"Dr. Drake why are you asking me those questions, I'm not crazy," from one of my elderly patients.
It is important for physicians to ascertain the competence of patients, especially the elderly. This is important so that patients may make advance directives, be competent to complete their wills, make decisions about their care and guide providers in treatment plans.
The mental status exam (MSE) includes general observations made during exams as well as specific testing based on the needs of the patient and physician. Multiple cognitive functions may be tested including attention, language, executive function, thought content, memory, visuospatial proficiency and orientation.
The MSE is helpful in differentiating between a variety of neurologic and psychiatric disorders ranging from delirium and dementia to bipolar and schizophrenia.It may include the administration of relatively standardized tools such as the Mini-Mental status exam (MMSE) and Mini-Cog.
General observations of the patient are important. What is the appearance of the patient, are they neatly dressed, have smell of urine which may indicate incontinence, do they maintain good eye contact? Do they move slowly or have minimal facial expressions that might suggest Parkinson disease. What is their mood and affect?
It is important for patients to understand the standardized questions that are asked and communicate their responses. The questions involve a cognitive portion;
* Memory the patient may be asked to remember three items repeat them then asked again in a few minutes to see if they remember them for example apple, table, penny.
* Orientation often asked what city, state and location are you at. What is the date, month, year.
* Executive function like spell world backwards.
* Attention spell a word backwards (world) or subtract 7 from 100, then 7 more, etc.
*Gnosia name an object-pencil, watch.
* Language write a sentence
* Praxsis carry out motor acts show how to use a pencil, fold a paper in half and put it on the floor.
* Visuospatial proficiency draw a clock and put the numbers on it draw 10 o'clock or copy a picture of intersecting pentagons.
*Cognition like explain proverbs. "What does it mean to not cry over spilt milk" or "Don't count your chickens before they hatch" Often patient will finish the proverb if I speak slowly. Some are unable to give an interpretation and respond you know what that means or simply repeat the words back as the meaning.
It is important for the examiner to not be judgmental or critical during the exam or for family members to not respond by giving answers.
Points are assigned for correct answers. Clinical judgment must be based on multiple observations over time. Additional testing may be ordered after the MSE and is based on clinical judgment and may include lab work and neuroimaging such as CatScan.
Information on this article is from American Family Physician, October 15, 2016.
Dr. Drake is Board Certified by the American Board of Family Medicine and is a past-president of the Kentucky Academy of Family Physicians and is a member of the American Academy of Family Physicians. Dr Drake has practiced in Somerset since 1984.