Clinical Assessment

Mental status examination should be performed, to some extent, in all patients, even if only to document that no problem exists. The examiner should explain to the patient the need for a mental status examination and request the patient's consent and cooperation. For example, the examiner can say, "I would like to ask you some questions about your feelings, your thinking, and your memory as a routine part of the examination. Is that all right with you?"

At the outset, the examiner should determine whether the patient can hear, see, and attend because impairments can worsen orientation and other cognitive functions. Impairments should be noted in the interpretation of the mental state. Refusal to respond or cooperate is often a sign that the patient is attempting to hide an impairment.

The examiner's questions and responses to the patient's answers should be sympathetic but direct. Each time a patient cannot answer a question, the examiner should move to the next question. Incorrect responses should not be pointed out or corrected. This approach avoids having the patient respond emotionally to the failure, which can worsen cognitive performance.

Appearance

Inappropriate or unkempt clothing and poor grooming may indicate neglect or inability to dress, perhaps because of apraxia (inability to perform learned motor acts despite the physical ability and willingness to do so). The use of hearing aids or glasses is noted.

Mood

Abnormalities of mood (eg, mania, depression) can affect cognitive function and must be thoroughly evaluated. Depression is particularly problematic because it can cause dementia, in which case it may be referred to as dementia of depression or pseudodementia. Patients with this condition improve after their depression is treated. In other cases, depression aggravates dementia, making subtle dementia overt or mild dementia more severe.

Mood is evaluated by observation of the patient (eg, facial expressions, posture, speed of movements and thoughts) and of verbal content. Although patients often spontaneously express feelings of helplessness, hopelessness, worthlessness, shame, or guilt, they should be asked directly about such feelings (eg, "Do you feel that you are a good person?" "Do you feel guilty about things you have done?") and about mood (eg, "How are your spirits?" or "How is your mood?"). Questions such as "How does the future look?" and "Do you feel you have unusual talents or abilities?" may detect excessive optimism or overconfidence. The patient should be asked about changes in energy, appetite, or sleep that are related to mood disturbances.

Depression in the elderly may manifest as a sense of dread or impending doom, as apathy, or as irritability without a specific cause. Depression may also be suggested by complaints of pain, tiredness, or other physiologic changes; by slow speech; by anxiety (sometimes as panic attacks with shortness of breath, palpitations, and sweating); by phobias, obsessions, or compulsions; or by abnormal perceptions (eg, delusions, hallucinations).

Anxiety Disorders

Patients should be asked about phobias (irrational fears of particular places, things, or situations leading to avoidance of the provoking stimulus).

Patients should also be asked about obsessions (recurrent, unwanted ideas that cannot be resisted, although they may seem unreasonable) and compulsions (repeated, unwanted behaviors, such as handwashing or rechecking a locked door). In the elderly, obsessions are usually due to severe depression, whereas compulsions often result from an obsession. Obsessions can be elicited by asking, "Do you have thoughts that keep coming to your mind and are difficult to get rid of? Are the thoughts reasonable, or do they sometimes seem silly?" Compulsions can be elicited by asking, "Must you do certain things (eg, wash your hands) repeatedly, more than you need to?"

Delusions and Hallucinations

Delusions are false, fixed, idiosyncratic ideas. Patients may reveal delusional thoughts when questioned (eg, "Are people treating you kindly? Is anyone trying to harm you?"). Delusions of harm (eg, of food poisoning) or of harassment may occur in elderly persons with paranoid schizophrenia or paraphrenia. Delusions also occur in 40% of persons with dementia. Delusions of poverty or of fatal illness may occur in depressed persons, who may believe that they are behaving badly and that their bad behavior will harm others. Delusions of persecution (eg, belief that someone is stealing from them) or of misidentification (eg, belief that family members are strangers or that persons long dead are alive) may occur in persons with dementia. Delusions should be differentiated from overvalued ideas (emotionally laden preoccupations or hobbies that override other activities or concerns), from culturally determined suspicions, and from religious beliefs.

Hallucinations are false visual, auditory, olfactory, or tactile perceptions. Visual or auditory ones may be elicited by asking, "Do you hear voices or see visions? If you hear voices, are they similar to my voice in your ear?" Further questioning is needed to determine whether the phenomena are really perceived (eg, "Do you hear the voices even when you do not see anyone talking? Do you hear them through your ears, or are they in your thoughts? Do you hear them as clearly as you hear me now?"). The examiner should respond with sympathy (eg, "That must have frightened you"), not with surprise or disbelief. Visual and tactile hallucinations are prominent in delirium; auditory hallucinations may occur in dementia and late-life schizophrenia (paraphrenia). Auditory hallucinations (eg, hearing one's name called) also may occur in late-life depression. Hallucinations may also occur in persons with sensory deficits, especially profound blindness, at which time the condition is called the Charles Bonnet syndrome. In addition, hallucinations may occur during bereavement, when the patient sees or hears the deceased person.

Cognition

Cognition (the ability to think and to understand the world) depends on alertness and is therefore impaired by drowsiness, stupor, and coma. However, cognition is impaired in the alert patient with mental retardation, Alzheimer's disease, or stroke. Cognitive functions--attention, orientation, memory, and language function--can be assessed quantitatively (eg, with the Mini-Mental State Examination).

Attention is the ability to focus and sustain thought and perception (eg, during reading or calculating). Attention can be evaluated by asking patients to subtract 7 from 100 and to keep subtracting 7 from each remainder. Patients with little education can be asked to count backward from 20 or to recite the months of the year backward. The ability to shift attention can be assessed by asking patients to count to 10, say the alphabet from A to J, and then combine the two tasks--alternating between numbers and letters (eg, 1, A, 2, B,...).

Most cerebral diseases and metabolic disorders affect attention. Inattention may suggest a brain lesion of the frontostriatal system, parietal cortex, or basal ganglia. Inattention may also occur in other conditions, including dementia, delirium, developmental disorders (eg, mental retardation, dyslexia), depression, mania, or schizophrenia.

Orientation to time and place is graded; ie, patients with cognitive impairment may know the year but not the day of the week; they may know the state they live in but not the floor of the building they are on. Impaired orientation may suggest delirium or dementia.

Memory involves learning (registration) or recalling what has been learned. Aging reduces the ability to learn but not the ability to recall material once it has been learned; dementia and delirium affect both. Normally, even the oldest old can recall at least two of three named objects. Patients who report memory loss but who can recall all three named objects should be evaluated for depression. Memory for events in the distant past is often retained in depression and dementia.

Language function is assessed by asking patients to name specific objects, repeat a phrase, follow an oral command, and read and write a sentence. Inability to perform these functions may suggest disease of the left hemisphere, which may occur in stroke or in Alzheimer's disease.

Other aspects of speech may give diagnostic clues. Rapid speech may indicate mania; slow speech, depression or dementia; and slurred dysarthric speech, stroke or parkinsonism. Language difficulty, such as an inability to repeat, name objects, follow commands, read, or write, occurs in stroke or Alzheimer's disease.

Praxis is the ability to perform learned motor tasks. It can be evaluated by asking patients to draw intersecting pentagons. Loss of praxis (ie, apraxia) may suggest lesions of the parietal lobes, particularly the right lobe (eg, due to stroke or Alzheimer's disease).

Specific functional abilities (eg, understanding and following instructions on drug labels, managing finances, arranging transportation, using the telephone) should be examined directly, because the mental status examination can predict impairment of functional ability only in severe cases.