Index of Mental Status Tasks

Verbal and Physical Stimulation. If a patient is not awake or responding to the environment, the examiner loudly calls the patient’s name while tapping him/her and, if still unresponsive, the clinicians applies pressure to the sternum or a fingernail or pinches the Achilles tendon.

Responsiveness to Stimulation. The examiner notes the type of responsiveness to stimulation. Note eye, verbal, and motor responses. Note whether the patient maintains eyes open and visually fixates, tracks stimuli, or attains eye contact. Note the presence of any verbal responses and their content. Finally, note any reactive movements to stimulation, reflex actions, or posturing. In addition, observe the patient’s overall behavior for hypoactivity, hyperactivity, or movement abnormalities, such as myoclonus or tremors. The examiner can semiquantify the eye, verbal, and motor responses with various scales, such as the Glasgow Coma Scale ( Chapter 7 , Table 7.2).

Verbal Digit (or Letter) Span. The examiner explains, “I am going to repeat a series of numbers. Please immediately repeat the same numbers after I give them to you.” Random digits are given, one per second, starting with three, at a regular rhythm of presentation ( Chapter 5 , Fig. 5.1). The patient must repeat the entire sequence in the same order immediately after presentation. If the patient can correctly repeat three digits, the examiner presents four digits, and then five digits, and so forth at increasing series. If the patient incorrectly repeats a string of digits, then another string of digits at the same series level is repeated. The examiner stops when the patient incorrectly repeats two strings of digits at the same series level. His/her digit span is the level just before missing both trials. A normal performance is correct recitation of seven (±2) digits. A patient attaining fewer than five digits may have a significant attentional problem.

Visual Sequence Span. An equivalent of the Digit Span Test may be performed as a nonverbal sequence span test using visual stimuli. The examiner asks the patient to serially tap four squares or blocks in the same sequence as tapped by the examiner ( Chapter 7 , Fig. 7.3). The test can be done with or without verbal input from the examiner or verbal responses from the patient. The procedures are otherwise the same as for the Digit Span Test.

Digits (or Letters) Backward. In the backward digit span, the patient repeats digits beginning with the last number and in reverse order to the first number. The instructions and methodology are the same as for the forward Digit Span Test with the examiner continuing until the patient incorrectly repeats two strings of digits backward at the same series level. A normal performance is correct backward recitation of five (±2) digits. A patient failing at three or fewer digits may have a significant attentional problem.

Serial Subtraction Tests. Two common serial subtraction tests are counting backward from 100 by 7s and counting backward from 20 by 3s. In the first, the examiner asks the patient to subtract by 7 beginning with the number 100, for example, 93, 86, 79, 72, 65, et cetera. The number of errors are the number of incorrect subtractions; if the patient makes an incorrect subtraction at one level, the examiner corrects the patient and instructs the patient to continue subtracting from the corrected number. Alternatively, the subsequent “correct” subtractions are determined from the incorrect number, that is, if the patient subtracts 7 from 100 as 94, then the subsequent correct subtraction is 87 and not 86. An alert patient should be able to get three or more subtractions in a row. Counting backward from 20 by 3s is a similar, but easier, version of serial subtractions.

Spelling “World” Backward. The examiner gives the patient a word, often the word “world,” and asks the patient to spell it backward beginning with the last letter and finishing with the first letter. In contrast to the serial subtraction tasks, the scoring of word backward is by “error of place,” that is, a correct performance would require a “d” in the first place, an “l” in the second, et cetera. For example, the score for a response of “d-r-l-o-w” is 3 as the “r” and “l” are absent or in the wrong place, and the score for a response of “d-o-w” is 1.

Calendar in Reverse Order. Additional reversal tasks include the months of the year in reverse order beginning with December and finishing with January. An easier version is to have the patient recite the days of the week backward from Saturday to Sunday. The item is missed if it is absent or if it is in the wrong sequence.

“A” Cross-Out Test. The examiner recites a list of 30 or more letters, one per second, and instructs the patient to tap on a table only when they hear the letter “A.” An abnormal performance includes any errors of omission in which the patient fails to tap for an “A,” or errors of commission in which the patient taps for a letter other than “A.” This test can also be done visually by asking the patient to cross out the letter “A” in a written paragraph or on a piece of paper with random letters scattered on the page ( Chapter 7 , Fig. 7.4). Alternatively, the patient can cross out every instance of a particular letter in a magazine or newspaper paragraph. More than a single omission in 60 seconds suggests a disturbance in sustained attention. Harder versions of this continuous performance measure involve indicating a target letter whenever it appears in a specific sequence, for example, “A” only when followed by “B,” or crossing out whole words that have a certain letter.

Visual Search Cancellation Task. Visual search tasks, which overlap with visuospatial processing, may be administered timed or untimed and involve searching for a target letter or figure on a piece of paper with scattered nontarget, random letters or figures ( Chapter 7 , Fig. 7.5; Chapter 10 , Fig. 10.10). The patient indicates the target letter or figure wherever it appears by marking it or circling it. A good format has at least 60 stimuli and 10% targets, and the patient should be able to locate all of them.

Serial Ordering of Digits. The examiner can ask the patient to serially order digits by asking the patient to reorder a forward digit span in an ascending order from smallest to largest. For example, if given the series “2-1-3,” the correct answer would be “1-2-3.” This task has a working memory component but can also indicate difficulties with attention. Most people can serially order four or more digits.

Modified Clinical “N-Back.” In the classical test, the participant hears a series of digits or letters and is asked to indicate if a letter was previously presented a set number of places back, for example, for N-3, the participant would indicate the ones shown in capital letters: n t s j o a J p q s t u S . In a simpler clinical variation, the examiner recites a long series of digits and, once the examiner stops, asks the patient to repeat the next to last digit in the sequence (“N-1”) or, for more challenging testing, two or three back from the last digit in the sequence (“N-2” and “N-3”). Most people have difficulty beyond the N-3 level.

Paced Auditory Serial Addition Test (PASAT). There are clinical variants of the PASAT, which is a relatively challenging attentional test. It requires the addition of the last numbers in a sequence of numbers, and it can be administered as cumulative addition (adding the last number to the prior sum). Alternatively, ask the patient to add the successive overlapping pairs as rapidly as possible: 5, 2, 7, 3, 4, et cetera (adds last to next to last for 7, 9, 10, 7). This test overlaps with calculations ability and is often difficult for people who are unimpaired.

Trail making A (“Trail Making A”) Test ( Chapter 7 , Fig. 7.6). The patient must draw a line connecting 25 randomly arrayed numbered circles in ascending numerical order (1-2-3, etc.). After a practice sample, the examiner tells the patient to go as fast as possible without lifting the pencil or pen, points out errors as they occur so that the patient can correct them, and times the overall performance. On the standard timed version, which also reflects psychomotor speed, an average completion time is <30 seconds, and an impaired completion time is greater than approximately 78 seconds. The examiner can give a version of the Trail making A Test in an untimed version to assess strictly for errors (as is done in the Montreal Cognitive Assessment).

Simultaneous Divided Attention Task. Evaluate the ability to divide attention by simultaneous tasks, such as having the patient do a forward digit span while manually tracking the examiner’s moving finger with their index finger. The examiner compares the results of this divided attention task to the results from the single task forward digit span.

Face-Hands Test. In this divided attention test, the examiner touches the patient on the hands and cheek simultaneously in 10 trials (4 contralateral, 4 ipsilateral, 2 symmetric). Any error in recognizing where the patient was touched suggests impairment, most often from dementia or frontal lobe disease.

Finger Tapping Test. This is a test of psychomotor speed and should be tested with both the left and right index finger for approximately 10 seconds each. The patient must keep tapping an index finger on a table until the examiner instructs the patient to stop. A modification of this requires the patient to perform a repetitive movement with the opposite hand, such as supination and pronation, while having them finger tap with the other hand. The examiner records the rapidity of tapping.

Counting Speed. There are several timed speed tasks available in a routine clinical encounter. First, the examiner has the patient count from one as fast as possible and records the number reached in 10 seconds. Second, the examiner asks the patient to recite the alphabet, or write it in uppercase letters, as fast as possible. The written alphabet should take the patient 30 seconds or less to accomplish. Third, the examiner asks the patient to draw lines between a series of three and five dots as rapidly as possible.

Pole Grasp Test. Patients grasp a measuring pole at the bottom, let it go, and then grasp it as fast as possible before it falls. The distance between the original and final grasp reflects reaction time.

Orientation to Date and Time. The examiner asks the patient to state the current date and place. Orientation in the clinical setting is a sensitive general measure of awareness, attention, and memory. In the absence of a watch or other obvious display of the time, the patient’s knowledge of the exact time of day can be a further extension of the assessment for temporal orientation. Ask the patient to tell you what time it is at the present moment. Normal subjects are orientated to within 4 hours of the time, 3 days of the date, and 2 days of the week, but they should know the month and year.

Orientation to Place. The next most common disorientation occurs to place, that is, home, clinic or hospital, city, county, state or province, and specific floor or localization in a building. In addition to inquiring whether the patient knows where they are, the examiner can ask what kind of place it is and under what circumstances they are there. Asking for the patient’s telephone number is another “place” orientation item. Patients should not be disoriented to place, but they may be off on the floor or ward if they are hospitalized or the city/location if they were taken there without their full awareness.

Conversational Fluency. Language fluency is the ability to produce words, phrases, and sentences proficiently and smoothly. The language examination starts with listening to the patient’s fluency during spontaneous discourse (with permission, an auditory recording can be made for later analysis). The examiner may elicit conversation with questions or by asking the patient to describe an activity or a picture, such as the “Cookie Theft” picture from the Boston Diagnostic Aphasia Examination ( Chapter 8 , Fig. 8.2). The examiner should have a checklist of items to consider for conversational fluency, including approximate words/minute, flow (interrupions from word-finding pauses, hesitancy, or effort), phrase length (four or more words/phrase), presence of agrammatism or telegraphic output (loss of prepositions, conjunctions, and other “functor” words), and presence of dysprosody ( Chapter 8 , Tables 8.1 and 8.2). Phonemic distortions and substitutions and increased inter-syllabic pauses due to “apraxia of speech” may accompany nonfluent aphasia. During the course of conversational speech, also listen for the information content, for the presence of paraphasic errors (word or phonemic substitutions), and for dysarthric speech.

Controlled Word Association Test. The examiner instructs the patient to name as many English words that begin with the letter “F” (or “A” or “S”) as they can in 1 minute and as quickly as possible. These letters reflect word frequencies in English and vary with the language tested (e.g., in Spanish the corresponding letters would be “P,” “M,” and “R”). Tell the patient: “I will say a letter of the alphabet. Then I want you to give me as many English words that begin with that letter as quickly as possible. I do not want you to use words that are proper names. Also do not use the same word again with a different ending, such as ‘eat’ and ‘eating’ or ‘sixty’ and ‘sixty-one.’ Begin when I say the letter.” Do not count close word variations of the same word, such as “six,” “sixth,” “sixtieth,” but do count word variations with a different meaning, for example, “sixteen.” Normal subjects can list 15 + 5 words/minute for each letter.

Category Word-List Generation (verbal fluency). Ask the patient to generate a list of as many animals as possible (or other category of items such as grocery items, articles of clothing, cities, colors) in 1 minute. “I am going to ask you to name as many animals as you can in 1 minute. An animal is any living thing that is not a plant. Please wait until we are ready to begin.” Do not count proper nouns, plurals, and repetitions in the total correct, but do count word variations or subcategory items (e.g., include both dogs and beagles). Do not suggest subcategories (e.g., “zoo animals”). Normal subjects can list 18 + 6 animals/minute without cueing.

Naming. The examiner tests word production primarily with confrontational naming, that is, asking the patient to name common items pointed out in the room or a series of pictures, such as the 15-item version of the mini–Boston Naming Test. In confrontational naming, the examiner should test a range of common and uncommon words across different word frequencies. Six readily accessible high-frequency items for naming include key, ring, button, collar, nose, chin; and six additional lower-frequency items include earlobe, eye lashes, lapel, shoelaces, sole or heel of shoe, and watch band or crystal. The examiner may increase the difficulty of word production tasks by asking the patient to “name-by-definition,” that is, the examiner provides a definition of an object or action, and the patient provides the appropriate name. A guide to normal performance on all these tasks involves correctly naming all high-frequency items and at least four of six low-frequency ones.

Sentence Comprehension Screening. The examination of sentence comprehension involves a series of tasks of increasing difficulty. First, there are simple axial and one-step commands such as “close your eyes” and “point to the floor.” This can be followed with yes-or-no questions such as “Are you sitting down?” and “Does March come before April?” Then do sequential commands such as “Touch your nose and then your chin” and “first point to the ceiling and then to the door.” Finally, evaluate complex grammatical sentence comprehension, for example, “If the lion was killed by the tiger, which animal is dead?” “If we were in a crowd of people and I said, ‘there’s my wife’s brother,’ would I be pointing to a man or a woman?”

The Token Test. A good way of testing comprehension is the token test. This involves presenting 20 tokens of 5 colors each having 2 shapes and 2 sizes and giving commands such as “put the red circle on the green rectangle” or “before touching the yellow circle, pick up the red rectangle.” The examiner can substitute commonly available objects for the tokens, such as pen, pencil, and different coins ( Chapter 8 , Table 8.3). The sequence of commands include “put the pencil on the coin” and “touch the coin with the pen.”

Word Comprehension. The examiner needs to test the ability to comprehend words and sentences. Problems with word comprehension may be initially evident on confrontational naming tasks. When this occurs, testing should be followed up with word recognition tests. The simplest procedure is to return to misnamed items from the prior naming testing. Give the patient the name and ask him/her to identify it. They can do this by either pointing to the object or picture or by identifying (defining or describing) the item. This “two-way” naming deficit, in which the patient can neither name an item nor point to it on command (despite being able to repeat the name), represents abnormal word comprehension.

Repetition. The examiner asks the patient to repeat digits, multisyllabic words, phrases, and sentences. Note that tests of repetition do not include “serial speech,” which are overlearned sequences (such as counting 1, 2, 3, etc., or the reciting the alphabet) as serial speech is relatively preserved in most aphasics. Begin with single word or short phrase repetitions, for example, “constitutional,” “Mississippi River,” “hopping hippopotamus,” or “Methodist Episcopal,” then proceed to longer utterances and sentences. “I’m going to read some sentences to you. Please repeat them back to me exactly the way I say it.” Examples include “No ifs, ands, or buts,” “they heard him speak on the radio last night,” “the truck rolled over the stone bridge,” and “the quick brown fox jumped over the lazy dog.” The examiner may allow one reattempt at repetition of the sentence if the patient requests it. If the patient succeeds, the examiner may ask for repetition of more complex sentences, for example, “if he comes soon, we will all go away with him.”

Prosody. There may be changes in prosody or intonation at the sentence level and in the stressed or accented syllable in a word (lexical stress). In addition to listening for changes in pitch (rising or falling) and stress (often increased loudness), further screening for prosody can be done with repetition of sentences in different tones and asking the patient to interpret them and then to repeat them with a certain meaning. For example, for prosodic comprehension, emphasize bolded and italicized word in the sentence: ____ I AM going to the other movies. ____ I am going to the OTHER movies. ____ I am going to the other movies. ____ I am going to the other MOVIES . ____ I am GOING to the other movies. For prosodic fluency, ask the patient to say the sentence with determination, sadness, anticipation, emphasis on himself/herself, and type of place or action.

Speech Examination. The examiner independently evaluates for apraxia of speech and for dysarthrias during the speech examination. Testing for apraxia of speech, or disturbed speech programming, involves testing for repetition of polysyllabic phrases. The examiner asks the patient to repeat each of the syllables, /pa/, /ta/, and /ka/, individually over and over again as quickly as possible (alternating motor rates), and then to repeat the three together in the sequence /pa-ta-ka/ over and over as quickly as possible (sequencing motor rates). An alternative approach is to ask the patient to repeat the words “catastrophe,” “artillery,” or “articulatory” as many times as possible in 5 or 10 seconds. The evaluation for dysarthrias involves listening to the patient’s speech for loudness, vocal cord function (strained if too apposed, breathy if too open), resonance or nasality from escape of air, articulatory disturbances from labial or lingual mispronunciation, and evidence of slurring from cerebellar system dysfunction. In addition, the examiner may ask the patient to maintain an “aah” sound loudly and for as long as possible to assess respiratory and vocal power.

Reading Test. The examiner starts by asking the patient to read aloud a short standard paragraph (or, for expediency, a paragraph from a newspaper or magazine). This reading material should be at the eighth-grade level. Then the examiner tells the patient: “I am going to present a list of words to you, one at a time. Please read each word out loud to the best of your ability.” The examiner then asks the patient to read regular words (usual grapheme-phoneme pronunciation), irregular words (irregular grapheme-phoneme pronunciation), and pseudowords (pronounceable nonsense words) aloud, e.g., “mint, blitor, colonel, shout, yacht, flarmic, bouquet, chrome, strotinale, quick, thartrist, pint.” When the patient reads aloud, the examiner looks for differential difficulties in the ability to read 1) regularly spelled words (e.g., mint, shout, chrome, quick); 2) irregularly spelled words (e.g., colonel, yacht, bouquet, pint); or 3) pronounceable pseudowords (blitor, flarmic, strotinale, thartrist).

Reading Comprehension. For reading comprehension, the examiner first presents a list of written names of objects in the room, such as door, sink, table, window, telephone, and then asks the patient to read them and point to the object. If this is successful, then the examiner presents two or more sentences with commands instructing the patient to do something, for example, “Fold this paper in half and put it on the table,” and “point to the source of illumination in this room.” Reading comprehension may also be tested with written word-picture matching tests and by asking the patient to comprehend words spelled orally.

Writing Test. First, the examiner asks the patient to copy single letters and a few printed words. Those with apraxic agraphia or spatial agraphia may have abnormal copying. Second, the examiner asks the patient to write a series of words dictated by the examiner. These words can be similar to the ones noted earlier for reading and should include regular words, irregular words, and nonsense pseudowords. Third, the examiner requests the patient to write at least two sentences, one sentence to dictation complete with punctuation, and a second sentence composed by the patient. Examples of sentences to dictation are: “The children are the heirs of the earth”; “it is hard to gauge the size of a sieve”; and “the bride was taken down the aisle by the colonel.” Finally, the examiner can elicit sentences for composition with a command, such as “describe what you did today in a full sentence.”