRMENT

The older person or their supporters should ensure that hearing aids are in working order and that spectacles and/or magnifying glasses are at hand if normally used. If the person is being seen at home, this should not usually be a problem. However, if the person is being seen in a community clinic or in a hospital outpatient department, the older person or their supporters should be advised to bring hearing aids and spectacles. Some community mental health teams for older people make it their practice to take a personal audio amplification system with them on home visits in case the person is deaf and without functioning hearing aids.

DETAILED MENTAL STATE EXAMINATION

The MSE starts as soon as you encounter the person, whether on the telephone, via a videolink or in person during a clinic attendance or a home visit. Much of the MSE can often be undertaken while obtaining the history from the person, and experienced mental health workers usually manage to conduct most of the MSE while engaging in friendly conversation with the person. It is often useful to commence proceedings with gentle inquiries about non-contentious issues. Many workers find it builds rapport to accept at least some offers of hospitality, such as a cup of tea or coffee, from the person.

General appearance and behaviour

Note the general appearance of the older person. Do they appear clean and well groomed? Have they dressed appropriately for the weather? Or have they neglected their appearance because of dementia or other serious mental illness? Perhaps they have a physical disability that limits their ability to care for themselves.

Is their attire so bright that elevated mood might be suggested or so dark and sombre that depressed mood might be indicated? Does their attire suggest that they belong to a particular subcultural group?

What is the person’s gait and posture? Do they have the flexed posture and shuffling gait of Parkinson’s disease or the small stepping gait of subcortical cerebrovascular disease? Is there evidence of disabling arthritis or stroke?

Note the state of the home. Is it appropriate to their needs? Is it clear of excessive junk and debris? Do they have ready access to the kitchen, bathroom and bedroom? Are there hazards such as loose rugs or open fires? Is there evidence of a reasonable diet? Are empty alcohol bottles lying around that might suggest excessive intake?

Abnormal motor behaviour

Look for evidence of the dyskinetic movements of tardive dyskinesia or of late-stage Parkinson’s disease. In tardive dyskinesia there may be involuntary movements of the face, lips and tongue, or writhing or jerking movements of the trunk or limbs. In Parkinson’s disease there may be jerky or dance-like movements, usually after many years of treatment with L-dopa or other dopamine agonists. A dancing gait is also found in Huntington’s disease.

Is the person pacing? This might reflect agitation in dementia or severe depression, or akathisia (motor restlessness) in someone on antipsychotic medication.

Is there evidence of mannerisms, stereotyped movements or posturing? These may occur in older people with early-onset schizophrenia or temporal lobe epilepsy.

Is there excessive checking or cleaning behaviour such as is often seen in obsessive-compulsive disorder?

Both psychomotor retardation and psychomotor agitation are often seen in severe depression in older people. Sometimes, gross motor retardation (e.g. lying in the fetal position) and fine motor agitation (e.g. wringing of the hands) occur together.

Level of conscious awareness

Conscious awareness can vary from full alertness to coma and death. The first stage on the downward path of consciousness from full alertness is known as clouding of consciousness. The person with clouding of consciousness often exhibits reduced alertness and may appear vague, lethargic or sleepy. However, they are easily rousable. In the next stage, the person is obtunded and only partially rousable. Next, the person is stuporous and is not rousable. In the final stage, coma, the person makes no purposeful response to stimuli.

The Glasgow Coma Scale (GCS) (Teasdale & Jennett 1974) is the standard measure of impaired consciousness that is used around the world. GCS scores range from 3 (deep coma or death) through to 15 (fully conscious and alert). It consists of three components: best eye response (scored 1–4); best verbal response (scored 1–5); and best motor response (scored 1–6). Scores of 8 or less indicate severe coma, whereas scores of 9–12 indicate moderate coma.

It is not uncommon for mental health workers to encounter older people at home or in residential aged care facilities (RACFs) who have a reduced level of consciousness.