neuropsychological and Psychiatric Examination

Degrees of impairment of consciousness, and other abnormal states of consciousness

Designation

Features

Normal consciousness

Oriented to place, time, and person (self), answers questions promptly and appropriately, follows commands correctly

Drowsiness

Mostly awake, responds to questions and commands slowly but usually correctly (after repetition if necessary), moves in response to a sufficiently intense stimulus, usually oriented and coherent

Somnolence

Mostly asleep, arousable with a moderately intense stimulus, generally requires repetition of questions or commands but then responds correctly, reacts slowly and after a delay but usually correctly

Stupor

Asleep unless awakened, can only be awakened with a strong (auditory) stimulus or perhaps only with a mechanical stimulus, cannot answer questions or follow commands or does so only after intense repetition, and then only incompletely

Coma

Unconscious, cannot be awakened, does not respond to a verbal or auditory stimulus, may respond to painful stimuli of graded intensities with specific (localizing) self-defense, nonlocalizing withdrawal of a limb, or abnormal flexion or extension responses

Confusion

Inappropriate spontaneous behavior and responses to questions and commands, deficient orientation to place, time, and/or person (self); the confused patient may be fully conscious, less than fully conscious, or agitated (see below)

Agitation

Motor unrest, inappropriate spontaneous behavior, cannot be calmed by verbal persuasion, more or less disoriented, does not follow commands appropriately

In addition to the patient’s level of consciousness and attention, the examiner should assess his or her orientation, concentration, memory, drive, affective state, and cognitive ability. The overall psychopathologic picture is composed of these elements. If mental functioning is disturbed by an underlying neurologic illness (so-called psycho-organic syndrome or organic brain syndrome), the manifestations often progress in a characteristic sequence, regardless of the etiology. At first, short- and long-term memory, concentration, and attention are impaired; the patient is easily fatigued and has difficulty processing new information or performing complex tasks. Later, the patient becomes progressively disoriented, first to time, then to place, and then to person (self). Reactive depression is common at this stage. Ultimately, all spontaneous activity ceases; the patient loses interest, lacks drive, and becomes permanently confused. Disturbances of this type can often be discerned in the patient’s behavior before the formal examination begins, growing increasingly evident to the examiner during history-taking and physical examination. Further details of the patient’s history from the family can often help. The Mini-Mental State Examination ( ▶ Table 3.11, ▶ Fig. 3.36) and the clock test ( ▶ Table 3.12) are widely used to assess cognitive function; the MOCA test is a well-validated alternative (see www.mocatest.org). For acquired dementia, see section ▶ 6.12.

**Table 3.11** Mini-Mental State Examination
Parameter	Questions
Name of patient: Date of birth: Date of examination: 1 point for each correct answer
Orientation in time
1.	“What day of the week is it?”
2.	“What is today’s date?”
3.	“What is the current month?”
4.	“What is the current season?”
5.	“What year is it?”
Orientation to place
6.	“Where are we (hospital, old age home, etc.)?”
7.	“On what floor?”
8.	“In what city?”
9.	“In what state (canton, province, etc.)?”
10.	“In what country?”
Retentiveness
	“Please repeat the following words” (to be spoken at one word per second; to be performed only once)
11.	“Lemon”
12.	“Key”
13.	“Ball”
Attention and calculations
14.	“Please count from 100 backward by sevens” (serial-7 test). One point for each correct subtraction, maximum five points
Recent memory
15.	“Which three words did you repeat earlier?” One point for each word correctly recalled
Language, naming
16.	“What is this?” (show a pencil)
17.	“What is this?” (show a watch)
18.	“Please say after me: ‘No ifs, ands, or buts’”
Language comprehension, motor execution
19.	“Take this piece of paper in your hand”
20.	“Fold it down the middle”
21.	“Put it on the ground” (each command to be given only once)
Reading
22.	“Please do what it says on this card” (show card: “Close your eyes”) ( ▶ Fig. 3.36a)
Writing
23.	“Write any sentence” (the patient is given a piece of paper and something to write with)
Drawing
24.	“Please copy this drawing” (overlapping pentagons, ▶ Fig. 3.36b; all 10 edges of the two pentagons must be drawn, and the pentagons must overlap, for the patient to receive one point for this task)
Level of wakefulness:
Total points achieved:
Source: Adapted from Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12(3):189–198.

**Table 3.12** The clock test
Task The patient is given a piece of paper with an empty circle drawn on it and is asked to complete the drawing of a clock, including numbers and hands. The time shown should be 10 minutes past 11 o’clock.
Interpretation	Points if correct
Are all 12 numbers present?	1
Is the number “12” at the top?	2
Are two hands of different lengths present?	2
Is the indicated time correct?	2
Note: A score of 5 or below raises the suspicion of dementia.

Fig. 3.36 Forms for the Mini-Mental State Examination. a A written command for the patient to follow (Task 22 in ▶ Table 3.11). b Pentagons to be copied (Task 24 in ▶ Table 3.11). (Reproduced from Mattle H, Mumenthaler M. Neurologie. 13th ed. Stuttgart: Thieme; 2013.)

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