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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 atten-
tion, executive functioning, gnosia, language, memory, orientation, praxis, prosody, thought content, thought pro-
cesses, 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 dis-
orders, 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 schizo-
phrenia. There are no guidelines to direct further testing in the setting of an abnormal mental status examination;
therefore, testing is based on clinical judgment. (Am Fam Physician. 2016;94(8):635-641. Copyright © 2016 American
Academy of Family Physicians.)
T
CME This clinical content he mental status examination is a more longitudinal insight into problems the
conforms to AAFP criteria useful tool to assist physicians in patient may be having. The physician should
for continuing medical
education (CME). See
differentiating between a variety maintain a nonjudgmental, supportive atti-
CME Quiz Questions on of systemic conditions, as well as tude during the encounter.1
page 598. neurologic and psychiatric disorders ranging The examination begins with a general
Author disclosure: No rel- from delirium and dementia to bipolar dis- assessment of the patient’s level of con-
evant financial affiliations. order and schizophrenia. The examination sciousness, appearance, activity, and emo-
itself may comprise a few brief observations tional state.1,2 Each of these items may be
made during a general patient encounter rapidly assessed by a physician in the initial
or a more thorough evaluation by the phy- moments of the encounter through history
sician. It also may include the administra- taking and general observation. These find-
tion of relatively brief standardized tools ings, combined with a brief memory test,
such as the Mini-Mental State Examination may be all that is needed to ascertain that no
(MMSE) and Mini-Cog. Highly detailed pathology is present.1
and time-consuming neuropsychological If the general assessment does reveal areas
testing is also available, but this is beyond of concern, further in-depth investigation is
the scope of this article. warranted. When a more thorough exami-
Culture, native language, level of edu- nation is indicated, it may be separated into
cation, literacy, and social factors such as two general portions: observations made by
sleep deprivation, hunger, or other stressors the physician about the patient’s physical
must be taken into account when interpret- state, and a cognitive evaluation in which
ing the examination, because these factors the patient’s neurologic and psychologi-
can affect performance.1 Language skills of cal functioning is assessed. The cognitive
the physician and patient are critical; the portion involves assessment of 11 different
patient must be able to understand the ques- functions: attention, executive function-
tions and communicate his or her answers, ing, gnosia, language, memory, orientation,
and the physician must be able to interpret praxis, prosody, thought content, thought
the examination results. If possible, the processes, and visuospatial proficiency.
mental status examination should occur Table 1 provides information about each
when the physician is alone with the patient portion of the examination, as well as dif-
and again in the presence of the patient’s ferential diagnoses that may be suggested by
friends or family members who can provide abnormalities in each area.1-5
General observations
Appearance Body habitus, eye contact, Appearance: attention to detail, attire, distinguishing
and behavior interpersonal style, style features (e.g., scars, tattoos), grooming, hygiene
of dress Behavior: candid, congenial, cooperative, defensive,
engaging, guarded, hostile, irritable, open, relaxed,
resistant, shy, withdrawn
Eye contact: fleeting, good, none, sporadic
Mood and Mood: subjective report of Body movements/making contact with others, facial
affect emotional state by patient expressions (tearfulness, smiles, frowns)
Affect: objective observation
of patient’s emotional state
by the physician
Motor activity Facial expressions, Akathisia: excessive motor activity (e.g., pacing, wringing
movements, posture of hands, inability to sit still)
Bradykinesia: psychomotor retardation (e.g., slowing of
physical and emotional reactions)
Catatonia: immobility with muscular rigidity or inflexibility
Cognitive functioning
Attention Ability to focus based on —
internal or external priorities
Executive Ordering and implementation Testing each cognitive function involved in completing
functioning of cognitive functions a task
necessary to engage in
appropriate behaviors
Memory Recall of past events Declarative: recall of recent and past events
Procedural: ability to complete learned tasks without
conscious thought
Praxis Ability to carry out intentional Apraxia: inability to carry out motor acts; deficits may
motor acts exist in motor or sensory systems, comprehension, or
cooperation
NOTE: Each of these items may be suggestive of various diagnoses, but none are sufficient to make a diagnosis without
a comprehensive clinical evaluation.
NA = not applicable.
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Sample questions/tests Potential diagnoses if abnormal
Clock drawing test: ask patient to draw a clock with hands set to 11:10 Delirium, dementia, mood disorder, psychotic disorder, stroke
Trail-making test: ask patient to alternate numbers with letters in
ascending order (e.g., A1B2C3)
Show patient a common object (e.g., pen, watch, cellular telephone) and Advanced dementia, stroke
ask if he or she can identify it and describe how it is used
What year/month/day/time is it? Amnesia, delirium, dementia, mania, previous stroke, severe
What city/building/floor/room are you in? depression
What is your name? When were you born?
Could you show me how to use this hairbrush/hammer/pencil? Delirium, dementia, intoxication, stroke
continues
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Table 1. Components of the Mental Status Examination (continued)
NOTE: Each of these items may be suggestive of various diagnoses, but none are sufficient to make a diagnosis without
a comprehensive clinical evaluation.
Information from references 1 through 5.
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Mental Status Examination
Repeat “Why are you here?” with multiple inflections (e.g., happy, Autism spectrum disorder, developmental delay, mood
surprised, excited, angry, sad) and ask patient to identify the emotion disorder, schizophrenia
Ask the patient to say the same sentence with each of the above
emotional inflections
Do you have thoughts or images in your head that you cannot get out? Delusions: fixed delusions, mania, psychotic disorder/psychotic
Do you have any irrational or excessive fears? depression
Do you think people are trying to hurt you in some way? Hallucinations: delirium, dementia, mania, schizophrenia,
severe depression, substance use
Are people talking behind your back?
Homicidality: mood disorder, personality disorder, psychotic
Do you think people are stealing from you?
disorder
Do you feel life is not worth living?
Obsessions: obsessive-compulsive disorder, posttraumatic
Do you see things that upset you? stress disorder, psychotic disorder
Do you ever see/hear/smell/taste/feel things that are not really there? Phobias: anxiety disorder, posttraumatic stress disorder
Have you ever heard or seen something other people have not? Suicidality: depression, posttraumatic stress disorder,
Have you ever thought about hurting others or getting even with substance use
someone who wronged you?
Have you ever thought about hurting yourself? If so, how would you do it?
Have you ever thought the world would be better off without you?
Generally apparent throughout the encounter Anxiety, delirium, dementia, depression, schizophrenia,
substance use
Ask patient to copy intersecting pentagons or a three-dimensional cube Delirium, dementia, stroke
on paper
Draw a triangle and ask patient to draw the same shape upside down
testing tool is the MMSE. It requires about The Mini-Cog is a brief (five minutes or
six to 10 minutes to administer, although less) screening tool that measures execu-
it may take longer depending on the extent tive functioning, memory, and visuospatial
of impairment. In 14 studies, the MMSE proficiency. Estimates of its sensitivity and
had a sensitivity of 88.3% (95% confidence specificity for dementia vary across stud-
interval [CI], 81.3% to 92.9%) and a speci- ies. However, a recent meta-analysis of
ficity of 86.2% (95% CI, 81.8% to 89.7%) cohort studies found a pooled sensitivity of
for dementia, with a score cutoff of 23 to 25 91% (95% CI, 80% to 96%) and specificity
indicating significant impairment.4 A more of 86% (95% CI, 74% to 93%).4 The Mini-
recent meta-analysis of 108 cohort studies Cog instructs the patient to say three words,
found a sensitivity of 81% (95% CI, 78% to engage in a clock drawing task, then repeat
84%) and specificity of 89% (95% CI, 87% the three words. The Mini-Cog is brief, easy
to 91%).6 The MMSE assesses a wide range to use, and widely available, and it is preferred
of domains, including attention, language, over the MMSE. However, it demonstrated
memory, orientation, and visuospatial pro- better performance in patients with demen-
ficiency. However, it is proprietary and may tia compared with those with only mild cog-
not be reproduced without a fee, and the nitive impairment, which may account for
patient’s education level must be taken into the variance in sensitivity (76% to 100%) and
account when interpreting the results.3,4 specificity (54% to 85.2%) in other reviews.4
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Mental Status Examination
Table 2. Summary of Cognitive Screening Tools
Time to
administer Sensitivity (95% Specificity (95%
Test (minutes) confidence interval) confidence interval) Domains assessed Accessibility
Addenbrooke’s ≤ 20 92% (90% to 94%) 89% (84% to 93%) Attention, executive functioning, Public domain
Cognitive language, memory, orientation,
Examination (revised) visuospatial proficiency
Mini-Cog ≤5 91% (80% to 96%) 86% (74% to 93%) Executive functioning, memory, Public domain
visuospatial proficiency
Mini-Mental State 6 to 10 81% (78% to 84%) 89% (87% to 91%) Attention, language, memory, Proprietary
Examination orientation, visuospatial proficiency
Montreal Cognitive ≤ 10 91% (84% to 95%) 81% (71% to 81%) Attention, executive functioning, Public domain
Assessment language, memory, orientation
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Mental Status Examination
creatinine clearance, as well as urinalysis. 3. McKhann GM, Knopman DS, Chertkow H, et al. The
diagnosis of dementia due to Alzheimer’s disease:rec-
These studies may reveal a potentially cor- ommendations from the National Institute on Aging–
rectable cause, such as hypoglycemia or Alzheimer’s Association workgroups on diagnostic
hyperglycemia, uremia secondary to acute guidelines for Alzheimer’s disease. Alzheimers Dement.
2011;7(3):263-269.
kidney injury, or urinary tract infection. 4. Tsoi KK, Chan JY, Hirai HW, Wong SY, Kwok TC. Cog-
Thyroid function testing is also reasonable, nitive tests to detect dementia:a systematic review
especially in women older than 50 years who and meta-analysis. JAMA Intern Med. 2015;175(9):
1450-1458.
have neurologic illness or mood disorders,
5. Snyderman D, Rovner B. Mental status exam in primary
or in younger women and men with clinical care:a review. Am Fam Physician. 2009;8 0(8):8 09-814.
signs of thyroid disease. However, such test- 6. Lin JS, O’Connor E, Rossom RC, Perdue LA, Eckstrom
ing should be avoided if it is unlikely to alter E. Screening for cognitive impairment in older adults:
the patient’s clinical outcome.7 Other tests a systematic review for the U.S. Preventive Services
Task Force [published correction appears in Ann Intern
(e.g., neuroimaging,8 electroencephalogra- Med. 2014;160(1):72]. Ann Intern Med. 2013;159(9):
phy,9 positron emission tomography,10 more 601-612.
extensive serum laboratory testing, cere- 7. Lukens TW, Wolf SJ, Edlow JA, et al.;American College
of Emergency Physicians Clinical Policies Subcommittee
brospinal fluid analysis) may be indicated
(Writing Committee) on Critical Issues in the Diagnosis
for patients with potentially nonpsychiatric and Management of the Adult Psychiatric Patient in the
symptoms or symptoms that may be caused Emergency Department. Clinical policy:critical issues in
the diagnosis and management of the adult psychiatric
by a general medical condition.11
patient in the emergency department. Ann Emerg Med.
Data Sources: PubMed and UpToDate searches were 2006;47(1):79-99.
completed using the key terms mental status examina- 8. Anfinson TJ, Stoudemire A. Laboratory and neuroen-
tion, general mental status examination, special mental docrine assessment in medical-psychiatric patients. In:
status examination, Mini-Mental Status Examination, and Stoudemire A, Fogel BS, Greenberg DB, eds. Psychiat-
Mini-Cog. The searches included meta-analyses, random- ric Care of the Medical Patient. 2nd ed. New York, NY:
ized controlled trials, clinical trials, and review articles. Oxford University Press;2000:119-148.
Also searched were Essential Evidence Plus and the 9. Sheth RD, Drazkowski JF, Sirven JI, Gidal BE, Hermann
Cochrane Database of Systematic Reviews. Search dates: BP. Protracted ictal confusion in elderly patients. Arch
September 2, 2015, and October 3, 2015. Neurol. 2006;63(4):529-532.
10. ACR Appropriateness Criteria:dementia and move-
The authors thank Elizabeth Hinton, MSIS, for her ment disorders. https://acsearch.acr.org/docs/69360/
research assistance during the preparation of this article. Narrative. Accessed October 11, 2015.
note :
This review updates a previous article on this topic 11. Dementia & amnestic disorders. In:Aminoff MJ, Green-
by Snyderman and Rovner.5 berg DA, Simon RP, eds. Clinical Neurology. 9th ed.
New York, NY:McGraw-Hill; 2015:105-133.
The Authors
DAVID R. NORRIS, MD, is an associate professor of family
medicine at the University of Mississippi Medical Center,
Jackson.
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