The worn-out mental Status exam

[Alemo]

How do you guys perform serial cognitive testing clinically?

Testing subtraction gets boring for the examiner and the patient, and there are only so many repetitions of sets or words spelled backwards one can stomach. What else besides AOx4?

Any other techniques for memory besides the three word recall? Specifically for more remote memories?

Variations on any other parts of the mental status exam would be interesting to discuss as well.

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[Stagg737]

You can always switch up the words instead of the classic "pen, tie, car". One of my attendings does a color, a city, and "baseball" which I have adopted and found to be a bit more useful for detecting more subtle problems with memory and concentration (anecdotally). For remote memories you can ask them about when they finished certain milestones for school or things like who was president at major points in their life.

There was a study showing that the most sensitive 2-question screen for delirium (study below) was day of the week and months backwards and is probably actually more sensitive than the full AOx4 spiel. I don't even bother with asking date anymore unless it's a holiday or their birthday since I don't know it half the time.

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[wolfvgang22]

Yes. I always make the third "object" a concept, not a physical object. For example: "ball, tree, justice." People developing dementia miss the abstract object first.

 

[Mass Effect]

How do you guys perform serial cognitive testing clinically?

Testing subtraction gets boring for the examiner and the patient, and there are only so many repetitions of sets or words spelled backwards one can stomach. What else besides AOx4?

Any other techniques for memory besides the three word recall? Specifically for more remote memories?

Variations on any other parts of the mental status exam would be interesting to discuss as well.

As said above, change the words. I also do days of the week or days of the month backwards. As for remote memory, I find that asking about their history, either medical, psychiatric, or maybe even personal with details, is informative and I can confirm it by reviewing the chart.

There are also different forms of the MoCA.

 

[NickNaylor]

Recall, verbal fluency, and abstraction are, IMO, the most sensitive for detecting a brewing neurocognitive impairment and are typically the things I specifically assess for if I have a suspicion for an underlying cognitive impairment. If there are abnormalities, I'll do a full MOCA. Orientation and attention are obviously important in delirium.

There are different ways of doing this - I'll usually just use the tests for these things from the MOCA at the bedside.

 

[hebel]

I expected a different sort of thread based on your title. I don't know if it's just psychiatrists fault for not doing a good MSE, but I rarely find the MSE to be useful in general. It has the potential to be useful, but in clinical practice rarely is. I admit that this is mostly in the outpatient setting...it does have more utility inpatient.

I actually would petition to have "countertransference" added to the MSE.

 

[wolfvgang22]

I expected a different sort of thread based on your title. I don't know if it's just psychiatrists fault for not doing a good MSE, but I rarely find the MSE to be useful in general. It has the potential to be useful, but in clinical practice rarely is. I admit that this is mostly in the outpatient setting...it does have more utility inpatient.

I actually would petition to have "countertransference" added to the MSE.

What sort of thread did you expect?

 

[hebel]

What sort of thread did you expect?

More similar to my first paragraph...how the overall MSE feels worn out. This is more about tips for the cognitive screening portion of the MSE, which is fine.

 

[watto]

I wish I could remember the test from my old neurobehavior elective days, but there was this great little test of suggestibility in the presence of perceived authority. I feel like the patient was given the old "what hand is the penny in" query but with actions taken to suggest that the obvious might be incorrect. I always thought it might be a good way to gain insight into future patients' refusal to be honest with me about themselves / taking meds / etc and to see who was presenting a facade in the face of authority.

 

[samac]

More similar to my first paragraph...how the overall MSE feels worn out. This is more about tips for the cognitive screening portion of the MSE, which is fine.

Can I say I was also surprised? I thought it was going to call the full mental status exam antiquated, but it was just about cognitive. You’re not alone in this lol

 

[Alemo]

Sorry, I went on vacation the week after I posted this.

The cognitive stuff is interesting to me clinically (really i Just wanted to know what every one else’s toolbox consisted of). It seems like standard stuff, but I appreciate weighing in.

I am writing a paper on the history of the psychiatric interview, and I have run into some interesting cognitive tests that don’t seem to have common clinical use now (Masselon and Ziehen tests). I also found one called the absurdity-appreciation that involves telling the patient a nonsense statement and seeing how they react (“an unfortunate young girl was found brutally mutilated and chopped into 18 pieces, it is said she committed suicide”).

Then of course there’s giving the patient words with which to make an associative pair to uncover complexes...

 

[clausewitz2]

Sorry, I went on vacation the week after I posted this.

The cognitive stuff is interesting to me clinically (really i Just wanted to know what every one else’s toolbox consisted of). It seems like standard stuff, but I appreciate weighing in.

I am writing a paper on the history of the psychiatric interview, and I have run into some interesting cognitive tests that don’t seem to have common clinical use now (Masselon and Ziehen tests). I also found one called the absurdity-appreciation that involves telling the patient a nonsense statement and seeing how they react (“an unfortunate young girl was found brutally mutilated and chopped into 18 pieces, it is said she committed suicide”).

Then of course there’s giving the patient words with which to make an associative pair to uncover complexes...

I do Luria sequences with people a lot, have caught a lot of people who were struggling more cognitively than I at first appreciated

 

[Stagg737]

I'd be interested in hearing people's thoughts on reliable substitutes for the clock-drawing test. It's fine for most adults, but something I've heard happening more and more is that kids, teens, and even some young adults can't do it because they never learned how to read an analog clock in the age of digital everything.

 

[Taddy Mason]

I do Luria sequences with people a lot, have caught a lot of people who were struggling more cognitively than I at first appreciated

Same. I’ve found Luria sequences helpful with catching more subtle deficits and have made it pretty much standard when doing a full MSE unless someone is blatantly impaired.

 

[psyguru]

They now have shorter version if the MOCA.

 

[asdf123g]

Sorry, I went on vacation the week after I posted this.

The cognitive stuff is interesting to me clinically (really i Just wanted to know what every one else’s toolbox consisted of). It seems like standard stuff, but I appreciate weighing in.

I am writing a paper on the history of the psychiatric interview, and I have run into some interesting cognitive tests that don’t seem to have common clinical use now (Masselon and Ziehen tests). I also found one called the absurdity-appreciation that involves telling the patient a nonsense statement and seeing how they react (“an unfortunate young girl was found brutally mutilated and chopped into 18 pieces, it is said she committed suicide”).

Then of course there’s giving the patient words with which to make an associative pair to uncover complexes...

can i read your paper? sounds very interesting!

 

[WisNeuro]

Sorry, I went on vacation the week after I posted this.

The cognitive stuff is interesting to me clinically (really i Just wanted to know what every one else’s toolbox consisted of). It seems like standard stuff, but I appreciate weighing in.

I am writing a paper on the history of the psychiatric interview, and I have run into some interesting cognitive tests that don’t seem to have common clinical use now (Masselon and Ziehen tests). I also found one called the absurdity-appreciation that involves telling the patient a nonsense statement and seeing how they react (“an unfortunate young girl was found brutally mutilated and chopped into 18 pieces, it is said she committed suicide”).

Then of course there’s giving the patient words with which to make an associative pair to uncover complexes...

The issue with a lot of the old bedside type "cognitive" tests, particularly dealing with abstraction that have fallen out of use, is that they lacked clinical utility. Sure, people with dementia did poorly on them, but so did a buttload of cognitively normal people. For a ton of these tests, specificity was bottomed out. This was a huge problem with many tests back in the day before we got better at looking at psychometrics of tests compared to the general population.

 

[whopper]

IMHO the MSE ought to have it's evidence base taught in training.
I started using a PHQ-9. It's easy and tells you far more about depression than an MSE. Of course there's more to psychiatry than simply depression. The PHQ-9 is only for depression but it's straight, to the point, gives you a measure, and depression is a bread and butter of our field with several stating that depression ought to be at least screened in psych visits.

 

[VA Hopeful Dr]

IMHO the MSE ought to have it's evidence base taught in training.
I started using a PHQ-9. It's easy and tells you far more about depression than an MSE. Of course there's more to psychiatry than simply depression. The PHQ-9 is only for depression but it's straight, to the point, gives you a measure, and depression is a bread and butter of our field with several stating that depression ought to be at least screened in psych visits.

Uspstf already says us primary care types should screen all adults for depression.