Quantitative Assessment

The Mini-Mental State Examination

The Mini-Mental State Examination (MMSE) is used to assess the elements of cognition: attention, orientation, memory (registration and recall), language function, and praxis. It can be used to screen for or document cognitive impairment. The MMSE can be administered reliably by any practitioner trained to do so (eg, physician, psychologist, nurse, social worker, occupational therapist, technician).

Education level and age affect MMSE scores, but race and sex do not. The expected score for an 85-year-old with 0 to 4 years of education is 20, with 5 to 8 years is 24, with 9 to 12 years is 26, and with > 12 years is 28. A score lower than expected for age and education level may indicate delirium, dementia, or severe depression. Some patients have low scores because they are in poor physical health and take more drugs than those with higher scores.

Other Quantitative Assessment Instruments

Several other quantitative instruments are available to assess different aspects of cognition--see Table 38-1. (see also page 353 and Table 39-4.)

Cognition can be quantitatively assessed by telephone, using such validated tests as the Telephone Interview for Cognitive Status (TICS). TICS assesses attention, orientation, recall, calculation, information, verbal praxis, finger tapping, and antonyms.

Patients with cognitive disorders often have behavior problems,

including insomnia, anorexia, wandering, incontinence, and violence, that require management by a physician. These behaviors can be assessed by several validated scales, including the Dementia Symptoms Scale and the Psychogeriatric Dependency Rating Scale.

Abnormalities of mental status often contribute to an inability to perform activities of daily living, make a will, or sign contracts. Although legal competency is determined only by the court, physicians and nurses are often asked to submit evidence about a patient's mental abilities. Competence to make decisions affecting medical care can be quantitatively assessed by the Hopkins Competency Assessment Test.

Several short rating scales can help in the assessment of mood. For patients with normal cognition, a self-rated questionnaire such as the General Health Questionnaire can be used to assess depression and anxiety. To test for depression in patients with cognitive impairment, the examiner can use the Hamilton Depression Rating Scale. (see Table 33-5)