The Mental Status Examination

 

Am Fam Physician. 2016 Oct 15;94(8):635-641.

Author disclosure: No relevant financial affiliations.

The mental status examination includes general observations made during the clinical encounter, as well as specific testing based on the needs of the patient and physician. Multiple cognitive functions may be tested, including attention, executive functioning, gnosia, language, memory, orientation, praxis, prosody, thought content, thought processes, and visuospatial proficiency. Proprietary and open-source clinical examination tools are available, such as the Mini-Mental State Examination and the Mini-Cog. Physician judgment is necessary in selecting the most appropriate tool for an individual patient. These tools have varying sensitivity and specificity for neurologic and psychiatric disorders, but none are diagnostic for any mental status disorder. Each must be interpreted in the context of physician observation. The mental status examination is useful in helping differentiate between a variety of systemic conditions, as well as neurologic and psychiatric disorders ranging from delirium and dementia to bipolar disorder and schizophrenia. There are no guidelines to direct further testing in the setting of an abnormal mental status examination; therefore, testing is based on clinical judgment.

The mental status examination is a useful tool to assist physicians in differentiating between a variety of systemic conditions, as well as neurologic and psychiatric disorders ranging from delirium and dementia to bipolar disorder and schizophrenia. The examination itself may comprise a few brief observations made during a general patient encounter or a more thorough evaluation by the physician. It also may include the administration of relatively brief standardized tools such as the Mini-Mental State Examination (MMSE) and Mini-Cog. Highly detailed and time-consuming neuropsychological testing is also available, but this is beyond the scope of this article.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReference

Interpretation of the mental status examination must take into account the patient's native language, education level, and culture.

C

1

Although screening can detect cognitive decline and dementia, there is no evidence that screening improves patient outcomes.

C

6

The Mini-Cog and revised Addenbrooke's Cognitive Examination are preferred alternatives to the Mini-Mental State Examination for dementia screening, and the Montreal Cognitive Assessment is a preferred alternative to detect mild cognitive impairment.

C

4


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReference

Interpretation of the mental status examination must take into account the patient's native language, education level, and culture.

C

1

Although screening can detect cognitive decline and dementia, there is no evidence that screening improves patient outcomes.

C

6

The Mini-Cog and revised Addenbrooke's Cognitive Examination are preferred alternatives to the Mini-Mental State Examination for dementia screening, and the Montreal Cognitive Assessment is a preferred alternative to detect mild cognitive impairment.

C

4


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

Culture, native language, level of education, literacy, and social factors such as sleep deprivation, hunger, or other stressors must be taken into account when interpreting the examination, because these factors can affect performance.1 Language skills of the physician and patient are critical; the patient must be able to understand the questions and communicate his or her answers, and the physician must be able to interpret the examination results. If possible, the mental status examination should occur when the physician is alone with the patient and again in the presence of the patient's friends or family members who can provide more longitudinal insight into problems the patient may be having. The physician should maintain a nonjudgmental, supportive attitude during the encounter.1

The examination begins with a general assessment of the patient's level of consciousness, appearance, activity, and emotional state.1,2 Each of these items may be rapidly assessed by a physician in the initial moments of the encounter through history taking and general observation. These findings, combined with a brief memory test, may be all that is needed to ascertain that no pathology is present.1

If the general assessment does reveal areas of concern, further in-depth investigation is warranted. When a more thorough

The Authors

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DAVID R. NORRIS, MD, is an associate professor of family medicine at the University of Mississippi Medical Center, Jackson....

MOLLY S. CLARK, PhD, is an associate professor of family medicine at the University of Mississippi Medical Center.

SONYA SHIPLEY, MD, is an assistant professor of family medicine at the University of Mississippi Medical Center.

Address correspondence to David R. Norris, MD, University of Mississippi Medical Center, 2500 N. State St., Jackson, MS 39216 (e-mail: drnorris@umc.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

REFERENCES

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1. Faber RA. The neuropsychiatric mental status examination. Semin Neurol. 2009;29(3):185–193....

2. The mental status, psychiatric, and social evaluations. In: LeBlond RF, Brown DD, Suneja M, Szot JF, eds. DeGowin's Diagnostic Examination. 10th ed. New York, NY: McGraw-Hill; 2015:688–705.

3. McKhann GM, Knopman DS, Chertkow H, et al. The diagnosis of dementia due to Alzheimer's disease: recommendations from the National Institute on Aging–Alzheimer's Association workgroups on diagnostic guidelines for Alzheimer's disease. Alzheimers Dement. 2011;7(3):263–269.

4. Tsoi KK, Chan JY, Hirai HW, Wong SY, Kwok TC. Cognitive tests to detect dementia: a systematic review and meta-analysis. JAMA Intern Med. 2015;175(9):1450–1458.

5. Snyderman D, Rovner B. Mental status exam in primary care: a review. Am Fam Physician. 2009;80(8):809–814.

6. Lin JS, O'Connor E, Rossom RC, Perdue LA, Eckstrom E. Screening for cognitive impairment in older adults: a systematic review for the U.S. Preventive Services Task Force [published correction appears in Ann Intern Med. 2014;160(1):72]. Ann Intern Med. 2013;159(9):601–612.

7. Lukens TW, Wolf SJ, Edlow JA, et al.; American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department. Clinical policy: critical issues in the diagnosis and management of the adult psychiatric patient in the emergency department. Ann Emerg Med. 2006;47(1):79–99.

8. Anfinson TJ, Stoudemire A. Laboratory and neuroendocrine assessment in medical-psychiatric patients. In: Stoudemire A, Fogel BS, Greenberg DB, eds. Psychiatric Care of the Medical Patient. 2nd ed. New York, NY: Oxford University Press; 2000:119–148.

9. Sheth RD, Drazkowski JF, Sirven JI, Gidal BE, Hermann BP. Protracted ictal confusion in elderly patients. Arch Neurol. 2006;63(4):529–532.

10. ACR Appropriateness Criteria: dementia and movement disorders. https://acsearch.acr.org/docs/69360/Narrative. Accessed October 11, 2015.

11. Dementia & amnestic disorders. In: Aminoff MJ, Greenberg DA, Simon RP, eds. Clinical Neurology. 9th ed. New York, NY: McGraw-Hill; 2015:105–133.


 

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