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General Mental Status Scales, Rating Instruments, and Behavior Inventories
There are over 50 general mental status scales for assessing cognition, and a large number of inventories for behavioral assessment. This does not include the many available targeted mental status scales, which focus on a particular disorder or syndrome that is not dementia or general cognitive impairment. Chapter 15 discusses general characteristics and guidelines for choosing among these instruments. This chapter expands on those guidelines and discusses individual general mental status scales, related rating instruments, and behavior inventories. The first section reviews 10 current or popular general mental status scales that can be administered under 15 minutes, plus one longer scale with an abbreviated version. These selected scales, by and large, have good sensitivity and specificity for “dementia” (although variable for “cognitive impairment”) and adequate test-retest and interrater reliability. The second section surveys most general mental status scales. The third section covers information-based rating instruments, and the final section is a brief overview of behavior inventories of interest to the mental status examiner. The information presented here is primarily derived from the in-person, face-to-face administration of these instruments; Chapter 18 discusses the application or modification of these mental status scales for telemedicine, such as over the telephone or by videoconferencing.
Evaluation of Select General Mental Status Scales
General mental status scales need to be brief for practical use in clinical settings. Although clinicians use these scales to screen patients for any cognitive impairment needing further assessment, these scales are mostly validated on patients with dementia rather than those with mild or focal cognitive deficits. Many scales take 5 minutes or less to administer, but they may evaluate only memory or a limited number of cognitive areas. Among these instruments are the Clock Drawing Test (CDT), Memory Impairment Screen (MIS), Mini-Cog, Six-Item Screener (SIS), Short Portable Mental Status Questionnaire (SPMSQ), and Short Test of Mental Status (STMS) ( Table 16.1 ). Mental status scales of somewhat longer length (>5–15 minutes) include more cognitive areas and are more sensitive to mild cognitive impairments than the brief scales. These instruments include the Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), Rowland Universal Dementia Assessment Scale (RUDAS), and the Saint Louis University Mental Status Examination (SLUMS). Longer cognitive assessments (>15 minutes) are clearly more comprehensive but at the price of decreased brevity in administration. The Addenbrooke Cognitive Examination-III (ACE-III) is an example.
TABLE 16.1
Select General Mental Status Scales - General Characteristics
| Abbreviation | Name | Time (minutes) | Total Score | Cutoff Scores for Dementia | Sensitivity for Dementia | Specificity for Dementia | Test- retest | Interrater | Cognitive Areas |
|---|---|---|---|---|---|---|---|---|---|
| CDT | Clock Drawing Test | 1–3 | 10 | <7 | 67–98 | 67–98 | 0.77–0.94 | 0.83–0.97 | Mental control/attention visuospatial numbers/calculation executive |
| MIS | Memory Impairment Screen | 4–5 | 8 | ≤4 | 43–86 | 93–97 | 0.69 | ….. | Memory |
| Mini-Cog | Mini-Cog | 2–4 | 5 | <3 | 76–100 | 54–89 | ….. | 0.96–0.97 | Memory mental control/attention visuospatial numbers/calculation executive |
| SIS | Six-Item Screener | 5 | 6 | ≤4 | 86–89 | 78–88 | 0.85 | 0.82 | Memory orientation |
| SPMSQ | Short Portable Mental Status Questionnaire | 5 | 10 | ≤7 | 67–74 | 91–100 | 0.82–0.83 | ….. | Memory orientation mental control/attention semantic memory |
| STMS | Short Test of Mental Status | 5 | 38 | ≤29 | 86–95 | 88–96 | ….. | 0.82 | Memory orientation mental control/attention visuospatial numbers/calculation executive semantic memory |
| MMSE | Mini-Mental State Examination | 8–13 | 30 | <24 | Pooled 81 | Pooled 89 | 0.80–0.95 | 0.83–0.97 | Memory orientation mental control/attention language visuospatial ±numbers/calculation |
| MoCA | Montreal Cognitive Assessment | 10–15 | 30 | <26 vs. <23 |
Pooled 91 | Pooled 81 | 0.82–0.92 | 0.87–0.99 | Memory orientation mental control/attention language visuospatial numbers/calculation executive |
| RUDAS | Rowland Universal Dementia Assessment Scale | 10–15 | 30 | <23 | 80.9–95 | 54–98 | 0.96–0.98 | 0.99 | Memory language visuospatial right-left orientation alternating movements safety question |
| SLUMS | Saint Louis University Mental Status Examination | 4–10 | 30 | <20 (less than high school) <21 (high school or greater) |
84–100 | 87–100 | 0.82 | 0.99 | Memory (includes story) orientation mental control/attention language (naming) visuospatial numbers/calculation executive |
| ACE-III | Addenbrooke’s Cognitive Examination-III | 15–20 | 100 | <82 | 79–100 | 83–100 | 0.91+ | 0.99+ | Memory (more than one) orientation mental control/attention language (multiple) visuospatial (multiple) numbers/calculation executive semantic memory |
Beishon LC, Batterham AP, Quinn TJ, et al. Addenbrooke’s Cognitive Examination III (ACE-III) and Mini-ACE for the detection of dementia and mild cognitive impairment. Cochrane Database Syst Rev. 2019;12:CD013282.
Breton A, Casey D, Arnaoutoglou NA. Cognitive tests for the detection of mild cognitive impairment (MCI), the prodromal stage of dementia: meta-analysis of diagnostic accuracy studies. Int J Geriatr Psychiatry . 2019;34:233–242.
Cullen B, O’Neill B, Evans JJ, Coen RF, Lawlor BA. A review of screening tests for cognitive impairment. J Neurol Neurosurg Psychiatry. 2007;78(8):790–799.
Matias-Guiu JA, Cortés-Martínez A, Valles-Salgado M, et al. Addenbrooke’s Cognitive Examination III: diagnostic utility for mild cognitive impairment and dementia and correlation with standardized neuropsychological tests. Int Psychogeriatr. 2017;29:105–113.
Matías-Guiu JA, Valles-Salgado M, Rognoni T, Hamre-Gil F, Moreno-Ramos T, Matías-Guiu J. Comparative diagnostic accuracy of the ACE-III, MIS, MMSE, MoCA, and RUDAS for screening of Alzheimer disease. Dement Geriatr Cogn Disord . 2017;43(5-6):237–246.
Tsoi KK, Chan JY, Hirai HW, et al. Cognitive tests to detect dementia: a systematic review and meta-analysis. JAMA Intern Med. 2015;175:1450–1458.
Wilterdink JL. Mental status scales to evaluate cognition. UpToDate Online Database.
Velayudhan L, Ryu SH, Raczek M, et al. Review of brief cognitive tests for patients with suspected dementia. Int Psychogeriatr. 2014;26(8):1247–1262. https://www.uptodate.com/contents/mental-status-scales-to-evaluate-cognition
CLOCK DRAWING TEST (CDT)
Many clinicians use the drawing of the face of a clock as an “all-purpose” mental status screen. Indeed, clock drawing is incorporated into other mental status scales, from the Mini-Cog to the STMS, MoCA, RUDAS, SLUMS, and ACE-III. There are reasons for this. Drawing the face of an analog clock, with correct placement of numbers and a proscribed time, taps into multiple cognitive domains. The correct performance of the CDT requires not only visuospatial ability, but mental control (working memory), other executive functions, and numerical ability. Consequently, the CDT can be quite sensitive to cognitive impairment. The CDT is easy to administer and is less language or culture dependent than other tests. The examiner usually asks the patient to draw the face of a clock, place the numbers, and indicate the time by placing the hands, most commonly at “10 after 11” or “5 past 4.” Clinicians may experience variable results with the CDT in screening for dementia. One reason for this is that there are different systems for scoring and interpreting the CDT. Regardless of scoring systems, the examiner should consider exactly how the patient performed in spatial relationships, number order and location, and placement of the hands with designated time. Errors can range from left hemispatial neglect with omission of numbers on the left side to executive dysfunction with “concrete” placement of the hands, for example, the long hand on the “10” when asked to indicate “10 after 11.”
MEMORY IMPAIRMENT SCREEN (MIS)
As its name suggests, the MIS is strictly a memory screen; however, this instrument has the advantage of testing both free recall and cued recall. In this way, the MIS probes in greater depth for the presence of declarative episodic verbal memory loss, the earliest impairment in typical Alzheimer disease and other dementias. The examiner asks the patient to read aloud four items presented on a sheet of paper. Then the examiner gives a different category cue for each of the four items and asks the patient to indicate which items belong to which categories. This allows for subsequent cued and free recall after 2 to 3 minutes. The patient gets two points for each item spontaneously recalled and one point if they required cuing. Given its structure, the best use of the MIS is in screening for typical Alzheimer disease; it is not a screen for nonmemory areas of cognitive decline. The MIS is relatively robust to the effects of age and education and is one of the tools recommended for use in the Medicare Annual Wellness Visit by the Alzheimer’s Association.
MINI-COG
The Mini-Cog combines memory with the clock drawing task, thus combining the main elements of the CDT and MIS. Much of the earlier discussion on the CDT and the MIS applies to the Mini-Cog. Where this instrument differs from the CDT is in its simplified binary scoring system without consideration of hand length and other variables, and where it differs from the MIS is in the absence of a cued recall portion, limited only to free recall. An additional advantage of the Mini-Cog is that it has alternate word lists, which is helpful for longitudinal follow-up. An abnormal score of less than 3 occurs if the patient has an abnormal clock and misses one memory item or if the patient misses all three memory items. It is relatively robust to the effects of age and education and, like the MIS, is one of the tools recommended for use in the Medicare Annual Wellness, primarily as a screening test for Alzheimer disease.
SIX-ITEM SCREENER (SIS)
The SIS adds orientation for time (year, month, day of the week) to three memory words (free recall). The introduction of orientation items is helpful in detecting patients with dementia, who become disoriented to time from recent memory difficulty or from attentional problems. The examiner asks the orientation questions during the “interference” period between presentation of the memory words and request for recall. Each of the three memory words and three orientation questions gets one point (six total). The SIS has value in quickly screening for dementia, but it misses deficits in most cognitive domains including those involved in the clock drawing task.
SHORT PORTABLE MENTAL STATUS QUESTIONNAIRE (SPMSQ)
The SPMSQ greatly expands on testing for orientation to include orientation for place and personal information, as well as orientation for time. This instrument has 10 questions that extend to questions about the patient’s telephone number, age, place of birth, and mother’s maiden name. The SPMSQ does not include direct testing of episodic declarative memory, nor does it sample multiple areas of cognition. However, it has remote memory questions that ask for the names of the current and last presidents, and the last item samples mental control/attention by asking the patient to count backward from 20 by 3s. Patients must answer eight of the questions correctly for a normal score. The developers state that “One more error is allowed in the scoring if a patient has had a grade school education or less. One less error is allowed if the patient has had education beyond the high school level.” Like most of the brief (≤5 minute) scales, the SPMSQ is more accurate in identifying patients with moderately or severely impaired dementia rather than detecting those with mild impairment.
THE SHORT TEST OF MENTAL STATUS (STMS)
Up to this point, the brief mental status scales have involved a limited number of cognitive areas or included the clock drawing as a vehicle to screen multiple domains. The STMS is distinctly different in this regard. It is a well-constructed test that incorporates all elements of the other tests, such as clock drawing, memory (learning and delayed recall of four items), orientation (time and place), semantic memory (presidents, weeks/year, island definition), and mental control/attention (digits forward). The STMS further adds calculations (four problems), abstractions (three similarities), and the copy of a cube. In essence, this is a much expanded “short” test, which the authors reported as still having an administration time of approximately 5 minutes. It is probable that many patients take longer to complete the STMS given all of its items. Of the brief (≤5 minute) mental status scales described here, the STMS is the most sensitive to mild impairments in cognition. One concern is that it does not have a language subtest, as language and word-finding difficulty are the second most common cognitive impairments in early dementia.
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