Mental Status Evaluation

The next topic of discussion is the mental status examination. Psychiatrists and general practitioners use the mental status examination to determine if the patient has a cognitive deficit. There are two types of mental status examinations that will be discussed in the next section. These include the mental status examination and the shorter version, known as the mini mental status examination. Both of these tests measure a person’s cognitive functioning.

In this section, we will discuss the ways doctors use mental status evaluations to evaluate the patient with a psychiatric disorder. It is not generally used by general practitioners or internists but is used by neurologists and psychiatrists who use the test to assess the cognitive abilities of the mental patient.

The mental status examination can detect impairments in cognition, memory, and can detect disorders of thought processes in patients suspected of having a mental or cognitive disorder. The goal is to detect subtle changes in the mental status examination that cannot be picked up by simply interviewing the patient.

There are several parts to the mental status examination. Together they are used to help detect mental disorders and cognitive deficits.

The first aspect of the mental status examination is to look at the patient’s appearance. Take note of how the patient looks. Are they neatly dressed and have they paid attention to their grooming and clothing? Are they disheveled and have they failed to pay attention to their clothing and grooming? A mentally disturbed or cognitively impaired patient generally does not have good grooming habits and will not be well dressed and clean.

The second aspect of the mental status examination is the level of alertness. Find out if the patient is conscious or not. If they aren’t conscious, can the patient be aroused using verbal stimuli or by eliciting a pain response from the patient. Find out if the patient can remain focused on the conversation and can answer questions appropriately. Determine if they have a normal attention span.

The third aspect of the mental status examination is an evaluation of the patient’s speech pattern. Do they have a normal speech pattern and is the volume, quantity, and tone of their speech within normal limits? Do they pronounce words correctly or is their speech slurred and incomprehensible?

The fourth aspect of the mental status examination is the patient’s behavior. Does the patient have a pleasant demeanor and cooperative with the examination? Are they agitated and unable to focus on the conversation? What is the attention span of the patient? Is the patient’s behavior appropriate for the situation they are in?

The fifth aspect of the mental status examination is an assessment of the patient’s orientation. Are they aware of their environment and do they know their location and what they are doing at the doctor’s office? Do they know the name of their examiner? Can they tell the examiner details of the day of the week, the date, and the current year?

The sixth aspect of the mental status examination is an evaluation of the individual’s mood? Ask them how they are feeling using direct questions, such as are they sad, depressed, angry or happy? Is their mood appropriate for the situation they are currently in?

The seventh aspect of the mental status examination is an assessment of the patient’s affect. Pay attention to the appearance of the patient. Observe the patient during the interview. Decide if they are making eye contact with you during the evaluation. Determine if they are especially excitable. Take note of the tone of their voice. You may observe that their affect is flat, which means that it doesn’t change throughout the evaluation. Other types of affect include being excitable, depressed or appropriate for the current conversation.

The eighth aspect of the mental status examination is the patient’s thought process. This is an evaluation of the way the patient is thinking. Do they seem to have a logical train of thought and do they present themselves in an organized fashion? If they do not seem to be organized, determine how far off base they are with respect to organization. Decide if they tend to stray away from the topic at hand. Find out if their thoughts are linked together or if they are having a flight of ideas as is seen in bipolar disorder.

The ninth aspect of the mental status examination is the content of their thoughts. Describe what the patient is thinking about. Do they seem to have paranoid ideation or are they having delusions, which are beliefs that are untrue? What are their delusions related to? Do they have phobic thoughts? Are they hallucinating? Ask them if they hear or see things that other people do not hear or see. Are they fixated on a single idea and unable to get off the topic? Is the content of their thoughts consistent with their observed affect? Do they have suicidal ideation or homicidal ideation? Ask them specifically about their suicidality and determine if they have a specific date, time, or plan related to suicide. Asking about suicide has not been shown to plant a seed of suicidal thinking in the patient so it is okay to ask them about it.

The tenth aspect of the mental status examination is an assessment of memory. Assess their short-term memory by giving them three objects to remember. Ask them to list back the objects so that you know that they have heard them correctly. Talk to them again for about five minutes and then ask them to recall the objects after waiting five minutes. Evaluate their long-term memory by asking about their past. Aske them where they were born and raised. Ask them about their family history. Ask them to list the jobs they have had in the past.

The eleventh aspect of the mental status examination is finding out if the patient can perform mathematical calculations. Can they add and multiply numbers together? Are their answers appropriate to their level of education? Ask them if they have difficulty balancing their checkbooks or giving the correct amount of money when buying things at the store. This part of the evaluation also assesses the patient’s attention span and their ability to remain focused on a task. The twelfth aspect of the mental status examination is an evaluation of the patient’s judgment. Give them a scenario and ask the patient what they would do in that scenario. You can ask them what they would do if they found a stamped letter on the ground in front of a mailbox. If they say they would put the stamped letter in the mailbox, this is an example of correct judgment. If they say anything else, perhaps their judgment is impaired.

The thirteenth aspect of the mental status examination is a measurement of the patients higher cortical functioning and abilities to reason. Have them give you an interpretation of complex ideas. This might involve giving them a common phrase such as “People in glass houses shouldn’t throw stones”. Ask them what this phrase means. If they give you a literal interpretation of the phrase, their higher cortical functioning may be abnormal. If they give you the correct abstract interpretation of the phrase, you can consider their higher cortical functioning to be intact.

When using the mental status examination, you can detect a couple of mental disorders. The first is delirium. This is also called an acute confusional state, a toxic metabolic state, or an altered mental status. It is a common diagnosis among hospitalized patients with physical illnesses, such as liver failure, kidney failure, hypoxia, sepsis, or the ingestion of toxic substances.

In delirium, there can be a wide variation in the patient’s presentation. The patient may be unarousable or very agitated. They may have abnormalities in their vital signs that can help diagnose the cause of the delirium. The patient may have delirium because of hypotension or infection that can be detected by evaluating their vital signs and doing medical testing.

The patient may be hallucinating or paranoid as part of their delirium. They may be suffering from delusions. In delirium, the onset of the confusion is sudden and will give them an abnormal mental status examination. The best way to deal with this type of delirium is to treat the underlying medical disorder that is the cause.

Patients at high risk for an abnormal mental status examination secondary to delirium are generally elderly patients who have many medical problems. They can become confused and will have an abnormal mental status examination with even a small precipitating illness.

In some cases, an early psychotic disorder or dementia can appear to be delirium. The difference is that psychotic disorders and dementia are not reversible with treating physical conditions and there doesn’t seem to be a recognizable physical illness causing the abnormal mental status examination. It sometimes takes time to sort out the difference between delirium and either acute psychosis or dementia.

Dementia can also be detected by an abnormal mental status examination. The onset of dementia is slow and develops over several years or months. It is an uncommon diagnosis in patients under the age of fifty (50), but its incidence rises dramatically with age. Patients with dementia are often disheveled and do not keep up appropriate appearances. Mildly impaired patients can answer basic questions and will only have difficulty with things like addition, multiplication, or memory.

More severely affected patients with dementia can be unable to answer even simple questions and will have wide variations in their affect and mood. Very severely affected patients will be completely unable to care for themselves and will have marked abnormalities in their mental status examination with impairments in judgment, memory, and higher cortical function that tend to get worse over time.

Next, we will discuss the mini-mental status examination or Folstein test. This is a questionnaire that has a total of 30 points. It is used in clinical settings and in research settings as a measurement of cognitive disabilities. It is a good screening tool for early dementia and can follow the course of the dementia when given to the patient several times over the course of a month or year. It takes only 5-10 minutes

to give and can measure the patient’s attention span, calculating abilities, memory recall, orientation, memory recall, and the ability to follow simple commands.

Because it is simple to do, it can be used by clinicians in all medical disciplines and can be used at the bedside or in an office setting. It has the disadvantage of not being able to detect minor cognitive impairments and may not be able to detect early Alzheimer’s dementia. It is a verbal test so that it doesn’t detect problems with visuospatial function or constructional function.

The mini mental status examination includes asking the patient simple questions and giving them problems to solve. It asks the patient to state the time and place of the test, to repeat a list of words given to them, to perform simple mathematical tasks, such as the serial seven test in which they are asked to count backward from one hundred seven numbers at a time. Their basic motor skills are assessed as are their use of language and the comprehension of language.

The basic aspects of the mini mental status evaluation include an assessment of these things:

The first is orientation to time. This is when the examiner asks the patient to tell them the time from the broadest representation of time to the narrowest representation of time. A lack of orientation to time has been linked to a future decline in cognitive functioning.

The second is orientation to place. This is also done from the broadest representation of time to the narrowest representation of time. The examiner can narrow down the place to the person’s street location or to the floor they are on in a facility.

The third is the evaluation of registration. The patient is asked to repeat named prompts to see if they can follow directions and speak clearly. The fourth is an evaluation of attention and calculation. This involves asking the patient to spell “world” backward or to count backward from one hundred in increments of seven. This serial seven evaluation is appropriate when the patient does not speak English as their primary language.

The fourth is an evaluation of recall. The patient is asked to recall words that are given to them by the examiner. They are given words and asked to recall them five minutes later. The fifth is an evaluation of the patient’s language abilities. They are asked to name a pencil and a watch shown to them by the evaluator. The sixth is an evaluation of the patient’s ability to speak back a phrase. This is known as repetition. The seventh is an evaluation of the patient’s ability to repeat complex commands. The patient can draw a figure to see if they can accurately draw it. Sometimes the patient is asked to draw the face of a clock to see if they put the numbers in the correct places.

Points are given for correct responses. There are a total of thirty points possible in the test. Any score of 24 points or higher represents normal cognition. Point scores below this can reflect a mild, moderate, or severe cognitive deficit. Very low scores are often seen in dementia, although low scores can be seen in other mental disorders. In some cases, physical impairments, such as hearing or vision impairments can cause an artificially low mini mental status examination because the patient physically cannot answer the questions properly. They may have a motor deficit that impairs their ability to write and draw.

The mini mental status examination can tell the difference between different types of dementias. For example, patients with Alzheimer’s dementia have low scores in time and place orientation and low scores in recall when compared to patients with Lewy body dementia, Parkinson’s dementia, or vascular