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Hello and welcome back to another episode of the Neurotransmitters, a podcast about everything neurology with the goal of reducing your neur a phobia. I'm Doctor Michael Ken Trees and thank you for joining me again for another episode. Today. Today, I wanted to keep going on our foundational aspects of neurology and talk about what I think might be one of the most complicated parts of the neurology assessment, which is the mental status examination. Now, the mental status exam can be very involved. It's important to know why you're assessing this person's mental status in the first place. Is there concern for maybe some dementia developing? Is there concern in the hospital for some sort of new cognitive deficit that might be a little more specific than just some memory loss? Are these new cognitive changes something that's been fixed or is there a waxing and waning character to it that might suggest something like delirium as opposed to a more progressive problem. So these are all things to think about when you're assessing someone or any cognitive changes. Again, you really have to put it in the context of what else is going on with this patient you know, new medications, particularly ones that can be sedating or have anti cholinergic side effects. All these things really tie into the assessment. So what goes into a mental status evaluation? So I think it's useful to break these up into some different cognitive domains, attention, language, memory, visual, perceptual spatial orientation, praxis, executive function and social or behavioral aspects and kind of go through these a little bit one by one here. Now, obviously, with cognitive testing, it can go very deep. That's why neuropsychology assessments can last hours. The goal of our conversations here are really more to help us be uh to provide better care for patient's and be better clinicians and who knows, maybe down the road, we will tackle some of these more complicated, more neuroscience based issues. So just like with any other assessment, the first thing that really comes into play is just the general appearance of the person in front of you, do they look the age that they're supposed to look? How is their hygiene? Are they well groomed? How is their demeanor? How are they comporting themselves? Do they seem anxious? Are they exhibiting any features that make you concerned that they might be responding to internal stimuli? The mental status exam is kind of the bread and butter of our psychiatry colleagues and we can certainly take some notes from them with respect to some of these aspects when they're talking to you. Do they make eye contact are they displaying appropriate social cues? And just when we get down to brass tacks, do you see any evidence of old head injuries, craniotomy scars? Do they have any abnormal features that would suggest maybe a genetic or congenital abnormality? What's the level of arousal or alertness of the person in front of you? How much stimulation does it take to provoke a response? Whether that's verbal motor response, you know, someone who's awake and walking around in the office, answering questions spontaneously, obviously has fairly normal level of alertness. But in the hospital, we might see someone who has more diminished levels of arousal. So the old terms you would sometimes come across would be like lethargic, obtunded, stuporous comatose. We tend to move a little bit away from those and just describe what does it take like, does, does it take some noxious stimulation, you know, some uncomfortable, painful stimulation to wake someone up? Do they stay awake for a little while? Do they answer questions or do they fall right back asleep as soon as you stop shaking their shoulder? And these kinds of observations can be important when you're taking care of a patient in the hospital who might be fluctuating on a day to day basis. And here we're going to deviate a little bit more into some of the psychiatric elements of the mental status exam. What is the motivation the patient displays or the person in front of you is displaying? Do they express goal, directed thoughts and feelings. Are they participating in the interview and exam? Are you having to beg borrow and plead to try and get them to be cooperative? Um And this ties into how is their mood? Are they displaying depressive signs, avoiding eye contact? Are they having unusual affect? Do they seem unusually cheerful or jubilant or is their mood and affect just inappropriate to the situation? You also want to assess what is the thought content and the thought processes that are going on with this person? What what are they thinking? Are they're delusional or obsession, uh type thinking? Uh Are they focused on things in an unreasonable fashion? Do they have any suicidal or homicidal ideas? If so, have there been plans made? Uh this can help you stratify a little bit in terms of the relative risk of them actually carrying through on things. Are their thoughts moving very quickly from one point to another sometimes called flight of ideas or is there flow of thoughts somewhat disorganized as opposed to more goal directed? You can also see whether their thought process is logical, you know, that kind of cause and effect linkage or are things a little more tangential or loosely associated? So they might be moving from topic to topic rather quickly and with relatively little connecting, substantive thought with just superficial associations and tying into that a little bit, we have judgment, you know, do they understand and identify the consequences of actions. The classic bedside example of a question testing judgment is what would you do if you found a stamped and addressed envelope on the sidewalk, would you put it in the post box? Would you keep it, etcetera, etcetera. And the last of the more observation or behavioral type characteristics I'll mention is insight. Does the person understand what's going on with them or do they rather lack knowledge and quote unquote insight into the current condition? Right? In medicine, we call this a nose, a nausea little linguistic lesson. When we have a in front of an English word, it comes from the Greek, the alpha preventive meaning without know. So's disease and nausea knowledge. So lack of knowledge of disease, we see this a lot with different types of dementia is and so forth where people may not have insight that anything is wrong with their thought processes. And that can be very challenging both from a caregiver standpoint as well as a physician. And is one of many reasons why when you are evaluating someone's cognitive status, it's always essential to get a bystander report. Hopefully from a close friend or family member who spends a lot of time with this person and can offer you a more objective report of what might be going on with this person after talking with the person you're assessing for a little while. Hopefully, that gives you a little bit of insight into what kind of abilities they have and how in depth you can go with your cognitive assessment. But one of the most fundamental pieces that has to be present for you to go deeper into these is the patient's attention or working memory. So they kind of lump this into basic and complex tasks. So when you're testing it, a basic task would be your forward digit span. So for instance, I'm going to use a copy of the Montreal cognitive assessment here. If you read the numbers 21854, then you just ask the person to repeat that back to you. And a normal result would be someone who can repeat about seven plus or minus two digits back to you in a forward span. For, don't make that a little more complicated. We'll do a backward digit span. So for instance, I might say 74 to ask you to repeat that back to me. And hopefully you would say 247 and for backward digit span, we should be able to get to about five plus or minus two serial sevens are another common bedside task, right? 100 minus 7 93 93 minus 7 86 and so on. And again, you should be able to do five plus or minus two iterations of that. Some other common tasks that can be done if you do the months or the days of the week or even the alphabet in reverse order. This is considered more complex attention, working memory type task. And why this is important is because if your attention is poor or you can't manipulate data that is coming in appropriately, you're not gonna be able to do a lot of the subsequent cognitive tests that you would want to do to get more in depth. Now, in terms of localization, this isn't super helpful, it's not very localizing, but it can be associated with either frontal lesions or right parietal lesion's. Although again, fairly nonspecific, unfortunately, moving on from there to language, language is a very interesting thing is just so essential to part of what people do. And when people aren't communicating as you would normally expect them to, it can be very jarring sometimes if you're not used to it. But this is something you begin your assessment when you're just having conversation regarding the patient's history, recent events that brought them to a medical attention. So you can start picking up some of these clues even before you begin a formal language assessment. But you want to listen for things like the articulation of the words. If the words are well formed, if it takes them a lot of effort or the words, certain syllables or word sounds are more distorted. And so some of the things you're listening for are things called paraphasias. And when those come in two flavours, we have phonemic, which is where you replace a word with a similar sounding word, an example, might be saying plant instead of pants or you can also sometimes see syllables from a previous word smooshed together. So there's a couple of different ways that though can manifest themselves. The other kind of primary flavor of paraphasia that I often see is a semantic paraphasic era where you'll get a word that has a similar content but isn't quite right, like maybe saying son instead of daughter or apple instead of banana, uh similar categories of things but not quite 100% correct in the context that they're trying to use it. Now, I know this isn't an English lesson per se, but grammar is also something you almost become unconsciously used to hearing certain word patterns in whatever language you're used to. So if we define grammar as the rules used to govern a language to communicate meaning accurately and compare that with syntax, which is a part of grammar and refers to the structure of words within a sentence. So, agrammatism, you see simplified syntax or simplified sentence structure with shorter phrase length and a lack of grammatical words like pronouns or prepositions and you'll see more errors in verb tense. So agrammatism often sounds telegraphic. And if we think about the telegram that used to charge by the letter, so that means to be concise and omitting any essential words, so you're trying to save on your cognitive cost there to continue my Old West Telegraph analogy. Another component that we're looking at is fluency of speech. And this refers to the phrase length and not necessarily to the number of breaks in between a sentence. I know I've been accused sometimes of being a slow talker, but I don't think I've been accused of being non fluent. At least not yet. So sometimes word finding difficulties may mimic uh some fluency errors, but there should be occasional episodes of being able to produce these longer sentences and phrases. We're also listening to proceed e which is kind of the musical content of speech if you'll allow me the license. So we're listening to things like the tone, the accent, the rhythm. One way you can test this is to have them mimic your uh speech. So if like try to say something sarcastically and have them try and reproduce that back. Uh This will often if there's some abnormality suggest a nondominant hemisphere lesion of some kind. Another important part of language testing is confrontational naming. So, pointing at a specific item in the room or a picture and asking them what is this called? And there's kind of two flavours in naming, there's high frequency items and low frequency items, high frequency items are things that might come up very commonly in conversation. So you might have a pencil in your pocket or a pen in your pocket. So if you pull up the pencil, like what is this? They can identify it. But then maybe you point to the pencil lead or the erasure. And maybe they have a little more of a struggle with that less commonly used word. And that might suggest a difficulty with some of those more low frequency words. We also check for repetition. So you can start simple with even as simple as single letters, single words and then up to complete sentences, difficulties and repetition are typically thought to be due to dominant hemisphere lesion of the arguing Fasciculus as it does facilitate communication between brokers and wear Nikes areas, which are both obviously very important in language. The brokers with the expression, wear Nikes with the comprehension. Speaking of comprehension, there are of course several layers to it. Semantic comprehension is usually referring to yes or no questions. Typically, questions that have an objective answer such as is the sky blue syntactic comprehension is usually asking the patient to complete tasks of some kind, usually of increasing complexity. Uh for instance, point to your nose after you touch the desk. So this is kind of your three step command that you might see in something like the mini mental status examination. Uh Another important part of language is reading. So again, you can start simple as simple as single letters than single words. Uh and then up two sentences, two paragraphs and so on. So talking about words, there are a few different categories uh what we call regular words, which are words that are written according to phonic rules which is to say, these are the kinds of words that you would tell someone who's learning how to read, how to sound it out as opposed to irregular words, which are words that don't necessarily follow the rules of that language. So in English, obviously, we have a lot of these, a lot of borrowed words. So something as simple as friend or straight, those are irregular words that don't necessarily make the sound that you would expect them to make based on phonic rules. There is also pure alexia, which is where you misidentify letters, deep dyslexia, which is characterized when you make semantic errors and you can't read non words and then surface dyslexia, which is where you try and regularize errors of irregular words such as pronouncing the word yacht as yeah, chit and trying to apply those phonic rules to these irregular words. Essentially when you're assessing writing, you, you're looking at a lot of the same things you're looking at as when you are listening to speech. However, there may be some effect if there's any errors of praxis or weakness or things like that, especially if someone had a previous stroke or other neurologic injury that impairs them from writing as easily moving onto memory. When we're assessing memory clinically, we're usually looking at explicit or declared of memory. So a lot of our very basic questions tie into this. So the one that people are most familiar with is probably just orientation. What is your name? Who are you, where are we right now? What is the month, day time? What is the current situation? You know, you might see this notated in charts as a and oh times for or something to be aware of. However, is that it's very unusual to not be oriented to yourself, to not know who you are your own identity, to not to not be aware of these very basic fundamental autobiographical details. That's not usually going to be from a neurologic problem. With some rare exceptions. Of course, in someone who's otherwise healthy, you should definitely be suspicious of a psychologic or psychogenic etiology as a confounder in your cognitive assessment. You can also ask if the patient's aware of any recent news events, anything that might be big in the news recently, which often times we'll have some emotional content to it, especially these days. You can also see if there's any recall of past events. So major past events, whether personal or on a national or international news level uh in an older generation, you know, people would know where they were when JFK was assassinated, um when 9 11 happened, uh things like that. So very major types of events can sometimes be recalled with remote memory and then you want to check and see how is their ability to learn and retain new information. So there's a couple different ways that we can check this at the bedside without too much fuss. So we're looking at interior grade memory and it's good to look at verbal versus non verbal. So, one of the verbal ways we do this is with wordless. So you might give the patient a list of 3 to 5 words and my recommendation is to use the same three frequently. So that way you'll have them memorized and you're less likely in the moment to forget what words you ask the patient to remember. And you can do this free recall, then you can do some category clues or you can even give multiple choice clues. And I can give you a little bit of an idea how much difficulty they're having, retaining this new information. Again. Uh This is a test that is explicitly listed out on the mocha the Montreal cognitive assessment. Another way to do this in a nonverbal fashion would be if you're in a hospital room or in an office, point at different objects around the room and ask the patient to remember those and then point at them uh several minutes down the road. And that's the way that someone's having difficulty with their speech. You can still assess this ability to retain new information, visual perceptual spatial or just visual spatial is another category. It's important for things like navigating, being able to manipulate things. So some of the ways you test that at the bedside is withdrawing specifically uh two different tasks, the interlocking Pentagon task where you draw two pentagons and you want them to intersect in such a fashion that you create a four sided shape by their intersection. Uh The other common task is drying o'clock. So, and you want to tell them, you know, I want all the numbers in the right places and I want to set the hands at a specific time. I usually say 10 till two, but there are a little different ways that can be done. So if the person is requiring multiple attempts, kind of has a disorganized approach that may suggest some executive dysfunction. If half the design is poorly drawn, it might suggest some neglect. We also want to assess for visual agnosia, which is the inability to recognize objects that are presented despite intact elementary visual processes. And this again comes in a few different flavours. So there's the a perceptive type which is an inability to form a complete percept, which is essentially your perception of an item. Another category of visual agnosia is associative, which is the quote inability to access stored knowledge of the percept and can be category specific such as faces, landmarks or other objects. A class example of this would be prosopagnosia, which is the inability to recognize faces properly. You can also get achromatopsia, the inability to recognize colors and then one that's a little more esoteric would be visual object agnosia, which is say you can't name it by site, but maybe when touching it using a different sensation, a different category of sense rather than site to identify an object. And lastly, there can be some spatial attention which can be tested with a line by section task. So you have a bunch of lines drawn on a paper and you ask the patient to draw through the center of the line. And if this is abnormal, you'll see them kind of off to one side of the line missing the center by a fair amount. Next, I wanted to talk about what I thought was one of the more complicated aspects of the mental status examination and not necessarily one that we do all the time. And that is praxis, which I'm going to quote here. So the learned or copied, imitated skilled movement programs provide the motor cortex with information about how to move or perform an Axion. And an abnormality of this is called apraxia. And there's a lot of different types of apraxia. Well, we're gonna talk about a few of them. One of the more common ones that we might encounter is called video motor apraxia. And this is the loss of the ability to perform skilled movements with a limb to perform an Axion or to follow a verbal command. So for instance, you might ask the patient to, to mimic you using a pair of scissors to cut a piece of paper instead of acting like they're holding a pair of scissors, they'll rather use their index and middle fingers as if they are the scissors themselves. Now, this is not uncommonly done and you should correct the person ask them know, like you're holding scissors, but someone with significant ideomotor apraxia will continue to use their hands as the tool. Similarly, you might also see when you ask them how you would use a hammer to pound in a nail, they will use their hand making a fist and use that as the hammer as opposed to as if they are holding a hammer in their hand. These specific types of a practices that are called body part as tool errors. We can also see limb kinetic apraxia, which is the loss of ability to make deft movements. Uh So some examples to be like buttoning a shirt, there is conceptual apraxia which is the loss of mechanical knowledge, including needed mechanical alterations. So this is sometimes you see this with problem unawareness, which is the inability to identify how you need to change a plan or tool to do a substitution or change tactic that isn't working. And then lastly, I'll mention ideation als apraxia, which is the impaired ability to correctly perform a sequence of actions needed to complete a task. And this is often seen with other forms of apraxia as well. The last cognitive domain I wanted to touch on today is executive function. And there's a lot of things that go into this things that fall into this include like motor planning, inhibition logic, things like that. So when testing someone's ability to understand abstract or uh to make some more reasoning type tasks, you can ask a simple version would be how are a banana and an apple similar to one another? And if they get that, you can make it more challenging. So how are a clock and a ruler similar to one another? And even by their answers to these questions, you can see, are they more concrete? Are they more uh more abstract in there? Thinking? So, so if they say like o clock and ruler both have numbers, yes, that is true. I was fairly concrete. If you say they both measure things that it's a little more abstract and that can obviously go both ways along that spectrum. You can also ask uh some common proverbs and what are the meanings inherent to those proverbs? And there will obviously be some differences between different cultures, geographic locations in terms of what proverbs are commonly used amongst different people. Some common ones that you might come across the grass is always greener on the other side, ask them what that means to them or people in glass houses shouldn't throw stones and you'll have to know what are the ones that are most likely if there's someone from a different culture, what are some proverbs that might be common to them specifically? Uh talking about some motor planning. So there are several different test that can be done one that I like to do is call the Luria test. And I apologize if I'm mispronouncing that. But essentially you have them hold one hand flat with the palm open. And with the other hand, you're going to demonstrate, firstly, make a fist going into the open palm, then the palm is open vertical and then it's palm to palm as if clapping and you're just going to go fist edge palm and you demonstrate this several times and ask them to repeat it. This is a relatively simple three step task. Uh Personally, I like it a bit better than folding the piece of paper, sitting on the chair next to you on the ground like they have in the mini mental just because I don't always have an extra piece of paper on hand. So this is a nice little quick test that you can do at the bedside to evaluate that. Lastly, one of the things we want to be evaluating for is inhibition is the person able to inhibit activity. So one of the classic tests for this is the go no go test. And there's a lot of different variations. Basically, you provide a stimulus, ask them to do an Axion and you provide a similar but different stimulus and they should not do it. So an example is I tap once on the desk, the patient taps, once I tapped twice, they shouldn't tap. And there's a lot of different variations on that um there's also alternating series test. So you might ask them to on a sheet of paper, write em followed by N, followed by MNMN or square, triangle, square triangle and just kind of do that alternating sequence. So if they're showing any per separation, that is say they just keep writing like mmmmm and they just keep sticking with one and they're not altering back and forth as quickly as they should be every other word or every other letter. Then that would suggest there is some executive dysfunction, some lack of inhibition activity that should be going on there. After all that, you're probably thinking dang, the mental status test is really exhaustive and it can be right, like I mentioned earlier, the neuropsychologist out there, they'll spend hours getting into the nitty gritty of all these things. So it's really important for you when you're seeing someone in the hospital in the clinic, what are the things that I need to, to find out to more accurately assess? Do I need to send them to a neuropsychologist? Can I get enough information to say right now that I think they have some sort of dementia, uh some other kind of deficit that might localize to a different part of the brain that will guide me in some fashion. So there are some standardized tests that can streamline this process a little bit, you know, one that most people who are listening to this are probably familiar with is the mini mental status exam and is similar one, the Montreal cognitive assessment, which I've mentioned a couple of times or the mocha and both of these are somewhat similar. I like the mocha a little bit better. It has a little bit better sensitivity. Uh Looking at a couple of studies, if we use a cut off score of 26 the mini mental had a sensitivity of 18% to detect mild cognitive impairment. But the mocha detected 90% of mild cognitive impairment subject. So the mocha is a little bit harder test and that's evidenced by its sensitivity in these very early sort of pre Alzheimer type patient's in the mild Alzheimer dementia group. The mini mental had a sensitivity of 78% and the mocha was 100%. The specificity was good for both mini mental and mocha with 100% and 87% respectively. So again, you might get a couple of false positives on the mocha, but they're both good screening tools to use. And after your practice with them shouldn't take more than 10 to 15 minutes to administer. The last standardized test I wanted to mention is called the mini cog. And this is the most abbreviated and still pretty reliable. So essentially you're doing three word recall and asking them to draw a clock. So it had a sensitivity of depending on what study you look at 76 to 99% and specificity of 89 to 93%. So in mild cognitive impairment, it's sensitivity was about 85% specificity around 79%. So if you're really in a hurry, you can get that mini cog done in just a few minutes and that will give you some pretty reliable data to make further recommendations, testing, etcetera. However, a word about mocha mini mental, the Minniecon, these are all focused on dementia, specifically Alzheimer dementia, particularly the amnestic aspect of Alzheimer dementia. So you might not pick up other types of dementia, other types of cognitive abnormalities. There is certainly good screening tools, but a diagnosis of dementia or things like that should not rely solely on these assessments. You really still need to put together that clinical picture and make sure everything is accounted for and fits together. Well. So we're going to end our discussion about the mental status examination there. I hope you enjoyed hearing about it. I know it can be a lot and not every piece of that needs to be done on every patient. I just want to emphasize that because I know it can be a lot of data, feel like you're drinking from a firehose there. But it's useful things to know because you may pick up on some of these subtleties and just your casual conversation with your patient's going forward. So you can get a lot of data just from observation like we've been talking about. So if you enjoyed this podcast. Please leave us a five star review on Apple itunes, Spotify, wherever you're getting your podcasts, leave us a review if possible and please share, subscribe for future episodes. If you like this episode, you can reach me on Twitter at Dr Kent, that's drkentris or by email at the Neuro transmitters podcast at gmail dot com. If you have any suggestions that you'd like me to cover in the future or people you'd like me to have on for discussion's about different topics. Please let me know at either of those two locations and I look forward to being able to talk with you again next time.