1. MENTAL STATUS
EXAMINATION

2. Outline Operational definition Purposes Components
Behavior
Cognition
Emotion
Cognitive examination
Mini Mental Status

3. MENTAL STATUS EXAMINATION: What is it?
ASSESSMENT of the:
Behavior (see it all)
Emotion (see some of it)
Cognition (see none of it)
Exhibited by the patient during the entire medical encounter

4. PURPOSES Abnormalities/deficits in: • Detect • Describe
• Neuroanatomical localization
• Assess functional implications of
Abnormalities/deficits in:
• Behavior
• Emotion
• Cognition

5. ABNORMALITIES & DEFICITS
Require diagnostic explanation
May compromise capacity
to coherently and reliably describe medical state
to give informed consent
to adhere to a therapeutic plan

6. MEDICAL
ENCOUNTER
Comprehensive
global assessment

7. BEHAVIOR
Appearance
Attitude
Activity
Speech
Dress
Grooming
Hygiene

8. BEHAVIOR
Appearance
Attitude
Activity
Speech
Dress
Grooming
Hygiene
COGNITION
Thought content
Thought progression
Insight/judgment

9. BEHAVIOR Appearance Attitude Activity Speech Dress Grooming Hygiene
COGNITION
Thought content
Coherence
Goal directedness
Insight/judgment
Operations
Arousal
Attention
Memory
Emotion
Language
Reasoning

10. BEHAVIOR Appearance Attitude Activity Speech Dress Grooming Hygiene
EMOTION
Affect
Mood
Suicide
Homicide
COGNITION
Thought content
Coherence
Goal directedness
Insight/judgment
Operations
Arousal
Attention
Memory
Emotion
Language
Reasoning

11. BEHAVIOR Appearance appears stated age, uses a cane to walk
Attitude cooperative, hostile, detached
Activity normal, increased, agitated, subdued
Speech normal rate/rhythm, dysarthric
Dress casual, provocative, dirty
Grooming disheveled, meticulous
Hygiene clean, malodorous

12. REASONING LANGUAGE COGNITIVE EXAM (“Mental status”) MEMORY ATTENTION
AROUSAL

13. REASONING Must know LANGUAGE education Can the patient hear?
COGNITIVE EXAM (“Mental status”)
Must
know
education
REASONING
LANGUAGE
MEMORY
ATTENTION
AROUSAL
Can the
patient
hear?

14. MEMORY Immediate memory = attention Recent memory (episodic)
Recall of three words at 5 minutes
Ensure that pt has registered the items
“Repeat these words after me, I want you to remember them.”
Remote memory (semantic & episodic)
Tends to overlap with knowledge, most of what we ask is overlearned
Presidents, date of W.W.II, etc..

15. REASONING (Higher cognitive fx)
Tests problem solving, abstract thinking
Fund of knowledge - overlaps with remote memory
How many weeks in a year?
Name four presidents since 1940?
What causes rust?
Calculations
Add, subtract, multiple, divide
Sequences
1, 2, 3, ...
1, 4, 9, 16, ....
2, 3, 5, 7, 11, ...

16. REASONING (continued)
Similarities
Apple - orange
Car - airplane
Poem - novel
Proverbs
Don’t cry over spilt milk
A stitch in time saves nine
People who live in glass houses shouldn’t throw stones

17. BEHAVIOR
Appearance
Attitude
Activity
Speech
Dress
Grooming
Hygiene
COGNITION
Thought content
Thought progression
Insight/judgment
Arousal
Attention
Memory
Language
Reasoning
EMOTION
Affect
Mood
Suicide
Homicide

18. EMOTION AFFECT “Affect is to weather as mood is to climate”
• predominate sad, euphoric, angry, anxious
• intensity unmodulated
• range narrow, broad
• congruence incongruent with content
MOOD euthymic, dysthymic, elated
SUICIDE Do you ever wish you won’t wake up?
Does it ever seem that life isn’t worth it?
HOMICIDE Is there someone who deserves to be hurt?

19. MEDICAL
ENCOUNTER
Comprehensive
global assessment
Focused
selected assessment

20. IN PRACTICE, MOST ENCOUNTERS ARE FOCUSED
Accordingly the formal mental status exam is often limited to an assessment of COGNITION
Further cognition is often assessed solely using:
ORIENTATION

21. TO ORIENT
To understand one’s
relationship to the
environment

22. Person
Place
Time
Situation
“Oriented X 3”
“O X3”

23. Person
Place
Time
Situation
“Oriented X 3”
“O X3”
“Oriented X 4”
“OX4”

24. ORIENTATION ASSESSES: “Oriented X 3” “O X3” “Oriented X 4” “OX4”
Person
Place
Time
Situation
“Oriented X 3”
“O X3”
“Oriented X 4”
“OX4”
• language
• perception
• reasoning
• remote memory
• recent memory
ORIENTATION
ASSESSES:

25. Mini Mental Status More precise Less precise More comprehensive
Less comprehensive
Shorter
Examiner norms
More precise
More comprehensive
Longer
Statistical norms
Mini Mental Status
Orientation
Full mental
status
Neuropsychological
Testing

26. MINI MENTAL STATE EXAM ADVANTAGES
brief (10 min), systematic bedside instrument
wide recognition among physicians
since it is standardized, the score it yields is meaningful to physicians familiar with it
DISADVANTAGES
specific deficits may be ignored if the overall score is not low (less than 25 out of 30)
the global score has no localizing valve
repeated use with intact patients produces a mechanical transaction

27. Examiner uses paper and pencil
Total of 30 points
orientation (10)
recent memory (3)
attention (3)
calculation, spell backward (5)
name, read, repeat (4)
write (1)
constructional ability (1)
ideomotor praxis (3)
Not timed

28. What is the (year) (season) (date) (day) (month)?
Where are we? (state) (county) (city) (hospital) (floor)(10)
Ask pt to repeat three objects - give one per second.
Number repeated first trial = score (3). Present till all
repeated or 6 presentations.
Serial 7’s - 5 subtractions (93, 86, 79, 72, 65) (5). Score
number of correct answers or spell “world” backward,
score is number of letters in correct order. “dlorw” is
3 points.

29. Ask the patient to name a watch and a pencil. (2)
Ask the patient to say “No ifs, ands or buts” (1).
Ask the patient to recall the three words (3).
Ask the pt to read and follow the command:
“Close your eyes”. Score (1 ) only if closes eyes.
Ask the pt to write a sentence. It must have a
subject and a verb and be sensible. Ignore
grammar and punctuation (1).

30. Place a piece of paper where the patient can
reach it with either hand. Ask him/her to:
(1) pick it up, (2) fold it in half, (3) lay it on the
floor. 1 pt for each step executed correctly (3).
Ask the patient to copy a drawing of intersecting
pentagons. All 10 angles must be present and two
must intersect to create a 4 sided figure. Ignore
tremor and rotation (1).

31. Normals can be expected to score > 25
However, even with > 25, if 0/3 or 1/3 for recent
memory or problems with naming, repeating,
writing or reading suggest focal deficits.
It is most sensitive to disturbances which
broadly effect function, it may miss subtle,
focal problems.

32. You may not always do a MMS:
Too little time
Patient becomes agitated at challenge
However, even without an MMS
Interacting with the patient and obtaining a
history have provided information to write
up a mental status exam
Lesson: YOU DO NOT HAVE TO DO
AN MMS TO THOROUGHLY EXAM A PT