II. Evaluation: Dementia Screening of Alert Patient

  1. Move to Dementia diagnostic tests below if positive screening
  2. See Mental Status Consolidated Screening
  3. Rapid Cognitive Screen
    1. https://www.slu.edu/medicine/internal-medicine/geriatric-medicine/aging-successfully/pdfs/rapid-cognitive-screen.pdf
    2. Abbreviated version of SLUMS Exam, that can be performed in <3 minutes
  4. Mini-Cognitive Assessment Instrument
    1. Three minute Dementia Screening
    2. Patient repeats and recalls 3 unrelated words, and draws a clock face with a given time
  5. General Practitioner Assessment of Cognition (GPCOG)
    1. https://www.alz.org/media/documents/gpcog-screening-test-english.pdf
    2. Part 1 evaluates orientation, memory and clock drawing by the patient
      1. Six item verbal evaluation that requires only 4 minutes to complete
    3. Part 2 obtains history from a reliable family member or friend who has known the patient for at least 5 years
      1. Six items that inquire about patients memory and independent functioning
  6. Ascertain Dementia 8-Item Informant Questionnaire
    1. https://www.alz.org/documents_custom/ad8.pdf
  7. Six Item Cognitive Impairment Test (6CIT)
    1. Designed as a Dementia Screening tool for primary care
    2. Formulated from a regression analysis of the Blessed Information Memory Concentration (BIMC)
    3. Medical providers are allowed free usage (although copyrighted)
  8. Confusion Assessment Method (CAM)
    1. Assesses for Delirium

III. Evaluation: Dementia Diagnosis of Alert Patient

  1. Indicated for positive Dementia Screening above
  2. Saint Louis University Mental Status (SLUMS)
    1. https://www.slu.edu/medicine/internal-medicine/geriatric-medicine/aging-successfully/pdfs/slums_form.pdf
    2. Seven minute test (11 items, 30 points), evaluates for Dementia as well as verbal fluency and abstraction
    3. Excellent, free non-proprietary alternative to the MMSE
    4. Results may be influenced by highest education level achieved
    5. Has been primarily studied in white males
  3. Copland's Short-Test of Mental Status
    1. Free scale with similar accuracy to MMSE
  4. Addenbrooke's Cognitive Examination (ACE)
    1. Differentiates Alzheimer Disease from other Dementias
    2. Detects early Dementia
    3. Most studies supporting ACE use were based on its second edition
      1. Current, ACE 3, is not recommended due to variable efficacy and lengthy exam
      2. Beishon (2019) Cochrane Database Syst Rev (12): CD013282 [PubMed]
  5. Montreal Cognitive Assessment (MoCA)
    1. https://mocacognition.com/
    2. Ten minute nonproprietary exam testing 8 cognitive domains
    3. High False Positive Rate (up to 40%) for Mild Cognitive Impairment (esp. in less educated subjects)
  6. Blessed Information Memory Concentration (BIMC)
    1. Tests orientation, memory, concentration, naming
    2. Positive if >10 mistakes (out of 28 possible)
  7. Blessed Orientation Memory Concentration (BOMC)
    1. Shortened version of BIMC (6 questions)
    2. Positive if >10 mistakes
  8. Short Test of Mental Status (STMS)
    1. Tests orientation, attention, recall, and copying
    2. Also tests calculation, abstraction, clock drawing
    3. Positive if score <30 (out of 38 possible points)
  9. Mini-Mental Status Exam (MMSE)
    1. Developed in 1975, and taught extensively in Medical Education for decades as a default MSE
      1. Among the most studied Mental Status Exam tools
      2. Available in multiple languages (e.g. english, spanish, chinese)
    2. In a controversial move in 2000, the exam started requiring payment for continued clinical use
      1. Feldman (2013) Stanf Technol Law Rev 16(3):623-55. +PMID: 25221427 [PubMed]
    3. Largely replaced by validated MSE tools that are free for use (e.g. SLUMS, Copeland, Addenbrooke)
      1. Unlike other tools (e.g. SLUMS), does not differentiate Mild Cognitive Impairment

IV. Evaluation: Mental Status in the non-alert patient

V. Precautions

  1. Tools described here are focused on screening and diagnosis of Dementia and its differential diagnosis
    1. Contrast for the extensive, broad testing performed in neuropsychiatric exams
  2. Mental Status Exam relies on the clinician's observations and clinical judgment
    1. Interpretation is subject to implicit bias
  3. Language and education heavily impact the mental state evaluation
    1. Patient must be able to understand questions and communicate answers
  4. Multiple external factors can negatively impact the Mental Status Exam's validity
    1. Demographics (age, education level, primary language)
    2. Medications
    3. Acute symptoms (e.g. Pain, anxiety, Fatigue)
    4. Family member presence
  5. Evaluation performed via Telemedicine has had inconsistent results
    1. MoCA and MMSE have versions intended for use over Telemedicine
    2. Evidence is weak to support Dementia Diagnosis accuracy over Telemedicine
      1. McCleery (2021) Cochrane Database Syst Rev (7): CD013786 [PubMed]

VI. Protocol

  1. Interview patient alone, and then again with family
  2. Full Mental State Exam evaluates 11 criteria
  3. Perform in a nonjudgmental environment without distractions

VIII. Exam: General Appearance, Behavior and Attitude

  1. See Appearance, Behavior and Attitude Exam
  2. Appearance
    1. Posture
    2. Clothing and grooming
    3. Old or young appearing
    4. Healthy or sickly appearing
    5. Angry, puzzled, frightened, anxious, contemptuous, apathetic, paranoid
    6. Effeminate or masculine
    7. Scars or Tattoos
    8. Grooming or hygiene
  3. Motor Activity
    1. Mannerisms, gestures, facial expressions, twitches, picking or clumsiness
    2. Psychomotor Agitation (e.g. Hand wringing or other Akathisia)
      1. Causes include substance Intoxication/withdrawal, anxiety, mania, Psychosis
    3. Psychomotor retardation or Bradykinesia (slowed physical and emotional responses)
      1. Causes include Major Depression, medication adverse effect, Parkinsonism
    4. Catatonia (immobile with muscular rigidity or inflexibility)
      1. Causes include severe Major Depression, Psychosis (e.g. Schizophrenia)
    5. Apraxia (unable to perform specific, intentional motor activity (e.g. "use this item")
      1. Causes include Delirium, Dementia, substance Intoxication, CVA
  4. Behavior
    1. Combative, hostile, guarded or irritable (e.g. anxiety, Personality Disorder)
    2. Rapid or pressured speech (e.g. anxiety, mania)
    3. Candid, congenial or cooperative
    4. Withdrawn or shy
    5. Paranoid (e.g. Psychotic Disorder)
    6. Eye contact (fleeting, good, sporadic or none)
      1. Poor eye contact may be seen in Major Depression or Psychosis
  5. Attitude toward examiner
    1. Cooperative or hostile
    2. Defensive, seductive, evasive, ingratiating
  6. Interpretation
    1. Psychotic: Disheveled, odd, grimacing
    2. Schizophrenic: Stare or blank look
    3. Paranoid: Agitated or hostile
    4. Depressed: Psychomotor retardation or mute
    5. Histrionic: Seductive manner
    6. Restlessness is seen in anxiety, mania, drug or Alcohol Withdrawal
    7. Provocative: Personality Disorder or trait

IX. Exam: Alertness and Orientation

  1. Alertness Level
    1. See Level of Consciousness
    2. Hyperalert
    3. Alert
    4. Lethargy
  2. Orientation
    1. See Orientation Exam
    2. Person (name, age, year of birth)
    3. Place (current location, home address)
    4. Time (date, day of week, time of day, season, month)
      1. Time is the first orientation factor to be lost
    5. Situation (reason for encounter)
  3. Interpretation
    1. Minor Disorientation may be induced by stressors
    2. Major Disorientation or decreased alertness suggests organic cause (see Delirium)
  4. Differential Diagnosis of altered orientation
    1. Amnesia
    2. Delirium
    3. Dementia
    4. Cerebrovascular Accident
    5. Severe Major Depression
    6. Mania

X. Exam: Attention and Concentration

  1. See Attention and Concentration
  2. Definitions
    1. Attention
      1. Ability to focus for at least short periods of time despite minor stimuli
    2. Concentration
      1. Attends for longer periods of time
  3. Tests
    1. Spell WORLD Backwards
    2. Serial 7s
      1. Subtract 7 from 100, then from 93, 86, 79, 72, 65, 58, 51, 44, 37, 30...
    3. Seraial 3s
      1. Subtract 3 from 20, then from 17, 14, 11, 8, 5
    4. Random Letter Test
      1. Examiner says each letter (one at a time): "S-A-V-E-A-H-A-A-R-T"
      2. Patient raises finger for each of the 4 A's
    5. Digit Span Test
      1. Patient repeats a series of numbers
      2. Start with 3 numbers, then 4 numbers, then 5 numbers and then 6 numbers
  4. Interpretation
    1. Significant deficits in attention are typically of organic cause
    2. Anxiety or Psychosis-related interrupted thoughts may also affect attention
  5. Differential Diagnosis of decreased Attention and Concentration
    1. Attention Deficit Hyperactivity Disorder
    2. Cognitive Disorder (e.g. Delirium, Dementia, CVA)
    3. Mood Disorder (e.g. Major Depression, Anxiety Disorder)
    4. Psychotic Disorder (e.g. Schizophrenia)

XI. Exam: Speech and Language

  1. See Speech Exam
  2. See Aphasia
  3. Characteristics
    1. Names objects (e.g. pen, watch, glasses, phone) and describes their function (gnosia)
      1. May be impaired in CVA or advanced Dementia
    2. Speech slow or fast
      1. Normal speech is >100 words per minute
      2. Abnormally slow is <50 words per minute (e.g. Delirium, Major Depression, Schizophrenia)
    3. Speech pressured and rapid (anxiety, mania)
    4. Speech loud or soft
    5. Spontaneous speech or mute
    6. Good vocabulary or impoverished speech?
    7. Articulates words with difficulty (Dysarthria)
    8. Language deficiency (Aphasia)
      1. Wrong words or poor grammar used
    9. Prosody
      1. Ability to recognize emotional context of language
      2. Ask patient to name the emotion
        1. Repeat a phrase (e.g. Why are you here?)
        2. Use different inflections (e.g. happy, suprised, excited, sad)
      3. Abnormal in Autism, Developmental Delay, Mood Disorder and Schizophrenia
  4. Interpretation
    1. Psychotic: Rambling, bizarre speech (distinguish from Aphasia)
    2. Manic: Loud and rapid speech
    3. Depressed: Slow and soft speech

XII. Exam: Mood and Affect

  1. Mood (Subjective)
    1. Constant emotional state (depression, euphoria, anxiousness, anger, irritability) the patient can describe
    2. Sad or discouraged (e.g. Major Depression)
    3. Energized or out of control (e.g. Anxiety Disorder, mania, Substance Abuse)
  2. Affect (Objective)
    1. Observable, current emotional state (flat, blunted, inappropriate)
    2. Facial Expressions (e.g. tearful, smiling, frowning)
  3. Interpretation
    1. Is Observed Affect consistent with Stated Mood?
    2. Is Stated Mood consistent with Thought Content?
  4. Differential Diagnosis of Altered Affect
    1. Mood Disorder (Major Depression, Anxiety Disorder)
    2. Psychotic Disorders (e.g. Bipolar Disorder, Schizophrenia)
    3. Substance Abuse

XIII. Exam: Thought Process

  1. Thought Form
    1. See Disorganized Speech
    2. Logical flow of ideas or circumstantial with lengthy story of loosely related or unrelated details?
    3. Evasive?
    4. Disorganized Thoughts
      1. Patient moves incoherently from topic to topic without organization
    5. Flight of ideas
      1. Rapidly moving from one idea to another related idea
    6. Tangential
      1. Loose Associations between unrelated thoughts, although connected in the patient's view
    7. Circumferential
      1. Multiple related thoughts expressed before answering a question
    8. Perseveration
      1. Frequently repeated thought or phrase
    9. Blocking
      1. Interrupted speech or train of thought, only to be resumed minutes later
  2. Thought Content
    1. Hypochondriacal symptoms?
    2. Deja Vu Sensations?
    3. Depersonalization?
    4. Excessively Ritualistic?
    5. Preoccupation or Obsession
      1. Do you think about some things often, that you cannot get out of your head?
      2. Causes include Obsessive Compulsive Disorder, PTSD, Psychosis
    6. Phobias?
      1. Do you have any irrational or excessive fears
      2. Causes include Anxiety Disorder, PTSD
    7. Homicidality
      1. Do you ever have thoughts of hurting or killing someone else?
      2. Causes include Mood Disorder, Personality Disorder, Psychosis
    8. Suicidality
      1. Do you ever feel suicidal or that life is not worth living?
      2. Causes include Major Depression, PTSD, Substance Abuse
    9. Delusions (fixed false beliefs, such as persecutory, grandiose, influential)?
      1. Do you have strong ideas that other people rarely see the same way?
      2. Paranoia (excessively suspicious)
        1. Do you think people are stealing from you?
        2. Are people talking about you behind your back?
      3. Causes include mania or Psychosis
    10. Hallucinations
      1. See Perceptions below
      2. Do you ever hear or see things that other people do not see?
      3. Causes include Delirium, Dementia, Psychosis, Substance Abuse
    11. Lack of Insight (unaware that thoughts are abnormal)?
    12. Concreteness (loss of abstract thinking)?
      1. Ask about relatedness between objects (what is similar?)
        1. Baseball and orange
        2. Car and train
        3. Desk and bookcase
        4. Happy and sad
      2. Test proverbs (what do these mean?)
        1. When the cats away, the mice will play
        2. You can lead a horse to water but you cannot make him drink
        3. Haste makes waste
        4. Ignorance is bliss
  3. Interpretation
    1. Abnormal Thought Process suggests Psychosis (especially Schizophrenia)
    2. Obsessions are seen in Psychosis and Obsessive Compulsive Disorder
    3. Concreteness with normal intelligence suggests Psychosis (especially with bizarre or personalized answers)

XIV. Exam: Insight and Judgement

  1. See Insight and Judgement
  2. Judgement
    1. Judgment is an assessment of real life problem-solving skills
    2. Testing
      1. What should you do if you find a stamped (not canceled) and addressed envelope?
  3. Insight
    1. Insight is an understanding of their condition (including abnormal thoughts)
    2. Testing
      1. Tell me about your illness and if it is worse now?
      2. What medications are you taking?

XV. Exam: Perceptions

  1. Characteristics
    1. Misperceptions (wrong conclusions from straight-forward information)?
    2. Illusions (misinterpreted Sensations such as a shadow seen as a person)?
    3. Hallucinations (auditory, visual, tactile, olfactory)?
      1. Are Auditory Hallucinations accusatory, threatening or commanding?
  2. Interpretations
    1. Illusions occur in Delirium and Psychosis
    2. Hallucinations are most common in Psychosis
      1. Auditory Hallucinations are most often seen in Schizophrenia
      2. Visual Hallucinations occur most often in organic conditions
      3. Tactile Hallucinations are most common with Alcohol Withdrawal or Benzodiazepine Withdrawal

XVI. Exam: Memory

  1. See Memory Evaluation
  2. Definitions
    1. Declarative Memory
      1. Recall of prior events
    2. Procedural Memory
      1. Completes learned tasks without required conscious thought
  3. Immediate Memory
    1. See Digit Span Test (digit repetition)
    2. Three word recall at 5 minutes
    3. Interrupted counting
      1. Patient counts from 1 to 100
      2. Examiner interrupts at 27 and asks patient to wait 1 minute and then restart counting (at 27)
      3. Examiner interrupts at 42 and asks patient to wait 3 minutes and then restart counting (at 42)
  4. Recent memory
    1. How did you come to the hospital (e.g. car, Ambulance)?
  5. Remote memory
    1. Name four presidents in the last 100 years?
    2. When is your birthday?
    3. What are the names of your parents?
    4. Where were you born?
  6. Constructional ability
    1. Copy 2 shapes (e.g. a diamond and a 3 dimensional cube)
    2. Clock Drawing Test
  7. Interpretation
    1. Memory Loss or impaired construction ability suggests organic cause
    2. Short term deficit causes include ADHD, Substance Abuse, inattention, Dementia
    3. Long term deficit causes include Amnesia, dissociative disorder, CVA, and advanced Dementia

XVII. Exam: Intellectual Functioning (Executive Function)

  1. See Cognitive Function Testing
  2. Fund of knowledge
    1. Number of weeks in a year?
    2. How many nickels in $1.15?
    3. Name the last 6 presidents?
  3. Calculations
    1. Also see the attention tests above
    2. Clock Drawing Test
      1. Draw a clock at 11:10
    3. Trail Making Test
      1. Patient alternates connecting consecutive letters with numbers (A1,B2,C3,D4)
    4. Simple calculations
      1. Multiply 2x3, 5x3, 4x7
  4. Visuospatial
    1. Test Perception and manipulation of objects and shapes in space
    2. Patient copies intersecting pentagons or three dimensional cube
    3. Draw a triangle and ask patient to draw the same triangle, but upside down
    4. Abnormal causes include Delirium, Dementia, CVA
  5. Intentional Motor Activity
    1. Show me how to use a hairbrush? hammer? pencil?
    2. Apraxia is an inability to carry out motor acts
  6. Differential Diagnosis of Impaired Executive Function
    1. Cognitive Disorder (e.g. Delirium, Dementia)
    2. Mood Disorder (e.g. Major Depression, Anxiety Disorder)
    3. Psychotic Disorder (e.g. Schizophrenia)

XIX. References

  1. Tomb (1992) Psychiatry, 4th Ed, Williams and Wilkins, Baltimore, p. 6-11
  2. Zum, Swaminathan and Egan in Herbert (2014) EM:Rap 14(7): 11-13
  3. Norris (2016) Am Fam Physician 94(8): 635-41 [PubMed]
  4. Veauthier (2021) Am Fam Physician 104(5): 461-70 [PubMed]
  5. Wiley (2024) Am Fam Physician 109(1): 51-60 [PubMed]

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