The history should be supplemented by information obtained from a person other than the patient, because, through lack of insight, the patient will have limited and variable grasp of his illness or its gravity; indeed, he may be unaware even of his chief complaint. Special inquiry should be made about the patient’s general behavior, capacity for work, personality changes, language, mood, special preoccupations and concerns, delusional ideas, hallucinatory experiences, personal habits and care in hygiene, and such faculties as memory and judgment.
The examination of the mental status should include some of the following general categories with suggested examples for testing as modified for each patient’s circumstances. In addition, the mode of answering and solving problems gives invaluable information about the mental operations of the subject and must be incorporated into any analysis of cognition. Many practitioners favor the formal assessment and scoring provided by the paper and pencil formalized testing of MMSE or MoCA because they are quicker and allow for quantified serial measurement as described in the following text. A perplexed or slowed individual may ultimately perform adequately but nonetheless have seriously flawed cortical or subcortical function.
Each of the categories in the following text is an abstraction but ones that separate particular functions of the brain. Examples are given for each group but practitioners often adopt their own based on background and training. As already emphasized, the patient must have normal, or nearly so, attentiveness to carry out these tasks and a deficiency in any one of them may disrupt the performance of others.
1. Immediate recall (attention, short-term working memory): This is necessary as a prelude to subsequent testing. Repeat these numbers after me (give series of 3, 4, 5, 6, 7, 8 digits at a speed of 1 per second). When I give a series of numbers, repeat them in reverse order. Cross out all the a’s on a printed page; count forward and backward; say the months of the year forward and backward; spell world forward and then backward. Verbal trail making (reciting alternating letters of the alphabet and their ordinal place, i.e., A-1, B-2, C-3, D-…).
2. Insight (patient’s replies to questions about the chief symptoms): What is your difficulty? Are you ill? When did your illness begin?
3. Orientation (knowledge of personal identity and present situation): What is your name, address, telephone number? What is your occupation? Are you married?
a. Place: What is the name of the place where you are now (building, city, state)? How did you get here? What floor is it on? Where is the bathroom?
b. Time: What is the date today (day of week and of month, year)? What time of the day is it? What meals have you had? When was the last holiday?
4. Memory: a. Long term: Tell me the names of your children (or grandchildren) and their birth dates. When were you married? What was your mother’s maiden name? What was the name of your first schoolteacher? What jobs have you held? These must be corroborated by a spouse or other family member. We also find it useful to quiz the patient about cultural icons of the past that are appropriate to his age. Most patients should be able to name the recent presidents in reverse order.
b. Recent past: Tell me about your recent illness (compare with previous statements). What is my name (or the nurse’s name)? When did you see me for the first time? What tests were done yesterday? What were the headlines of the newspaper today?
c. Memorization (learning): The patient is given three or four simple data (examiner’s name, date, time of day, and a fruit, structure, or trait, such as honesty—we use “a red ball, Beacon street, and an envelope”) and is asked to repeat them after a minute; or is given a brief story containing several facts and is asked to recount the main facts as soon as the story is over. The capacity to reproduce them at intervals after committing them to memory is a test of memory span.