The mental status examination (MSX) employs a cognitive domain approach, examining fundamental aspects, such as arousal and attention, and instrumental aspects, such as language, memory, perception, and executive abilities. The mental status examiner often starts with a more limited screening procedure, either a brief MSX, mental status scales, or a targeted MSX, which can be composed of isolated parts of the neurobehavioral status examination (NBSE). Here we will expand on the brief MSX and outline the major elements of the NBSE.
Brief MSX
For most clinical encounters, either in-person or by telemedicine, the clinician may quickly probe wide areas of the patient’s cognition with a brief MSX. This has the advantage of being able to assess critical cognitive domains in 5 minutes or less; clinicians can quickly examine one or two representative tasks in awareness, orientation, attention, language, memory, and perception ( Table 5.1 ). The subsequent NBSE sections discuss these cognitive domains in greater detail.
| Awareness | Observation for awareness; if necessary, loudly call name, sternal pressure, pinch Achilles tendon. |
| Orientation | What is the date (day, month, year, day of week, time)? Where are we; the name of this place, city, state, floor/location? |
| Attention | Digit span forward (until misses two trials at a level); If necessary, subtraction by 7s from 100 (or by 3s from 20). |
| Language | Naming of six common items in the room or pictures/drawings; if necessary, ask for as many names of animals in a 1 minute. |
| Memory | Give three to four unrelated words for subsequent recall in 1 or more minutes; (during delay period, can ask for three recent or current events). |
| Perception | Copy a three-dimensional “Necker” cube; if necessary, add two-dimensional drawing (e.g., intersecting pentagons). |
Step 1: Awareness. The brief MSX starts with deliberate observation of the patient’s general behavior with the most prominent focus on determining their state of alertness and wakefulness. Although most patients requiring mental status testing are sufficiently aware and awake, occasionally there is evidence of disturbances of arousal, such as lethargy, drowsiness, sleepiness, stupor, and coma. In situations in which the patient lacks significant awareness, the examiner can check for arousal with verbal stimulation (loudly calling their name) or applying mild physical discomfort (sternal pressure, pinching the Achilles tendon).
Step 2: Orientation. The examiner asks the patient to state the current date and place. Orientation in the clinical setting is a sensitive general measure of awareness, attention, and memory. In the absence of a watch or other obvious display of the time, the patient’s knowledge of the exact time of day can be a further extension of the assessment for temporal orientation. For place, asking about their floor or location in the building is of additional value.
Step 3: Attention. Proficiency in attention is a prerequisite for adequate performance in instrumental abilities, such as memory and perception. The examiner most commonly screens the patient’s ability to maintain attention with a digit span. Random digits are given, one per second, starting with three ( Fig. 5.1 ). The patient is asked to recite them back in the same order. Two trials are given at each ascending level until the patient misses both trials. His/her digit span is the level just before missing both trials. If necessary, the examiner can do other serial recitation tasks that include subtracting from 100 by 7s (or the easier version of subtracting from 20 by 3s).
Step 4: Language. Most MSX depends on understanding verbal commands and the ability to give verbal responses. Abnormal language function (aphasia) can therefore compromise subsequent aspects of the MSE. Two subtests—naming ability and word-list generation (verbal fluency)—are particularly sensitive to language disturbances and act as good screening tests. First, ask the patient to name six common items pointed out in the room or as pictures/drawing. If more language information is desired, have the patient generate the names of as many animals as he or she can in 1 minute, with the expectation of generating at least 12.
Step 5: Memory. The examiner can screen declarative episodic memory through the patient’s ability to recall a list of words. One easy test in the clinical setting is with a three to four word-learning task with a 1 or more minute delay before asking for their recall. To avoid continued rehearsal, the patient must do other cognitive tasks during this recall or “interference” period, such as recalling three current events in the news and performing the perception task from Step 8. One can also save the orientation questions for this interference period.
Step 6: Perception. Visuospatial skills depend on a number of areas of the brain, which can harbor perceptual deficits without demonstrable abnormality on other MSX tests. The ability to copy a three-dimensional cube drawing is a common visuospatial perceptual screening test ( Fig. 5.2 ). Abnormalities can involve its three-dimensional perspective, the presence of parallel faces, the number of surfaces, and the placement of internal lines. The examiner can add two-dimensional drawings if the patient is quite impaired (e.g., copying intersecting pentagons).
Although a detailed evaluation is not necessary in all patients, a more extensive assessment is indicated if the brief MSX discloses problems or if the patient complains of ongoing cognitive difficulty. In this situation, the clinician may choose additional mental status tasks from the NBSE that offer information of value for a particular patient’s deficits. Although this can also be performed through formal psychometric examinations, the clinician can obtain excellent information from the NBSE, and in many instances, this provides information unavailable from any laboratory study.
Overview of the NBSE
The following is an outline of the NBSE, which can take a few minutes to several hours to complete, depending on how much of it is done. It is organized into 14 “domains” ( Table 5.2 ), which are much expanded with many more tests or tasks elaborated on in Chapters 6–14. This is not the only possible organization of the NBSE, but it is one method that has proven practical in terms of the hierarchical order of testing and the ability to localize dysfunction in the brain. The examiner can use elements of the NBSE for targeted MSX or can modify them for patients with visual or auditory impairment. The examiner needs to consider the patient’s education, intellectual background, and facility with English before. Finally, the examiner must perform the NBSE as part of the overall neurological examination.
- 1.
General Behavioral Observations. The experienced examiner begins with a thoughtful inspection of the patient’s overt behavior and interactions with others and the environment. The patient’s general behavior may be the only method of assessment available in a very uncooperative, agitated, or arousal-impaired patient. Yet, careful behavioral observations in and of themselves can provide a very informative mental status assessment.
If the patient is sufficiently awake and aware, further consideration of his/her general behavior includes attention to the patient’s appearance, attitude, and affect. For example, a slovenly appearance with poor personal hygiene can reflect dementia, psychosis, depression, apathy, and other behavioral disturbances. Specific findings such as neglect of one side of the body can indicate a focal hemispheric insult. Patients may be cooperative, indifferent, disinterested in the interview, or hostile. The examiner also considers their prevailing affect, whether it reflects anger, depression, fear, or other emotion. The examination of a violent or agitated patient requires unique considerations. Always use a calm, nonthreatening tone of voice, and never examine a violent patient alone, keeping an open, unimpeded exit quickly accessible to you. Additional aspects of behavioral observations are discussed in Chapter 6.
- 2.
Arousal. An adequate state of arousal is a prerequisite to other cognitive functions. Arousal is the state of awareness or responsiveness to environmental stimuli. A disturbance of arousal is usually evident on initial patient presentation. States of arousal include alertness, wakefulness, lethargy, clouding of consciousness, sleep, obtundation, stupor, and coma. Disorders of arousal arise from brain stem lesions, bihemispheric metabolic or structural disturbances, or disorders causing increased intracranial pressure.
If a disturbance of arousal is suspected, the examiner evaluates the patient’s response to verbal and, if necessary, physical stimulation. Patients with abnormal arousal may need vigorous stimulation to maintain a conversation, or even keep their eyes open. Record the nature of the stimulus necessary to evoke a response and the character of that response. Thus if the patient awakens to loudly calling his or her name but eventually drifts off, necessitating restimulation, this pattern should be recorded. If firm rubbing of the sternum or a pinch of the Achilles tendon is needed to evoke a response, both the stimulus and the degree of response should be recorded. The examination also assesses whether the patient waxes and wanes, has spontaneous movements, maintains eyes open, or visually tracks environmental stimuli.
- 3.
Orientation. Further assessment of the “sensorium” includes a determination of orientation to time and place. In some patients, deficits in arousal may preclude the opportunity to pursue the MSX much further, but the examiner should still attempt to assess orientation as much as possible. The least common disorientation occurs to person, that is, the loss of personal identity, and usually indicates a psychiatric as opposed to a neurological disorder. The most common disorientation occurs to time, that is, day of the week, date, month, year, season, and time. Patients who are off 3 days on the date, 2 days on the day of the week, or 4 hours on the time of day may be significantly disoriented to time.
The next most common disorientation occurs to place, that is, clinic or hospital, city, county, state, and specific floor or localization in a building. In addition to inquiring whether the patient knows where they are, the examiner can ask what kind of a place it is and under what circumstances they are there. The assessment of orientation can extend all the way to an evaluation of their understanding of their medical situation.
- 4.
Psychomotor Speed and Activity. Psychomotor speed is often difficult to assess beyond observation of cognitive or motor activity. Decreased speed, activity, and movements can reflect psychomotor speed or a neurological or psychiatric disorder, for example, bradykinesia, decreased facial expressiveness, or overall paucity of movement. Conversely, there may be signs of increased speed or activity, such as fidgetiness and inability to sit still, hand wringing stereotypical movements or mannerisms, and tremors or other movement disorders. Causes of decreased psychomotor speed and activity include delirium, dementia, depression, parkinsonism, frontal lobe disease, or catatonia. Causes of increased psychomotor speed and activity include delirium, agitation, anxiety, mania, psychosis, delirium, or akathisia.
The examiner should consciously note spontaneity in movements, the overall speed of movements, and the latency in initiating responses. Individual differences in psychomotor speed may occur from the patient’s personality and regional or cultural background, and large variations in psychomotor speed occur from state conditions such as fatigue, anxiety, or sleep disturbance. Nevertheless, interpretation of psychomotor speed can be based on intraindividual differences, as informed by history or by comparison to prior examinations. It is sometimes useful to record the speed of counting (e.g., count as fast as you can for 10 seconds) or speed of reciting the alphabet.
- 5.
Attention and Mental Control. Attention is the ability to concentrate awareness or to focus mental activity on one thing to the exclusion of others. Elements of attention include selectivity and the ability to sustain, divide, and shift attention. In addition to difficulty concentrating, patients with abnormal attention may have impersistence, distractibility, and increased vulnerability to interference. Attention requires the ascending reticular activating system in the upper brain stem, the reticular nucleus of the thalamus for modulating sensory input, prefrontal cortex for complex attention, and parietal cortex for shifting attention. Abnormal attention is the hallmark of delirium, the most common cause of behavioral disturbance among hospitalized elderly patients.
The most common clinical tests of attention are serial recitation tasks, and the most common serial recitation task is the Digit Span test ( Fig. 5.1 ). The examiner speaks a series of digits, one per second and in a clear voice, and asks the patient to repeat the sequence. If the patient can correctly repeat three digits, the examiner presents four digits, and then five digits, until the patient incorrectly repeats a string of digits twice at the same level. A normal performance is a forward digit span of 7 ± 2, regardless of age. This task may also be performed as a nonverbal sequence span test. The examiner asks the patient to serially tap four blocks (or objects, spots, or squares) in the same sequence as presented by the examiner. The test can be done with or without verbal counting. In the reverse digit span, the patient repeats digits in reverse order, beginning with the last number. The elderly have a modest decline in the reverse digit span but can normally reverse a string of three or more digits. A more difficult serial recitation is the Serial 7s Test. The examiner asks the patient to subtract by 7s beginning with the number 100, for example, 93, 86, 79, 72, 65, et cetera. Mathematical competence is required for this task. If serial 7s is too difficult, the examiner may do the serial 3s test, that is, subtract by 3s beginning with the number 20. Other common serial reversal tasks include spelling “world” backward, reciting the months of the year in reverse order beginning with December, or reciting the days of the week backward. A different set of “attention” tasks require continuous performance or alternating sequences and are described in Chapter 7.
- 6.
Spoken Language. Language is the brain’s use of symbols for communication. Language is distinct from speech, which is the verbal expression of language. The spoken language examination evaluates verbal fluency, auditory comprehension, repetition, and naming. In addition, prosody, or the inflection and melodic quality of speech, is an ancillary part of the spoken language examination. The different language disorders or aphasias have different patterns of impaired language skills. In right-handed individuals, aphasias result from focal lesions in the left-hemisphere, perisylvian language zones, whereas disturbances of prosody usually occur from right-hemispheric abnormalities. Aphasia also develops as part of the cognitive deficits of Alzheimer disease or other dementias. Speech disorders, as distinct from the aphasias, are limited to the verbal expression of language, and include the dysarthrias, stuttering and stammering, and logoclonia (repetition of the last syllables).
The language examination evaluates fluency (spontaneous and word-list generation), comprehension, repetition, and naming in a systematic fashion. The fluency examination starts with engaging the patient in conversation and listening to the patient’s spontaneous discourse. Some elements of fluency are quantity (in U.S. English normal is approximately 100 ± 50 words/minute), flow (uninterrupted without word-finding pauses, hesitancy, or effort), phrase length (four or more words/phrase), absent agrammatism or telegraphic output (loss of prepositions, conjunctions, and other “functor” words), and normal prosody. During the course of conversational speech, also listen for the information content, for the presence of paraphasic errors (word or phonemic substitutions), and for dysarthric speech. These aspects of conversational discourse can distinguish between fluent and nonfluent aphasias ( Table 5.3 ). For word fluency, also ask the patient to generate a list of as many animals as possible (or other category of items) in 1 minute. Normal subjects can list 18 ± 6 animals/minute without cueing. The patient may also generate as many words as possible that begin with the letters “F,” “A,” or “S” (the Controlled Oral Word Association Test in English). Normal subjects can list 15 + 5 words/minute for each letter. Tests of auditory comprehension include responses to simple commands, for example, “close your eyes” or “touch your nose,” followed by multiple step commands, for example, “point to the floor and then point to the window.” The examiner can also ask yes-or-no questions, for example, “Are you sitting down?” “Is a hammer good for cutting wood?” “Does March come before April?” “If the lion was killed by the tiger, which animal is dead?” Tests of repetition involves asking the patient to repeat “No ifs ands or buts,” “The quick brown fox jumped over the lazy dog,” and other sentences. Finally, tests of naming involve asking the patient to name at least six items, pictures, or drawings of common objects; for example, watch, ring, button, collar, nose, chin; plus six lower-frequency items, for example, eyelashes, eyebrows, lapel, shoe laces, sole or heel of shoe, watch band, or crystal.
Table 5.3Related posts:
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