Assessment of Mental Status

Assessing the mental status of patients with a neurobehavioral disorder is a critical element in the diagnosis and treatment of these patients. 

This assessment should always be performed after :

1- the patient's history it taken 

2-a general physical as well as a neurologic examination is completed. 

The mental status examination commences with observing the patient's

  (( appearance and level of consciousness. ))

The examiner should also pay attention to patient's

((social behavior, emotional state and mood. ))

There are 3 major means of assessing a patient's mentalstatus:

. FIRST type ---attempts to determine if the patient is demented and the severity of the dementia as it pertains to their ability to perform activities of daily living as well as instrumental activities. 

A second type of assessment utilizes what may be termed as:

 "screening tests" or "omnibus tests". These brief tests are performed independent of the patient's history and examination:

((The two most frequently used screening tests are :

1-Mini-Mental Status Examination (MMSE) 

2-the Montreal Cognitive Assessment (MoCA).

3-The third means of assessing a patient's mental status is by using specific neuropsychological tests))

 *THE THIRD neuropsychological tests

that focus on specific domains of cognition, such as frontal executive functions, attention, episodic verbal and visuospatial memory, declarative knowledge such as language (speech, reading and writing) and arithmetical, as well as visuospatial and perceptual abilities. These neurobehavioral, neuropsychiatric and neuropsychological assessments of patients with a cognitive decline and behavioral abnormalities should often be accompanied by laboratory tests, and neuroimaging that can help determine the underlying pathologic process so that effective therapeutic and management approaches can be provided.

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Montreal Cognitive Assessment (MoCA) Test for Dementia

How Is the MoCA Test Administered/Scored and Is It Accurate?

The Montreal Cognitive Assessment (MoCA) is a brief 30-question test that takes around 10 to 12 minutes to complete and helps assess people for dementia. It was published in 2005 by a group at McGill University working for several years at memory clinics in Montreal. Here's a look at what the MoCA includes, how it's scored and interpreted, and how it can assist in identifying dementia.

Assessment

The MoCA evaluates different types of cognitive abilities. These include:

• Orientation: The test administrator asks you to state the date, month, year, day, place, and city.  
• Short-Term Memory/Delayed Recall: Five words are read, the test-taker is asked to repeat them, they are read again and asked to repeat again. After completing other tasks, the person is asked to repeat each of the five words again and given a cue of the category that the word belongs to if they are not able to recall them without the cue.  
• Executive Function/Visuospatial Ability: These two abilities are assessed through the Trails B Test, which requires you to draw a line to correctly sequence alternating digits and numbers (1-A, 2-B, etc.) and through a task which requires you to draw a copy of a cube shape.  
• Language Abilities: This task consists of repeating two sentences correctly and then listing all of the words that can be recalled that begin with the letter "F".
• Abstraction: You are asked to explain how two items are alike, such as a train and a bicycle. This measures your abstract reasoning, which is often impaired in dementia. The Proverb Interpretation Test is another way to test abstract reasoning skills.

• Animal Naming: Three pictures of animals are shown and the individual is asked to name each one. 
• Attention: The test-taker is asked to repeat a series of numbers forward and then a different series backwards to evaluate attention. 
• Clock-Drawing Test: Unlike the Mini-Mental State Exam (MMSE) which does not include the clock drawing test, the MoCA asks the person being evaluated to draw a clock that reads ten past eleven.

Scoring

Scores on the MoCA range from zero to 30, with a score of 26 and higher generally considered normal.

In the initial study data establishing the MoCA, normal controls had an average score of 27.4, compared with 22.1 in people with mild cognitive impairment (MCI) and 16.2 in people with Alzheimer's disease.

The scoring breakdown is as follows:

• Visuospatial and Executive Functioning: 5 points
• Animal Naming: 3 points
• Attention: 6 points
• Language: 3 points
• Abstraction: 2 points
• Delayed Recall (Short-term Memory): 5 points
• Orientation: 6 points
• Education Level: 1 point is added to the test-taker's score if he or she has 12 years or less of formal education 

Usefulness

The MoCA is a relatively simple, brief test that helps health professionals determine quickly whether a person has abnormal cognitive function and may need a more thorough diagnostic workup for Alzheimer's disease.

It may help predict dementia in people with Mild Cognitive Impairment(MCI), and because it tests for executive function, it is more sensitive in this regard than the MMSE. Finally, it's been shown to better identify cognitive problems in people with Parkinson's disease.

Advantages vs. Disadvantages

The MoCA's advantages include its brevity, simplicity, and reliability as a screening test for Alzheimer's disease. In addition, it measures an important component of dementia that's not measured by the MMSE, namely executive function. It seems to work well in Parkinson's disease dementia, and unlike the MMSE, it is free for non-profit use.

Of note, the MoCA is available in more than 35 languages, and there is also a MoCA Test Blind which allows cognitive testing for those who are visually impaired.

A disadvantage of the MoCA is that it takes a little longer than the MMSE to administer, and like many other screenings, it should be paired with multiple other screenings and tests to accurately identify and diagnose dementia.

A Word From Verywell

Being aware of what the MoCA includes and how it's scored can help you better understand its results for you or your loved one. Remember, also, that the MoCA, while helpful in identifying cognitive concerns, should be combined with several other assessments conducted by a physician in order to fully evaluate mental functioning and identify possible causes of memory loss.  

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Mini–Mental State Examination tests

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Not to be confused with Mental status examination or Mini-international neuropsychiatric interview.

Mini-Mental State Examination
Medical diagnostics
Purpose	measure cognitive impairment

The Mini-Mental State Examination (MMSE) or Folstein test 

it is  a  30-point questionnaire:

that is used extensively in clinical and research settings to measure cognitive impairment.^[1] It is commonly used in medicine and allied health to screen for dementia. It is also used to estimate the severity and progression of cognitive impairment and to follow the course of cognitive changes in an individual over time; thus making it an effective way to document an individual's response to treatment. 

The MMSE's purpose has been not, on its own, to provide a diagnosis for any particular nosological entity.^[2]

Administration of the test takes between 5 and 10 minutes and examines functions including registration (repeating named prompts), attention and calculation, recall, language, ability to follow simple commands and orientation.^[3] It was originally introduced by Folstein et al. in 1975, in order to differentiate organic from functional psychiatric patients^[4][5] but is very similar to, or even directly incorporates, tests which were in use previous to its publication.^[6][7][8] This test is not a mental status examination. The standard MMSE form which is currently published by Psychological Assessment Resources is based on its original 1975 conceptualization, with minor subsequent modifications by the authors.

Advantages to the MMSE include requiring no specialized equipment or training for administration, and has both validity and reliability for the diagnosis and longitudinal assessment of Alzheimer's disease. Due to its short administration period and ease of use, it is useful for cognitive assessment in the clinician's office space or at the bedside.^[9] Disadvantages to the utilization of the MMSE is that it is affected by demographic factors; age and education exert the greatest effect. The most frequently noted disadvantage of the MMSE relates to its lack of sensitivity to mild cognitive impairment and its failure to adequately discriminate patients with mild Alzheimer's disease from normal patients. The MMSE has also received criticism regarding its insensitivity to progressive changes occurring with severe Alzheimer's disease. The content of the MMSE is highly verbal, lacking sufficient items to adequately measure visuospatial and/or constructional praxis. Hence, its utility in detecting impairment caused by focal lesions is uncertain.^[10]

Other tests are also used, such as the Hodkinson^[11] abbreviated mental test score (1972), Geriatric Mental State Examination (GMS),^[12] or the General Practitioner Assessment of Cognition, computerised tests such as CoPs^[13] and Mental Attributes Profiling System,^[14] as well as longer formal tests for deeper analysis of specific deficits.

administration and scoring instructions

 Say: I am going to ask you some questions and give you some problems to solve.

 Please try to answer as best you can.

 1. Allow ten seconds for each reply. Say: a) What year is this? (accept exact answer only) 

/1 b) What season is this? (during the last week of the old season or first week of a new season, accept either) 

/1 c) What month is this? (on the first day of a new month or the last day of the previous month, accept either) 

/1 d) What is today’s date? (accept previous or next date) /1 e) What day of the week is this? (accept exact answer only) /1

 2. Allow ten seconds for each reply. Say: a) What country are we in? (accept exact answer only) 

/1 b) What state are we in? (accept exact answer only) 

/1 c) What city/town are we in? (accept exact answer only) /1 d) What is the street address of this house? (accept street name and house number or equivalent in rural areas) /1 What is the name of this building? (accept exact name of institution only)

/1 e) What room are we in? (accept exact answer only) /1 What floor of the building are we on? (accept exact answer only) /1 

3. Say: I am going to name three objects. When I am finished, I want you to repeat them. Remember what they are because I am going to ask you to name them again in a few minutes (say slowly at approximately one-second intervals).

 Ball Car Man For repeated use:

 Bell, jar, fan; bill, tar, can; bull, bar, pan Say: Please repeat the three items for me 

(score one point for each correct reply on the first attempt) 

/3 Allow 20 seconds for reply; if the person did not repeat all three, repeat until they are learned or up to a maximum of five times (but only score first attempt)

 4. Say: Spell the word WORLD (you may help the person to spell the word correctly). Say: Now spell it backwards please (allow 30 seconds; if the person cannot spell world even with assistance, score zero). Refer to accompanying guide for scoring instructions (score on reverse of this sheet) /5

 5. Say: Now what were the three objects I asked you to remember? /3 (score one point for each correct answer regardless of order; allow ten seconds) 

6. Show wristwatch. Ask: What is this called? /1 (score one point for correct response; accept ‘wristwatch’ or ‘watch’; do not accept ‘clock’ or ‘time’, etc.; allow ten seconds) 2

 7. Show pencil. Ask: What is this called? /1 (score one point for correct response; accept ‘pencil’ only; score zero for pen; allow ten seconds for reply) 

8. Say: I would like you to repeat a phrase after me: No ifs, ands, or buts /1 (allow ten seconds for response. Score one point for a correct repetition. Must be exact, e.g. no ifs or buts, score zero) 

9. Say: Read the words on this page and then do what it says /1 Then, hand the person the sheet with CLOSE YOUR EYES (score on reverse of this sheet) on it. If the subject just reads and does not close eyes, you may repeat: Read the words on this page and then do what it says, a maximum of three times. See point number three in Directions for Administration section of accompanying guidelines. Allow ten seconds; score one point only if the person closes their eyes. The person does not have to read aloud. 

10. Hand the person a pencil and paper. Say: Write any complete sentence on that piece of paper (allow 30 seconds. Score one point. The sentence must make sense. Ignore spelling errors). /1 

11. Place design (see page 3), pencil, eraser and paper in front of the person. Say: Copy this design please. Allow multiple tries. /1 Wait until the person is finished and hands it back. Score one point for a correctly copied diagram. The person must have drawn a four-sided figure between two five-sided figures. Maximum time: one minute.

 12. Ask the person if he is right or left handed. Take a piece of paper, hold it up in front of the person and say the following: Take this paper in your right/left hand (whichever is non-dominant), fold the paper in half once with both hands and put the paper down on the floor. 

Takes paper in correct hand_________ /1 Folds it in half___________ /1 Puts it on the floor________ /1 TOTAL TEST SCORE: /30 ADJUSTED SCORE: / The SMMSE tool and guidelines are provided for use in Australia by the Independent Hospital Pricing Authority