Bedside Approach to the Mental Status Assessment (Behavioral Neurology and Psychiatry 2018)

Educational Objectives

The goal of this program is to improve diagnosis and treatment of behavioral and psychiatric disorders in patients presenting for neurologic evaluation. After hearing and assimilating this program, the clinician will be better able to:

1. Perform an initial evaluation of a patient who, per report by a family member, has developed cognitive deficits.

Summary

Approach to patient: Patient should be evaluated globally (issues seldom limited to behavior or memory); knowledge of cardinal symptom may help clinician classify disorder; nature of onset may indicate whether symptoms have vascular, subacute, or chronic neurodegenerative etiology.

Symptoms: Clinician should ask about course of symptoms (eg, fluctuating symptoms may be associated with seizures or Lewy bodies); longer duration of symptoms increases likelihood of neurodegenerative process; interruption of expected chronology may indicate secondary pathology; clinician should assess how signs and symptoms affect daily activities to determine whether patient has dementia versus mild cognitive impairment; for example, early amnestic component followed by deficits in executive function, language, and decision making suggests Alzheimer disease; if patient initially becomes apathetic or more outgoing, then displays changes in behavior and language, clinician should consider frontotemporal disorder; medications should be reviewed to determine whether any have potential to contribute to impairment; smoking, drinking, or using illicit drugs may exacerbate process.

Bedside mental status examination: Standardized approaches include, eg, Montreal Cognitive Assessment (MoCA), Mini-Mental State Examination (MMSE); however, when test results do not correlate with presentation, some relevant history may have been missed; clinician must consider whether instrument used appropriate for evaluating symptoms.

Taking history: Clinician should begin by questioning patient to assess his or her degree of insight into problem; if patient has minimal insight, clinician should ask patient’s permission to speak with caregiver or informant who accompanies patient; in most cases, adequate history reveals diagnosis or differential diagnosis.

Case: 75-year-old man brought to clinic by wife, who reports that he has become forgetful, loses his way while driving, shows poor attention to hygiene, and has been “bouncing” checks.

Pointers for evaluation: History helps clinician determine which instrument most likely to be informative; patient in case may be evaluated with MoCA; Toronto Cognitive Assessment useful for patients with milder impairment; during testing, clinician should note areas in which patient performs poorly and nature of responses or errors; for example, patient who cannot draw clock may be unable to plan drawing, write numbers, or understand where hands of clock should be placed to indicate time, each of which may represent impairment of different cognitive domain; clinician should assess whether greatest difficulty for patient language, executive function, attention, or visuospatial domain.

Choosing instruments: MoCA good initial screening test for impaired patients but too difficult for those with severe impairments; other instruments should be added if results of testing do not match clinical suspicion; examples include Trail Making Test Part B, Multilingual Naming Test, and Boston Naming Test; MMSE (from Folstein and colleagues) less sensitive than MoCA for identifying mild deficits; MMSE may be better choice for patients with advanced disease who cannot complete MoCA; clinician should note length of time required for patient to complete MoCA.

Other assessments: Useful cognitive assessments for general neurologic clinicians include tests of semantic fluency (eg, naming as many animals as possible in 1 minute), which assess functioning of temporal lobe; in contrast, impairment of letter fluency localizes to front of brain; calculation tests evaluate functioning of parietal lobe.

Detecting malingering or pseudodementia: Clinician should look for discrepancy between history and testing; in patient with cognitive impairment, simple screening tests and additional assessments should show pattern consistent with history; when malingering or pseudodementia suspected, another test may be added.

Summary: History most important component of evaluation; it should be used to select tests and interpret their results and correlate these results with findings of neurologic examination.

Readings

Tang-Wai DF, Freedman M. Bedside approach to the mental status assessment. Continuum (Minneap Minn) 2018;24(3 Behavioral Neurology and Psychiatry).

Disclosures

For this program, the following was disclosed: Dr Tang-Wai has provided expert legal testimony for the Canadian Medical Protection Association on a case determining whether a patient had cognitive impairment. Unlabeled Use of Products/Investigational Use Disclosure: Dr Tang-Wei reports no disclosures. To view disclosures of planning committee members with relevant financial relationships, visit: audiodigest.org/continuumaudio/committee. All other members of the planning committee report nothing to disclose.

Acknowledgements

CME/CE INFO

Accreditation:

Lecture ID:

CA070301

Qualifies for:

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.