Está en la página 1de 14

History and Mental Status Examination

Author: Guy E Brannon, MD; Chief Editor: David Bienenfeld, MD .et.al

Appearance
Record the patient's sex, age, race, and ethnic background. Document the patient's nutritional status by observing the patient's current body weight and appearance. Remember recording the exact time and date of this interview is important, especially since the mental status can change over time such as in delirium. Recall how the patient first appeared upon entering the office for the interview. Note whether this posture has changed. Note whether the patient appears more relaxed. Record the patient's posture and motor activity. If nervousness was evident earlier, note whether the patient still seems nervous. Record notes on grooming and hygiene. Most of these documentations on appearance should be a mere transfer from mind to paper because mental notes of the actual observations were made when the patient was first encountered. Record whether the patient has maintained eye contact throughout the interview or if he or she has avoided eye contact as much as possible, scanning the room or staring at the floor or the ceiling.

Attitude toward the examiner


Next, record the patient's facial expressions and attitude toward the examiner. Note whether the patient appeared interested during the interview or, perhaps, if the patient appeared bored. Record whether the patient is hostile and defensive or friendly and cooperative. Note whether the patient seems guarded and whether the patient seems relaxed with the interview process or seems uncomfortable. This part of the examination is based solely on observations made by the health care professional.

Mood
The mood of the patient is defined as "sustained emotion that the patient is experiencing." Ask questions such as "How do you feel most days?" to trigger a response. Helpful answers include those that specifically describe the patient's mood, such as "depressed," "anxious," "good," and "tired." Elicited responses that are less helpful in determining a patient's mood adequately include "OK," "rough," and "don't know." These responses require further questioning for clarification. Establishing accurate information pertaining to the length of a particular mood, if the mood has been reactive or not, and if the mood has been stable or unstable also is helpful.

Affect
A patient's affect is defined in the following terms: expansive (contagious), euthymic (normal), constricted (limited variation), blunted (minimal variation), and flat (no variation). A patient whose mood could be defined as expansive may be so cheerful and full of laughter that it is difficult to refrain from smiling while conducting the interview. A patient's affect is determined by the observations made by the interviewer during the course of the interview.

Speech
Document information on all aspects of the patient's speech, including quality, quantity, rate, and volume of speech during the interview. Paying attention to patients' responses to determine how to rate their speech is important. Some things to keep in mind during the interview are whether patients raise their voice when responding, whether the replies to questions are one-word answers or elaborative, and how fast or slow they are speaking.

Thought process
Record the patient's thought process information. The process of thoughts can be described with the following terms: looseness of association (irrelevance), flight of ideas (change topics), racing (rapid thoughts), tangential (departure from topic with no return), circumstantial (being vague, ie, "beating around the bush"), word salad (nonsensical responses, ie, jabberwocky), derailment (extreme irrelevance), neologism (creating new words), clanging (rhyming words), punning (talking in riddles), thought blocking (speech is halted), and poverty (limited content). Throughout the interview, very specific questions will be asked regarding the patient's history. Note whether the patient responds directly to the questions. For example, when asking for a date, note whether the response given is about the patient's favorite color. Document whether the patient deviates from the subject at hand and has to be guided back to the topic more than once. Take all of these things in to account when documenting the patient's thought process.

Thought content
To determine whether or not a patient is experiencing hallucinations, ask some of the following questions. "Do you hear voices when no one else is around?" "Can you see things that no one else can see?" "Do you have other unexplained sensations such as smells, sounds, or feelings?" Importantly, always ask about command-type hallucinations and inquire what the patient will do in response to these commanding hallucinations. For example, ask "When the voices tell you do something, do you obey their instructions or ignore them?" Types of hallucinations include auditory (hearing things), visual (seeing things), gustatory (tasting things), tactile (feeling sensations), and olfactory (smelling things). To determine if a patient is having delusions, ask some of the following questions. "Do you have any thoughts that other people think are strange?" "Do you have any special powers or abilities?" "Does the television or radio give you special messages?" Types of delusions include grandiose (delusions of grandeur), religious (delusions of special status with God), persecution (belief that someone wants to cause them harm), erotomanic (belief that someone famous is in love with them), jealousy (belief that everyone wants what they have), thought insertion (belief that someone is putting ideas or thoughts into their mind), and ideas of reference (belief that everything refers to them). Aspects of thought content are as follows: Obsession and compulsions: Ask the following questions to determine if a patient has any obsessions or compulsions. "Are you afraid of dirt?" "Do you wash your hands often or count things over and over?" "Do you perform specific acts to reduce certain thoughts?" Signs of ritualistic type behaviors should be explored further to determine the severity of the obsession or compulsion. Phobias: Determine if patients have any fears that cause them to avoid certain situations. The following are some possible questions to ask. "Do you have any fears, including fear of animals, needles, heights, snakes, public speaking, or crowds?" Suicidal ideation or intent: Inquiring about suicidal ideation at each visit is always important. In addition, the interviewer should inquire about past acts of self-harm or violence. Ask the following types of questions when determining suicidal ideation or intent. "Do you have any thoughts of wanting to harm or kill yourself?" "Do you have any thoughts that you would be better off dead?" If the reply is positive for these thoughts, inquire about specific plans, suicide notes, family history (anniversary reaction), and impulse control. Also, ask how the patient views suicide to determine if a suicidal gesture or act is egosyntonic or ego-dystonic. Next, determine if the patient will contract for safety. For homicidal ideation, make similar inquiries. Homicidal ideation or intent: Inquiring about homicidal ideation or intent during each patient interview also is important. Ask the following types of questions to help determine homicidal ideation or intent. "Do you have any thoughts of wanting to hurt anyone?" "Do you have any feelings or thoughts that you wish someone were dead?" If the reply to one of these questions is positive, ask the patient if he or she has

any specific plans to injure someone and how he or she plans to control these feelings if they occur again. Sensorium and cognition: Perform the Folstein Mini-Mental State Examination. Consciousness: Levels of consciousness are determined by the interviewer and are rated as (1) coma, characterized by unresponsiveness; (2) stuporous, characterized by response to pain; (3) lethargic, characterized by drowsiness; and (4) alert, characterized by full awareness. Orientation: To elicit responses concerning orientation, ask the patient questions, as follows. "What is your full name?" (ie, person). "Do you know where you are?" (ie, place). "What is the month, date, year, day of the week, and time?" (ie, time). "Do you know why you are here?" (ie, situation). Concentration and attention: Ask the patient to subtract 7 from 100, then to repeat the task from that response. This is known as "serial 7s." Next, ask the patient to spell the word "world" forward and backward. Reading and writing: Ask the patient to write a simple sentence (noun/verb). Then, ask patient to read a sentence (eg, "Close your eyes."). This part of the MSE evaluates the patient's ability to sequence. Visuospatial ability: Have the patient draw interlocking pentagons in order to determine constructional apraxia. Memory: To evaluate a patient's memory, have them respond to the following prompts. "What was the name of your first grade teacher?" (ie, for remote memory). "What did you eat for dinner last night?" (ie, for recent memory). "Repeat these 3 words: 'pen,' 'chair,' 'flag.' " (ie, for immediate memory). Tell the patient to remember these words. Then, after 5 minutes, have the patient repeat the words. Abstract thought: Assess the patient's ability to determine similarities. Ask the patient how 2 items are alike. For example, an apple and an orange (good response is "fruit"; poor response is "round"), a fly and a tree (good response is "alive"; poor response is "nothing"), or a train and a car (good response is "modes of transportation"). Assess the patient's ability to understand proverbs. Ask the patient the meaning of certain proverbial phrases. Examples include the following. "A bird in the hand is worth 2 in the bush" (good response is "be grateful for what you already have"; poor response is "one bird in the hand"). "Don't cry over spilled milk" (good response is "don't get upset over the little things"; poor response is "spilling milk is bad"). General fund of knowledge: Test the patient's knowledge by asking a question such as, "How many nickels are in $1.15?" or asking the patient to list the last 5 presidents of the United States or to list 5 major US cities. Obviously, a higher number of correct answers is better; however, the interviewer always should take into consideration the patient's educational background and other training in evaluating answers and assigning scores. Intelligence: Based on the information provided by the patient throughout the interview, estimate the patient's intelligence quotient (ie, below average, average, above average).

Insight
Assess the patients' understanding of the illness. To assess patients' insight to their illness, the interviewer may ask patients if they need help or if they believe their feelings or conditions are normal.

Judgment
Estimate the patient's judgment based on the history or on an imaginary scenario. To elicit responses that evaluate a patient's judgment adequately, ask the following question. "What would you do if you smelled smoke in a crowded theater?" (good response is "call 911" or "get help"; poor response is "do nothing" or "light a cigarette").

Impulsivity
Estimate the degree of the patient's impulse control. Ask the patient about doing things without thinking or planning. Ask about hobbies such as coin collecting, golf, skydiving, or rock climbing.

Reliability
Estimate the patient's reliability. Determine if the patient seems reliable, unreliable, or if it is difficult to determine. This determination requires collateral information of an accurate assessment, diagnosis, and treatment.

Confidentiality Health care professionals should discuss with the patient what can and cannot be kept confidential based on both legal and ethical considerations. In most cases, patients must give permission to release information and their medical records. The exception to confidentiality is cases of suicidal and homicidal ideations. With regard to child abuse and abuse of elderly people, Clinicians are mandatory reporters of abuse and must do so if abuse is suspected.

Admission types Note the following admission types: Informal voluntary: These are patients admitted to the hospital but who are free to leave at any time, even against medical advice. Formal voluntary: These are patients admitted to the hospital who can leave the hospital only when discharged by the physician. Requests to leave the hospital may be made by the patient, but they must be made in writing. During a specific period of time, the person is evaluated by the physician and is either released or committed (ie, changed to involuntary type of admission for further evaluation and treatment). Involuntary: Patients not recognizing their need for hospitalization may be placed in the hospital to ensure the safety of themselves or others or because they are considered gravely disabled. Before patients are admitted under this type of admission, they are evaluated by a physician and, if deemed necessary, admitted for safety reasons. Patients are then evaluated by a second physician. Both physicians must agree to keep a patient in the hospital. The judicial system may place someone in the hospital for treatment, but generally, patients are kept in the hospital under the least restrictive measure to receive treatment. Patients do have the right to file a "writ of habeas corpus," a legal procedure to allow the courts to decide if a patient has been hospitalized without due process of law. Seclusion (empty room for safety) and restraint (device to restrict patient's movement for safety) procedures The American Psychiatric Association task force on seclusion and restraint provides guidelines for these procedures. Become familiar with local laws and hospital rules regarding the use of these procedures. Informed consent procedures Written or at least verbal confirmation, with documentation in the medical record, of informed consent must be obtained before performing a procedure or administering a medication. The patient must be competent to discuss the risks, benefits, alternatives, and adverse effects of a procedure or medication. A competent adult may refuse treatment. If a patient is not competent to give informed consent, a guardian may give consent or the court may rule about administering a procedure or medication to ensure the safety of the patient or others.

Mental Status Examination in Primary Care: A Review


DANIELLE SNYDERMAN, MD, and BARRY W. ROVNER, MD, Thomas Jefferson University, Jefferson Medical College, Philadelphia, Pennsylvania
Am Fam Physician. 2009 Oct 15;80(8):809-814. This article exempifies the AAFP 2009 Annual Clinical Focus on management of chronic illness.

The mental status examination is an essential tool that aids physicians in making psychiatric diagnoses. Familiarity with the components of the examination can help physicians evaluate for and differentiate psychiatric disorders. The mental status examination includes historic report from the patient and observational data gathered by the physician throughout the patient encounter. Major challenges include incorporating key components of the mental status examination into a routine office visit and determining when a more detailed examination or referral is necessary. A mental status examination may be beneficial when the physician senses that something is not quite right with a patient. In such situations, specific questions and methods to assess the patient's appearance and general behavior, motor activity, speech, mood and affect, thought process, thought content, perceptual disturbances, sensorium and cognition, insight, and judgment serve to identify features of various psychiatric illnesses. The mental status examination can help distinguish between mood disorders, thought disorders, and cognitive impairment, and it can guide appropriate diagnostic testing and referral to a psychiatrist or other mental health professional.

Although it is unrealistic to routinely perform a comprehensive mental status examination (MSE) in a single primary care office visit, incorporating key components of a formal MSE when the physician senses that something is not quite right with the patient can help the physician identify psychiatric illnesses, follow up as needed for more extensive evaluation, and make referrals when necessary. The examination can also help distinguish mood disorders, thought disorders, and cognitive impairment. Key components of the MSE are summarized in Table 1. 1,2 1 4

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendations The mental status examination can help distinguish mood disorders, thought disorders, and cognitive impairment. The USPSTF cites insufficient evidence to recommend for or against screening for cognitive impairment (dementia). The USPSTF recommends screening adults for depression in clinical practices that have systems in place to assure accurate diagnosis, effective treatment, and follow-up.
USPSTF = U.S. Preventive Services Task Force.

Evidence rating C C A

References 1,2 8 8

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.xml.

TABLE 1.

Components of the Mental Status Examination

Component Appearance and general behavior

Elements to assess Body habitus, grooming habits, interpersonal style, degree of eye contact, how the patient looks compared with his or her age Appearance: wellgroomed, immaculate, attention to detail, unkempt, distinguishing features (e.g., scars, tattoos), ill- or wellappearing Eye contact: good, fleeting, sporadic, avoided, none General behavior: congenial, cooperative, open, candid, engaging, relaxed, withdrawn, guarded, hostile, irritable, resistant, shy, defensive Motor activity Body posture and movement, facial expressions Akathisia (restlessness), psychomotor agitation: excessive motor activity may include pacing, wringing of hands, inability to sit still Bradykinesia, psychomotor retardation: generalized slowing of physical and emotional reactions Catatonia: neurologic condition leading to psychomotor retardation; immobility with muscular rigidity or inflexibility; may present in excited forms, including excessive motor activity Speech Quantity: talkative, expansive, paucity, poverty (alogia) Rate: fast, pressured, slow, normal

Potential illnesses Disheveled appearance may suggest schizophrenia Provocative dress may suggest bipolar disorder Unkempt appearance may suggest depression, psychosis

Sample questions

Poor eye contact may occur with psychotic disorders Paranoid, psychotic patients may be guarded Irritability may occur in patients with anxiety

Parkinsonism, schizophrenia, severe major depressive disorder, posttraumatic stress disorder, anxiety, medication effect (e.g., depression), drug overdose or withdrawal, anxiety Symptoms may develop within weeks of starting or increasing dosages of antipsychotic agents Tendency toward exaggerated movements occurs in the manic phase of bipolar disorder and with anxiety

Schizophrenia; substance abuse; depression; bipolar disorder; anxiety; medical conditions

Component

Elements to assess Volume and tone: loud, soft, monotone, weak, strong, mumbled Fluency and rhythm: slurred, clear, hesitant, aphasic Coherent/incoherent Affect: physician's objective observation of patient's expressed emotional stateMood: patient's subjective report of emotional state

Mood and affect

Potential illnesses affecting speech, such as cerebrovascular accident, Bell palsy, poorly fitting dentures, laryngeal disorders, multiple sclerosis, amyotrophic lateral sclerosis Depression, bipolar disorder, anxiety, schizophrenia

Sample questions

Thought process

Form of thinking, flow of thought

Thought content

What the patient is thinking about

Anxiety, depression, schizophrenia, dementia, delirium, substance abuse Obsessions, phobias, delusions (e.g., schizophrenia, alcohol or drug intoxication), suicidal or homicidal thoughts

How are your spirits? How would you describe your mood? Have you felt discouraged/low/blue lately? Have you felt angry/irritable/on edge lately? Have you felt energized/high/out of control lately?

Perceptual Hallucinations disturbances

Obsessions: Do you have intrusive thoughts or images that you can't get out of your head? Phobias: Do you have an irrational or excessive fear of something? Delusions: Do you think people are stealing from you? Are people talking behind your back? Do you think you have special powers? Do you feel guilty, as if you committed a crime? Do you feel like you are a bad person? (Positive responses to last two questions may also suggest a psychotic depression) Suicidality: Do you ever feel that life is not worth living? Have you ever thought about cutting yourself? Have you ever thought about killing yourself? If so, how would you do it? Homicidality: Have you ever thought about killing others or getting even with those who have wronged you? Schizophrenia, severe Do you see things that upset you? unipolar depression, Do you ever bipolar disorder, see/feel/hear/smell/taste things that dementia, delirium, acute are not really there? If so, when

Component

Elements to assess

Potential illnesses intoxication and withdrawal Underlying medical conditions, dementia, delirium

Sensorium Sensorium: level and and cognition stability of consciousness Cognition: attention, concentration, memory Insight Patient's awareness and understanding of illness and need for treatment Judgment Patient's recognition of consequences of actions

Sample questions does it occur? Have you had any strange sensations in your body that others do not seem to have? See Tables 2 and 3

Bipolar disorder, What brings you here today? What schizophrenia, dementia, is your understanding of your depression problems? Do you think your thoughts and moods are abnormal? Bipolar disorder, What would you do if you found a schizophrenia, dementia stamped envelope on the sidewalk? Physician should adapt questions to clinical circumstances and patient's education level

Information from references 1 through 4.

Appearance and General Behavior


The MSE begins when the physician first encounters and observes the patient. How the patient interacts with the physician and the environment may reveal underlying psychiatric disturbances or clues signifying the patient's emotional and mental state. Collaborative observations from office staff may also be useful. If the physician has known the patient for some time, it may be helpful to acknowledge and document any changes that have occurred over time that may correlate with changes in mental health. Important observations of appearance may include the disheveled appearance of a patient with schizophrenia, the self-neglect of a patient with depression, or the provocative style of a patient with mania.
1

Motor Activity
Observations of motor activity include body posture; general body movement; facial expressions; gait; level of psychomotor activity; gestures; and the presence of dyskinesias, such as tics or tremors. Psychomotor retardation (a general slowing of physical and emotional reactions) may signify depression or negative symptoms of schizophrenia. Psychomotor agitation may occur with anxiety or mania. Changes in motor activity over time may correlate with progression of the patient's illness, such as increasing bradykinesia with worsening parkinsonism. In addition, changes in motor activity may be related to treatment response (e.g., parkinsonism secondary to an antipsychotic medication).
2 5

Speech
Observations of speech may include rate, volume, spontaneity, and coherence. Incoherent speech may be caused by dysarthria, poor articulation, or inaudibility. The form of speech is more important
2

than the content of speech in this portion of the examination, and may provide clues to associated disorders. For example, patients with mania may speak quickly, whereas patients with depression often speak slowly.

Mood and Affect


Mood is the patient's internal, subjective emotional state. Of note, this is one of the few elements of the MSE that rely on patient self-report in addition to physician observation. It is helpful to ask the patient to report his or her mood over the past few weeks, as opposed to merely asking about the moment. It may also be helpful to determine if mood remains constant over time or varies from visit to visit. Physicians may perform a more objective assessment by asking the patient at each visit to rate mood from 1 to 10 (with 1 being sad, and 10 being happy).
1

Affect is the physician's objective observation of the patient's expressed emotional state. Often, the patient's affect changes with his or her emotional state and can be determined by facial expressions, as well as interactions. Descriptors of affect may address emotional range (broad or restricted), intensity (blunted, flat, or normal), and stability. Affect may or may not be congruent with mood, such as when a patient laughs when talking about the recent death of a family member. Additionally, affect may not be appropriate for a given situation. For example, a patient with delusions of persecution may not seem frightened, as expected. Inappropriateness of affect occurs in some patients with schizophrenia.
1

Thought Process
Thought process can be used to describe a patient's form of thinking and to characterize how a patient's ideas are expressed during an office visit. Physicians may note the rate of thought (extremely rapid thinking is called flight of ideas) and flow of thought (whether thought is goaldirected or disorganized). Additional descriptors include whether thoughts are logical, tangential, circumstantial, and closely or loosely associated. Often, a patient's thought process can be described in relation to a continuum between goal-directed and disconnected thoughts. Incoherence of thought process is the lack of coherent connections between thoughts.
2 2

Thought Content
Thought content describes what the patient is thinking and includes the presence or absence of delusional or obsessional thinking and suicidal or homicidal ideas. If any of these thoughts are present, details regarding intensity and specificity should be obtained. More specifically, delusions are fixed, false beliefs that are not in accordance with external reality. Delusions can be distinguished from obsessions because persons who experience the latter recognize that the intrusiveness of their thoughts is not normal. Bizarre delusions that occur over a period of time often suggest schizophrenia and schizoaffective disorder, whereas acute delusions are more consistent with alcohol or drug intoxication.
3

Perceptual Disturbances

Hallucinations are perceptual disturbances that occur in the absence of a sensory stimulus. Hallucinations can occur in different sensory systems, including auditory, visual, olfactory, gustatory, tactile, or visceral. The content of the hallucination and the sensory system involved should be noted. Hallucinations are symptoms of a schizophrenic disorder, bipolar disorder, severe unipolar depression, acute intoxication, withdrawal from alcohol or illicit drug use, delirium, and dementia. Perceptual disturbances may be difficult to elicit during an office visit because patients may deny having hallucinations. The physician may conclude that hallucinations are present if the patient is responding to internal stimuli as if the patient is hearing somebody speaking to him or her.
2

Sensorium and Cognition


The evaluation of a patient's cognitive function is an essential component of the MSE. The assessment of sensorium includes the patient's level and stability of consciousness. A disturbance or fluctuation of consciousness may indicate delirium. Descriptors of a patient's level of consciousness include alert, clouded, somnolent, lethargic, and comatose. Elements of a patient's cognitive status include attention, concentration, and memory. Table 2 presents assessment tools for these and other elements of cognition. Attention and concentration can be assessed by asking the patient to spell world forward and backward, or to subtract serial sevens from 100. Another key element of cognition is the patient's memory. A deeper understanding of memory function and brain systems has served to refine and expand the classification of short- and long-term memory into four memory systems (Table 3). In the cognitive portion of the MSE, it is important that questions match the patient's education level and cultural background.
6

TABLE 2.

Assessment Tools for the Elements of Cognition


Cognitive element Language functions Visuospatial ability Abstract reasoning Executive functions General intellectual level/fund of knowledge Attention and concentration Memory Assessment tools Naming, reading, writing Copying a figure; drawing the face of a clock Explaining proverbs; describing similarities (e.g., comparing an apple to a pear) List making (e.g., name as many animals [or fruits or vegetables] as you can in one minute); drawing the face of a clock Identify the previous five presidents; physician must take into account the patient's education level and socioeconomic status; screen for mental retardation Spell world forward and backward, subtract serial sevens from 100 Mini-Cog, MMSE

Mini-Cog = Mini-Cognitive Assessment Instrument; MMSE = Mini-Mental State Examination.

TABLE 3.

Classification of Memory Systems

Memory type Episodic

Description Ability to recall personal experiences

Semantic

Ability to learn and store conceptual and factual information

Significance of deficit May be transient secondary to seizure, concussion, amnesia, medication use, hypoglycemia Also occurs with degenerative disorders, including Alzheimer disease, vascular dementia, dementia with Lewy bodies Most common with advanced Alzheimer disease

Examples Knowing what you had for breakfast, how you celebrated your last birthday

Procedural Ability to learn behavioral and cognitive skills that are used on an unconscious level

Working

Ability to temporarily maintain information

Most common with Parkinson disorders May also occur with Huntington disease, cerebrovascular accident, tumors, depression (secondary to effect on basal ganglia) May not be present in early Alzheimer disease Combination of attention, concentration, and short-term memory May occur with delirium

Knowing who is the president of the United States, how many planets are in the solar system Learning to ride a bike, play a musical instrument, swim

Remembering a list of seven words in order, a phone number

Information from reference 6.

A systematic approach to evaluating for cognitive impairment is helpful. The most commonly used method is the Mini-Mental State Examination (MMSE), which takes five to 10 minutes to administer. The MMSE has been validated and used extensively in practice and in research. In clinical practice, it is usually used to detect cognitive impairment in older patients. The MMSE includes 11 questions that test five areas of cognitive function: orientation, registration, attention and calculation, recall, and language. Using the MMSE as a screening instrument has not been supported because the specificity of screening tools is poor despite good sensitivity. Table 4 summarizes U.S. Preventive Services Task Force screening recommendations for cognitive impairment and other mental disorders. However, the MMSE is a useful measure of change in cognitive status over time, as well as potential response to treatment. The test is limited in patients who have visual impairment, are intubated, or have a low literacy level.
7 8 8,9 10

TABLE 4.

USPSTF Screening Recommendations for Mental Disorders


Disorder Dementia Recommendation The evidence is insufficient to recommend for or against routine screening for dementia in older adults Clinical considerations Sensitivity and specificity of the MMSE range from 71 to 92 percent and 52 to 96 percent, respectively, depending on the cutoff for an abnormal test result
8

Disorder

Clinical considerations Accuracy is also reliant on patient age, education level, and ethnicity Depression Screening adults for depression is The following two-question screen can be recommended in clinical practices that have as effective as longer instruments systems in place to assure accurate diagnosis, (sensitivity = 96 percent, specificity = 57 effective treatment, and follow-up percent) Over the past two weeks, have you felt down, depressed, or hopeless? Over the past two weeks, have you had little interest or pleasure in doing things? Illicit drug The evidence is insufficient to determine the Physicians should evaluate for symptoms use benefits and harms of screening for illicit drug and signs of drug use use in adolescents, adults, and pregnant women
9

Recommendation

MMSE = Mini-Mental State Examination; USPSTF = U.S. Preventive Services Task Force. Information from references 8 and 9.

Another tool for assessing cognition is the Mini-Cognitive Assessment Instrument (Mini-Cog), which combines a clock drawing test and a three-word memory test. Advantages of the Mini-Cog include its brevity, its validity irrespective of the patient's education level and language, and its high sensitivity for identifying adults with cognitive impairment.
11

Insight
Insight is the patient's awareness and understanding of his or her illness and need for treatment. When evaluating a patient's insight, the physician may assess the degree to which the patient understands how the psychiatric illness impacts his or her life, relationship with others, and willingness to change. Evaluating insight is crucial for making a psychiatric diagnosis and for assessing potential adherence to treatment. Compared with patients with other psychiatric disorders, those with schizophrenia are often unaware of their mental illness and often have a poorer response to treatment. A recent study showed an association between unawareness and executive dysfunction, suggesting that cognitive impairment may be the basis for lack of insight in patients with schizophrenia. Patients with dementia may also lack insight, a feature that is particularly characteristic of frontotemporal dementia affecting function and performance. Patients in the manic phase of bipolar disorder may demonstrate little insight, whereas patients having a depressive episode may overemphasize problems.
12,13 14 15 3

Judgment
Judgment, the ability to identify the consequences of actions, can be assessed throughout the MSE, by asking What would you do if you found a stamped envelope on the sidewalk? Yet, asking more pertinent questions specific to the patient's illness is likely to be more helpful than hypothetical questions. A patient's compliance with prescribed treatments can also serve as a measure of judgment.
2

Further Evaluation and Referral


Depending on MSE findings, further evaluation may include laboratory testing to identify causative or potentially reversible medical conditions. Additionally, if an underlying brain disorder is suspected, brain imaging (computed tomography or magnetic resonance imaging) may be helpful. The primary care physician should consult a psychiatrist, and possibly other mental health professionals, if the diagnosis is uncertain, the patient's safety is in question, the patient is actively psychotic, or treatment response is inadequate.

The Authors
DANIELLE SNYDERMAN, MD, is an instructor in the Department of Family and Community Medicine at Thomas Jefferson University's Jefferson Medical College, Philadelphia, Pa. BARRY W. ROVNER, MD, is a professor of psychiatry and neurology at Thomas Jefferson University's Jefferson Medical College, and is director of clinical Alzheimer's disease research at the university's Farber Institute for Neurosciences. Address correspondence to Danielle Snyderman, MD, 1015 Walnut St., Suite 401, Philadelphia, PA 19107 (email: danielle.snyderman@jefferson.edu). Reprints are not available from the authors. Author disclosure: Nothing to disclose.

REFERENCES 1. Vergare MJ, Binder RL, Cook IA, Galanter M, Lu FG, for the Work Group on Psychiatric Evaluation. Practice
guideline for the psychiatric evaluation of adults. 2nd ed. Washington, DC: American Psychiatric Association; 2006:2325. 2. The psychiatric interview and mental status examination. In: Hales R, Yudofsky SC, Gabbardd GO, eds. The American Psychiatric Publishing Textbook of Psychiatry. 5th ed. Arlington, Va.: American Psychiatric Publishing, Inc.; 2008. 3. Kaplan HI, Sadock BJ. Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. 8th ed. Philadelphia, Pa.: Lippincott Williams & Wilkins; 1998: 254282, 556. 4. Penland HR, Weder N, Tampi RR. The catatonic dilemma expanded. Ann Gen Psychiatry. 2006:5:14. 5. Brbion G, Amador X, Smith M, Malaspina D, Sharif Z, Gorman JM. Depression, psychomotor retardation, negative symptoms, and memory in schizophrenia. Neuropsychiatry Neuropsychol Behav Neurol. 2000:13(3):177183. 6. Budson AE, Price BH. Memory dysfunction. N Engl J Med. 2005:352(7):692699. 7. Folstein MF, Folstein SE, McHugh PR. Mini-Mental State. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975:12(3):189198. 8. Guide to clinical preventive services. September 2008. Rockville, Md.: Agency for Healthcare Research and Quality; 2008. AHRQ Publication no. 08-05122. http://www.ahrq.gov/clinic/pocketgd.htm. Accessed May 13, 2009. 9. Whooley MA, Avins AL, Miranda J, Browner WS. Case-finding instruments for depression: two questions are as good as many. J Gen Intern Med. 1997:12(7):439445. 10. Freidl W, Schmidt R, Stronegger WJ, Irmler A, Reinhart B, Koch M. Mini Mental State Examination: influence of sociodemographic, environmental and behavioral factors and vascular risk factors. J Clin Epidemiol. 1996:49(1):7378. 11. Borson S, Scanlan JM, Chen P, Ganguli M. The Mini-Cog as a screen for dementia: validation in a populationbased sample. J Am Geriatr Soc. 2003:51(10):14511454. 12. David AS. Insight and psychosis. Br J Psychiatry. 1990:156:798808.

13. Lysaker PH, Buck KD. Insight, outcome and recovery in schizophrenia spectrum disorders: an examination of
their paradoxical relationship. Curr Psychiatry Rev. 2007:3(1):6571. 14. Mysore A, Parks RW, Lee KH, Bhaker RS, Birkett P, Woodruff PW. Neurocognitive basis of insight in schizophrenia. Br J Psychiatry. 2007:190:529530. 15. Mendez MF. Shapira JS. Loss of insight and functional neuroimaging in frontotemporal dementia. J Neuropsychiatry Clin Neurosci. 2005:17(3):413416. Copyright 2009 by the American Academy of Family Physicians.