The Mental Status

Examination in Adults

Dorotheo Floresca Jr. MD FPCP FPNA

Assistant Professor
 ▪ Determine integrity of
underlying brain function
Mental Status
▪ Play a critically important role
Examination
▪ Evaluate cognitive disorders
▪ Evaluate behavioral disorders
 Hierarchy and Scopes of Cognitive Assessments

Screening Tools

• Mini-Mental State Examination (MMSE)

• Montreal Cognitive Assessment (MoCA)

Extended Mental Status Exam

Formal Neuropsychological Testing

 Clinical Interview

Aspects of mental status, cognition, behavior observed

• Attention
• Response latency
• Ability to answer questions & provide relevant information
• Overall appearance
• Degree of cooperation

Establish rapport with patient

 MSE: Domains Evaluated
Level of
Attention and
consciousness Memory Language
concentration
(arousal)

Visuospatial Executive
Praxis Calculations
perception functioning

Mood and
thought
content
 Level of Consciousness (Arousal)

Is the patient alert, attentive, sleepy, or

unresponsive

Adequate state of arousal → prerequisite

for further mental status testing
 Attention & Concentration

Attention: Ability to focus and direct cognitive processes and

to resist distraction

Concentration: Ability to sustain attention over a period of

time
 ▪ Attention
▪ Critical to interpretation of other
parts of the MSE
▪ Deficits will undermine
Attention & performance in other cognitive
domains (memory and executive
Concentration functions)
▪ Prominent deficits typical in
▪ Delirium in toxic-metabolic
encephalopathies
▪ Acute psychiatric disorders
 Attention & Concentration
Digit span forward test
Examiner recites a random sequence of digits at a rate
of one number per second
Normal: 7 plus or minus 2 digits for adults, regardless of
age or educational level

Serial subtraction

Spelling words backward

Stating months of the year in reverse

 Memory
Immediate and working memory
• Best measured with digit span forward and backward

Recent memory
• Reflects ability to learn new material
• Orientation to time and place
• Current events
• Ask patients to remember 3 to 5 words, by repeating, then recalling after 5- to 10-minute
delay

Remote memory
• Name presidents in reverse order
• Details of personal life
• Birthday
• Children and grandchildren
• Work history
 Language Domains

Fluency Content Repetition Naming

Comprehension Reading Writing

 ▪ Fluency
▪ Listen to patient’s speech
▪ Rate
▪ Ease of production
▪ Use of grammar
Language ▪ Category fluency
▪ Animals
Domains ▪ Cutoff: 12
▪ Sensitive for temporal lobe damage
▪ Letter fluency
▪ Words beginning with letter F
▪ Cutoff: 10
▪ Sensitive for frontal lobe damage
 ▪ Content
▪ Paraphasic errors
▪ Phonemic
▪ "papple" for apple or "lelephone" for telephone
▪ "gingerjed" for gingerbread

Language ▪ Semantic
▪ tiger for lion

Domains ▪ foot with shoe

▪ Neologisms
▪ Examiner: Are you feeling better than this
morning?
▪ Patient: Not too melsise, I don't think.
▪ Examiner: Pardon me?
▪ Patient: I motsumsirs, orie.
 Language Domains

Repetition • Repeat phases of increasing length and complexity

Naming • Name objects or pictures presented to them

• One-step, midline commands: “close your eyes”

Comprehension • Multistep commands: “point to ceiling, then to the
door, then to the source of illumination in this room”
 Language Domains

Reading Writing
Read aloud from a paragraph Spontaneously generate a
or a list of single words written sentence
 ▪ Examples of visuospatial difficulties
▪ History of losing objects
▪ Getting lost
Visuospatial ▪ Difficulty navigating familiar or unfamiliar
terrain
Perception ▪ Ignore visual stimuli in one visual field
(usually the left)
▪ Ignore half their plate at mealtime
▪ Only groom one side of their face or body
Visuospatial Perception
Visuospatial
Perception
Visuospatial
Perception
 ▪ Assessment
▪ Copy visual stimuli
Visuospatial ▪ Diamond
Perception ▪ Overlapping pentagons
▪ 3D cube
▪ Clock drawing test
Visuospatial
Perception
Visuospatial
Perception
 Praxis

Execution of Intact motor

learned motor and spatial Apraxia
movements abilities

Dressing Feeding Bathing

 Praxis
Ideomotor praxis

• Ability to perform learned motor movements

• Ask patient to perform increasing complex motor tasks
• Demonstrate use of an object (e.g. comb, hammer, fork) with and
without the actual object in their hands

Ideational praxis

• Ability to carry out a sequential set of actions toward a final goal

• Asking patient to perform step-wise series of coordinated tasks
• “Take this paper, fold it in half, and place it in the envelope”
 Calculations

ADD A SERIES OF PERFORM “SERIAL

COINS SEVENS”
 Executive Functioning
Complex set of abilities

Volition Planning Purposive action Effective performance

Enable goal-directed, socially responsible, and self-serving behavior

Supported by the prefrontal cortex and its connections with the caudate nucleus
 Mood & Thought Content
Have strong impact on mental status and cognitive functioning

Affect
• Depression → withdrawn affect
• Poor eye contact
• Tearfulness
• Emotional blunting
• Apathy

May be incongruent
• Pseudobulbar palsy
 ▪ Thought content
▪ Spontaneous speech
▪ Note presence of
Mood & ▪ Abnormal intrusions
Thought Content ▪ Preoccupations
▪ Perseverations
▪ Delusions
▪ Hallucinations
BECK DEPRESSION GERIATRIC NEUROPSYCHIATRIC
INVENTORY DEPRESSION SCALE INVENTORY

Mood & Thought Content

 ▪ Mini-Mental State Examination (MMSE)
▪ Most popular
▪ Well-known
▪ Score: 0 – 30
Cognitive ▪ Assesses multiple cognitive domains
Screening Tests ▪ Memory
▪ Language
▪ Performed in 5 – 10 minutes
▪ Most sensitive at the mild to moderate
stages of AD dementia
MMSE
 ▪ Montreal Cognitive Assessment (MoCA)
▪ More sensitive to earlier stages of cognitive
decline, including mild cognitive
impairment
▪ Surveys a broader range of cognitive
Cognitive function (with a greater emphasis on
executive function)
Screening Tests ▪ Has more difficult items.
▪ Takes slightly longer to administer
(approximately 15 minutes)
▪ Less useful in patients with more advanced
disease.
MoCA
MoCA
 Cognitive ▪ Clock drawing
▪ Screening tool for cognitive problems
Screening Tests ▪ Covers multiple cognitive domains
That’s All
Folks!!