Second last post this week for our series on Mental State Exams. Over the past few weeks we have been building an understanding of the core components of a mental state exam so that we can support our young people as best we can. This week I was speaking with a youth worker in one of Victoria’s largest Christian denominations about a mental health conference he was at. I was reminded about how important it is for all youth workers to have a strong understanding of mental health. So far we have discussed how a young persons appearance, behaviour, speech and language, mood and affect, thought process and content and their perceptions can provide indicators as to their mental state. Today we discuss how a young persons cognition can provide insight into their current mental health status.
In this section of the Mental State Exam we are looking at a young person’s level of alertness, orientation, attention, memory and executive functions. It is often this part of the MSE which requires the use of structured tests in conjunction to unstructured observation. However, an astute youth worker can use the basic understanding learnt here to gain a base level to work from. Cognition is observed through judging alertness, orientation, attention and concentration, memory and executive functioning.
When observing alertness
we are looking into the young person’s level of consciousness
i.e. awareness of, and responsiveness to their environment. Their level of alertness may be described as alert, vigilant, clouded, drowsy, or stuporous. If you are on a camp or at the end of a long Friday night youth group then alertness may be low. Conversely, on your way to a concert or game of laser tag alertness may be quite high. There are many factors which you must take into account when observing alertness. Rock, paper, scissors is a great game for testing the alertness of a young person.
Orientation is assessed by asking the young person their name, age etc (orientation to person) where he or she is (for example what building, town and state) and what time it is (time, day, date). What we are looking for is that they are oriented in person, place and time. People who have taken a big knock on the football field and are dazed are often asked these questions to observe whether they have a concussion. In the drug and alcohol field we often use these questions when people seem substance affected to judge how affected they are.
Attention and concentration are assessed by using structured tests such as series seven tests, or if you are in a pinch getting them to spell a five-letter word backwards), and by testing digit span. Here we are looking to see if the young person can keep their focus and concentration whilst completing given tasks. These tests are great for judging inebriation, attention deficits and anxiety.
Memory is assessed in terms of immediate registration (repeating a set of words), short-term memory (recalling the set of words after an interval, or recalling a short paragraph), and long-term memory (recollection of well known historical or geographical facts). If there is a severe issue with memory it may indicate dementia or neurological issues. Short term memory loss can be a symptom of anxiety.
Executive functioning can be screened for by asking the “similarities” questions (“what do x and y have in common?”) and by means of a verbal fluency task (e.g. “list as many words as you can starting with the letter F, in one minute”). The mini-mental state examination is a simple structured cognitive assessment which is in widespread use as a component of the MSE. These tests are looking at higher order brain functioning and a persons ability to stay on task. This is important for their ability to think in a critical way.
Note: The kind of brief cognitive testing discussed here are regarded as a screening process only, and any abnormalities should be more carefully assessed using formal neuropsychological testing.
Stay tuned for our final segment next week: Insight and Judgement.
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