This chapter aims to provide the foundation for mental status testing. The first step is to establish the goal or purpose for assessing cognition. This guides the decision on what level of examination is needed and whether to refer for neuropsychological testing. Second, when performing the mental status examination (MSX), there are a number of principles or key factors to consider in giving tests to patients and, afterward, in interpreting the results. Finally, there is the consideration for how to report or discuss the results with patients and families.
Goals and Levels
Mental status testing aims for the practical evaluation for cognitive problems along a medical model. The overriding goal is to screen for cognitive deficits in the clinic or at the bedside with readily available stimulus materials. Within this goal, a rapid MSX can occur with brief screening of key cognitive domains when time and circumstances are limited, such as on an inpatient service. With somewhat more time, mental status scales and inventories allow for a semiquantitative assessment of general cognition. Alternatively, the screening may use targeted tests or scales for special situations, such as delirium (see Chapter 3). For all three of these approaches, brief MSX screening, mental status scales or inventories, and targeted MSX, clinicians must be able to recognize abnormalities requiring further testing. A more extensive and comprehensive neurobehavioral status examination (NBSE) is part of a subspecialty clinical assessment for neurocognitive disorders and is a major focus of this book. NBSE is indicated when time is not an issue and the clinician can devote time to a thorough assessment of the different cognitive domains. Finally, referral for neuropsychological testing should be a consideration under certain situations, to be described later.
Brief MSX Screen
(see Chapter 5)
The initial aspects of the brief assessment are observation, interaction, and orientation. The briefest assessment involves pausing to observe the patient’s general behavior, such as state of alertness and wakefulness, interaction with others, and coherence of verbal output and physical movements. Clinicians often overlook the importance of just observing patients, yet this can be a very informative “MSX.” If possible, engage the patient in conversation and note the quality and quantity of the interaction, including use of language and any clues to memory for recent events. Orientation, which involves asking patients to state the current date and place, is not an actual “cognitive domain,” but it is a sensitive measure of either attentional or memory impairment. 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.
Beyond observation, interaction, and orientation, clinicians can perform a brief MSX screen in approximately 5 minutes. Most clinicians can quickly examine one or two representative tasks in critical mental status areas, including awareness (arousal and attention), language (naming by confrontation), declarative episodic memory (delayed recall of a few words), and perception (three-dimensional visuospatial construction) ( Table 2.1 ).
| Awareness | Arousal or alertness |
| Orientation | Orientation for time and place |
| Attention | Basic and complex attention |
| Language | Naming to confrontation and category word list |
| Memory | 3–5 minute recall of three unrelated words |
| Perception | Ability to copy three-dimensional shapes |
Mental Status Scales and Inventories
(see Chapters 15 and 16)
When 5 to 15 minutes are available, short instruments containing a number of heterogeneous items are useful in evaluating memory plus other cognitive domains and deriving a general cognitive score. Usually, there are guidelines for administration and cutoff scores for impaired cognition. These cutoff scores may have age- and education-dependent adjustments. These instruments are useful for screening for referral for more extensive evaluation; they are less informative for assessing specific brain-behavior impairments or localization.
There are many cognitive and behavioral rating scales. Although the choice of rating scale may vary with the specific goals of the evaluation, the clinician should gain familiarity with a limited number of widely used scales, such as the Mini-Mental State Examination (MMSE) (5–10 minutes) or the Montreal Cognitive Assessment (MoCA) (10–15 minutes). Some scales are shorter and more quickly administered (e.g., the Mini-Cog or the Six-Item Screen) and others are longer and more extensive (e.g., Addenbrooke Cognitive Examination). Scales have different levels of difficulty, for example, the MMSE is easier than the MoCA, and there are differential floor and ceiling effects, for example, the MMSE shows more variance in more impaired ranges, and the MoCA shows more variance at higher levels of functioning.
Targeted MSX
(see Chapters 3 and 16)
The usual mental status scales and tests may not help in differentiating specific conditions, and the clinician may want to target tests and scales to the affected cognitive domains. A major example is delirium. Here, the examiner is more concerned with an acute or subacute encephalopathy; hence the mental status focus is more on attentional systems, or even arousal. The examiner may want to use targeted scales such as the Confusion Assessment Method, the Delirium Rating Scale-Revised-98, or the Memorial Delirium Assessment Scale.
Targeted MSX is often applied to patients with specific neurologic, psychiatric, or medical illnesses. One example is HIV infection, in which there are several dedicated mental status scales sensitive to psychomotor slowing and other potential cognitive effects of HIV-associated neurocognitive disorder, for example, the International HIV Dementia Scale. Additionally, elements of the NBSE can used in isolation to target specific cognitive dysfunction or localization, such as from strokes, tumors, and other focal neurologic lesions.
The NBSE
(see Chapters 6–14)
Other tasks are part of a more extended MSX, often referred to as the Neurobehavioral Status Examination (NBSE), which may take up to several hours, depending on how much is included. An extended MSX is necessary when patients have memory difficulty, language impairment, perceptual or spatial difficulty, or other instrumental problems requiring a more detailed assessment in the clinic or at the bedside. This evaluation can comprehensively examine the major cognitive domains, or parts of it can be administered in isolation as a targeted MSX ( Table 2.2 ).
| General Behavior | Appearance, attitude, personality, affect, mood |
| Arousal | Response to verbal and physical stimulation |
| Orientation | Orientation to time and place |
| Psychomotor Speed | Physical activity and movements |
| Attention | Digit span, months backward, continuous performance |
| Language: Verbal | Fluency, repetition, naming, comprehension |
| Language: Read, Write | Reading sample, writing to command |
| Memory | Word list learning with recognition |
| Perception and Spatial | Two and three-dimensional copies, search/cancellation tasks |
| Praxis | Limb ideomotor mime and imitation |
| Calculations | Simple mathematics |
| Executive Operations | Antisaccades, alternate tapping, GoNoGo, Luria hand sequence |
| Executive Attributes | Awareness of illness, proverb interpretation |
| Neurological Behaviors | Motivation, social, aggression, perceptive |
The NBSE is organized around the major cognitive domains. The “fundamental domains” include arousal, selective attention, and psychomotor activity and speed. Fundamental functions are also reflected in multidomain processes, such as orientation (place and time) and mental control. Fundamental functions are required for optimal performance of the “instrumental domains” of language, memory and semantics, perception, praxis, calculation, and executive operations and attributes. In addition, although not cognitive, the NBSE considers neuropsychiatric disturbances in socioemotional functions and the presence of disturbances in mood, affect, and thought content.
Referral for Neuropsychological Testing
(see Chapter 17)
Clinicians can request neuropsychological testing when an extensive and in-depth evaluation is desired. Neuropsychological testing is not the focus of this handbook, but in certain situations it is the gold standard for cognitive evaluation. This testing requires greater time, effort, and expense than does MSX at a clinic visit or at the bedside and is not practical for screening assessments. However, in nonurgent clinical situations in which there is time and resources for referral, neuropsychological testing can be invaluable for specific indications. Among those situations are the following:
- 1.
To evaluate for mild deficits not detected on screening. This is particularly indicated for comparing with age and education normative data. MSX tests, including mental status scales and inventories, may not be sensitive enough to detect mild impairments, particularly among patients with higher intellectual backgrounds. In this situation, neuropsychological testing may show abnormalities for the patient’s age and education.
- 2.
To differentiate primary psychiatric conditions from dementia. For example, distinguishing the effects of a mood disorder on memory and cognition is often quite difficult and can be greatly aided by a neuropsychological assessment.
- 3.
To determine the degree and extent of impairment. This may be important when designing a rehabilitation program for a patient, or there is a need for precise information on how the patient functions in each cognitive domain.
- 4.
To determine detailed cognitive assessment for legal determinations, such as capacity and competence. Capacity describes decision-making ability, for example, whether to leave the hospital or accept a medical treatment. Competence, in contrast, is a legal term that refers to an individual’s legal right to make these decisions. Clinicians are primarily concerned with capacity, which depends on cognition. Capacity is expressed in understanding the nature of the situation (e.g., their medical illness), the ability to express a choice, an appreciation of the alternatives and consequences, and an ability to reason rationally to reach a decision. The results of precise neuropsychological testing is better than MSX screening for providing the cognitive profile that underlies the elements of capacity.
Principles of MSX
Mental status testing requires much skill in assessment, interpretation, and reporting. What follows are some basic principles in these areas ( Table 2.3 ).
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