The Mental Status Examination (MSE)Mental StatuslMental status is the total expression of a persons emotional responses, mood, cognitive function, and personalitylIt is closely linked to the individuals executive functioning, i.e. motivation, initiative, goal formation, planning and performing, self-monitoring, and integration of feedbackQuick Neurology ReviewlFrontal lobe lSpeech formation (Broca area)lEmotions/affectlDrive lAwareness of selflShort-term memory lGoal-oriented behaviorQuick Neurology ReviewlParietal lobe lSensory perceptionlSpatial sense and navigationQuick Neurology ReviewlTemporal lobe lPerception and interpretation of sounds lWernickes area lIntegration of behavior, emotion, and personalitylLong-term memoryQuick Neurology ReviewlLimbic system lSurvival behaviors (mating, aggression, fear, affection)lReactions to emotions, and expression of affect is mediated by connections of the limbic system and the frontal lobeDementialDementia is a clinical syndrome, characterized by deteriorating cognition, behavior, and functional independencelIt is usually related to obvious structural disease of the brain (most commonly atrophy)lDementia affects 3-11% of adults older than 65Mnemonic for causes of dementialD: drugs and toxinslE: endocrinelM: metabolic and mechanicallE: epilepsy lN: nutritional and nervous systemlT: tumor and traumal I: infectionlA: arterial DeliriumlDelirium is different than dementia lIt is an acute confusional state accompanied by a disorder of perceptionlSymptoms include alterations in mental status (disorientation), attention span, sleep patterns, and affectlSudden and fluctuatinglUsually reversibleMental Status Examination lThe MSE is one component of an exam and may be viewed as the psychological equivalent of the physical examlIt is an important component to a neurological evaluationFactors affecting the MSElCulture and educational background of the patient lWhat is abnormal for a person with high intellectual ability may be normal for a person of less educationlPatients with ESL may have difficulty with some components of the examMajor Components of the MSE1.Appearance 2.Motor3.Speech4.Affect & mood5.Thought Content6.Thought Process7.Perception8.Intellect9.InsightAppearancelAgelGenderlRacelBody buildlPosturelEye contact lDresslGroominglMannerlAttentiveness to examinerlEmotional facial expressionlAlertnessMotorlBehavior: Pleasant? Cooperative? Appropriate for the particular situation? lHesitancylAgitationlAbnormal movementslGaitlCatatoniaSpeechlRate lRhythm lVolumelAmount lArticulation lSpontaneityAffect and MoodlAffect: How do they appear to you?lStabilitylRangelAppropriatenesslIntensitylMood: Dr. asks the patient directly how he/she feelsThought ContentlSuicidal ideationlDeath wisheslHomicidal ideationlDepressive cognitionlObsessionslRuminationslPhobiaslParanoid ideationlMagical ideationlDelusionslOvervalued ideasDescription of what the patient is thinking aboutThought ProcesslAssociationslCoherencelLogiclStreamlClang associations lPerseverationlNeologism lThought blockinglAttentionDescription of the way in which the patient thinksPerceptionlHallucinationslIllusionslDepersonalizationlDerealizationldj vuljamais vuIntellectlGlobal impression: average, above average, below averageInsightlAwareness of illnessMSElThe full MSE is a lengthy examlYou assess many components of the MSE in your normal work up of a patientlWhen you need to do a shorter neurological screening exam, you may shorten the MSE to the Mini Mental Status Exam (MMSE)MMSElTakes approximately 10 minuteslThe MMSE tests:lOrientationlImmediate and short-term memorylConcentration lArithmetic ability lLanguagelPraxis (learning)MMSElOrientation:lWhat is the (year) (season) (date) (day) (month)? lWhere are we?(state) (country) (town) (office) (floor) 5 pointslRegistration:lName 3 objects, taking 1 second to name each. Then ask the patient to repeat them. 1 point for each correct.lAttention and Calculation:lAsk the patient to count backwards from 100 in 7s. Stop after 5 answers. lAlternatively, ask the patient to spell “world” backwards. l1 point for each correct answer (5)l1 point for each correct answer (5)l1 point for each correct answer (3)l1 point for each correct answer (5)MMSElRecall:lAsk the patient for the 3 objects named under “Registration”.lLanguage:lPoint to two objects and ask the patient to name them (pen and watch).lAsk the patient to repeat “No ifs, ands, or buts.”lAsk the pt. to follow a 3-step command: “Take this paper in your right hand, fold it in half, and put it on the table.”lAsk the pt. to read and obey the following: “Close your eyes.” lWrite a sentence. lCopy a drawing of intersecting pentagons. l1 point for each correct answer (3) l1 point for each correct answer (2)l1 point for correct answer (1) l1 point for each correct task (3)l1 point for correct task (1)l1 point for correct task (1)l1 point for correct task (1)lTotal (30) Interpretation of the MMSElThe traditional threshold for the MMSE is a score of 23 or greaterlScores of 0-23 argue strongly for the diagnosis of dementiaBut, false-positive results are a concern when applied to large populations with low incidence of dementia, so some experts prefer the following scoring system:l0-20: dementia highly probablel26-30: dementia highly unlikelyl21-25: results not conclusivelThe MMSE is a copyrighted psychological test published by Psychological Assessment Resources (PAR), Inc. So, why do DCs need to do MSEs?lEmotional and behavioral changes are often the first signs of organic brain diseaselDoes the patient see his or her M.D. as frequently as he or she sees you, the chiropractor? lBrain tumors, subdural hematomas, small infarcts, and cerebral atrophy may be undetected on routine neurological examination, whereas the cognitive effects of these lesions may be apparent on an MSEDrawbackslDoes a normal MSE or MMSE indicate competence? lNolCompetence relates to a pt.s ability to provide food & shelter, to manage $, and to participate in activities and decisionslPts. who score well may have difficulty with basic activities of daily living DrawbackslDoes an abnormal MSE or MMSE indicate incompetence?lNot necessarilylMany pts. with cognitive limitations develop alternative means of coping with deficits, allowing them to live fairly independent livesDrawbackslThe MSE and MMSE screenings have limitations lThey are subject to interpretive bias and experience of the interviewer lThey have a fairly significant false-negative rate, esp. in pts. with right hemisphere lesionslDemographics and culture: Age (60), education (9th grade), limited cultural experiences, and low socioeconomic status limit usefulness lScreening questionnaires are less sensitive to cognitive impairmentsDo you have to be a DC & a Psychiatrist/Psychologist? lNo. It is not realistic to expect that you evaluate a patient to the same level of a psychiatrist or a psychologist lBut, a large part of a persons overall health is his or her mental health lAs subluxations may be caused by “thoughts”, a persons mental status should be important to youDocumentation of Mental StatuslDocumentation of the patients mental status is not remarkably different than the documentation for the history exam or physical examlInclude it in the Neurology section of your narrative historyExample of normal: “The patient is alert and oriented x 3. Correct registration of 3 objects was noted. Attention and calculation are appropriate with serial 7 counting. Short term memory is intact. Language skills are demonstrated without evidence of agnosia, aphasia or apraxia.” Example of abnormal:l“The patient is alert and oriented to person and time, but is unable to identify the location, believing she is in her childhood home in Omaha. Correct registration of 3 objects is noted. The patients attention and calculation are deficient, with the patient correctly counting backwards from 100 by 7s to 86. The patient correctly repeats the names of objects, without evidence of agnosia or aphasia. The patient is unable, however, to complete commands or purposeful actions and demonstrates difficulty completing written or verbal commands. Apraxia is suspected. The MMSE and CPTlThe MMSE is considered a component of the neurological portion of the E&M; therefore, no separate CPT code is entered