Chapter 9: Cognition, Behavior, & Mental Status

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Hello and welcome back to the Deep Dive.

We are glad to have you with us.

Today we are shifting gears a little bit.

Usually we're looking outward at tech trends, history, or big economic shifts, but today we are looking inward.

We are taking a flashlight and shining it into the most complex, frustrating,

and fascinating square foot of real estate in the known universe.

The human brain.

The human brain, and specifically we are pulling apart Bates's Guide to Physical Examination and History Taking.

We are focusing exclusively on chapter 9, Cognition, Behavior, and Mental Status.

Right.

Now I have to be honest, when I saw Physical Examination on the cover, I expected stethoscopes and reflex hammers, but looking at our notes for today, this feels different.

This feels a bit more, you know, abstract.

It does feel different, but I would argue it is the most critical chapter in the entire book.

You know, a lot of students and even seasoned clinicians find this chapter daunting.

I can see why.

When you look at the heart, it's a pump.

It falls in mechanical rules.

But the brain, the brain is where biology meets biography.

That is a great line.

Biology meets biography.

I like that.

It's true.

And the mission for this deep dive is to demystify that intersection.

We are going to walk through this chapter exactly as it is laid out in the text.

Okay.

We want to take this from abstract and scary

to concrete and clinical for anyone listening, especially if you're a student.

So let's map out the journey for the listener.

We have a clear roadmap today.

First, we are going to get under the hood with the anatomy and physiology.

Yep.

The fundamentals.

We need to know the wiring before we can fix the lights.

Then we move to the health history, how to ask the questions that uncover the invisible red flags like anxiety and depression, which is an art form in itself.

It really is.

Absolutely.

Then the heavy lifter of the episode, the mental status examination, or MSE, we are going to break down the techniques step by step.

And finally, we will wrap up with health promotion and screening the high stakes stuff like suicide risk and dementia.

And my goal for you listening is to connect the dots.

We don't want you to just memorize a checklist.

We want you to understand why you are asking a patient to spell world backward and what it actually tells you about their neural circuitry.

That's the key, isn't it?

The why.

So let's get right into it.

Section one, anatomy and physiology.

The text opens with a really interesting comparison to set the stage.

It does.

It contrasts the brain with the heart or the digestive system.

Right.

And this is key to understanding why psychiatry and neurology are so difficult.

If you look at the heart, the cause and effect is usually pretty linear.

If a valve fails, blood flows backward.

If a coronary artery is blocked, the muscle dies.

It's mechanical.

You can point to the broken part.

But the text calls the brain highly challenging when it comes to pinpointing the source of a disorder.

Why is that?

What makes it so tough?

It's the complexity and the connectivity.

So the central nervous system or CNS covers the brain and the spinal cord.

But for mental status, we are really zeroing in on the brain.

You have the cerebrum.

That's a massive part with the cortical lobes we all learned in high school.

Frontal, temporal, parietal, occipital.

And it's not just the surface, right?

It's the deep structures too.

Exactly.

You have the deencephalon, which includes the thalamus and the hypothalamus.

You have the basal ganglia, the brain stem, and the cerebellum.

The problem is these aren't isolated islands.

They're all connected.

You don't have a sadness department or a math department located in one single spot.

It's a network.

It is a massive, incredibly dense network.

And the text emphasizes that the brain

functions through these complex circuits.

So attributing a specific psychiatric symptom to one spot is often impossible.

So you can't just say, oh, the problem is right there.

Almost never.

For a mental disorder to manifest, you usually have deficits occurring across multiple points in a network simultaneously.

So if the hardware is the circuit board, then the software or maybe the electricity is the chemistry.

The text talks about modulatory systems.

These are the neurotransmitters.

And this is high yield because if you understand these four chemicals, you understand the basis of almost all psychiatric medication and pathology.

OK, so this is important stuff.

It is deep within the brain, primarily in the brain stem.

There are clusters of neurons called nuclei that produce these chemical messengers and just spray them across the brain.

Let's run through the big four that Bates highlights then.

First up, serotonin.

Serotonin is the heavy hitter for mood.

It is produced in the raffi nuclei, which are located in the brain stem.

If you look at figure nine to one in the text, you see these pathways projecting everywhere, down to the spinal cord to regulate pain, up to the cerebellum and all over the cortex.

So it's a broadcast signal.

It's not just going from point A to point B.

Exactly.

It's a modulator.

It regulates mood, arousal and cognition.

And the clinical correlation.

I mean, what happens when it's off?

When serotonin is low, we see depression and anxiety.

That's why SSRIs, selective serotonin reuptake inhibitors, are the first line treatment for depression.

They boost that signal.

Got it.

OK, next up is norepinephrine.

This is produced in a spot with a great name, the locus coeruleus, also in the brainstem.

Sounds like a spell from Harry Potter.

It does.

I've always thought that.

Norepinephrine is essentially the brain's version of adrenaline.

It regulates mood, arousal, attention and cognition.

So this is the wake up and focus chemical.

That's a perfect way to put it.

It gets you going.

And what happens when it's out of balance?

Well, low levels are associated with depression, feeling sluggish, foggy, no energy, but high levels.

That's anxiety or overaroused.

It's that feeling of being keyed up, jittery.

Then we have dopamine.

This is the one everyone talks about in pop culture regarding addiction and, you know, our phones.

It is the reward chemical, but it's also crucial for movement.

It's produced in two main places, the substantia nigra and the ventral tegmental area.

OK, let's break down the two sides of dopamine, the movement part first.

On one side, you have motor control.

If you lose the dopamine neurons in the substantia nigra, you get Parkinson's disease, the classic tremors, rigidity, slow movement.

And the other side, the psychiatric side.

That's the reward and pleasure system.

It drives motivation.

And the text links this to psychosis.

Right.

The dopamine hypothesis of schizophrenia suggests that too much dopamine activity in certain pathways leads to hallucinations and delusions.

It's like the significance filter is broken.

What do you mean by that?

Everything feels intensely meaningful or threatening.

A passing car isn't just a car, it's a sign.

It's also elevated in the manic phase of bipolar disorder, which drives that grandiosity and euphoria.

OK, and finally, the fourth one, acetylcholine.

Produced in the basal forebrain.

Think of this one as the maintenance worker for the cortex.

It regulates sleep, arousal, and attention.

It keeps things running smoothly.

And the big clinical nugget here, what do we need to know?

Dementia.

In Alzheimer's disease, there is a profound loss of acetylcholine.

That's why we use drugs like Dunpezel.

They are cholinesterase inhibitors.

They stop the breakdown of acetylcholine to try and, well, keep the lights on a little longer.

So we have this soup of chemicals and this web of neurons.

When the system glitches, we get what the text calls a mental disorder.

But reading Bates, it feels like the authors are a little conflicted about that term.

They are and rightfully so.

The text uses the definition from the DSM -5.

It says a mental disorder is a syndrome characterized by significant impairment in cognition,

emotion regulation, or behavior.

And the key phrase there is significant distress or disability.

That's the threshold.

Exactly.

That is the line.

You can be eccentric.

You can be sad for a few days.

You can be quirky.

That is not a disorder.

It becomes a disorder when it impacts your social, occupational, or other important activities.

If you can't go to work or you can't maintain relationships, that is when it crosses into a clinical diagnosis.

But the text also points out a philosophical flaw in the term mental disorder.

Yes.

It implies a Cartesian dualism, this old idea from Descartes that the mind and the body are separate entities.

Like the mind is a ghost in the machine.

Pretty much.

And Bates is very clear.

This is a false distinction.

A mental disorder is a physical disorder of the brain circuits.

Just because we can't see it on a standard x -ray like a broken bone doesn't mean it isn't physiological.

So we use the term because it's the standard, but we should remember it's all physical.

Exactly.

But we stick with the term mental disorder because that is the current medical language.

It's what we use for communication and billing.

That is a perfect transition to section two, the health history, because if we can't see it on an x -ray, we have to find it another way.

We have to be detectives.

And the stakes are incredibly high.

The prevalence of these issues is staggering.

The text cites data from 2016 stating that 18 .3 % of U .S.

adults had a mental illness.

That's almost one in five.

That is nearly 45 million people.

Think about that.

And for the students listening who are planning to go into primary care, internal medicine, and think, well, I'll leave this to the psychiatrists.

The text has a wake -up call for you.

A huge one.

It states that 20 % of primary care outpatients have mental disorders.

That is one in five patients sitting in your waiting room.

Okay, so you will see this.

You will.

But here is the scary statistic.

50 % to 75 % of those diagnoses go undetected and untreated.

That is a massive gap.

Why?

Why are we missing so many?

There are a few reasons.

First, the symptoms are often masked.

A patient rarely comes in and says, doctor, my serotonin is depleted.

Right.

They don't speak our language.

They come in with somatic complaints.

Somatic meaning physical.

Right.

They come in with fatigue, back pain, headaches, insomnia, or stomach issues.

If the clinician just treats the back pain and ignores the underlying depression, the patient never gets better.

The symptoms are camouflaged, but there's also the issue of the patient hiding them, right?

Stigma.

We cannot gloss over this.

The text emphasizes how powerful this is.

Patients often feel that their anxiety or depression is a sign of weakness.

They think it's a character flaw, not a disease.

They feel guilty.

They think, I should just be able to snap out of this, or what will people think of me?

So what is the clinician's role in that moment?

How do you break through that?

It is to validate and reframe.

The text says the clinician must reinforce that these are real, treatable medical conditions, just like hypertension or diabetes.

So you explicitly make that comparison.

You have to.

You have to tell them this is biology, not willpower.

You'd never tell a diabetic to just will their blood sugar down.

It's the same principle.

That simple validation can be the key that unlocks the patient's willingness to talk.

Let's get into the specifics of that talk.

Section three covers common or concerning symptoms.

The chapter breaks this down into four main buckets.

I want to deep dive into each of these because this is the bread and butter of diagnosis.

Bucket one is anxiety.

Anxiety is the most common category.

Lifetime prevalence is over 30%.

But anxiety is a big umbrella term.

Underneath it, you have generalized anxiety disorder, social phobia, panic disorder, PTSD.

You need to distinguish between them.

And the text gives us some high yield screening questions to start with.

It does.

And notice the time frame.

The questions focus on the past two weeks.

Okay.

Question one,

over the past two weeks, have you been feeling nervous, anxious, or on edge?

And question two, have you been unable to stop or control worrying?

If they say yes to those, then you have to peel the onion.

How do you tell the difference between generalized anxiety and say panic disorder?

It's about the nature of the fear.

In generalized anxiety disorder or GAD, the core feature is worry.

It's a constant hum.

I like that.

They worry about bills, the kids, the car, the weather.

It's free -floating and omnipresent.

It latches onto everything.

Versus panic disorder.

That's different.

Totally different.

Panic is an explosion.

It is characterized by recurrent, unexpected attacks, sudden, intense fear, heart palpitations, sweating, chest pain, feeling like you were going to die or go crazy.

It sounds like a heart attack.

It feels like a heart attack.

That's why so many of these patients end up in the ER.

It hits like a lightning bolt, often without a specific trigger.

And social anxiety.

How does that fit in?

That is driven by the fear of scrutiny.

It's avoidance.

I can't go to that meeting because I might say something stupid and everyone will look at me.

The core fear is embarrassment or humiliation.

And then there's OCD.

Obsessive -compulsive disorder.

This is distinct.

You have two parts.

First, obsessions, which are intrusive, unwanted thoughts.

Did I leave the stove on?

Are my hands dirty?

Did I hit someone with my car?

And then the compulsions.

The compulsions are the ritualistic behaviors performed to neutralize the anxiety of the thought, checking the stove five times, washing hands until they bleed, driving back to check the road.

Got it.

Okay.

Bucket number two, depressed mood.

Again, screening is vital.

The text recommends the two -question screen, which is often called the PHQ -2.

The PHQ -2.

One, over the last two weeks, have you felt down, depressed, or hopeless?

Two, over the last two weeks, have you felt little interest or pleasure in doing things?

That second one is really important.

That's anhedonia.

Exactly.

Anhedonia is the inability to feel joy.

It's not just being sad.

It's being empty.

A profound loss of interest.

So if a patient says, I used to love fishing, but now I just sit there and don't care,

that is a massive red flag.

A massive red flag.

It's one of the core symptoms of major depression.

The text warns us about a terminology trap here.

Patients might not use the word depressed.

Never assume the patient uses your medical vocabulary.

A depressed man, for instance, might say he is angley or irritable.

An older person might say they have low spirits or are just tired all the time.

You have to listen for the synonyms.

You have to listen for the feeling behind the word.

We also need to distinguish between the types of depression.

We have major depressive disorder, or MDD, and persistent depressive disorder.

What's the difference?

It's about intensity and duration.

Think of MDD as a severe storm.

It requires symptoms for at least two weeks and includes things like insomnia or sleeping too much, significant weight change, guilt, and thoughts of death.

It knocks you down.

And persistent depressive disorder?

What's that like?

That used to be called dysthymia.

It's like a constant gray drizzle.

It lasts for at least two years.

Two years.

Wow.

Yeah.

You can function.

You go to work.

You feed the dog.

But you aren't functioning well.

It's a chronic, low -grade misery that just grinds you down over time.

And then the one we really cannot miss, bipolar disorder.

This is critical.

Bipolar is defined by the presence of manic or hypomanic episodes.

You have to ask about the highs, not just the lows.

What does that sound like?

What do you ask?

Have you ever felt the opposite of depressed?

Like you were on top of the world, full of energy, a time when you needed much less sleep but didn't feel tired?

Did you spend way too much money or do things that were out of character?

Why is it so dangerous to miss this distinction?

Because the treatment is totally different.

If you give a bipolar patient a standard antidepressant without a mood stabilizer, you can actually trigger a manic episode.

Oh, wow.

You can flip them from depressed to manic, which can be a medical emergency.

It's one of the most important distinctions to make in all of psychiatry.

Okay.

Back at number three, memory problems.

The text notes a terminology shift here.

Yes, the DSM -5, the diagnostic manual, now uses the term neurocognitive disorders.

But clinically, on the wards, you are still going to hear dementia and delirium used all the time.

These two get confused all the time by families and students.

So how do we tell them apart just from the history?

The speed of the train.

That is the key.

Is the onset sudden or is it insidious?

Let's look at sudden first.

What's that story like?

If a family member says, grandma was fine yesterday, but today she is confused pulling at her clothes and doesn't know where she is, that is delirium.

Okay.

That is an acute confused state.

It's usually caused by a medical issue, a urinary tract infection, pneumonia, a new medication, electrolyte imbalance, or withdrawal.

So delirium is a medical emergency.

It's a symptom of something else going wrong.

Absolutely.

You have to find the cause and treat it.

When you do, the mind usually clears.

It's reversible.

Versus the slow burn.

If the story is mom has been forgetting her keys for a year, then she started forgetting names, and now she's getting lost driving to the grocery store.

That is dementia.

It's a slow progressive decline.

And the text gives us clues to narrow down the type of dementia to, not just its presence.

Yes.

If the memory loss is the primary first feature, you should think Alzheimer's.

That's the most common.

But if you see tremors, rigidity, or other movement issues early on, that points toward Parkinson's or Huntington's.

What if the personality changes first?

That points to frontotemporal dementia.

This is tragic.

A sweet, polite person might suddenly start swearing, making crude sexual comments, or gambling away their savings.

The filter in the frontal lobe is deteriorating before the memory does.

And I see a note here about visual hallucinations.

Yes.

Seeing things that aren't there, like little people or animals.

That is a hallmark of Lewy body dementia.

It's a very specific symptom to ask about.

Okay.

And finally, bucket number four, medically unexplained symptoms.

We touched on this with the masked depression.

We did.

This is the somatic link.

The text states that 30 % of Alden symptoms reported in office visits are medically unexplained.

That's a huge number.

And the overlap is significant.

It is.

Two -thirds of depressed patients present primarily with physical complaints,

not emotional ones.

So the takeaway is don't just treat the symptom.

Look for the source.

Right.

If you are treating back pain and it's not getting better with standard treatments, you have to take a step back and screen for depression.

The pain might be real, but the depression is the amplifier.

If you don't turn down the amplifier, the pain won't resolve.

Okay.

We have gathered all this history.

We have our suspicions.

Now we move to the examination, section four.

The physical examination or rather the mental status examination, the MSE.

And the first rule of the MSE is it is not a separate event.

You don't say, okay, stop talking.

Now I'm going to examine your mind.

So you're doing it the whole time from the second you meet them.

From the moment you call their name in the waiting room, how do they get up?

Are they alert?

Are they dressed appropriately for the weather?

Do they make eye contact?

You are gathering data before you ask a single test question.

But when we do get to the formal testing, there is a sequence logic here.

The text says there's a specific order.

Yes.

You generally want to assess level of consciousness and language first.

Why is that order so important?

Well, imagine you are trying to test someone's memory, but they are half asleep.

Or you are testing their abstract logic, but they have aphasia and don't understand your language well.

You're going to get a false abnormal.

The test will be invalid.

Exactly.

You have to establish that the input and output channels are open and working before you can test the processor.

That makes perfect sense.

So let's break down the techniques of examination.

Section five lists six components.

We are going to walk through them one by one.

Component one, appearance and behavior.

This is the Sherlock Holmes part.

You are observing.

Yeah.

Pure observation.

Let's start with level of consciousness.

We have specific terms here and the text emphasizes we need to use them correctly.

Alert is obvious.

Right.

Patient is awake and engaged, but then we have lethargic.

In medicine, that doesn't just mean lazy.

It means drowsy.

Okay.

They'll answer you, but then they drift back to sleep.

If you stop talking, you have to keep stimulating them verbally.

Then obtunda.

That's a deeper level of unconsciousness.

You have to physically shake them.

A tactile stimulus to get them to open their eyes and look at you.

They're confused and slow when you do get them roused.

Next is stupor.

Even deeper.

They only arouse to pain, a sternal rub or a pinch on the trapezius muscle, and they don't really wake up.

They just groan or withdraw from the pain.

And finally, coma.

Unarousable.

Eyes closed.

No response to any stimulus, including deep pain.

Okay.

Next in appearance is posture and motor behavior.

Body language tells a story.

The text points out the slumped heavy posture of major depression, the agitated pacing and inability to sit still of anxiety.

And mania.

The expansive movements of many big sweeping gestures take up a lot of space.

Very dramatic.

What about dress and grooming?

What are we looking for there?

You're looking for a change for the baseline.

If a successful lawyer who is normally impeccably dressed comes in wearing dirty sweatpants and hasn't showered in a week, that's a massive signal.

It could be depression, schizophrenia or dementia.

The text mentions a specific anatomical clue here regarding grooming.

One -sided neglect.

This is fascinating.

If a patient has shaved only the right side of their face, or put makeup on only half their face, they literally are ignoring the other half of space.

Their brain isn't processing that side of the world?

Exactly.

This usually points to a lesion in the opposite parietal cortex, usually the right parietal lobe, which causes neglect of the left side of the world.

Next is facial expression and affect.

Facial expression is about mobility.

Is the face moving naturally?

If it's immobile, mask -like, unblinking, that's Parkinsonism, a classic sign.

And affect.

We used the weather analogy earlier.

Right.

Affect is the weather.

It is the fluctuating pattern of observable behaviors right now in the room with you.

And there are specific terms for this.

Yes.

Is it flat or blunted, meaning no emotional range?

Is it labile, meaning they are crying one second and laughing the next?

Or is it inappropriate, like giggling while telling you their mother just died?

Okay, moving on.

Component two, speech and language.

We aren't checking what they say yet, just how they say it.

Correct.

We look at quantity, rate,

volume, and articulation.

Rate is a big clue, isn't it?

Oh, yes.

If the speech is rapid, pressured, and you literally cannot interrupt them, that is the hallmark of mania.

And the opposite.

If it is slow, monotonic, and quiet, with long pauses,

that's very common in severe depression.

And what does dysarthria mean?

That means defective articulation.

Slurred speech.

Think of someone who is very intoxicated.

The words are there, but the muscles of the mouth and tongue aren't forming them correctly.

It can be from a stroke, for example.

And this is where we test for aphasia.

This is a language disorder caused by brain damage, usually a stroke in the dominant hemisphere.

The text suggests a specific battery of tests in Box 9 -6.

It's a pretty straightforward four -step check.

One.

Comprehension.

Can they follow a command?

Start simple.

Point to your nose.

Then make it more complex.

Point to the ceiling, then to the floor.

Step two.

Repetition.

The classic phrase is no ifs, ands, or buts.

It's a tongue twister intentionally to test their ability to reproduce complex sounds.

Three is naming.

Simple enough.

Point to a pen, a watch, a tie.

Ask, what is this?

Can they retrieve the word?

And four is reading and writing.

Yes.

Ask them to read a paragraph out loud.

Then ask them to write a sentence.

Why is writing so important?

Because if a person can write a grammatically correct sentence, they generally do not have aphasia.

It's the ultimate output test that integrates multiple parts of the language centers.

Component three.

Mood.

Now, earlier we talked about affect being the weather.

Mood is the climate.

It is the pervasive, sustained emotion that the patient feels internally over time.

So you can't observe mood, you have to ask.

Exactly.

Unlike affect, which we observe, mood is something we have to ask about.

How is your mood?

Or how have you been feeling in your spirits?

Simple as that.

But sometimes patients can't name it.

There's a word for that.

Alexithymia.

If that happens, you offer options.

Are you feeling sad, angry, content, neutral?

This is also where the text emphasizes assessing suicidality.

And this is non -negotiable.

You must ask directly about thoughts, plans, and intent.

There is a myth out there, a fear, that asking about suicide puts the idea in their head.

The text is very clear on this, and all the evidence supports it.

Asking these questions does not increase the risk of suicide.

It is often the only way to uncover the danger.

So what's the progression of questions?

You start broad.

Have you had any thoughts that life isn't worth living or about hurting yourself?

If yes, you get more specific.

Do you have a plan?

If yes, what is the plan?

Do you have the means to carry out that plan?

The more specific the plan, the higher the risk.

Got it.

Component 4.

Thought.

This is split into process and content.

Process is how they think.

This is where we get into some fascinating terms.

You're listening to the logic and the flow of their ideas.

Like circumstantiality.

Right.

Circumstantiality is when they give you tons of unnecessary detail.

What they had for breakfast, the color of the bus, but eventually they get to the point.

And derailment.

Derailment is when they shift topics loosely and never get back to the point.

The train jumps the tracks and ends up in a different town.

And flight of ideas.

That's mania again.

It's an extreme form of derailment.

It's accelerated, continuous speech with abrupt changes.

They are jumping from idea to idea based on puns or rhymes or just loose associations.

I bought a cat.

Cats have paws.

Paws for effect.

Effect is the weather.

It's exhausting to listen to.

What about confabulation?

That's an interesting one.

That's fabricating facts to filling gaps in their memory.

You see this in Korsakoff syndrome from chronic alcohol use.

The patient isn't lying on purpose.

Their brain is just filling in the blanks with fiction because it can't stand a vacuum.

Then there's thought content.

What they are actually thinking about.

This includes compulsions and obsessions, which we talked about.

But also delusions, which are false.

Fixed beliefs that are not shared by the person's culture.

And there are different types.

Yes.

Persecutory delusions.

The FBI is bugging my phone.

Grandiose delusions.

I am the king of England and I have a secret mission.

Somatic delusions.

My insides are rotting or there are bugs under my skin.

Okay.

Component five.

Perceptions, insight, and judgment.

Perceptions covers hallucinations and illusions.

It's very important to distinguish them.

What's the difference?

A hallucination is a perception -like experience without an external stimulus.

Hearing voices in a completely silent room.

That's a hallucination.

And an illusion.

An illusion is a misinterpretation of a real external stimulus.

Seeing a coat rack in a dark corner of the room and thinking it's a person.

The stimulus is real.

The coat rack.

But the perception is wrong.

And insight versus judgment.

Insight is awareness.

Does the patient know they are ill?

Do they understand that their symptoms are abnormal?

In psychotic disorders like schizophrenia, insight is often completely absent.

They believe their delusions are real.

And judgment.

Judgment is about decision -making.

You test it with hypothetical situations.

What would you do if you found a stamped, addressed envelope on the street?

Or, more relevant to their life, how will you manage your finances if you lose your job?

We are testing their ability to evaluate alternatives and make sound decisions.

Okay.

Finally, component six.

Cognitive functions.

This is the part that feels most like a test.

It is.

This is where we are explicitly testing their cognitive machinery.

We start with orientation, person, place, and time.

What's your name?

Where are we?

What's the date?

Then attention.

Right.

The text suggests a few ways.

Digit span, asking them to repeat a series of numbers forward, and then a different series backward.

Or the classic serial sevens, starting at 100 and subtracting 7.

93, 86, 79.

What's normal for serial sevens?

Completing it in about 1 .5 minutes with fewer than four errors.

If they can't do math, or if they have low education, you can ask them to spell world backward.

D -L -R -O -W.

Exactly.

Then memory.

We check three types.

Remote memory, which is long -term birthdays, schools attended, historical events.

Recent memory, which is from earlier in the day, the weather, what they had for breakfast, their appointment time.

And new learning.

This is key for dementia screening.

Absolutely.

This is where you give them three or four unrelated words.

The book suggests table, flower, green.

Have them repeat it back immediately to show they registered it, and then tell them you'll ask for it again in a few minutes.

Then after three to five minutes of other conversation, you ask them to recall the words.

And lastly, higher cognitive functions.

This is where we get into more complex processing.

We check information and vocabulary.

Ask about the current president or the names of five large cities.

This is highly dependent on education, so you have to be careful.

And calculations.

Simple math problems.

If you buy something for $7 and pay with a $10 bill, how much change do you get?

And abstract thinking.

This is fun.

You use proverbs.

Ask them what a rolling stone gathers no moss means.

If they say it means a stone doesn't get moss on it, that's a concrete answer.

Exactly.

We're looking for the abstract interpretation.

If you keep moving and stay busy, you don't get stuck in a rut.

Another one is asking for similarities, like how are an orange and an apple alike?

The concrete answer is they're round.

The abstract answer is they're both fruits.

And the last part of this is constructional ability.

Yes.

You ask the patient to copy figures, like two intersecting pentagons, or the famous clock drawing test.

Drawing a clock face with all the numbers and then drawing the hands to show a specific time, like 10 past 11.

It sounds simple, but it tests visuospatial skills, planning, number sense, and motor control all at once.

It's an incredibly powerful screen for cognitive impairment.

We've gathered all this data.

Section 6 is about recording findings.

The text contrasts a normal versus abnormal write -up.

Documentation is key.

You can't just write, patient is crazy, or a patient is confused.

It's not helpful.

You need to be specific and objective.

So what does a good normal note look like?

A normal finding might read something like mental status.

Patient is alert, well -groomed, and cheerful.

Speech is fluent and coherent.

Thought processes are logical.

Oriented to person, place, and time.

Serial 7 is accurate.

Recent and remote memory intact.

And an abnormal one.

It would be specific about the deficits.

Patient appears sad and fatigued.

Clothes are wrinkles and stained.

Speech is slow with delayed responses.

Affect is flat.

Insight into their illness seems limited.

You paint a picture with clinical terms so the next person who reads your note knows exactly what you saw.

We are in the home stretch.

Section 7, health promotion and counseling.

This is about screening the general population, not just someone who comes in with a complaint.

Right, and we circle back to depression screening.

The US Preventive Services Task Force, the USPSTF, gives this a grade B recommendation, which means we should be doing it.

And the tool for that is the PH2 -2.

Exactly.

Using just those two questions we mentioned earlier has an 83 % sensitivity.

It's a quick, effective screen.

If it's positive, you then move to the full PHQ -9, which is a nine -question survey to assess severity.

And suicide risk again.

The text brings this up in the context of public health.

The stats are sobering.

It's the 10th leading cause of death overall in the US, but it's the second leading cause for 15 - to 24 -year -olds.

It's a crisis.

There is a gender paradox mentioned here.

Yes.

Women have higher rates of suicide attempts,

often using methods like poisoning.

But men have much higher rates of death from suicide, often because they use more lethal means, like firearms.

And the text highlights some high -risk demographics.

Yes.

Risk factors include being in the 45 - to 54 -year -old age bracket or being over 85.

And in terms of ethnicity,

white men and American Indian Alaska Native men have the highest rates.

What about screening for neurocognitive disorders like dementia?

Should we screen everyone?

The evidence is less clear for universal screening.

But for patients where you have a concern, there are good tools.

The MMSE, or Mini Mental State Exam, is famous, but it's copyrighted and costs money to use.

So what are the alternatives?

The text recommends the Mini Cog, which is just the three -word recall plus the clock drawing test.

It takes three minutes and is very effective.

Or, for a more detailed look, the MOCA, the Montreal Cognitive Assessment.

It takes about 10 minutes and assesses multiple cognitive domains.

And for delirium in a hospital setting, for example, the text mentions the CAM.

The Confusion Assessment Method.

It's an algorithm.

To diagnose delirium using CAM, you need two main features.

One, an acute onset and fluctuating course.

AD2, inattention.

Okay, so those two are required.

They're required.

And then you need at least one of the next two.

Either three, disorganized thinking, or four, an abnormal level of consciousness.

It's a very specific and reliable tool for diagnosing delirium at the bedside.

Finally, substance use.

It's a major comorbidity.

It's often intertwined with depression, anxiety, and psychosis.

The text highlights the terrible rise in overdose deaths from synthetic opioids like Sentinel.

And the recommendation here?

The USPSTF recommends we screen all adults 18 and older for alcohol misuse.

And we should be asking everyone about drug use as well.

Wow.

We have unpacked the brain stem, analyzed the history, walked through the entire exam, and covered screening.

It's a huge amount of ground.

It's a lot.

But remember, understanding the whole patient means understanding their mind as well as their body.

You can't effectively treat the heart failure if the patient is too depressed to take their medication or too cognitively impaired to understand the instructions.

Absolutely.

This chapter is your toolkit for making those connections, for seeing the person behind the physical symptoms.

And for keeping your patients safe.

That's the bottom line.

Asking about suicide,

screening for delirium.

These are life -saving interventions.

Thank you so much for listening to this deep dive into Bates Chapter 9.

We hope this helps you on your clinical journey and makes this challenging topic feel a little more manageable.

Keep asking the hard questions.

And keep listening to your patients.

This is the Last Minute Lecture Team signing off.