Introduction

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Mental status testing, or the evaluation of cognition in the clinic and at the bedside, is among the most useful examination techniques in a clinician’s tool bag. It is an art as well as a skill that can be extremely rewarding and valuable in the care of patients. Consideration of a patient’s cognition is pertinent to many if not most clinical encounters. This is because cognitive dysfunction is a sensitive barometer of brain dysfunction, and brain dysfunction is sensitive to medical and physiological disturbances beyond neurological disease. In fact, mental status testing is applicable to many disorders and is an important tool for a range of clinicians and health care providers, and not just those specialized in neurologic or psychiatric diseases. Knowing how to recognize and evaluate early and subtle changes in cognition can lead to earlier diagnosis and better management of patients with drug effects or other toxic-metabolic disturbances, major organ dysfunction, inflammatory or endocrine disorders, as well as neurological disease or psychiatric disorders. Primary care providers and specialists alike can learn to assess cognition in clinical encounters, whether in-person or via telemedicine, in a process that can take as little as a few minutes, but that can be as informative, if not more so, as other aspects of the examination.

Despite the great value of mental status testing, significant barriers exist for many clinicians in acquiring these skills. Physicians and other health care providers may not understand the cognitive consequences of brain dysfunction. Some view cognition as too complex, incomprehensible, or enigmatic. These beliefs begin in professional schools, which may not devote sufficient time to teaching, or at least exposing, students to cognitive and related behavioral changes. “Neurophobia,” or the intimidating effect of applied neuroscience with its neuroanatomy and neurologic examination, extends to cognition and brain-behavior localization. Consequently, knowledge of mental status abnormalities, and confidence in its assessment, may be deficient well into postgraduate training and beyond. Another barrier to acquiring mental status testing skills is the attitude that cognitive assessment is not the role of most clinicians, either because it is too difficult, prohibitively time consuming, or simply not in their domain. Some clinicians see the assessment of mental status as solely the province of neurologists, psychiatrists, or neuropsychologists. This book aims to counter these misconceptions and show how mental status testing skills can be easily acquired, efficiently applied, and relevant to any clinician who cares for patients.

An initial step to gaining proficiency in mental status testing is understanding the concepts of mental status and cognitive domains. There is a narrow and a broad usage of the term “mental status.” This handbook uses the narrow concept of mental status evaluation, which refers to methods and techniques of cognitive assessment in the clinic and at the bedside. Nevertheless, this handbook acknowledges the broader use of “mental status” evaluation to include the psychiatric interview and the neuropsychological examination, complementary and valuable areas of examination in their own right. Cognition, or the mental processes involved in perceiving, storing, understanding, and applying information, is composed of domains such as attention, language, memory, perception, and executive abilities, among others discussed further in this and subsequent chapters ( Box 1.1 ). The term “neurocognition,” incorporated into the DSM-5 (American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders . 5th ed. Arlington, VA: American Psychiatric Association; 2013) for dementia (major) and mild cognitive impairment (minor), refers to cognition linked to cortical networks and neural pathways and directly affected from brain mechanisms or disease.

BOX 1.1

MAJOR NEUROCOGNITIVE DOMAINS UNDERLYING THE MENTAL STATUS EXAMINATION (MSX)

Fundamental Aspects of MSX

1.

General Behavioral Observations
2.

Arousal
3.

Orientation
4.

Psychomotor Speed and Activity
5.

Attention and Mental Control

Instrumental Aspects of MSX

6.

Spoken Language and Speech
7.

Written Language and Reading
8.

Memory and Semantic Knowledge
9.

Constructional, Perceptual, and Spatial Abilities
10.

Praxis and Other Motor Movements
11.

Calculations and Related Functions
12.

Executive Operations
13.

Executive Attributes
14.

Neurological Behaviors

Another initial step is knowing that there are different levels of mental status examination (MSX), depending on the context and clinical needs. Levels may be divided into four broad categories, which include a brief MSX screen; mental status scales and inventories; targeted MSX; and the extended MSX, often referred to as the “neurobehavioral status examination” (NBSE) ( Box 1.2 ). Brief screening quickly assesses a few cognitive domains, such as attention, language, and memory, in a few minutes when urgency and expediency are indicated. Mental status scales and inventories, such as the Mini-Mental State Examination or the Montreal Cognitive Assessment (see Chapters 15 and 16), are another level of screening with semiquantitative cutoffs for detecting cognitive impairment. Targeted MSX may include isolated elements of the NBSE, or dedicated scales focused on localized neurologic dysfunction or the assessment of specific disorders, such as delirium. Finally, there is the extended MSX or NBSE. These include tasks and tests that probe cognitive domains and that include a broad range of techniques for assessing aphasia, agnosia, apraxia, perceptual deficits, frontal-executive dysfunction, and other “neurobehavioral” symptoms and signs. The NBSE may include a battery with or without a mental status scale, or they may be applied individually. Chapter 2 elaborates on how to choose between these four MSX options.

BOX 1.2

LEVELS OF MENTAL STATUS EXAMINATION (MSX)

1.

Brief MSX Screen (≤5 minutes); screens limited major cognitive domains, usually attention, language, memory, and perception (constructions).
2.

MSX Scales and Inventories (≥5, >5–15, and >15 minutes); examples include the Mini-Mental State Examination and the Montreal Cognitive Assessment among many others.
3.

Targeted MSX; indicated for specific clinical conditions, such as delirium.
4.

Neurobehavioral Status Examination; essentially the extended MSX in neurology and neuropsychiatry, including detailed assessment of all cognitive domains.