What is the proper procedure for conducting a mental status examination?

Mental Status Examination: Procedure and Implementation

Initial Approach and Patient Communication

Begin the mental status examination by explaining to the patient: "I'd like to ask you some questions to assess your thinking and memory. This is a standard part of our evaluation that helps us provide the best care for you." 1

• Clarify that this is routine medical evaluation, not an indication of suspected pathology, to reduce patient anxiety and establish rapport 1
• Ensure a comfortable, nonjudgmental environment without family member input or other distractions to avoid affecting examination results 2
• Maintain confidentiality throughout to facilitate honest responses, especially regarding sensitive topics like suicidal ideation 1

Core Components to Systematically Assess

General Appearance and Behavior

• Evaluate nutritional status, coordination, and gait as indicators of neurological function 1, 3
• Assess for involuntary movements or abnormalities of motor tone 3
• Examine skin for signs of trauma, self-injury, or substance use 3

Speech Assessment

• Evaluate fluency and articulation as indicators of cognitive and neurological function 1, 3

Mood and Affect

• Assess current mood state and level of anxiety 1, 3
• Document presence of hopelessness, as this is critical for suicide risk assessment 1, 3
• Screen for suicidal ideation, including both active and passive thoughts of suicide or death 3

Thought Process and Content

• Evaluate organization, coherence, and logical flow of thoughts 1, 3
• Screen for aggressive or psychotic ideas 3
• Assess for specific plans if suicidal or aggressive ideation is present 1

Perception and Cognition

• Screen for hallucinations or delusions 1
• Assess orientation to person, place, time, and situation 3
• Evaluate memory (both short-term and long-term) and executive functioning 3
• Test sensory function including sight and hearing 3

Validated Cognitive Screening Tools

For Brief Screening (2-3 minutes)

Use the Mini-Cog as the first-line brief screening tool, which has 76% sensitivity and 89% specificity for possible dementia and is endorsed by the Alzheimer's Association for primary care settings. 4, 1

The Mini-Cog consists of three steps: 4

1. Present 3 unrelated words and ask the patient to repeat and remember them (can repeat up to 3 times)
2. Instruct the patient to draw a clock face with numbers and set the hands to "10 past 11"
3. Ask the patient to recall the 3 words

• Score 1 point for each word recalled correctly and 0 or 2 points for the clock draw 4
• A score less than 3 is concerning for possible dementia 4
• This tool is validated in heterogeneous populations, available in multiple languages, and can be administered by any trained healthcare team member 4

For Comprehensive Assessment (10-15 minutes)

Use the Montreal Cognitive Assessment (MoCA), St. Louis University Mental Status Examination (SLUMS), or Short Test of Mental Status (STMS) when more detailed evaluation is needed 4, 1, 3

Alternative Tools for Special Populations

• Use the Memory Impairment Screen for patients with motor disabilities that prevent clock drawing 4
• Use the Picture-Based Memory Impairment Screen to overcome educational and cultural limitations 4
• Consider the AD8 (Eight-Item Informant Interview) when the patient does not wish to participate directly 4

Context-Specific Implementation

Primary Care Setting

• Structured tools increase detection of cognitive impairment by two- to threefold compared to unaided detection 4
• Any trained healthcare team member, including nurses and physician assistants, can successfully complete objective assessments 4
• Most emergency physicians take less than 5 minutes to evaluate mental status 5

Emergency Department Setting

First rule out medical causes of altered mental status, ensure the patient undergoes a personal belongings search, and place them in a safe setting with close supervision. 1

• Focus on seven major areas: affect, attention, language, orientation, memory, visual-spatial ability, and conceptualization 6

Specialty Settings

• Use more comprehensive tools that provide specific domain scores (attention, memory, language, etc.) 1
• Consider Addenbrooke's Cognitive Examination (ACE-III) or Frontal Assessment Battery (FAB) for detailed evaluation 1

Interpretation and Follow-Up

Scores on any assessment are not a diagnosis per se and must be interpreted in the context of a comprehensive evaluation of the patient. 4

• A "normal" score does not necessarily exclude subtle impairment or substantial functional/behavioral problems 4
• When impairment is noted, obtain comprehensive medical history focusing on cognitive function, behavior/neuropsychiatric status, ADLs, medications, medical comorbidities (including neurologic and psychiatric conditions), and laboratory testing 4
• Consider neuropsychological evaluation to establish extent and severity of cognitive impairment objectively and track progression over time 4

Critical Pitfalls to Avoid

• Do not ignore patient characteristics such as native language, education level, and age, as these can significantly affect test performance 4, 3
• Avoid failing to consider cultural factors that may influence the patient's presentation and responses 1, 3
• Do not overlook subtle signs of cognitive impairment in high-functioning individuals 3
• Avoid not obtaining collateral information when available and necessary, especially when evaluating patients with potential cognitive impairment 3
• Be aware that the Mini-Mental Status Exam (MMSE), while widely used, has limited effectiveness for detecting MCI in earlier stages, lacks standardization, is highly susceptible to socioeconomic factors, and is subject to user fees 4