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CHAPTER
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Mental Status Examination
KEY TEACHING POINTS
• Several brief, well-validated bedside tests are available to diagnosis dementia or
delirium. These tests are accurate when compared to more cumbersome and lengthy
neuropsychiatric standards.
• The clock-drawing test, Mini-Cog test, and Mini-Mental Status Examination each
accurately diagnoses dementia.
• The confusion assessment method accurately diagnoses delirium.
6
Introduction
I.
Dementia is a clinical syndrome characterized by deteriorating cognition, behavior, and autonomy. Dementia affects 9% to 13% of adults older than 65 years living in the community.
diagnosing dementia, clinicians must exclude delirium (i.e., acute confusion; see the section on
diagnosis of delirium).
Of the many simple and rapid bedside tests developed to diagnose dementia, the most exten
sively
investigated ones are the clock-drawing test, Mini-Cog test, and Mini-Mental Status
Examination (MMSE).
II.
Clock-Drawing Test
e clock-drawing test was originally developed in the early 1900s to evaluate soldiers who had
suffered head wounds to the occipital or parietal lobes, injuries that often led to difficulty composing
images with the appropriate number of parts of correct size and orientation (i.e., con
structional apraxia).
language, visualize the proper orientation of an object, and execute normal movements, all tasks
that may be disturbed in dementia.
A.
TECHNIQUE AND SCORING
ere are 20 or more different methods for performing and scoring the clock-drawing test, some
with intricate grading systems that defeat the test’s simplicity.
5
method,
eter and states to the patient “draw a clock.” If the patient has any questions, the clinician only
repeats the same instructions and gives no other guidance. e patient may take as long as he or
she wants to complete the task. Fig. 6.1 describes how to score the drawing.
the clinician gives the patient a piece of paper with a preprinted circle 4 inches in diam-
2
To depict a clock, patients must be able to follow directions, comprehend
3,4
In a simple and well-investigated
1
Before
-
-
43
44
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Normal patterns:
Abnormal patterns:
Fig. 6.1 The clock-drawing test (Wolf-Klein method). The clock-drawing is normal if the patient has included
most of the 12 numbers in the correct clockwise orientation. The patient does not need to draw the hands of
the clock, and abnormal spacing of the numbers, however inappropriate, is still regarded normal as long as the
numbers are in correct order and near the rim. Normal clock-drawing patterns, from left to right, are “normal,”
“missing one number,” and “inappropriate spacing.” Abnormal clock-drawing patterns, from left to right, are
“irrelevant figures,” “unusual arrangement” (i.e., vertical orientation of numbers), “counterclockwise rotation,” and
“absence of numbers.” Adapted with permission from Wolf-Klein GP, Silverstone FA, Levy AP, Brod MS, Breuer J.
Screening for Alzheimer's disease by clock drawing. J Am Geriatr Soc. 1989;37:730–734.
3—GENERAL APPEARANCE OF THE PATIENT
B. CLINICAL SIGNIFICANCE
In patients without other known causes of constructional apraxia (e.g., parietal lobe lesion), a positive clock-drawing test increases the probability of dementia (likelihood ratio [LR] = 4, EBM
Box 6.1). A normal clock-drawing test is a less useful result, being elicited from many patients
with dementia as defined by other measures. In contrast to the MMSE, the clock-drawing test is
unaffected by the patient’s level of education.
6
III. Mini-Cog Test
A. TECHNIQUE AND SCORING
e Mini-Cog test combines a clock-drawing test with tests of recall to provide a brief
screening tool suitable for primary care patients, even those who do not speak English as
their native language.12 To perform the test, the clinician asks the patient to register three
unrelated words (e.g., banana, sunrise, and chair) and then asks him or her to draw a clock,
stating “Draw a large circle, fill in the numbers on a clock face, and set the hands at 8:20.” e
patient is allowed 3 minutes to draw the clock, and instructions may be repeated if necessary.
After drawing the clock (or after 3 minutes have elapsed), the patient is asked to recall the
three words. e Mini-Cog is scored by assigning 1 point for each word recalled (score, 0 to
3) and 2 points for a “normal” clock, which should have the correct orientation and spacing
of numbers and hands. An “abnormal” clock receives 0 points, thus creating possible score
range of 0 to 5.
44
6—MENTAL STATUS EXAMINATION
DEMENTIA
Mini-mental status score, 23 or less
Mini-mental status score,
method positive
method negative
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EBM BOX 6.1 Dementia and Delirium*
45
Finding (Reference)
†
Dementia
Abnormal clock drawing test
Mini-Cog score 2 or less
Mini-Mental Status Examination: traditional threshold
23 or less
13,17–32
12–17
Sensitivity
(%)
5–11
36–75 72–98 4.0 0.5
75–99 59–93 4.5 0.1
47–100 71–99 7.8 0.2
Mini-Mental Status Examination: 3 levels
Specificity
(%)
20,22–24,29
Likelihood Ratio‡ if Finding Is
Present Absent
20 or less 29–69 93–99 14.4 …
21–25 26–57 … 2.1 …
26 or more 4–14 14–31 0.1 …
Delirium
Positive test using “confusion
assessment method”
*Diagnostic standard: for dementia, dementia by NINCDS-ADRDA criteria,
8–19,21,22,24,26,27,29,31,32
criteria,
DMS criteria.
†
Definition of findings: for abnormal clock drawing test, see Fig. 6.1; for Mini-Cog test and confusion
assessment method, see text.
‡
Likelihood ratio (LR) if finding present = positive LR; LR if finding absent = negative LR.
NS, Not significant.
33–43
33–43
CAMDEX instrument,20 AGECAT,
46–98 83–99 11.5 0.2
5,6
25,28
or neurologist opinion;
DMS
23,30
for delirium, the
Probability
Decrease Increase
+45%+30%+15%–15%–30%–45%
LRs
0.1 0.2 0.5 12510
LRs
26 or more
Mini-Cog score 3 or more
LRs
0.1 0.2 0.5 12510
Confusion assessment
Mini-mental status score, 20 or
less
Mini-Cog score 2 or less
Abnormal clock-drawing test
DELIRIUM
Probability
Decrease Increase
Confusion assessment
+45%+30%+15%–15%–30%–45%
LRs
46
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3—GENERAL APPEARANCE OF THE PATIENT
B. CLINICAL SIGNIFICANCE
As displayed in EBM Box 6.1, a Mini-Cog score of 2 or less increases the probability of dementia
(LR = 4.5). A score of 3 or more decreases probability of dementia (LR = 0.1).
IV. Mini-Mental Status Examination (MMSE)
A. INTRODUCTION
e MMSE was introduced by Folstein in 1975 as an 11-part bedside test requiring only 5 to
10 minutes to administer, a much briefer time compared to the 1 to 2 hours required by more
formal tests of dementia.45 e 30-point test combines questions addressing the patient’s
orientation, registration, recall, and language. Historically the MMSE has been widely distributed, but now its use is copyrighted and the test may be administered free of charge only
from memory, by consultation of the original paper, or by using forms sold by the copyright
46
owner.
B. CLINICAL SIGNIFICANCE
EBM Box 6.1 illustrates that, assuming there is no evidence of delirium (see section on diagnosis
of delirium), a MMSE score of 23 or less increases the probability of dementia (LR = 7.8) whereas
a score 24 to 30 decreases it (LR = 0.2). Nonetheless, because false-positive results become a
concern when applying this threshold to large populations with a low incidence of dementia (such
as elderly persons living independently), some experts prefer interpreting the MMSE score in 3
ranges (see EBM Box 6.1): a score of 20 or less rules-in dementia (LR = 14.4); one of 26 or more
rules-out dementia (LR = 0.1); and scores 21 to 25 are regarded as less conclusive (LR = 2.1), thus
prompting further investigation.
e MMSE score may be used to follow patients over time, but only changes of 4 points or
more reliably indicate a change of cognition.47 e level of the patient’s education also affects the
MMSE score, regardless of the presence of dementia,
threshold for a positive test downward slightly in more poorly educated persons.
19,48
and some have suggested adjusting the
19
V. Diagnosis of Delirium (Confusion Assessment Method)
Delirium is an acute and reversible confusional state that affects up to 50% of elderly patients
hospitalized with acute medical illnesses.49 Of the several screening tools available to diagnose
delirium, one simple and well-investigated one is the confusion assessment method.
A. SCORING
When administering the confusion assessment method, the clinician looks for the following four
clinical features: (1) change in mental status (compared to the patient’s baseline) that is acute and
fluctuating; (2) difficulty focusing attention or trouble keeping track of what is being said; (3)
disorganized thinking (e.g., rambling or irrelevant conversation, unpredictable switching between
subjects, illogical flow of ideas), and (4) altered level of consciousness (e.g., lethargic, stuporous,
or hyperalert).
A positive test requires both features (1) and (2) and either (3) or (4).
33
6—MENTAL STATUS EXAMINATION
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47
B. CLINICAL SIGNIFICANCE
As illustrated in EBM Box 6.1, a positive test argues strongly for delirium (LR = 11.5) and a
negative test argues against delirium (LR = 0.2). is test has been adapted with similar accuracy
to mechanically ventilated patients who cannot talk50 and to patients in emergency departments.51
In any patient with delirium, positive bedside tests for dementia are inaccurate because of a high
false-positive rate.
References may be accessed online at Elsevier eBooks for Practicing Clinicians.
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48.e3
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Stance and Gait
KEY TEACHING POINTS
• Observation of the patient’s gait helps diagnose important neurologic and
musculoskeletal problems and allows clinicians to predict the patient’s risk of falls.
• Gait abnormalities may be symmetric or asymmetric. Pain, immobile joints, and muscle
weakness cause asymmetric gaits. Rigidity, proprioceptive disorders, cerebellar diseases,
and problems with central control all cause symmetric gaits. Spasticity may cause
asymmetric gait abnormalities (i.e., hemiplegia) or symmetric ones (i.e., paraplegia).
• Simple observation may result in prompt diagnosis. Examples include the lateral lurch of
hip disease, the backward lean of gluteus maximus weakness, the Trendelenburg gait of
gluteus medius weakness (often after hip replacement), the steppage gait and foot slap
of foot drop, the leg circumduction of hemiplegia, and the shuffling steps with narrow
base and flexed posture of Parkinson disease.
• Gait abnormalities are prominent in Lewy body dementia and vascular dementia but are
uncommon in Alzheimer dementia until late in its course.
• The timed-up-and-go test, stops-talking-when-walking test, and observation of the
patient’s ability to stand with feet together for 10 seconds all accurately assess the elderly
patient’s risk of falls.
7
Introduction
I.
Observation
(e.g.,
the patient’s emotions, overall function, and even prognosis. For example, the speed of an elderly
person’s gait accurately predicts falls, future disability, and risk of institutionalization.
with congestive heart failure, gait speed predicts cardiac index, future hospitalization, and mortality as well as the ejection fraction and better than the treadmill test.
have a characteristic gait, marked by an abnormally short stride and weak lift-off of the heel.
e phases of the normal gait are depicted in Fig. 7.1.
II. Etiology of Gait Disorders
Among patients presenting to neurologists, the most common causes of gait disorder are stroke
and Parkinson disease, followed by frontal gait disorder, myelopathy (e.g., cervical spondylosis, B
deficiency), peripheral neuropathy, and cerebellar disease.
clinicians, most gait abnormalities are caused by arthritis, followed by orthostatic hypotension,
stroke, Parkinson disease, and intermittent claudication.
of gait not only uncovers important neurologic and musculoskeletal problems
Parkinson disease, hemiparesis, spinal stenosis, hip disease), but it also provides clues to
1–4
In patients
5,6
Even depressed patients
8,9
Among patients presenting to general
10
7
12
49
50
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Stance Swing
Fig. 7.1 Normal gait. This figure illustrates the phases of normal gait, focusing on the right leg (shaded).
Normal gait consists of the stance phase (the period during which the leg bears weight) and swing phase (the
period during which the leg advances and does not bear weight). The stance and swing make up the stride,
which is the interval from the time one heel strikes the ground to when it again strikes the ground. During
the normal stance phase, it is the extensor muscles that contract—the gluteus maximus in early stance, the
quadriceps in mid stance, and the plantar flexors (soleus and gastrocnemius) in terminal stance pushing off
the heel. The healthy swing, in contrast, requires contraction of the flexor muscles, all of which are activated
early in the swing phase—hip flexors (iliopsoas muscles), knee flexors (hamstring muscles), and ankle flexors
(tibialis anterior and toe extensor muscles).
service and the physical therapy department of the Rancho Los Amigos Medical Center. Observational Gait
Analysis. 4th ed. Downey, CA: Los Amigos Research and Educatio Institute, Inc.; 2001.
11,12
Figure adapted with permission from The Pathokinesiology
3—GENERAL APPEARANCE OF THE PATIENT
Types of Gait Disorders and Their Significance
III.
Disorders of gait reflect one of four possible problems: pain, immobile joints, muscle weakness, or
abnormal limb control. Abnormal limb control, in turn, may result from spasticity, rigidity, diminished proprioception, cerebellar disease, or problems with cerebral control.
When analyzing a patient’s gait, the most important initial question is whether the gait is sym
metric or asymmetric. Pain, immobile joints, and muscle weakness are usually unilateral and thus
cause asymmetric abnormalities of gait. Rigidity, proprioceptive disorders, cerebellar diseases, and
-
problems with central control all cause symmetric abnormalities of the gait. Spasticity may cause
asymmetric gait abnormalities (hemiplegia) or symmetric ones (paraplegia).
A.
PAINFUL GAIT (ANTALGIC GAIT)
If
bearing weight on a limb is painful, patients adopt an antalgic gait to minimize the pain.
(Antalgic is from the Greek an and algesis, meaning “against pain.”) All antalgic gaits are characterized by a short contralateral step, along with other characteristic features.
1.
Short Contralateral Step
After bearing weight on the affected leg, patients with pain quickly step onto the sound leg. e
short contralateral step produces an uneven cadence, one identical to that produced by a rock in
one shoe.
2.
Other Characteristic Features
Depending on whether the pain is located in the foot, knee, or hip, each antalgic gait is distinctive,
allowing diagnosis from a distance.
a. Foot Pain
In patients with foot pain, the foot contacts the ground abnormally. For example, patients may
bear weight during stance on their heel only, forefoot only, or along the lateral edge of the foot.
b. Knee Pain
Patients with knee pain display a stiff knee that does not extend or flex fully during stride.
13
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