MENTAL STATUS EXAM

I. MENTAL STATUS EXAM OF AN AWAKE PATIENT

A. When to do Complete MSE?

  • Assessment of the nervous system begins with the first moments of the patient encounter and continues throughout the interview.

  • If you suspect that the patient's mental status is abnormal, you may need to proceed to formal mental status testing directly.

B. Mental Status Exam Essentials

  • The Mental Status Exam (MSE) does not require specific tools.

  • It is an evaluation of mental functioning at a given point in time.

  • The examiner interprets the patient's communication, both verbal and non-verbal.

    • Rapport: The foundation of the assessment.

    • Observation Skills: Essential, as most of the MSE is based on observation.

    • Importance: Essential for evaluating Neurologic and Psychiatric disorders and distinguishing between them.

    • In neurology, MSE is a critical element in the assessment of the nervous system and is widely used to chart cognitive function in various neurologic disorders.

    • Testing for the Supratentorial Area (Cortex) evaluates cognitive function.

C. The Mental Status Exam

  • Warning: Many neurologic patients may present with personality and mood changes due to prefrontal lobe function, thus requiring careful differentiation between cognitive changes due to neurologic issues versus psychiatric issues.

II. PARTS OF THE MENTAL STATUS EXAM

  • A. Appearance and Behavior

    • Attributes Observed:

    • Posture and motor behavior (i.e., mannerisms, gestures, activity levels).

    • Relaxation levels (e.g., slouched vs. restless).

    • Eye contact (poor vs. normal).

    • Basic grooming and hygiene (e.g., appropriate attire).

    • Attitude (Observed): Cooperative, hostile, open, evasive, suspicious, apathetic, easily distracted.

  • B. Stream of Talk/Speech

    • Assessment of fluidity and responsiveness:

    • Red Flags: Stuttering, poor speech, or lack of responsiveness.

  • C. Mood and Affect

Table 1. Difference between Mood and Affect

MOOD

AFFECT

Relaxed, happy, anxious, angry

Appropriate or not; Labile or not

Depressed, hopeless, hopeful

Fluctuations: labile, even

Apathetic, euphoric, euthymic

Range: broad, restricted

Intensity: blunted, flat, normal intensity

This reflects what the patient is feeling at that moment.

  • D. Thought Content and Perception

Illusions, Hallucinations, and Delusions:

  • Illusion: Incorrect interpretation of external stimuli.

    • Example: A breeze blowing curtains interpreted as a ghost.

  • Hallucination: Perception without external stimuli.

    • Example: Seeing ghosts in an empty room.

  • Delusion: A false belief.

    • E. Sensorium/Cognition

Key Components:

  1. Consciousness: Awareness of self and environment.

    • Functions of the Consciousness System:

      • Maintenance of the waking state (arousal).

      • Content of experience (awareness of surroundings).

  2. Attention Span: Assessed by the following test:

    • Serial 7s: Command patient to subtract 7 from 100 until told to stop.

  3. Orientation: Assessing awareness in three domains:

    • Person, Place, Time.

  4. Memory: Evaluation of recall abilities through immediate and delayed recall.

  5. Fund of Information: Questioning about current events or trivia.

  6. Calculation: Testing simple mathematical skills using serial subtraction.

  7. Insight, Judgment & Planning, Abstract Thinking

    • Insight: Understanding of one's condition.

    • Judgment: Problem-solving based on hypothetical scenarios.

    • Planning: Discussion of future steps following the current consultation.

    • Abstract Thinking: Metaphor interpretation.

III. HIGHER CORTICAL FUNCTION/CORTICAL MAPPING

  • A. Agnosia: Inability to recognize significance of sensory stimuli.

    • Criteria for Agnosia:

    • Intact sensory pathways.

    • Intact sensorium and mental status.

    • Prior understanding of stimulus value.

    • Organic cerebral lesion causing the deficit.

Different Types of Agnosia and Techniques:

TYPE

TECHNIQUE

LESION

Astereognosis

Identify objects by feel without vision.

Contralateral parietal lobe

Prosopagnosia

Recognizing faces in photos + person.

Inferomedial temporo-occipital region

Agraphestesia

Recognizing letters/numbers via felt tracing.

Contralateral parietal lobe

Autotopagnosia

Locating/identifying body parts.

Left angular gyrus

  • B. Apraxia: Inability to perform purposeful actions.

    • Formal criteria for Apraxia:

    • Intact motor system.

    • Sufficient cognitive understanding of commands.

    • Previous skills to perform the act exist.

Different Types of Apraxia, Its Technique, and Site of Lesion:

TYPE

TECHNIQUE

LESION

Ideomotor Apraxia

Demonstrate using utensils & everyday tools.

Left parietal lobe

Constructional Apraxia

Copy geometric figures or construct from simple shapes.

Non-dominant parietal lobe

Dressing Apraxia

Observe difficulties in dressing correctly.

Non-dominant parietal lobe

  • C. Aphasia: Complete or partial loss of language.

    • Testing for Aphasia includes:

    1. Fluency assessment.

    2. Comprehension: Perform multi-step commands.

    3. Repetition: Repeat given phrases.

    4. Naming: Identify objects.

    5. Reading and writing instructions.

IV. FRONTAL LOBE ASSESSMENT

Functions of the Frontal Lobe:

  • Restraint, Initiative, Order, Judgment, Foresight, Perseverance, Self-governance, Concentration, Curiosity, Spontaneity, Motivation, Creativity, Mental flexibility, Perspective taking.

  • Clinical signs of Frontal Lobe lesions:

    • Poor restriction of primitive reflexes.

    • Executive function impairments (e.g., judgment, organization).

Primitive Reflexes

  • Typically seen in babies; abnormal if present in adults with certain neurological conditions.

    • Signs include: Snout reflex, Suck reflex, Palmomental reflex, Grasp reflex, Glabellar Tap Reflex.

V. SCREENING TOOLS USED IN CLINICS/BEDSIDE

  • Mini-Mental State Examination (MMSE): Score interpretation to distinguish cognitive decline severity:

    • 27-30: Normal

    • 21-26: Moderate abnormality

    • <21: Severe abnormality

  • Clock Drawing Test (CDT): Assesses executive function and cognitive impairment.

    • Score Interpretation:

    • <8 indicates cognitive impairment; 10 suggests impairment unlikely.

VI. CONDITIONS WITH MENTAL STATUS DYSFUNCTION

  • Some conditions associated with mental status dysfunction include:

    • Dementia (e.g., Alzheimer's Disease)

    • CNS infections, neoplasms.

    • Psychiatric disorders (e.g., depression)

    • Nutritional deficiencies/toxicity (e.g., alcohol intoxication)

    • Delirium from medical/metabolic causes.