The mental status portion of the neurologic examination is a complex process. Mental status is the total expression of a person’s emotional responses, mood, cognitive functioning (ability to think, reason, and make judgments), and personality. A major focus of the examination is identification of the individual’s strengths and capabilities for interaction with the environment. This chapter focuses on mental status evaluation of the individual’s overall cognitive state. See Chapter 23 for the assessment of neurologic lesions that cause alterations in mental status.
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Observe physical appearance and behavior
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Investigate cognitive abilities:
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State of consciousness
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Response to analogies
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Abstract reasoning
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Arithmetic calculation
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Memory
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Attention span
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Observe speech and language for voice quality, articulation, coherence, and comprehension.
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Evaluate emotional stability for signs of depression, anxiety, thought content disturbance, and hallucinations.
Anatomy and Physiology
The cerebrum of the brain is primarily responsible for a person’s mental status. Many areas in the cerebrum contribute to the total functioning of a person’s mental processes. Two cerebral hemispheres, each divided into lobes, comprise the cerebrum. The gray outer layer—the cerebral cortex—houses the higher mental functions and is responsible for perception and behavior ( Fig. 7.1 ).
The frontal lobe, containing the motor cortex, is associated with speech formation (in the Broca area). This lobe is responsible for decision making, problem solving, the ability to concentrate, and short-term memory. Associated areas—related to emotions, affect, drive, and awareness of self and the autonomic responses related to emotional states—also originate in the frontal lobe.
The parietal lobe is primarily responsible for receiving and processing sensory data.
The temporal lobe is responsible for perception and interpretation of sounds as well as localizing their source. It contains the Wernicke speech area, which allows a person to understand spoken and written language. The temporal lobe is also involved in the integration of behavior, emotion, and personality, as well as long-term memory.
The limbic system mediates certain patterns of behavior that determine survival (e.g., mating, aggression, fear, and affection). Reactions to emotions such as anger, love, hostility, and envy originate here, but the expression of emotion and behavior is mediated by connections between the limbic system and the frontal lobe. A major function is memory consolidation needed for long-term memory.
The reticular system, a collection of nuclei in the brainstem, regulates vital reflexes such as heart and respiratory functioning. It also maintains wakefulness, which is important for consciousness and for awareness and arousal functions. Disruption of the ascending reticular activating system can lead to altered mental status (e.g., confusion and delirium).
Infants and Children
All brain neurons are present at birth in a full-term infant, but brain development continues with myelinization of nerve cells over several years. Brain insults, such as infection (e.g., Zika virus or rubella), trauma, or metabolic imbalance, can damage brain cells, which may result in serious permanent dysfunction in mental status. Genetic disorders may also affect cognitive development and mental status.
Adolescents
Intellectual maturation continues, with greater capacity for information and vocabulary development. Abstract thinking (i.e., the ability to develop theories, use logical reasoning, make future plans, use generalizations, and consider risks and possibilities) develops during this period. Judgment begins to develop with education, intelligence, and experience.
Older Adults
Cognitive function should be intact in the healthy older adult, but declines in cognitive abilities occur in some older adults after 60 or 70 years of age. Speed of information processing and psychomotor speed begin declining at a modest rate after 30 years of age. However, verbal skills and general knowledge continue to increase into the 60s and often remain stable into the 80s. Cognitive declines in executive functioning (the ability to plan and develop strategies, organize, concentrate and remember details, and manage activities) may precede memory loss and other cognitive impairments ( Carlson et al, 2009 ). The cognitive decline leading to dementia may occur over 20 to 30 years, and it may begin as early as 45 years of age in some persons ( Singh-Manoux et al, 2012 ).
Review of Related History
For each of the symptoms or conditions discussed in this section, targeted topics to include in the history of the present illness are listed. Responses to questions about these topics provide clues for focusing the physical examination and the development of an appropriate diagnostic evaluation. Questions regarding medication use (prescription and over-the-counter preparations) as well as complementary and alternative therapies are relevant for each area.
History of Present Illness
Disorientation and Confusion
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Abrupt or insidious onset: intermittent, fluctuating, or persistent; association with time of day or emotional crisis
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Associated health problems: new hearing or vision impairment; neurologic disorder, vascular occlusion, or brain injury; systemic infection; withdrawal from alcohol; metabolic or electrolyte disorder
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Associated symptoms: delusions, hallucinations (imaginary perceptions), mood swings, anxiety, sadness, lethargy or agitation, insomnia, change in appetite, drug toxicity
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Medications: anticholinergics, benzodiazepines, opioid analgesics, tricyclic antidepressants, levodopa or amantadine, diuretics, digoxin, antiarrhythmics, sedatives, hypnotics, or alternative and complementary therapies such as gingko biloba and St. John’s wort
Depression
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Troubling thoughts or feelings, constant worry; change in outlook on life or change in feelings; feelings of hopelessness; inability to control feelings
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Low energy level, awakens feeling fatigued, agitation, feels best in the morning or at night
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Recent changes in living situation, death or relocation of friends or family members, changes in physical health
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Thoughts or plans for hurting self and/or others, thoughts about dying, hopelessness, no plans for the future
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Medications: antidepressants; medications that may cause or worsen depression (e.g., antihypertensive agents, corticosteroids, beta-blockers, calcium channel blockers, barbiturates, phenytoin, anabolic steroids)
Anxiety
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Sudden, unexplained episodes of intense fear, anxiety, or panic for no apparent reason; afraid will be unable to get help or will be unable to escape in certain situations; unable to control worrying; spends more time than necessary repeatedly doing or checking things
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Feels uncomfortable in or avoids situations or events that involve being with people
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Prior experience with a frightening or traumatic event
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Associated symptoms: panic attacks, obsessive thoughts, or compulsive behaviors
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Medications: antidepressants, steroids, benzodiazepines
Past Medical History
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Neurologic disorder, brain surgery, brain injury, residual effects, chronic disease, or debilitating condition
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Psychiatric disorder or hospitalization
Family History
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Psychiatric disorders, mental illness, alcoholism
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Alzheimer disease
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Learning disorders, intellectual disability, autism
Personal and Social History
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Emotional status: feelings about self; anxious, restless, or irritable; discouraged or frustrated; problems with money, job, legal system, spouse, partner, or children; ability to cope with current stressors in life
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Life goals, attitudes, relationship with family members
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Intellectual level: educational history, access to information, mental stimulation
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Communication pattern, able to understand questions, coherent and appropriate speech, change in memory or cognitive thought processes
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Changes in sleeping or eating patterns; change in appetite or diet, weight loss or gain; decreased sexual activity
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Use of alcohol or recreational drugs, especially mood-altering drugs
Children
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Speech and language: timing of first words, words understood, progression to phrases and sentences
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Behavior: temper tantrums, ease in separating from family or adjusting to new situations
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Performance of self-care activities: dressing, toileting, feeding
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Personality and behavior patterns: changes related to any specific event, illness, or trauma
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Learning or school difficulties: associated with interest, hyperactivity, or ability to concentrate
Adolescents
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Risk-taking behaviors
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School performance and peer interactions
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Family interactions
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Reluctance to talk about attitudes, behaviors, and experience
Older Adults
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Changes in cognitive functioning, thought processes, memory; association with medications prescribed (e.g., opiates, benzodiazepines, antidepressants, corticosteroids, muscle relaxants)
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Changes in activities of daily living, e.g., money management, food preparation
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Depression: somatic complaints, hopelessness, helplessness, lack of interest in personal care
Examination and Findings
Mental status is assessed continuously throughout the entire interaction with a patient by evaluating the patient’s alertness, orientation, cognitive abilities, and mood ( Box 7.1 ). Observe the patient’s physical appearance, behavior, and responses to questions asked during the history ( Fig. 7.2 ). Note any reliance on an accompanying adult to answer questions. Make a point of asking the patient to provide responses. Note any variations in response to questions of differing complexity. Speech should be clearly articulated. Questions should be answered appropriately, with ideas expressed logically, relating current and past events.
The shorter screening examination is commonly used for health visits when no known mental status problem is apparent. Information is generally obtained during the history by observation of behavior and responses to questions in the following areas.
Appearance and Behavior
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Grooming
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Emotional status
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Body language
Emotional Stability
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Mood and feelings
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Thought processes
Cognitive Abilities
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State of consciousness
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Memory
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Attention span
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Judgment
Speech and Language
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Voice quality
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Articulation
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Comprehension
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Coherence
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Aphasia
Physical Appearance and Behavior
Grooming
Assess the patient’s hygiene, grooming, and appropriateness of dress for age and season. Poor hygiene, lack of concern with appearance, or inappropriate dress for season or occasion in a previously well-groomed individual may indicate depression, a psychiatric disorder, or dementia.
Emotional Status
Note the patient’s behavior, which is usually cooperative and friendly. The patient’s manner should demonstrate concern appropriate for the topics discussed. Consider cultural variations when assessing emotional responses. Note patient behavior that conveys carelessness, apathy, loss of sympathetic reactions, unusual docility, hostility, rage reactions, or excessive irritability.
Nonverbal Communication (Body Language)
Note the patient’s posture, eye contact, and facial expression. Some cultural groups will not maintain eye contact with you. Slumped posture and a lack of facial expression may indicate depression or a neurologic condition such as Parkinson disease. Excessively energetic movements or constantly watchful eyes suggest tension, mania, anxiety, a metabolic disorder, or the effects of recreational or prescription drug use (e.g., methamphetamine, amphetamine salts, cocaine, and steroids).
State of Consciousness
The patient should be oriented to person, place, and time and make appropriate responses to questions, as well as physical and environmental stimuli. Person disorientation results from cerebral trauma, seizures, or amnesia. Place disorientation occurs with psychiatric disorders, delirium, and cognitive impairment. Time disorientation is associated with anxiety, delirium, depression, and cognitive impairment. See Table 7.1 for potential causes of unresponsiveness. The Glasgow Coma Scale is used to quantify the level of consciousness after an acute brain injury or medical condition (see Chapter 26 ).
| TYPE OF DISORDER | CAUSE |
|---|---|
| Focal lesions of the brain | Hemorrhage, hematoma, infarction, tumor, abscess, trauma |
| Diffuse brain disease | Drug intoxications |
| Disturbances of glucose, sodium, or calcium metabolism, renal failure, myxedema, pulmonary insufficiency | |
| Hypothermia, hyperthermia | |
| Hypoxic or anoxic event such as strangulation, drowning, cardiac arrest, pulmonary embolism | |
| Encephalitis, meningitis | |
| Seizures | |
| Psychogenic unresponsiveness | Dementia |
Cognitive Abilities
Evaluate cognitive functions as the patient responds to questions during the history-taking process. Specific questions and tasks can provide a detailed assessment of cognition, the execution of complex mental processes (e.g., learning, perceiving, decision making, and memory). See tools (e.g., Montreal Cognitive Assessment and miniCog) later in the chapter to assess cognitive function in older adults if quantification of cognitive function is needed.
Signs of possible cognitive impairment include the following: significant memory loss, confusion (impaired cognitive function with disorientation, attention and memory deficits, and difficulty answering questions or following multiple-step directions), impaired communication, inappropriate affect, personal care difficulties, hazardous behavior, agitation, and suspiciousness (see Clinical Pearl, “The Importance of Validation” ).
Interview a family member or friend of the patient if you have any concerns about a patient’s responses or behavior. Determine whether the patient has any problems remembering appointments or important events, paying bills, shopping independently for food or clothing, preparing meals, taking medication, getting lost while walking or driving, making decisions about daily life, or asking the same thing again and again.
Analogies
Ask the patient to describe simple analogies first and then more complex analogies:
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What is similar about these objects: Peaches and lemons? Ocean and lake? Trumpet and flute?
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Complete this comparison: An engine is to an airplane as an oar is to a ____.
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What is different about these two objects: A magazine and a cookbook? A bush and a tree?
Correct responses should be given when the patient has average intelligence. An inability to describe similarities or differences may indicate a lesion of the left or dominant cerebral hemisphere.
Abstract Reasoning
Ask the patient to tell you the meaning of a fable, proverb, or metaphor, such as the following:
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A stitch in time saves nine.
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A bird in the hand is worth two in the bush.
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A rolling stone gathers no moss.
When the patient has average intelligence, an adequate interpretation should be given. Inability to explain a phrase may indicate poor cognition, dementia, brain damage, or schizophrenia.
Arithmetic Calculation
Ask the patient to do simple arithmetic, without paper and pencil, such as the following:
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Subtract 7 from 50, subtract 7 from that answer, and so on, until the answer is 8.
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Add 8 to 50, add 8 to that total, and so on, until the answer is 98.
The calculations should be completed with few errors and within 1 minute when the patient has average intelligence. Impairment of arithmetic skills may be associated with depression, cognitive impairment, and diffuse brain disease.
Writing Ability
For a comprehensive mental status examination, ask the patient to write his or her name and address or a dictated phrase. Omission or addition of letters, syllables, words, or mirror writing may indicate aphasia (impairment in language function). Alternatively, if poor literacy is a concern, ask the patient to draw simple geometric figures (e.g., a triangle, circle, or square) and then more complex figures such as a clock face, a house, or a flower. Uncoordinated writing or drawing may indicate dementia, parietal lobe damage, a cerebellar lesion, or peripheral neuropathy.
Execution of Motor Skills
Ask the patient to unbutton a shirt button or to comb his or her hair. Apraxia (the inability to translate an intention into action that is unrelated to paralysis or lack of comprehension) may indicate a cerebral disorder.
Memory
Immediate recall or new learning: Ask the patient to listen and then repeat a sentence or a series of numbers. Five to eight numbers forward or four to six numbers backward can usually be repeated.
Recent memory: Give the patient a short time to view four or five test objects, telling him or her that you will ask about them in a few minutes. Ten minutes later, ask the patient to list the objects. All objects should be remembered. See Clinical Pearl, “Testing Memory in the Visually Impaired.”
Remote memory: Ask the patient about verifiable past events or information such as sibling’s name, high school attended, or a subject of common knowledge.
Memory loss may result from disease, infection, or temporal lobe trauma. Impaired memory occurs with various neurologic or psychiatric disorders, such as anxiety and depression. Loss of immediate and recent memory with retention of remote memory suggests dementia.
When a patient is visually impaired, test recent memory with unrelated words rather than observed objects. Pick four unrelated words that sound distinctly different, such as “green,” “daffodil,” “hero,” and “sofa” or “bird,” “carpet,” “treasure,” and “orange.” Tell the patient to remember these words. After 5 minutes, ask the patient to list the four words.
Attention Span
Ask the patient to follow a short set of commands. Alternatively, ask the patient to say either the days of the week or to spell the word “world” forward or backward. The ability to perform arithmetic calculations is another test of attention span. Appropriate response to directions is expected. Easy distraction, confusion, negativism, and impairment of recent and remote memory may all indicate a decreased attention span. This may be related to fatigue, depression, delirium, or toxic or metabolic causes that result in confusion.
Judgment
Determine the patient’s judgment and reasoning skills by exploring the following topics:
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How is the patient meeting social and family obligations?
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What are the patient’s plans for the future? Do they seem appropriate?
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Ask the patient to provide solutions to hypothetical situations, such as: “What would you do if you found a stamped envelope?” “What would you do if a police officer gave you a ticket after you drove through a red light?”
If the patient is meeting social and family obligations and adequately dealing with financial obligations, judgment is considered intact. The patient should be able to evaluate the situations presented and recognize the consequences of action. Impaired judgment may indicate intellectual disability, emotional disturbance, frontal lobe injury, dementia, or psychosis.
Speech and Language Skills
Detailed evaluation of the patient’s communication skills, both receptive and expressive, should be performed if the patient has difficulty communicating during the history. The patient’s voice should have inflections, be clear and strong, and be able to increase in volume. Determine whether the patient’s rate of speech is excessively fast or slow, normal, or has hesitations. Speech should be fluent with clear expression of thoughts.
Voice Quality
Determine whether there is any difficulty or discomfort in phonation, or if laryngeal speech sounds are present. Dysphonia, a disorder of voice volume, quality (e.g., harsh, nasal, or breathy), or pitch (e.g., monotony of pitch or loudness), suggests a problem with laryngeal innervation or disease of the larynx.
Articulation
Evaluate spontaneous speech for pronunciation and ease of expression. Abnormal articulation includes imprecise pronunciation of consonants, slurring, difficulty articulating a single speech sound, hesitations, repetitions, and stuttering. Dysarthria, a motor speech disorder, is associated with many conditions of the nervous system such as stroke, inebriation, cerebral palsy, and Parkinson disease.
Comprehension
Ask the patient to follow simple one- and two-step directions during the examination, such as during the attention span assessment. The patient should be able to follow simple instructions.
Coherence
The patient’s intentions or perceptions should be clearly conveyed to you. Communication characteristics that may be associated with a psychiatric disorder include the following:
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Circumlocution—pantomime or word substitution to avoid revealing that a word was forgotten
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Perseveration—repetition of a word, phrase, or gesture
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Flight of ideas or use of loose associations—disordered words or sentences
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Word salad—meaningless, disconnected word choices
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Neologisms—made-up words that have meaning only to the patient
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Clang association—word choice based on sound so that words rhyme in a nonsensical way (e.g., The far car mar to the star)
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Echolalia—Repetition of another person’s words
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Utterances of unusual sounds
Aphasia, a speech disorder that can be receptive (understanding language) or expressive (speaking language), may be indicated by hesitations and other speech rhythm disturbances, omission of syllables or words, word transposition, circumlocutions, and neologisms. Aphasia can result from facial muscle or tongue weakness or from neurologic damage to brain regions controlling speech and language. Characteristics of different types of aphasia are listed in the Differential Diagnosis box following this section.
Emotional Stability
Emotional stability is evaluated when the patient does not seem to be coping well or does not have resources to meet his or her personal needs.
Mood and Feelings
During the history and physical examination, observe the mood and emotional expression evident from the patient’s verbal and nonverbal behaviors. Note any mood swings or behaviors indicating anxiety, depression, anger, hostility, or hypervigilance.
Ask the patient how he or she feels right now, whether feelings are a problem in daily life, and whether any time or experience is particularly difficult for the patient. The U.S. Preventive Health Task Force recommends depression screening of adults with the self-administered Patient Health Questionnaire (PHQ) ( Siu and U.S. Preventive Health Task Force, 2016 ). Two- and a nine-item versions of the PHQ exist. The PHQ-2 has two questions with a reported sensitivity of 96% and specificity of 57% ( Snyderman and Rovner, 2009 ):
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Over the past 2 weeks, have you felt down, depressed, or hopeless?
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Over the past 2 weeks, have you felt little interest or pleasure in doing things?
If the response is positive to both questions perform the PHQ-9 or ask more questions about depression symptoms, such as trouble sleeping or sleeping too much, moving too slow or restlessness, poor appetite or overeating, poor concentration, feeling like a failure, or thoughts of hurting yourself. The PHQ-9 has good sensitivity and specificity for identifying a major depressive disorder ( Manea et al, 2012 ). This tool has been translated into several languages. See www.phqscreeners.com for full access to the PHQ-9.
Be concerned if the patient does not express appropriate feelings that correspond to the situation. For example, does the patient laugh when talking about a seriously ill family member? Unresponsiveness, hopelessness, agitation, aggression, anger, euphoria, irritability, or wide mood swings indicate disturbances in mood, affect, and feelings.
Identify the potential for suicide, particularly if the patient has signs of depression or risk factors for suicide could be present. See Risk Factors : Suicide. Two questions on the Columbia-Suicide Severity Risk Screener (C-SSRS) help identify the patient at higher risk for suicide ideation and behavior:
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Have you wished you were dead or wished you could go to sleep and not wake up?
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Have you actually had any thoughts of killing yourself?
