Obtaining a history and observing the patient are the first steps in a comprehensive mental status examination (MSX). Obtaining a history involves a skilled interview, a targeted cognitive history, and an evaluation of the patient’s personal background. Except for telephone encounters, the examiner should be able to make important observations of the patient’s behavior while conducting the interview and history taking. In addition to an excellent history, a skilled examiner can make an effective visual assessment of the patient either in-person or by videoconferencing.
The Neurobehavioral History
INTERVIEWING TECHNIQUES
The opening and introduction must focus on putting the patient at ease and establishing rapport. The examiner is establishing a relationship. To this end he or she first addresses the patient, introducing him- or herself while looking and speaking directly to the patient. Although initial small talk can help put some patients at ease, it should be minimal, and the examiner should not talk about him- or herself. The introduction requires some preparation, not only in knowing the patient’s medical information but also how to pronounce the patient’s name and what the expectations might be. The examiner must briefly explain the purpose and nature of the examination, his or her role, and the goals of interview. Other aspects of the opening and introduction include attending to one’s own attitude and body language (i.e., conveying an empathic attitude), the environment (i.e., if in-person, sitting at the same level and about 2 feet from the patient), and the patient’s verbal and nonverbal cues (i.e., cooperative or hostile toward the interview) ( Box 6.1 ). Rapport is most facilitated if the examiner searches for the patient’s underlying emotions and areas of concern and adjusts his or her demeanor accordingly.
Opening and Introduction
Preparation (know medical record, pronunciation of patient’s name)
Establishing rapport
Introducing oneself directly to patient
Interviewing patient alone if possible or appropriate
Attending to interview environment and where you are in relation to patient or videocameras
Explaining goals and your role
Open-Ended Questions and Active Listening
Determineing when to interview family/caregivers
Open-ended questioning: e.g.: “Tell me your problem?” or “Why are you seeing a doctor today?”
Active listening with echoing and encouragement
Facilitation of free speech from the patient
Do not rush the patient’s explanation or description
Closed-Ended Questions
Specific questions clarifying the patient’s responses
Clarifying particularly with examples of mental status difficulty
Assure that patient understands and avoid jargon
Summarizing problem in patient’s own words
Neurobehavioral review of systems
Personal history
The interview then proceeds with open-ended questions, allowing the patient to talk freely in their responses. Open-ended questions include “Why are you seeing a doctor today?”; “Tell me your problem and how it started?”; and “What difficulty do you want to talk about?” At the beginning, the examiner listens attentively, minimizing interruptions and distractions. In fact, much of the interview involves just listening while occasionally repeating the patient’s words (“echoing”) and giving nonverbal encouragement to continue talking. Let this first part of the initial interview follow the patient’s train of thought. Of course, the examiner may need to probe with additional open-ended questions and provide structure to help patients who have trouble ordering their thoughts or just giving a history.
Directed questions probing specific cognitive and behavioral areas follow later. These close-ended questions focus on obtaining more in-depth information. For example, if the patient reports memory loss, then the examiner asks about the type, duration, and impact of memory difficulty. The examiner should ask for clarification particularly with examples. In asking close-ended questions, it is important to assure that the patient understands the questions by not rushing, using the patient’s own words, and avoiding jargon, technical terms, or long sentences. It is often helpful to assure comprehension by asking the patient to repeat back their understanding of the questions. Conversely, it is also helpful to briefly summarize what the patient said in his or her own words.
Two additional points in the interview are note-taking and the presence of family or others. First, note-taking, now often directly on the computer, need not interfere with listening to the patient. If in-person, the body is positioned in a “golden triangle” facing the patient as much as possible while maintaining intermittent eye contact. Incidentally, everyone in the room should be situated with ready access to the exit in case of an emergency. Second, determine if the patient would rather be interviewed alone, with a separate interview with the caregiver or informants. The examiner should not direct initial questions to family, caregivers, or others unless and until it is clear that the patient cannot provide history. Cognitive deficits or behavioral disorders can interfere with the patient’s ability to provide history, and the examiner often needs to interview family members or friends but only if the patient agrees or cannot give history. Furthermore, patients may lack the insight into their disorder and may deny or minimize any difficulty, and the contrast between the patient’s history and that of the caregiver can reveal valuable information.
COGNITIVE HISTORY
The examiner elicits a chief cognitive complaint from the patient, family, and/or caregivers. The examiner asks the patient to describe their specific behavioral difficulties, including the onset and progression. Common chief complaints are problems forgetting recently learned information, word-finding difficulty, or getting lost in familiar surroundings. As noted, it is important to get specific examples of the mental status difficulties. In addition to the chief complaint, obtain a neurobehavioral review of systems encompassing the major cognitive domains with questions on arousal and attention, language, memory, visuospatial abilities, motor movements, calculations, and “executive” or goal-directed behavior ( Box 6.2 ). The past medical history further includes neuropsychiatric disorders and neurological conditions that could impact on behavior.
Does the patient have any of the following?
Clouded or “foggy” thinking
Confabulation
Decreased ability to stay alert and awake
Decreased initiation of activity
Decreased retrieving old information
Delusions
Depression, mood problems, or anxiety
Dietary changes
Difficulty with calculations and manipulating numbers
Difficulty following through or completing usual activities
Disorientation to time and place
Distractibility
Ease of forgetting
Episodes of confusion
Getting lost in familiar surroundings
Hallucinations, illusions, or other perceptual phenomena
Impaired reading or writing
Impropriety in social behavior
Inability to find items in their visual environment
Inability to get around in space
Inability to speak clearly
Learning impairment for new information
Poor concentration
Poor memory for recent events
Poor performance of goal-oriented behavior
Poor performance of learned motor tasks
Repetitive behaviors or thoughts
Slowed thinking
Stereotypical or other movement disorders
Understanding of spoken words is impaired
Word-finding difficulty
The examiner may reserve specific cognitive questions for family and caregivers that require their particular perspective. These involve the neurobehavioral review of systems but worded as informant observations. For example, for memory, the examiner can ask whether the patient has had trouble with recent memory, such as remembering daily household events, where the patient puts things, and what they were recently told. A particular area for questioning for family and caregivers is the nature of the patient’s overall pervasive pattern of behavior. For example, the history provides the most important information for personality changes from frontal-executive dysfunction including decreased goal-directed behavior (initiation of productive behavior, follow-through, monitoring and correction, success and completion), disinhibition, and apathy and disengagement. Other dysexecutive symptoms and signs include deficits when there is a history of poor problem-solving and impaired judgment. Is the current pattern of behavior a change from a prior level of functioning? Compare the current pattern of behavior with premorbid functioning based on educational, occupational, economic, and marital attainment, performance, and stability.
As part of the cognitive history, the examiner gets a functional history for activities of daily living, such as dressing, personal hygiene, continence, the pattern of eating and sleeping, and instrumental activities, such as making change at a store, balancing their accounts, cooking a meal, or driving an automobile. The functional history also evaluates whether there is a decline in their usual occupational activities. The functional history extends to an assessment of who is taking care of most of the responsibilities, what the living and safety situation is, what the status of caregiving is, and whether there is other support.
PERSONAL HISTORY
Several personal characteristics may impact on mental status testing, specifically the patient’s age; education; sex, ethnic, and socioeconomic background; and language proficiency. It is important to emphasize these as part of the history because they may influence the interpretation of performance on any subsequent mental status tests.
Age. The examiner must be aware of how the patient’s age could impact on the neurobehavioral status examination (NBSE) and MSX. Five characteristics of behavioral evaluation in the elderly may affect the mental status assessment. First, the range of “normality” broadens with age, and there is increased overlap between disturbed cognition and some of the changes of normal aging. This is reflected in neuropsychological tests, which have age-stratified norms. Second, cognitive changes occur at different rates for different cognitive functions as people get older. For example, there are age-associated decreases in psychomotor speed, and older people perform less efficiently on time-dependent mental tasks. Third, mental status testing may not be entirely comparable between the elderly and the young. Even after age-adjustment, there is a cohort effect due to differences in generational experiences and education with regard to taking these tests. Fourth, older patients have physical difficulties that can affect the mental status testing. Changes in vision, hearing, sleep patterns, health status, and drug effects, all of which are more common in older people, can affect cognition and behavior. Because of these age-associated changes, the interpretation of mental status tasks and rating scales in the elderly must be done with these considerations in mind.
Longitudinal and cross-sectional studies on aging have shown a decline in the speed of neuronal processing, selective attention, memory, and certain aspects of higher cognitive function ( Box 6.3 ). The elderly have a decreased ability to concentrate and maintain attention over prolonged periods. This is consistent with increased daytime somnolence, fragmented sleep and decreased deep sleep (stage III, IV) and rapid eye movement sleep. Short-term/working memory, for example, the ability to temporarily retain a telephone number, is more difficult. New learning, although slower, is relatively spared, as are old well established memories. However, it is the retrieval of old information at the time that is needed, which is of greater concern to older people. Moreover, they can “forget” where the car keys are or what someone’s name is one moment but bring it to mind later.
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