Advertisement
Previous article
Acute Asthma Exacerbations: Management Strategies
Jan 2024
Next article
Injections of the Hip and Knee

Mental Status Examination in Primary Care

Anna T. Wiley, MD
James W. Dreher, MD
Jill D. London, DO

American Family Physician. 2024;109(1):51-60.

Author disclosure: No relevant financial relationships.

The mental status examination relies on the physician's clinical judgment for observation and interpretation. When concerns about a patient's cognitive functioning arise in a clinical encounter, further evaluation is indicated. This can include evaluation of a targeted cognitive domain or the use of a brief cognitive screening tool that evaluates multiple domains. To avoid affecting the examination results, it is best practice to ensure that the patient has a comfortable, nonjudgmental environment without any family member input or other distractions. An abnormal response in a domain may suggest a possible diagnosis, but neither the mental status examination nor any cognitive screening tool alone is diagnostic for any condition. Validated cognitive screening tools, such as the Mini-Mental State Examination or the St. Louis University Mental Status Examination, can be used; the tools vary in sensitivity and specificity for detecting mild cognitive impairment and dementia. There is emerging evidence for the validity of cognitive screening performed during telemedicine visits, but it should not replace in-person evaluation of patients who have comorbidities that would preclude reliable testing via telephone or video. The workup after abnormal results of a mental status examination or cognitive screening tool is based on clinical judgment and primarily focuses on ruling out reversible causes of impairment and considering the need for further neuropsychiatric evaluation.

The mental status examination (MSE) is an evaluation of a patient's cognitive and affective state and begins at the start of the patient encounter. Clinical judgment is the foundation of the MSE because much of the examination depends on the physician's observations and interpretations.1 Implicit bias, if not appropriately addressed, may alter the results.2

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating Comment
There is insufficient evidence that screening asymptomatic older adults for cognitive impairment improves patient outcomes.4,5 B U.S. Preventive Services Task Force I Recommendation, evidence-based guidelines
The mental status examination or cognitive screening tools should be administered in a nonjudgmental environment free from distraction.1 C Expert opinion in the setting of a lack of studies
Due to its inability to detect mild cognitive impairment that will progress to dementia, the Mini-Mental State Examination should not be used to screen for mild cognitive impairment in the primary care setting.15 B Review of several heterogenous studies of good quality
The Addenbrooke's Cognitive Examination (ACE)-III or the Mini-ACE should not be used to screen for cognitive impairment if alternative tests are available. This is due to variable sensitivity across diverse populations and a lack of studies in the primary care setting.12 C Review of limited-evidence studies, none performed in the primary care setting
Although the Mini-Cog provides a small time benefit when conducted in a primary care clinic, other short cognitive assessments are supported by more evidence and cover a wider range of cognitive domains; therefore, the Mini-Cog should not be used if other screening tools are available.34–36 B Multiple systematic reviews of limited-evidence studies
Telemedicine evaluation of cognitive impairment should not replace in-person evaluation in patients who have comorbidities that may affect the reliability of testing and in those who have a negative screening result with a high clinical suspicion for impairment.38,41 B Limited-quality patient-oriented evidence

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 https://www.aafp.org/afpsort.

ANNA T. WILEY, MD, is a faculty physician in the Department of Family Medicine at the Uniformed Services University of the Health Sciences, Offutt Air Force Base, Neb.

JAMES W. DREHER, MD, is a faculty physician in the Offutt Air Force Base Family Medicine Residency Program, Omaha, Neb.

JILL D. LONDON, DO, FAWM, is an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences, Offutt Air Force Base, Neb.

Address correspondence to Anna T. Wiley, MD, Offutt Air Force Base, 2501 Capehart Rd., Bellevue, NE 68123 (anna.t.wiley.md@gmail.com). Reprints are not available from the authors.

Author disclosure: No relevant financial relationships.

  1. 1.Mendez MF. Principles of mental status testing. In: The Mental Status Examination Handbook. Elsevier; 2022: 9–15.
  2. 2.FitzGerald C, Hurst S. Implicit bias in healthcare professionals: a systematic review. BMC Med Ethics. 2017;18(1):19.
  3. 3.Norris DR, Clark MS, Shipley S. The mental status examination. Am Fam Physician. 2016;94(8):635-641.
  4. 4.Owens DK, Davidson KW, Krist AH, et al.; US Preventive Services Task Force. Screening for cognitive impairment in older adults: US Preventive Services Task Force recommendation statement. JAMA. 2020;323(8):757-763.
  5. 5.Ismail Z, Black SE, Camicioli R, et al.; CCCDTD5 participants. Recommendations of the 5th Canadian Consensus Conference on the diagnosis and treatment of dementia. Alzheimers Dement. 2020;16(8):1182-1195.
  6. 6.American Academy of Neurology. Practice guideline update: mild cognitive impairment. Accessed June 11, 2023. https://www.aan.com/Guidelines/home/GuidelineDetail/881
  7. 7.Malmstrom TK, Voss VB, Cruz-Oliver DM, et al. The Rapid Cognitive Screen (RCS): a point-of-care screening for dementia and mild cognitive impairment. J Nutr Health Aging. 2015;19(7):741-744.
  8. 8.Seitz DP, Chan CC, Newton HT, et al. Mini-Cog for the detection of dementia within a primary care setting. Cochrane Database Syst Rev. 2021(7):CD011415.
  9. 9.Fink HA, Hemmy LS, Linskens EJ, et al. Diagnosis and treatment of clinical Alzheimer’s-type dementia: a systematic review. April 2020. Accessed March 25, 2023. https://www.ncbi.nlm.nih.gov/books/NBK556556/
  10. 10.Davis DH, Creavin ST, Yip JL, et al. Montreal Cognitive Assessment for the detection of dementia. Cochrane Database Syst Rev. 2021(7):CD010775.
  11. 11.Tariq SH, Tumosa N, Chibnall JT, et al. Comparison of the Saint Louis University Mental Status Examination and the Mini-Mental State Examination for detecting dementia and mild neurocognitive disorder—a pilot study. Am J Geriatr Psychiatry. 2006;14(11):900-910.
  12. 12.Beishon LC, Batterham AP, Quinn TJ, et al. Addenbrooke’s Cognitive Examination III (ACE-III) and Mini-ACE for the detection of dementia and mild cognitive impairment. Cochrane Database Syst Rev. 2019(12):CD013282.
  13. 13.Schroeder RW, Martin PK, Walling A. Neuropsychological evaluations in adults. Am Fam Physician. 2019;99(2):101-108.
  14. 14.PAR, Inc. Mini-Mental State Examination, 2nd edition. Accessed July 22, 2023. https://www.parinc.com/Products/Pkey/238
  15. 15.Arevalo-Rodriguez I, Smailagic N, Roqué-Figuls M, et al. Mini-Mental State Examination (MMSE) for the early detection of dementia in people with mild cognitive impairment (MCI). Cochrane Database Syst Rev. 2021(7):CD010783.
  16. 16.Mendez MF. General mental status scales, rating instruments, and behavior inventories. In: The Mental Status Examination Handbook. Elsevier; 2022: 181–199.
  17. 17.Ciesielska N, Sokołowski R, Mazur E, et al. Is the Montreal Cognitive Assessment (MoCA) test better suited than the Mini-Mental State Examination (MMSE) in mild cognitive impairment (MCI) detection among people aged over 60? Meta-analysis. Psychiatr Pol. 2016;50(5):1039-1052.
  18. 18.Pinto TCC, Machado L, Bulgacov TM, et al. Is the Montreal Cognitive Assessment (MoCA) screening superior to the Mini-Mental State Examination (MMSE) in the detection of mild cognitive impairment (MCI) and Alzheimer’s disease (AD) in the elderly?. Int Psychogeriatr. 2019;31(4):491-504.
  19. 19.Breton A, Casey D, Arnaoutoglou NA. Cognitive tests for the detection of mild cognitive impairment (MCI), the prodromal stage of dementia: meta-analysis of diagnostic accuracy studies. Int J Geriatr Psychiatry. 2019;34(2):233-242.
  20. 20.MoCA Cognition. Training and certification. Accessed March 24, 2023. https://mocacognition.com/training-certification
  21. 21.MoCA Cognition. Digital tools. Accessed March 24, 2023. https://mocacognition.com/digitaltools
  22. 22.Carson N, Leach L, Murphy KJ. A re-examination of Montreal Cognitive Assessment (MoCA) cutoff scores. Int J Geriatr Psychiatry. 2018;33(2):379-388.
  23. 23.White RS, Barber JM, Harp JP, et al. Examining the effects of formal education level on the Montreal Cognitive Assessment. J Am Board Fam Med. 2022;35(6):1043-1057.
  24. 24.O’Driscoll C, Shaikh M. Cross-cultural applicability of the Montreal Cognitive Assessment (MoCA): a systematic review. J Alzheimers Dis. 2017;58(3):789-801.
  25. 25.Rossetti HC, Smith EE, Hynan LS, et al. Detection of mild cognitive impairment among community-dwelling African Americans using the Montreal Cognitive Assessment. Arch Clin Neuropsychol. 2019;34(6):809-813.
  26. 26.Saint Louis University School of Medicine. SLU Mental Status Exam. Accessed March 22, 2023. https://www.slu.edu/medicine/internal-medicine/geriatric-medicine/aging-successfully/assessment-tools/mental-status-exam.php
  27. 27.Cummings-Vaughn LA, Chavakula NN, Malmstrom TK, et al. Veterans Affairs Saint Louis University Mental Status Examination compared with the Montreal Cognitive Assessment and the short test of mental status. J Am Geriatr Soc. 2014;62(7):1341-1346.
  28. 28.Zhang S, Wu YH, Zhang Y, et al. Preliminary study of the validity and reliability of the Chinese version of the Saint Louis University Mental Status Examination (SLUMS) in detecting cognitive impairment in patients with traumatic brain injury. Appl Neuropsychol Adult. 2021;28(6):633-640.
  29. 29.Wu Y, Wang Y, Zhang Y, et al. A preliminary study of the Saint Louis University Mental Status Examination (SLUMS) for the assessment of cognition in moderate to severe traumatic brain injury patients. Appl Neuropsychol Adult. 2023;30(4):409-413.
  30. 30.Merz ZC, Lace JW. Clinical utility of the Saint Louis University Mental Status Examination (SLUMS) in a mixed neurological sample: proposed revised cutoff scores for normal cognition, mild cognitive impairment, and dementia [published online August 5, 2022]. Appl Neuropsychol Adult. Accessed June 11, 2023. https://www.tandfonline.com/doi/abs/10.1080/23279095.2022.
  31. 31.Spencer RJ, Noyes ET, Bair JL, et al. Systematic review of the psychometric properties of the Saint Louis University Mental Status (SLUMS) Examination. Clin Gerontol. 2022;45(3):454-466.
  32. 32.Kaya D, Isik AT, Usarel C, et al. The Saint Louis University Mental Status Examination is better than the Mini-Mental State Examination to determine the cognitive impairment in Turkish elderly people. J Am Med Dir Assoc. 2016;17(4):370.e11-370.e15.
  33. 33.American Family Physician. Evidence-based medicine toolkit. Accessed June 11, 2023. https://www.aafp.org/pubs/afp/authors/ebm-toolkit.html#04
  34. 34.Chen MZ, Chan YH, Wong MWK, et al. Comparison of Rapid Cognitive Screen against Montreal Cognitive Assessment in screening for cognitive impairment in the old and old-old. Psychogeriatrics. 2022;22(4):460-468.
  35. 35.Fage BA, Chan CC, Gill SS, et al. Mini-Cog for the detection of dementia within a community setting. Cochrane Database Syst Rev. 2021(7):CD010860.
  36. 36.Chan CC, Fage BA, Burton JK, et al. Mini-Cog for the detection of dementia within a secondary care setting. Cochrane Database Syst Rev. 2021(7):CD011414.
  37. 37.Carrillo de Albornoz S, Sia KL, Harris A. The effectiveness of teleconsultations in primary care: systematic review. Fam Pract. 2022;39(1):168-182.
  38. 38.Lu AD, Veet CA, Aljundi O, et al. A systematic review of physical examination components adapted for telemedicine. Telemed J E Health. 2022;28(12):1764-1785.
  39. 39.MoCA Cognition. Paper versions. Accessed March 24, 2023. https://mocacognition.com/paper
  40. 40.McCleery J, Laverty J, Quinn TJ. Diagnostic test accuracy of telehealth assessment for dementia and mild cognitive impairment. Cochrane Database Syst Rev. 2021(7):CD013786.
  41. 41.Riley CO, McKinstry B, Fairhurst K. Accuracy of telephone screening tools to identify dementia patients remotely: systematic review. JRSM Open. 2022;13(9) ): 20542704221115956.
  42. 42.Zietemann V, Kopczak A, Müller C, et al. Validation of the telephone interview of cognitive status and telephone Montreal Cognitive Assessment against detailed cognitive testing and clinical diagnosis of mild cognitive impairment after stroke. Stroke. 2017;48(11):2952-2957.
  43. 43.Falk N, Cole A, Meredith TJ. Evaluation of suspected dementia. Am Fam Physician. 2018;97(6):398-405.
  44. 44.American College of Radiology. ACR Appropriateness Criteria: acute mental status change, delirium, and new onset psychosis. Accessed March 15, 2023. https://acsearch.acr.org/docs/3102409/Narrative
  45. 45.American College of Radiology. ACR Appropriateness Criteria: dementia. Accessed March 15, 2023. https://acsearch.acr.org/docs/3111292/Narrative
  46. 46.Veauthier B, Hornecker JR, Thrasher T. Recent-onset altered mental status: evaluation and management. Am Fam Physician. 2021;104(5):461-470.
  47. 47.Snyderman D, Rovner BW. Mental status examination in primary care: a review. Am Fam Physician. 2009;80(8):809-814.
Previous article
Acute Asthma Exacerbations: Management Strategies
Jan 2024
Next article
Injections of the Hip and Knee

Current issue

September 2026

September 2026

Copyright © 2026 by the American Academy of Family Physicians.

This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. See permissions for copyright questions and/or permission requests.