Mental Status Exam Notes

Terminology of the Mental Status Examination

  • Level of Consciousness: Refers to alertness or state of awareness of the environment.

  • Attention: The ability to focus or concentrate over time on a task or activity. Inattentiveness or distractibility can impair history taking and responsiveness.

  • Memory: The process of registering or recording information. It's tested by immediate repetition and assessing storage and retention.

  • Orientation: Awareness of personal identity, place, time, and situation. Requires both memory and attention.

  • Perceptions: Sensory awareness of objects and their interrelationships (external stimuli). Also includes internal stimuli like dreams or hallucinations.

  • Thought processes: The logic, coherence, and relevance of thought as it leads to select goals, reflecting how people think.

  • Thought content: What the patient thinks about, including level of insight and judgment.

  • Insight: Awareness that symptoms or disturbed behaviors are normal or abnormal.

  • Judgment: Process of comparing and evaluating alternatives when deciding on a course of action. Reflects values that may or may not be based on reality and social norms.

  • Affect: An observable, usually episodic, feeling or tone expressed through voice, facial expression, and demeanor.

  • Mood: A more sustained emotion that may color a person’s view of the world.

  • Language: A complex symbolic system for expressing, receiving, and comprehending words. Like consciousness, attention, and memory, it is essential for assessing other mental functions.

  • Higher cognitive functions: Assessed by vocabulary, amount of information, abstract thinking, calculations, and construction of objects in two or three dimensions.

Health History

  • Common or concerning symptoms:

    • Changes in attention, mood, or speech.

    • Changes in orientation or insight.

    • Changes in memory.

    • Medical symptoms without an explanation.

  • Overview:

    • Level of alertness and orientation.

    • Mood.

    • Attention.

    • Speech.

    • Memory.

    • Insight and judgment.

    • Recurring or unusual thoughts or perceptions.

  • Assessing attention, mood, speech, insight, and orientation involves evaluating:

    • Level of consciousness.

    • General appearance.

    • Mood.

    • Ability to pay attention.

    • Remember.

    • Understand.

    • Speak.

  • Memory changes:

    • Many reasons for changes in memory.

    • Use open-ended questions to start the conversation.

    • Collect additional information about changes in socialization, personality, wandering or getting lost, and activities of daily living.

  • Memory changes – (cont.):

    • Delirium.

    • Major neurocognitive disorder.

    • Dementia (document in parenthesis due to widespread clinical usage).

    • Mild neurocognitive disorder.

    • Traumatic brain injury.

Physical Examination

  • Important areas of the Mental Status Examination:

    • Appearance and behavior.

    • Speech and language.

    • Mood and affect.

    • Thought process and content.

    • Cognitive function.

  • Appearance and behavior:

    • Level of consciousness.

      • Is the patient awake and alert?

      • Do they understand questions?

      • Are they responding appropriately and reasonably quickly?

      • Do they lose track of the topic?

      • Do they fall silent or even asleep?

    • Dress, grooming, and personal hygiene.

      • Does the patient appear to be the stated age?

      • Compare one side of the body to the other.

      • Is clothing clean and appropriate for age and weather?

      • Assess hair, nails, teeth, skin, and facial hair. Observe for scars.

      • Is grooming and hygiene comparable to other people?

    • Posture and motor behavior.

      • Patient preference to sit, lie quietly, or walk around?

      • Posture and ability to relax.

      • Pace, range, and type of movement.

      • Is movement voluntary, spontaneous, and fluid?

      • Are any limbs immobile, flaccid, or fixed?

      • Gait.

    • Facial expression.

      • At rest.

      • During interaction with others.

      • Variations with topics.

      • Appropriateness.

      • Is the expression relatively immobile throughout?

Behavior - Speech & Language

  • Characteristics of normal speech.

  • Abnormal Speech:

    • Dysphonia: Issues with volume.

    • Dysarthria: Distorted speech, articulation problems.

    • Aphasia: Word-finding difficulties.

      • Global aphasia: Most common and severe, caused by a large lesion.

      • Broca’s aphasia: Expressive, motor speech area affected.

      • Wernicke’s aphasia: Receptive, trouble relating.

  • Speech and language:

    • Quantity:

      • Talkative or silent?

      • Spontaneous or limited to direct questions?

    • Rate:

      • Fast or slow?

    • Loudness:

      • Loud or soft?

    • Articulation of words:

      • Clear and distinct?

      • Nasal quality to speech?

    • Fluency:

      • Rate, flow, and melody of speech.

    • Content and use of words:

      • Hesitancies and gaps?

Behavior - Mood & Affect

  • Body language.

  • Facial expression.

  • Is the affect appropriate to the situation?

Physical Examination - Thought Process and Content

  • Thought content:

    • Follow appropriate leads as they occur.

    • May need to make more specific inquiries.

    • Be tactful and accepting.

    • Assess for the presence of delusions, obsessions, phobias, suicidal thoughts.

  • Perceptions:

    • Inquire about false perceptions in a manner similar to that used for thought content.

    • Illusions, hallucinations.

    • Examples:

      • “When you heard the voice speaking to you, what did it say?”

      • “Sometimes after major surgery like this, people hear peculiar or frightening things. Has anything like this ever happened to you?”

Physical Examination - Insight and Judgment

  • Usually best assessed during the interview.

  • Insight:

    • Note whether the patient is aware that a particular mood, thought, or perception is abnormal or part of an illness.

  • Judgment:

    • Note patient’s responses to family situations, jobs, use of money, and interpersonal conflicts.

    • Note whether decisions and actions are based on reality or impulse, wish fulfillment, or disordered thought content.

Physical Examination - Cognitive Functions

  • Orientation:

    • Can be determined by the context of the interview.

    • Ask naturally for clarification about specific dates and times, address, phone number, etc.

      • Person.

      • Place.

      • Time.

      • Situation.

  • Attention/concentration:

    • Digit span.

    • Serial 7s.

    • Spelling backward.

    • Need to consider educational level.

  • Remote memory:

    • Birthdays, anniversaries, SSN, names of schools attended, jobs held, past historical events.

  • Recent memory:

    • Events of the day, weather, today’s appointment time, medications, or laboratory tests taken during the day.

Health Promotion, Counseling, and Screening Recommendations

  • Substance use disorders:

    • Alcohol, tobacco, and illicit drugs account for more illness, deaths, and disabilities than any other preventable condition.

    • Prescription drugs are the leading cause of drug-induced deaths.

    • Universal screening questions for substance use disorders.

    • Audit Use Disorder Identification Test (AUDIT).

    • Drug Abuse Screen Test (DAST).

  • Mini-Mental State Examination (MMSE):

    • Brief questionnaire, widely used to screen adult patients for cognitive dysfunction or dementia.

    • Tests orientation, registration, attention, calculation, recall, language, and the ability to follow simple instructions.

    • Can use to follow patient’s mental ability over time.

The Mini-Mental State Exam

The following are components of the Mini-Mental State Exam:

  • Orientation

    • Maximum Score: 5

    • Examiner asks: What is the (year) (season) (date) (day) (month)?

    • Examiner asks: Where are we (state) (country) (town) (hospital) (floor)?

  • Registration

    • Maximum Score: 3

    • Name 3 objects: 1 second to say each. Then ask the patient all 3 after you have said them. Give 1 point for each correct answer. Then repeat them until he/she learns all 3. Count trials and record.

  • Attention and Calculation

    • Maximum Score: 5

    • Serial 7's. 1 point for each correct answer. Stop after 5 answers. Alternatively spell "world" backward.

  • Recall

    • Maximum Score: 3

    • Ask for the 3 objects repeated above. Give 1 point for each correct answer.

  • Language

    • Maximum Score: 9

    • Name a pencil and watch.

    • Repeat the following "No ifs, ands, or buts"

    • Follow a 3-stage command: "Take a paper in your hand, fold it in half, and put it on the floor."

    • Read and obey the following: CLOSE YOUR EYES

    • Write a sentence.

    • Copy the design shown.

  • Total Score

  • ASSESS level of consciousness along a continuum

    • Alert Drowsy Stupor Coma

Common Disorders of Mental Status

  • Delirium

    • Disturbed level of consciousness.

    • Change in thought processes.

    • Develops rapidly and fluctuates.

    • Usually related to a general medical condition or substance use or abuse.

  • Dementia

    • Memory impairment.

    • Cognitive disturbance.

    • Impaired occupational or social functioning.

    • Gradual, slow onset or related to results of trauma or disease sequelae.

  • Depression/Mania

  • Schizophrenia

  • Panic Attack

  • Obsessive-Compulsive Disorder

  • PTSD

Substances that Alter Mood or Behavior

  • Alcohol

  • Sedatives/Hypnotics

  • Nicotine

  • Marijuana

  • Cocaine

  • Amphetamines

  • Opiates