d. Another test of memory and verbal fluency we have found useful is the generation of a list of objects in a category; ask the patient to give the names of animals, vegetables, or makes of cars, as many as come to mind in 30 s or so; most individuals can list at least 12 items in each category.
e. Visual facility: Show the patient a picture of several objects; then ask him to name the objects.
5. Capacity for calculation, construction, and abstraction: a. Calculation: Test ability to add, subtract, multiply, and divide. Subtraction of serial 3s and 7s from 100 is a good test of calculation as well as of concentration.
b. Constructions: Ask the patient to draw a clock and place the hands at 7:45, a map of the United States, a floor plan of her house; ask the patient to copy a cube and other figures.
c. Abstract thinking: See if the patient can describe the similarities and differences between classes of objects (orange and apple, horse and dog, desk and bookcase, newspaper and radio) or explain a proverb or fable (“People who live in glass houses shouldn’t throw stones”; “A stitch in time saves nine”; “A rolling stone gathers no moss”; “Idle hands are the devil’s workshop”).
6. General behavior: Attitudes, general bearing, evidence of hallucinosis, stream of coherent thought and attentiveness (ability to maintain a sequence of mental operations), mood, manner of dress, etc.
7. Special tests of localized cerebral functions: Grasping, sucking, aphasia battery, praxis with both hands, and corticosensory function.
To enlist the full cooperation of the patient, the physician must prepare him for questions of this type. Otherwise, the patient’s first reaction will be one of embarrassment or anger because of the implication that his mind is unsound. It could be pointed out to the patient that some individuals are rather forgetful or have difficulty in concentrating, or that it is necessary to ask specific questions in order to form some impression about his degree of nervousness when being examined. Reassurance that these are not tests of intelligence or of sanity is helpful. If the patient is agitated, suspicious, or belligerent, intellectual functions must be inferred from his remarks and from information supplied by the family.
This type of mental status survey can be accomplished in about 10 min. A high level of performance on all tests eliminates the possibility of dementia in almost all cases and accords well with scores on the more formal paper and pencil tests mentioned earlier. It may fail to identify a dementing disease in an uncooperative patient and in a highly intelligent individual in the earliest stages of disease.
The question of whether to resort to formal psychologic tests is certain to arise. Such tests yield quantitative data of comparative value but perhaps may be less valuable for diagnostic purposes. The Mini-Mental Status Examination (MMSE) devised by Folstein and coworkers, and the Montreal Cognitive Assessment (MoCA) (Fig. 20-3) are popularly used. A score above 24/30 on the “mini-mental” is considered normal and scores below 21 indicate cognitive impairment (but in our practices, most educated adults in an office setting can exceed a score of 25). Patients with lower levels of education and older age have lower normative scores, but even individuals in their eighties with a high school education score 23 or above if not demented (see Crum et al for age and education adjusted normal score). The MoCA has been validated for adults ages 55 to 85 and also has a maximum score of 30. For patients who cannot finish the written portion because of physical disability, the test can be scored with 25 as the maximum and proportionately converted to 30. Several versions of the MoCA are available for use to avoid a learning effect if testing is done at 3 month intervals or less. Patients with mid cognitive impairment usually score in the range of 19 to 25 and those with confirmed Alzheimer disease, below 22.