Mental Status Examination

Definition

A mental status examination (MSE) is an assessment of a patient's level of cognitive (knowledge-related) ability, appearance, emotional mood, and speech and thought patterns at the time of evaluation. It is one part of a full neurologic (nervous system) examination and includes the examiner's observations about the patient's attitude and cooperativeness as well as the patient's answers to specific questions. The most commonly used test of cognitive functioning per se is the so-called Folstein Mini-Mental Status Examination (MMSE), developed in 1975.

Purpose

The purpose of a mental status examination is to assess the presence and extent of a person's mental impairment. The cognitive functions that are measured during the MSE include the person's sense of time, place, and personal identity; memory; speech; general intellectual level; mathematical ability; insight or judgment; and reasoning or problem-solving ability. Complete MSEs are most commonly given to elderly people and to other patients being evaluated for dementia (including AIDS-related dementia). Dementia is an overall decline in a person's intellectual function—including difficulties with language, simple calculations, planning or decision-making, and motor (muscular movement) skills as well as loss of memory. The MSE is an important part of the differential diagnosis of dementia and other psychiatric symptoms or disorders. The MSE results may suggest specific areas for further testing or specific types of required tests. A mental status examination can also be given repeatedly to monitor or document changes in a patient's condition.

Precautions

The MSE cannot be given to a patient who cannot pay attention to the examiner, for example as a result of being in a coma or unconscious; or is completely unable to speak (aphasic); or is not fluent in the language of the examiner.

Description

The MMSE of Folstein evaluates five areas of mental status, namely, orientation, registration, attention and calculation, recall and language. A complete MSE is more comprehensive and evaluates the following ten areas of functioning:

• Appearance. The examiner notes the person's age, race, sex, civil status, and overall appearance. These features are significant because poor personal hygiene or grooming may reflect a loss of interest in self-care or physical inability to bathe or dress oneself.
• Movement and behavior. The examiner observes the person's gait (manner of walking), posture, coordination, eye contact, facial expressions, and similar behaviors. Problems with walking or coordination may reflect a disorder of the central nervous system.
• Affect. Affect refers to a person's outwardly observable emotional reactions. It may include either a lack of emotional response to an event or an overreaction.
• Mood. Mood refers to the underlying emotional "atmosphere" or tone of the person's answers.
• Speech. The examiner evaluates the volume of the person's voice, the rate or speed of speech, the length of answers to questions, the appropriateness and clarity of the answers, and similar characteristics.
• Thought content. The examiner assesses what the patient is saying for indications of hallucinations, delusions, obsessions, symptoms of dissociation, or thoughts of suicide. Dissociation refers to the splitting-off of certain memories or mental processes from conscious awareness. Dissociative symptoms include feelings of unreality, depersonalization, and confusion about one's identity.
• Thought process. Thought process refers to the logical connections between thoughts and their relevance to the main thread of conversation. Irrelevant detail, repeated words and phrases, interrupted thinking (thought blocking), and loose, illogical connections between thoughts, may be signs of a thought disorder.
• Cognition. Cognition refers to the act or condition of knowing. The evaluation assesses the person's orientation (ability to locate himself or herself) with regard to time, place, and personal identity; long- and short-term memory; ability to perform simple arithmetic (counting backward by threes or sevens); general intellectual level or fund of knowledge (identifying the last five Presidents, or similar questions); ability to think abstractly (explaining a proverb); ability to name specified objects and read or write complete sentences; ability to understand and perform a task (showing the examiner how to comb one's hair or throw a ball); ability to draw a simple map or copy a design or geometrical figure; ability to distinguish between right and left.
• Judgment. The examiner asks the person what he or she would do about a commonsense problem, such as running out of a prescription medication.
• Insight. Insight refers to a person's ability to recognize a problem and understand its nature and severity.

The length of time required for a mental status examination depends on the patient's condition. It may take as little as five minutes to examine a healthy person. Patients with speech problems or intellectual impairments, dementia, or other organic brain disorders may require fifteen or twenty minutes. The examiner may choose to spend more time on certain portions of the MSE and less time on others, depending on the patient's condition and answers.

Preparation

Preparation for a mental status examination includes a careful medical and psychiatric history of the patient. The history helps the examiner to interpret the patient's appearance and answers with greater accuracy, because some physical illnesses may produce psychiatric symptoms or require medications that influence the patient's mood or attentiveness. The psychiatric history should include a family history as well as the patient's personal history of development, behavior patterns, and previous treatment for mental disorders (if any). Symptoms of dissociation, for example, often point to a history of childhood abuse, rape, or other severe emotional traumas in adult life. The examiner should also include information about the patient's occupation, level of education, marital status, and right- or left-handedness. Information about occupation and education helps in evaluating the patient's use of language, extent of memory loss, reasoning ability, and similar functions. Handedness is important in determining which half of the patient's brain is involved in writing, picking up a pencil, or other similar tasks that he or she may be asked to perform during the examination.

Aftercare

Depending on the examiner's specific observations, the patient may be given additional tests for follow-up. These tests might include blood or urine samples to test for drug or alcohol abuse, anemia, diabetes, disorders of the liver or kidneys, vitamin or thyroid deficiencies, medication side effects, or syphilis and AIDS. Brain imaging (CT, MRI, or PET scans) may be used to look for signs of seizures, strokes, head trauma, brain tumors, or other evidence of damage to specific parts of the brain. A spinal tap may be performed if the doctor thinks the patient may have an infection of the central nervous system.

Normal results

Normal results for a mental status examination depend to some extent on the patient's history, level of education, and recent life events. For example, a depressed mood is appropriate in the context of a recent death or other sad event in the patient's family but inappropriate in the context of a recent pay raise. Speech patterns are often influenced by racial or ethnic background as well as by occupation or schooling. In general, however, the absence of obvious delusions, hallucinations, or thought disorders together with the presence of insight, good judgment, and socially appropriate appearance and behavior are considered normal results. A normal numerical score for the MMSE is between 28 and 30.

Abnormal results

Abnormal results for a mental status examination include:

• Any evidence of organic brain damage.
• Evidence of thought disorders.
• A mood or affect that is clearly inappropriate to its context.
• Thoughts of suicide.
• Disturbed speech patterns.
• Dissociative symptoms.
• Delusions or hallucinations.

A score below 27 on the MMSE usually indicates an organic brain disorder.

KEY TERMS

Aphasia— The loss of the ability to speak, or to understand written or spoken language. A person who cannot speak or understand language is said to be aphasic.

Cognition— The act or process of knowing or perceiving.

Coma— A state of prolonged unconsciousness in which a person cannot respond to spoken commands or mildly painful physical stimuli.

Delusion— A belief that is resistant to reason or contrary to actual fact. Common delusions include delusions of persecution, delusions about one's importance (sometimes called delusions of grandeur), or delusions of being controlled by others.

Dementia— A decline in a person's level of intellectual functioning. Dementia includes memory loss as well as difficulties with language, simple calculations, planning or decision-making, and motor (muscular movement) skills.

Dissociation— The splitting off of certain mental processes from conscious awareness. Specific symptoms of dissociation include feelings of unreality, depersonalization, and confusion about one's identity.

Hallucination— A sensory experience, usually involving either sight or hearing, of something that does not exist outside the mind.

Illusion— A false visual perception of an object that others perceive correctly. A common example is the number of sightings of "UFOs" that turn out to be airplanes or weather balloons.

Obsession— Domination of thoughts or feelings by a persistent idea, desire, or image.

Organic brain disorder— An organic brain disorder refers to impaired brain function due to damage or deterioration of brain tissue.

Resources

BOOKS

Beers, Mark H., MD, and Robert Berkow, MD, editors. "Neurologic Disorders: Neurologic Examination." In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 2004.

Eisendrath, Stuart J., MD, and Jonathan E. Lichtmacher, MD. "Psychiatric Disorders: Psychiatric Assessment." In Current Medical Diagnosis & Treatment 2001, edited by L. M. Tierney, Jr., MD, et al., 40th ed. New York: Lange Medical Books/McGraw-Hill, 2001.

MENTAL STATUS EXAMINATION

Almost everyone is familiar with the idea of going to the doctor for a physical examination for school, employment, a driver's license, or for summer camp. Such an examination includes measurement of pulse and blood pressure, listening to the heart and lungs through a stethoscope, tapping tendons to elicit neurological reflexes, and so on. Everyone may not be aware, however, that the doctor is also making an assessment of mental status. Put simply, in order to assess the patient as a whole person, doctors determine not just how the heart and the lungs are working, but also how the brain is working.

For all organ systems (e.g., cardiovascular, respiratory, neurological) the assessment includes two components. The first part, the history, takes place when the doctor asks the patient about any symptoms or problems that may have been experienced subjectively. The second part, the examination, consists of objective observations that the doctor makes. For example, a patient may report heart palpitations, and the doctor may observe that the patient's pulse is rapid. Similarly, the patient may complain of having difficulty remembering, and the doctor may observe that the patient is repeating himself or herself during the conversation. The doctor may also perform a brief memory test as part of the mental status examination.

A mental status examination comprises a number of components. Orientation refers to the person knowing where he or she is (the location and address), what the date is, and so on. Attention refers to the person being able to concentrate on a mental task, such as doing a series of simple subtractions. Registration is the ability to listen and repeat back (showing that one has learned) a few words; recall is the ability to remember those words a few minutes later. The doctor may also ask the patient to name some familiar objects or write a simple sentence, to test language functions. The patient may be asked to copy a simple diagram, or draw a familiar object, to test constructional or visuospatial functions. The patient may also be asked to explain the meaning of a common phrase or proverb, or to explain the difference between two different objects or concepts, to test abstract thinking. The above are all examples of different cognitive functions that make up one's day-to-day intellectual functioning. They are not trick questions, and while they are not especially hard, they are designed to challenge patients sufficiently for the doctor to determine where potential problems may lie. Quite often, the end result of the examination is that the doctor can reassure the patient that his or her mental status seems normal. Or, for example, a memory problem may be present, possibly caused by depression, a stroke, Alzheimer's disease, or thyroid disease. One must first recognize the problem before one can identify the cause and recommend the appropriate treatment. Thus, the mental status examination is an important and essential part of the overall health assessment, and should be performed routinely.

Mary Ganguli

See also Psychological Assessment.

BIBLIOGRAPHY

Folstein, M.; Folstein, S.; and McHugh, P. R. "Mini-Mental State: A Practical Method of Grading the Cognitive State of Patients for the Clinician." Journal of Psychiatric Research 12 (1975): 189–198.

Strub, R. L., and Black, F. W. The Mental Status Examination in Neurology, 3rd ed. Philadelphia, Pa.:, FA Davis, 1993.