Please provide a concise script for a mental status examination that assesses orientation, attention/concentration, memory, knowledge/fund of information, reading and writing ability, abstract/concrete thinking, visuospatial ability, insight, and judgement in adults, especially older adults when dementia is suspected.

Mental Status Examination Script for Psychiatric Assessment

Orientation Assessment

Begin by assessing orientation to person, place, time, and situation in a conversational manner:

• Ask the patient to state their full name, current location (building, city, state), today's date (day, month, year), and current season 1
• For place orientation, ask "What is the name of this facility?" and "What city are we in?" 1
• Document any errors or hesitations, as disorientation—particularly to time and place—is an early indicator of cognitive impairment 1

Attention and Concentration

Test sustained attention and working memory using standardized tasks:

• Digit span forward and backward: Ask the patient to repeat increasingly longer sequences of numbers (start with 3 digits forward, then 4-5 digits; then 2-3 digits backward) 1
• Serial 7s or serial 3s: Ask the patient to subtract 7 from 100 repeatedly (100,93,86,79,72,65) or subtract 3 from 20 if education level is lower 1
• Spell "WORLD" backward: A quick alternative attention task that takes less than 30 seconds 1
• Note: Impaired attention may indicate delirium, depression, or frontal-executive dysfunction rather than primary dementia 1, 2

Memory Assessment

Evaluate both immediate recall, short-term memory, and long-term memory systematically:

• Immediate recall (registration): Present 3 unrelated words (e.g., "apple, table, penny") and ask the patient to repeat them immediately; you may repeat up to 3 times for encoding 1
• Delayed recall: After 3-5 minutes of intervening tasks (during which you assess other domains), ask the patient to recall the 3 words without prompting 1
• Cued recall: If the patient cannot recall spontaneously, provide category cues (e.g., "one was a fruit") 1
• Long-term memory: Ask about verifiable personal historical events (e.g., wedding date, children's birthdates) or major historical events (e.g., recent presidents, major news events) 1, 2
• Anterograde amnesia (inability to form new memories) is the hallmark of Alzheimer disease, while difficulty with both encoding and retrieval suggests other etiologies 3

Knowledge and Fund of Information

Assess general knowledge appropriate to the patient's educational and cultural background:

• Ask the patient to name the current president, previous president, or major current events 1
• Request naming of 5 large cities, state capitals, or countries 2
• Ask simple calculation questions: "How many nickels are in $1.35?" or "If you buy something for $3.75 and pay with a $5 bill, how much change do you get?" 1
• Critical caveat: Always interpret performance in the context of the patient's education level, cultural background, and primary language, as these significantly affect performance 1

Capacity to Read and Write

Evaluate language production and comprehension through reading and writing tasks:

• Reading comprehension: Present a written command (e.g., "Close your eyes" or "Pick up the paper, fold it in half, and place it on the floor") and ask the patient to read it silently and follow the instruction 1
• Writing: Ask the patient to write a complete sentence about any topic (must have a subject and verb and make sense) 1
• Naming: Ask the patient to name common objects you point to (e.g., watch, pen, parts of the watch like "wristband" or "buckle") to assess confrontation naming 1
• Impaired reading/writing with preserved other cognitive functions suggests primary progressive aphasia or focal left-hemisphere pathology 1, 3

Abstract vs. Concrete Thinking

Distinguish between abstract reasoning ability and concrete, literal thinking:

• Proverb interpretation: Ask the patient to explain common proverbs (e.g., "A rolling stone gathers no moss" or "Don't cry over spilled milk") 1
  • Abstract response: Explains the general principle or metaphorical meaning
  • Concrete response: Interprets literally (e.g., "A stone that rolls won't have moss on it")
• Similarities: Ask "How are an apple and an orange alike?" (abstract: "both are fruits"; concrete: "both are round") 1
• Differences: Ask "What is the difference between a lie and a mistake?" 1
• Loss of abstraction with preserved concrete thinking suggests frontal-executive dysfunction or frontotemporal dementia 3

Visuospatial Ability

Assess visuospatial perception, construction, and spatial orientation:

• Clock Drawing Test: Provide a pre-drawn large circle and ask the patient to "fill in the numbers of a clock face" and then "set the hands to show 10 past 11" (or "11:10") 1, 4
  • Score: 2 points for correct clock (all numbers in correct positions, hands pointing to 11 and 2), 0 points for any errors 1
• Three-dimensional figure copy: Ask the patient to copy intersecting pentagons or a cube 1
• Line bisection or cancellation tasks: Present a page with multiple lines or letters and ask the patient to mark the center of each line or cross out all instances of a target letter to screen for visual neglect 1
• Visuospatial deficits occur early in Lewy body dementia and posterior cortical atrophy variant of Alzheimer disease 3

Insight Assessment

Evaluate the patient's awareness of their cognitive difficulties and need for help:

• Ask directly: "Do you think you have any problems with your memory or thinking?" 2, 4
• Follow up: "How do these problems affect your daily life?" 2
• Compare the patient's self-report with the informant's report of cognitive and functional decline 1, 4
• Anosognosia (lack of awareness of deficits) is common in moderate-to-severe dementia and frontotemporal dementia, and predicts poorer outcomes and safety risks 1, 2
• Document whether insight is intact, partially impaired, or absent 1

Judgment Assessment

Evaluate decision-making capacity and safety awareness through hypothetical scenarios:

• Fire safety: "What would you do if you woke up in the middle of the night and smelled smoke?" (appropriate: call 911, leave the building, alert others) 1
• Found wallet: "If you found a stamped, addressed envelope on the ground, what would you do with it?" (appropriate: mail it or take it to post office) 1
• Financial judgment: "If someone called you and said you won a prize but needed to send money first, what would you do?" 2
• Assess real-world judgment by asking about recent decisions regarding finances, medication management, driving, or living situation 1, 4
• Impaired judgment with preserved other cognitive functions suggests frontal-executive dysfunction or behavioral variant frontotemporal dementia 3

Integration and Documentation

Synthesize findings to characterize the cognitive-behavioral syndrome:

• Compare performance across all domains to identify patterns: amnestic (memory predominant), dysexecutive (attention/executive predominant), language-predominant, or multi-domain impairment 1, 3
• Document whether deficits represent a decline from the patient's baseline functioning based on informant history 1, 4
• Note any discrepancies between patient self-report and informant report, which has prognostic significance 4
• Consider whether performance is affected by depression, anxiety, delirium, sensory deficits (hearing/vision loss), low education, language barriers, or medication effects before attributing deficits to dementia 1, 2