THEMEDPRACTICALEXAM.COM

Components of Higher Mental Function Assessment in CNS Cases:

A systematic approach is essential when assessing and documenting HMF.

1. Level of Consciousness (LOC):

This is the most fundamental aspect of HMF assessment, reflecting the patient's overall arousal and responsiveness to stimuli, particularly vital in CNS cases. Use clear and standardized terminology:

  • Alert: The patient is awake, aware of their surroundings, and responds appropriately to stimuli.

  • Lethargic/Somnolent: The patient is drowsy, can be easily aroused by verbal or gentle tactile stimuli, but tends to drift back to sleep if not stimulated.

  • Obtunded: The patient is difficult to arouse, requires repeated or stronger stimuli to achieve arousal, and may have slowed responses.

  • Stuporous: The patient is only responsive to vigorous and repeated stimuli (e.g., painful stimuli) and may only exhibit brief, non-verbal responses.

  • Comatose: The patient is unarousable and does not respond to any external stimuli, including pain. Reflexes may be present, absent, or abnormal.

In your CNS case summary: Clearly state the patient's current level of consciousness using one of these terms. If there has been a change in LOC, document the sequence of changes.

Example: "At the time of examination, the patient was alert and oriented to time, place, and person."

2. Orientation:

Orientation refers to the patient's awareness of themselves and their surroundings in three domains:

  • Time: Awareness of the current day, date, month, year, and time of day.

  • Place: Awareness of their current location (e.g., hospital, ward, city).

  • Person: Recognition of themselves and significant individuals.

Assessment: Ask direct questions like "What is today's date?", "Where are you right now?", and "What is your name?".

In your CNS case summary: Document the patient's orientation to each of the three domains. If disoriented, specify to which domain(s) they are disoriented.

Example: "The patient was oriented to person and place but disoriented to time, stating the year was 2022."

3. Attention:

Attention is the ability to focus and maintain concentration on a specific task or stimulus while filtering out distractions. Several aspects of attention can be assessed:

  • Digit Span: The ability to repeat a sequence of numbers forward and backward. Normally able to repeat 7 numbers forwards and 5 numbers backwards.

  • Serial Subtraction: Subtracting a specific number (e.g., 7) repeatedly from a starting number (e.g., 100).

  • Spell a Word Backwards: Asking the patient to spell a simple word (e.g., "WORLD") backward.

  • Continuous Performance Tasks: Observing the patient's ability to stay focused during a conversation or a simple task.

In your CNS case summary: Describe the patient's ability to maintain attention during the interview and any specific tests performed.

Example: "The patient was able to repeat a digit span of 5 forward and 3 backward. They struggled with serial subtraction of 7, making frequent errors after the third subtraction, suggesting impaired attention."

4. Memory:

Memory encompasses the processes of encoding, storing, and retrieving information. Different aspects of memory should be assessed:

  • Immediate Recall (Registration): The ability to immediately recall a small amount of information presented (e.g., repeating three unrelated words).

  • Recent Memory (Short-Term Memory): The ability to recall information learned a few minutes ago (e.g., the three words from immediate recall after a brief distraction).

  • Remote Memory (Long-Term Memory): The ability to recall past events, personal history, and general knowledge (e.g., date of birth, significant life events).

Assessment:

  • Immediate Recall: Present 3

  • unrelated words and ask the patient to repeat them immediately.

  • Recent Memory: After a 5-10 minute interval (with a distracting task), ask the patient to recall the same words.

  • Remote Memory: Ask about verifiable past events or personal details. Corroborate with family members if necessary.

In your CNS case summary: Document the patient's performance in each aspect of memory tested.

Example: "Immediate recall was intact (recalled 3/3 words). Recent memory was impaired (recalled 1/3 words after 5 minutes). Remote memory for significant personal events appeared intact."

5. Speech:

Assessment of speech involves evaluating various aspects of verbal communication:

  • Fluency: The rate and smoothness of speech production. Note any hesitancy, word-finding difficulties (anomia), or halting speech.

  • Comprehension: The ability to understand spoken language. Assess by asking the patient to follow simple and complex commands.

  • Repetition: The ability to repeat words and phrases accurately.

  • Articulation: The clarity of speech. Note any dysarthria (difficulty forming words due to motor impairment).

  • Prosody: The rhythm, intonation, and stress patterns of speech. Note any unusual or flat prosody.

  • Naming : Ability to name the unrelated objects put towards them.

  • Reading : Check whether the patient can read words/sentences and paragraphs and comprehend what he is reading

  • Writing : Check whether the patient can write short sentences and copy a sentence.

In your CNS case summary: Describe the characteristics of the patient's speech in detail, noting any abnormalities in fluency, comprehension, repetition, naming, articulation, or prosody.

Example: "Speech was fluent but with occasional word-finding difficulties. Comprehension was intact for simple commands but impaired for multi-step instructions. Repetition was intact. Naming of common objects was accurate. Articulation was clear."

6. Intelligence (General Knowledge and Abstract Thinking):

While a formal IQ test is not usually performed during a routine neurological examination, you can gain insights into the patient's general intellectual functioning by assessing:

  • General Knowledge: Asking questions about common facts, current events, or historical figures (appropriate to their age and background).

  • Abstract Thinking: Evaluating their ability to understand similarities and differences between concepts (e.g., "How are an apple and a banana alike?"), interpret proverbs or idioms, and identify patterns.

In your CNS case summary: Briefly describe the patient's level of general knowledge and their ability to think abstractly based on your observations and brief questioning.

Example: "The patient demonstrated adequate general knowledge for their age and educational background. Their ability to think abstractly was impaired, as evidenced by a concrete interpretation of the proverb 'A rolling stone gathers no moss.'"

7. Appearance and Behaviour:

Observe the patient's overall appearance and behaviour during the interview:

  • Appearance: Note their hygiene, grooming, dress, and any unusual physical features.

  • Behaviour: Describe their motor activity (e.g., restless, agitated, slowed), cooperation with the examination, eye contact, and any unusual mannerisms or stereotypies.

In your CNS case summary: Provide a concise description of the patient's appearance and behaviour.

Example: "The patient appeared well-groomed and cooperative during the examination. There were no observed abnormalities in motor behaviour."

8. Mood and Affect:

Mood refers to the patient's sustained emotional state, while affect is the outward expression of their emotions at a particular moment.

  • Mood: Ask the patient directly about their current mood (e.g., "How have you been feeling lately?"). Note if they report feeling sad, anxious, irritable, euphoric, etc.

  • Affect: Observe the patient's facial expressions, tone of voice, and body language. Describe the affect in terms of its type (e.g., happy, sad, angry), intensity (e.g., blunted, flat, exaggerated), and appropriateness to the situation and reported mood.

In your CNS case summary: Document the patient's reported mood and your observed affect.

Example: "The patient reported feeling persistently sad for the past two weeks. Their affect appeared congruent with their reported mood, with frequent downward gaze and a subdued tone of voice."

9. Delusions and Hallucinations:

These are important features of psychotic disorders and can sometimes occur in neurological conditions that affect the CNS.

  • Delusions: False, fixed beliefs that are not based on reality and are not shared by others in the patient's culture. Explore for common types of delusions (e.g., persecutory, grandiose, somatic, nihilistic).

  • Hallucinations: Sensory experiences that occur without external stimulation. Ask specifically about hallucinations in different modalities (e.g., auditory, visual, tactile, olfactory, gustatory).

In your CNS case summary: Specifically inquire about the presence of delusions and hallucinations. If present, describe their content and characteristics. If absent, explicitly state this.

Example: "The patient denied experiencing any delusions or hallucinations." OR "The patient reported hearing voices that are not there (auditory hallucinations) telling them they are worthless. They also expressed a belief that their food is being poisoned (persecutory delusion)."

Example Case Structure:

Higher Mental Functions:

  • Level of Consciousness: The patient was alert and responsive.

  • Orientation: Oriented to time, place, and person.

  • Attention: Attention span appeared intact during the interview. Digit span was [number] forward and [number] backward. Serial subtraction of 7 was [description of performance].

  • Memory: Immediate recall was [number/number]. Recent memory was [number/number] after 5 minutes. Remote memory for [mention a specific aspect tested] was seemingly intact/impaired.

  • Speech: Speech was fluent, with no evidence of dysarthria, aphasia, or dysprosody. Comprehension, repetition, and naming were intact.

  • Intelligence (General Knowledge and Abstract Thinking): Demonstrated appropriate general knowledge. Abstract thinking was [description of performance on proverb interpretation or similarity/difference tasks].

  • Appearance and Behaviour: The patient was [description of appearance] and [description of behaviour], cooperative with the examination.

  • Mood: Reported mood was [patient's description].

  • Affect: Affect was [description of affect] and [congruent/incongruent] with reported mood.

  • Delusions and Hallucinations: Denied any delusions or hallucinations.

Viva Questions and Answers on Higher Mental Functions

1. General Approach to Mental Functions Examination

Q1: What are the initial points you should note before starting the actual examination of mental functions?

Before the actual examination, you should note the patient’s:

  • Educational Status

  • Occupation

  • Handedness

  • Knowledge of languages

Q2: How do you assess the level of consciousness, and what terms are used to describe it? A2: You assess the patient's level of consciousness and report it using the following guidelines:

  • Alert: When the patient is fully aware of oneself and surroundings.

  • Confusion: Patient is unable to think with customary speed and clarity.

  • Delirious: When the patient is in a confusional state with increased psychomotor activity.

  • Lethargic/Drowsy: When the patient is unable to sustain a wakeful state in the absence of external stimulus.

  • Obtunded: When the patient is able to answer only in response to painful stimuli.

  • Stupor: When the patient groans to painful stimuli.

  • Coma: When no response is obtained even with deep painful stimuli.

Q3: Is there an objective method to assess the level of consciousness?

Yes, a relatively objective method is using the Glasgow Coma Scale (GCS), which may be used in appropriate situations.

Q4: Can you briefly explain the components of the Glasgow Coma Scale?

The Glasgow Coma Scale assesses:

  • Eye Opening Response: Spontaneous (4), to verbal command (3), to pain (2), Absent (1).

  • Verbal Response: Well oriented (5), Confused conversation (4), Inappropriate responses (3), Incomprehensible speech (2), Absent (1).

  • Motor Response: Obeys commands (6), Purposeful movements to painful stimulus (5), Withdraws from pain (4), Abnormal flexion (3), Extensor response (2), Absent (1).

Q5: How do you assess orientation?

Orientation is assessed in three aspects

  • Time: Ask the patient to tell the approximate time, day, date, month, and year.

  • Place: See if the patient knows that he/she is in the hospital. Ask about the place, floor, town, state, and country where he/she is at present.

  • Person: Ask the patient about themselves, bystanders, the treating doctor, nurse, attendant, and co-patients.

Q6: How do you assess attention?

To assess attention

  • Observe whether the patient is attentive to questions put to them, to environmental cues, and to the bystanders.

  • Ask the patient to serially subtract 3, 5, or 7 from 100.

Q7: How do you test different types of memory?

Memory assessment includes

  • Immediate memory: Ask the patient to repeat 5 digits forward and 3 digits backward.

  • Recent memory: Ask the patient what they had for breakfast, to recall specific words or to recall the position of hidden objects.

  • Remote memory: Ask about personal information like the school they studied in, their first job, dates of social events (e.g., Independence Day), or family events like a son’s marriage.

Q8: What is the purpose of speech assessment, and what conditions are you looking for?

The purpose is to detect whether the patient has aphasia, dysarthria, dysphonia, or normal speech.

Q9: What is Aphasia, and how do you assess it?

Aphasia is the loss or impairment of the production and/or comprehension of spoken or written language due to an acquired brain lesion. To detect aphasia, follow a scheme of examination and report each parameter as normal or impaired:

  • Fluency: Scrutinize word output (normal 50-150/minute), word-finding difficulty, initiation difficulty, circumlocution, grammar, prosody, paraphasias, and neologisms.

  • Comprehension: Ask the patient to point to objects (single-word comprehension), give multi-step commands (e.g., "Point to nose, shirt, and cot"), and ask yes/no questions.

  • Repetition: Ask the patient to repeat words and phrases.

  • Naming and Word Finding: Check the ability to identify and name colors, body parts, and objects in the room.

  • Reading: If literate, check if they can read words/sentences/paragraphs and comprehend what they are reading (by asking simple questions).

  • Writing: Evaluate the ability to write letters and numbers to dictation, short sentences describing their disease, and copying a sentence.

Q10: What is Dysarthria, and what types are mentioned?

Dysarthria is speech impairment. The document mentions characteristics of:

  • Flaccid: Nasal twang, abnormalities of linguals, labials, and gutturals.

  • Ataxic: Staccato (undue emphasis on syllables) and Scanning (undue separation of syllables).

  • Dyskinetic: Unexpected punctuations due to dyskinesia.

Q11: How is intelligence assessed during a clinical examination? A11: Intelligence is assessed based on:

  • The educational status of the patient.

  • Comparison with that of a sibling.

  • The vocabulary of the patient.

Q12: What aspects of appearance and behavior should you note?

You should note whether the patient is

  • Well dressed

  • Clean / Shabby

Q13: What should you assess regarding mood, delusions, and hallucinations?

"Mood, delusions and hallucinations" are components of mental functions to be assessed, implying inquiry into the patient's emotional state and presence of false beliefs or sensory experiences.

Mini-Mental State Examination (MMSE)

(Administer and score each section as instructed)

I. Orientation (Maximum Score: 10 points)

  • Time Orientation (5 points):

    • What is the year? (1 point)

    • What is the season? (1 point)

    • What is the date? (1 point)

    • What is the day of the week? (1 point)

    • What is the month? (1 point)

  • Place Orientation (5 points):

    • Where are we now? (e.g., State/Country) (1 point)

    • What county are we in? (1 point)

    • What city/town are we in? (1 point)

    • What building are we in? (1 point)

    • What floor are we on? (1 point)

II. Registration (Maximum Score: 3 points)

  • I am going to name three objects. I want you to repeat them after I say them. Remember them, because I will ask you to say them again in a few minutes.

    • Choose three unrelated objects, e.g., "Apple," "Table," "Penny." Say them clearly, about one second apart.

    • Score 1 point for each correctly repeated word on the first attempt. Repeat until all three are learned, up to six trials, but only score the first repetition.

III. Attention and Calculation (Maximum Score: 5 points)

  • Serial Sevens: I would like you to subtract 7 from 100, then subtract 7 from that answer, and so on. Continue subtracting 7 until I tell you to stop.

    • 100 - 7 = ? (93)

    • 93 - 7 = ? (86)

    • 86 - 7 = ? (79)

    • 79 - 7 = ? (72)

    • 72 - 7 = ? (65)

    • Score 1 point for each correct subtraction. Stop after five subtractions.

  • Alternative if Serial Sevens is too difficult: Spell the word "WORLD" backwards.

    • D-L-R-O-W

    • Score 1 point for each letter in correct order.

IV. Recall (Maximum Score: 3 points)

  • Now, what were those three objects I asked you to remember earlier?

    • Prompt for each of the three objects from the Registration section.

    • Score 1 point for each object correctly recalled without prompting.

V. Language (Maximum Score: 8 points)

  • Naming (2 points):

    • Point to a pencil. What is this called? (1 point for "pencil")

    • Point to a watch. What is this called? (1 point for "watch")

  • Repetition (1 point):

    • Now, I want you to repeat this phrase after me: "No ifs, ands, or buts."

    • Score 1 point for correct repetition.

  • Three-Stage Command (3 points):

    • Take this piece of paper in your right hand, fold it in half, and put it on the floor.

    • Score 1 point for each action correctly performed.

  • Reading (1 point):

    • Please read this sentence aloud and then do what it says: "CLOSE YOUR EYES."

    • Present the written phrase "CLOSE YOUR EYES" clearly.

    • Score 1 point if the patient closes their eyes.

  • Writing (1 point):

    • Please write a complete sentence about anything you like. It must contain a subject and a verb.

    • Provide a blank piece of paper and a pen/pencil.

    • Score 1 point if the sentence is grammatically correct and meaningful.

VI. Copying (Maximum Score: 1 point)

  • Copy this design.

    • Draw two intersecting pentagons, with each side of one pentagon intersecting a side of the other, forming a four-sided figure in the middle. Ensure all ten angles are present and two intersect.

    • Score 1 point if the drawing is a reasonable copy of the stimulus, with all 10 angles and the two intersecting pentagons evident. Tremors or rotations are acceptable if the overall form is preserved.

Total Score: _____ / 30