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Don’t overlook mental status changes in elderly
An 85-year-old woman comes to the ED with an ankle fracture. An elderly gentleman complains of chest pain.
Would you assess the mental status of both these patients? If not, you could be missing important information that could adversely affect patients’ outcomes, says Karen Hayes PhD, ARNP, professor at the school of nursing at Wichita (KS) State University.
"It is essential that the ED nurse perform a mental status exam on each elderly patient," stresses Hayes.
A recent study found that although mental status impairment is very common in older ED patients, this impairment often goes unrecognized. Of 271 ED patients aged 70 years or older, 74 had impaired mental status, but this status was recognized in only 28 of the patients, and of 19 patients with delirium, five were discharged to home from the ED.1
Hayes says that your goal is to determine two things: Does impairment in cognitive ability or affective functioning exist? If so, is the impairment new in onset, or does it reflect the patient’s existing mental ability?
To significantly improve assessment of mental status for elderly patients, do the following:
• Observe closely.
During the history and physical exam, closely observe the patient’s awareness, orientation, cognitive ability, and mood, Hayes advises. "In addition, observation of physical appearance, behavior, and responses to questions give clues to functional ability," she says.
• Don’t assume mental status changes are caused by aging.
Many emergent conditions present themselves as changes in mental status or acute confusion, including infection, electrolyte abnormalities, and dehydration, notes Hayes. "Remember that acute delirium or confusion caused by a physical problem is generally reversible when the physical problem is corrected," she says.
In any elderly patient with a change in mental status, a thorough metabolic work-up must be considered, says Hayes. "Too often, we assume normal aging causes mental status changes, which it does not," she emphasizes.
• Involve others as needed.
You may need to double-check your observations by consulting with another source who is familiar with the patient, says Hayes. "I like to clarify the functional status of an elder with a family member or friend," she says. "For example, I may see disorientation to place or time. A family member could tell me if that was usual for the patient or a new finding."
If no family members are available, contact the patient’s primary physician, recommends Hayes. "I place a lot of calls to doctors’ offices to get information about an older patient," she says. "The primary care physician is in a better position to tell me if my assessment of mental status is accurate."
• Give patients a Mini-Mental State Examination.
A Mini-Mental State Examination is a brief, standardized measure of mental status and takes about 10 minutes to administer, says Cynthia Bautista, PhD, RN, CNRN, neuroscience clinical nurse specialist at Yale New Haven (CT) Hospital.
The test measures five areas of cognitive function: orientation, registration, attention and calculation, recall, and language, says Bautista.
"The Mini-Mental State Exam is effective as a screening instrument to separate patients with cognitive impairment from those without it," she says.
Changes in cognitive function often call for prompt and aggressive action, says Bautista. "Cognitive functioning may decline during illness or injury," she says. "Your assessment of a patient’s cognitive status is instrumental in identifying early changes in physiological status and ability to learn, and in evaluating responses to treatment," she says.
Patients with visual impairment and immobilized limbs usually are able to complete most of the items, but the accuracy is questionable if the patient has less than an eighth-grade education or is not fluent in English, and it is very difficult to obtain an accurate score if the patient has a severe hearing impairment, notes Bautista.
"The exam relies heavily on verbal response, reading and writing skills," she says. "If elderly patient is hard of hearing and visually impaired, they may perform poorly even when cognitively intact."
1. Hustey FM, Meldon SW, Smith MD, et al. The effect of mental status screening on the care of elderly emergency department patients. Ann Emerg Med 3003; 41:678-684.
For more information about assessing mental status in elderly patients, contact:
• Cynthia Bautista, PhD, RN, CNRN, Neuroscience Clinical Nurse Specialist, Yale New Haven Hospital, 20 York St., New Haven, CT 06504. Telephone: (203) 688-3352. E-mail: firstname.lastname@example.org.
• Karen Hayes, PhD, ARNP, School of Nursing, Wichita State University, 1845 Fairmount, Wichita, KS 67260. Telephone: (316) 978-5721. E-mail: Karen.Hayes@wichita.edu.
The Mini-Mental State Examination is a brief, quantitative measure of cognitive status in adults, which can be used to screen for cognitive impairment, to estimate the severity of cognitive impairment at a given point in time, to follow the course of cognitive changes in an individual over time, and to document an individual’s response to treatment. An introductory kit with 50 test forms and a user’s guide costs $44, plus $8 shipping charge. To order, contact: Psychological Assessment Resources, 16204 N. Florida Ave., Lutz, FL 33549. Telephone: (813) 968-3003. Fax: (813) 968-2598. E-mail: email@example.com. Web: www.parinc.com.