MENTAL STATUS
EXAMINATION
Outline
• Operational definition
• Purposes
• Components
– Behavior
– Cognition
– Emotion
• Cognitive examination
• Mini Mental Status
MENTAL STATUS EXAMINATION:
What is it?
ASSESSMENT of the:
• Behavior (see it all)
• Emotion (see some of it)
• Cognition (see none of it)
Exhibited by the patient during the
entire medical encounter
PURPOSES
•
•
•
•
Detect
Describe
Neuroanatomical localization
Assess functional implications of
Abnormalities/deficits in:
• Behavior
• Emotion
• Cognition
ABNORMALITIES & DEFICITS
Require diagnostic explanation
May compromise capacity
• to coherently and reliably describe
medical state
• to give informed consent
• to adhere to a therapeutic plan
MEDICAL
ENCOUNTER
Comprehensive
global assessment
BEHAVIOR
Appearance
Attitude
Activity
Speech
Dress
Grooming
Hygiene
BEHAVIOR
Appearance
Attitude
Activity
Speech
Dress
Grooming
Hygiene
COGNITION
Thought content
Thought progression
Insight/judgment
BEHAVIOR
Appearance
Attitude
Activity
Speech
Dress
Grooming
Hygiene
COGNITION
Thought content
Coherence
Goal directedness
Insight/judgment
Operations
Arousal
Attention
Memory
Emotion
Language
Reasoning
BEHAVIOR
Appearance
Attitude
Activity
Speech
Dress
Grooming
Hygiene
COGNITION
Thought content
Coherence
Goal directedness
Insight/judgment
Operations
Arousal
Attention
Memory
Emotion
Language
Reasoning
EMOTION
Affect
Mood
Suicide
Homicide
BEHAVIOR
Appearance
appears stated age, uses a cane to walk
Attitude
cooperative, hostile, detached
Activity
normal, increased, agitated, subdued
Speech
normal rate/rhythm, dysarthric
Dress
casual, provocative, dirty
Grooming
disheveled, meticulous
Hygiene
clean, malodorous
COGNITIVE EXAM (“Mental status”)
REASONING
LANGUAGE
MEMORY
ATTENTION
AROUSAL
COGNITIVE EXAM (“Mental status”)
Must
know
education
REASONING
LANGUAGE
MEMORY
ATTENTION
AROUSAL
Can the
patient
hear?
MEMORY
Immediate memory = attention
Recent memory (episodic)
Recall of three words at 5 minutes
Ensure that pt has registered the items
“Repeat these words after me, I want you
to remember them.”
Remote memory (semantic & episodic)
Tends to overlap with knowledge, most of
what we ask is overlearned
Presidents, date of W.W.II, etc..
REASONING (Higher cognitive fx)
Tests problem solving, abstract thinking
Fund of knowledge - overlaps with remote
memory
How many weeks in a year?
Name four presidents since 1940?
What causes rust?
Calculations
Add, subtract, multiple, divide
Sequences
1, 2, 3, ...
1, 4, 9, 16, ....
2, 3, 5, 7, 11, ...
REASONING (continued)
Similarities
Apple - orange
Car - airplane
Poem - novel
Proverbs
Don’t cry over spilt milk
A stitch in time saves nine
People who live in glass houses shouldn’t
throw stones
BEHAVIOR
Appearance
Attitude
Activity
Speech
Dress
Grooming
Hygiene
COGNITION
Thought content
Thought progression
Insight/judgment
Arousal
Attention
Memory
Language
Reasoning
EMOTION
Affect
Mood
Suicide
Homicide
EMOTION
AFFECT “Affect is to weather as mood is to climate”
• predominate
sad, euphoric, angry, anxious
• intensity
unmodulated
• range
narrow, broad
• congruence
incongruent with content
MOOD
euthymic, dysthymic, elated
SUICIDE
Do you ever wish you won’t wake up?
Does it ever seem that life isn’t
worth it?
HOMICIDE
Is there someone who deserves
to be hurt?
MEDICAL
ENCOUNTER
Comprehensive
global assessment
Focused
selected assessment
IN PRACTICE, MOST ENCOUNTERS
ARE FOCUSED
• Accordingly the formal mental
status exam is often limited to an
assessment of COGNITION
• Further cognition is often assessed
solely using:
• ORIENTATION
TO ORIENT
To understand
one’s
relationship to the
environment
Person
Place
Time
Situation
“Oriented X 3”
“O X3”
Person
Place
Time
Situation
“Oriented X 3”
“Oriented X 4”
“O X3”
“OX4”
Person
Place
Time
“Oriented X 3”
“Oriented X 4”
“O X3”
“OX4”
Situation
ORIENTATION
ASSESSES:
•
•
•
•
•
language
perception
reasoning
remote memory
recent memory
Less precise
Less comprehensive
Shorter
Examiner norms
More precise
More comprehensive
Longer
Statistical norms
Mini Mental Status
Orientation
Full mental
status
Neuropsychological
Testing
MINI MENTAL STATE EXAM
ADVANTAGES
• brief (10 min), systematic bedside instrument
• wide recognition among physicians
• since it is standardized, the score it yields is
meaningful to physicians familiar with it
DISADVANTAGES
• specific deficits may be ignored if the overall
score is not low (less than 25 out of 30)
• the global score has no localizing valve
• repeated use with intact patients produces a
mechanical transaction
• Examiner uses paper and pencil
• Total of 30 points
orientation (10)
recent memory (3)
attention (3)
calculation, spell backward (5)
name, read, repeat (4)
write (1)
constructional ability (1)
ideomotor praxis (3)
• Not timed
What is the (year) (season) (date) (day) (month)?
Where are we? (state) (county) (city) (hospital) (floor)(10)
Ask pt to repeat three objects - give one per second.
Number repeated first trial = score (3). Present till all
repeated or 6 presentations.
Serial 7’s - 5 subtractions (93, 86, 79, 72, 65) (5). Score
number of correct answers or spell “world” backward,
score is number of letters in correct order. “dlorw” is
3 points.
Ask the patient to name a watch and a pencil. (2)
Ask the patient to say “No ifs, ands or buts” (1).
Ask the patient to recall the three words (3).
Ask the pt to read and follow the command:
“Close your eyes”. Score (1 ) only if closes eyes.
Ask the pt to write a sentence. It must have a
subject and a verb and be sensible. Ignore
grammar and punctuation (1).
Place a piece of paper where the patient can
reach it with either hand. Ask him/her to:
(1) pick it up, (2) fold it in half, (3) lay it on the
floor. 1 pt for each step executed correctly (3).
Ask the patient to copy a drawing of intersecting
pentagons. All 10 angles must be present and two
must intersect to create a 4 sided figure. Ignore
tremor and rotation (1).
Normals can be expected to score > 25
However, even with > 25, if 0/3 or 1/3 for recent
memory or problems with naming, repeating,
writing or reading suggest focal deficits.
It is most sensitive to disturbances which
broadly effect function, it may miss subtle,
focal problems.
You may not always do a MMS:
•Too little time
•Patient becomes agitated at challenge
However, even without an MMS
Interacting with the patient and obtaining a
history have provided information to write
up a mental status exam
Lesson: YOU DO NOT HAVE TO DO
AN MMS TO THOROUGHLY EXAM A PT