MENTAL STATUS EXAMINATION

Mental Status Examination: The MSE records ONLY observed behaviour, cognitive abilities and inner experiences
expressed during the interview. MSE is a core component of the assessment process necessary to arrive at a provisional
diagnosis and thus formulate a management plan.

Appearance and Behaviour:

• Describe physical appearance: build a vivid description for the reader
o Describe grooming/hygiene/clothing/hair/nails/build
o Do they look stated age, are they appropriately dressed for weather/situation,
• Describe motor behaviour (psychomotor retardation, restless, repetitive, hyperactive, tremors):
• Describe individual’s reaction to present situation (cooperative, friendly, guarded, withdrawn,
uncommunicative):

Mood: – Internal or subjective (what patient describes) feeling or emotion which often influences behaviour/perception of
the world.
Report what the individual says they feel, use inverted “commas” e.g.
depressed, paranoid
angry, down,
happy sad,
suspicious, fearful,
great, irritable
rotten miserable
fantastic high
Affect – External or objective (what interviewer sees) emotional response
• Describe the individual’s affect, how the interviewer sees the person’s mood displayed.
• There are a number of components of affect, including:
o Quality: “miserable”, “suspicious”, “euphoric”, “hostile”, etc,
o Range:
▪ Restricted affect: Decrease in intensity and range of emotional expression
▪ Blunted affect: Severe decrease in intensity and range of emotional expression
▪ Flat affect: Total or near absence of emotional expression, face immobile, voice
monotonous)
o Reactivity: is the affect pervasive, reactive or labile,
o Congruence: mood-congruent or mood-incongruent
o (Normal affect : Variation in facial expression, voice, use of hands, body movements
Speech:
• Physical aspects of speech can be described in terms of
o Rate (slow, halting, hesitant, normal, fast, and pressured), volume (loud, quiet, whispered, barely
audible, etc) and quality (slurred, dysarthric, nasal, accented, etc).
o Consider particular characteristics – mutism, poverty of speech, pressured speech, intelligent,
articulate, thoughtful, and rambling.

Disorders of Thinking:
1. Disorders of Stream of Thought
• Tempo (, fast, slow or normal,)
2 Disorders of the Form of Thought:
• Derailment (loosening of association), circumstantiality, flight of ideas, incoherence (word salad),
neologisms, tangentiality, word approximation, thought blocking, perseveration.
3. Disorders of Content of Thinking:
• Delusions eg.
Paranoid Bizarre Grandiose Persecutory Somatic
Jealousy Erotomanic Mood congruent Referential
• Overvalued ideas
• Pre-occupations,
• Anti-social urges,
 • Hypochondriacal symptoms
• Suicidal and homicide ideation
4. Disorders of the Possession of Thought
• Obsessions (own thought that appears against ones own will)
• Thought Alienation (thought insertion, thought withdrawal, thought broadcasting)

Perception: (process of experiencing the environment via all the senses)

• Hallucinations
o Tactile eg crawling sensations under or on the skin
o Auditory eg Voices or noises most common type of hallucination
o Olfactory eg smells that don’t exist more common in organic disorders
o Visual eg seeing objects, people or images that others can’t (seen more in organic disorders)
o Gustatory eg relation to taste (more seen in organic disorders)
o Somatic eg false perception that things are occurring in or to the body
• Derealization the external world appears different or unfamiliar. The individual feels distanced from the
world and things may seem colorless and dead. Associated with extreme anxiety/panic disorder
• Depersonalization The perception or experience of the self seems different or unfamiliar. The individual
may feel unreal or that his body is somehow distorted or may have the sense of perceiving himself from a
distance. In severe form individual may feel as though they are dead. Associated generally with extreme
anxiety, stress or fatigue.
• Dissociation Unconscious defense mechanism involving the segregation of any group of mental or
behavioral processes from the rest of the person’s psychic activity: may entail the separation of an idea
from its accompanying emotional tone, as seen in dissociative and conversion disorders.
• Illusions A misperception or misinterpretation of a real external stimulus, such as hearing the rustling of
leaves as the sound of voices.

Cognition: (refers to information processing – thinking and memory). If cognition impaired complete a MMSE.
Orientation: Test for orientation to
• Time
• Place
• Person
Write down exactly what they say use inverted commas (does the interviewer know this
themselves?)

Attention: (test with 7 digit span) Forward (5 – 7) Backward (4 – 6)

Concentration: Serial 7’s (subtract 7’s from 100) Spell WORLD backwards

NB: The best way to assess attention and concentration is simply to talk to your patient and
observe how they think. Are they able to concentrate on your questions? Can they maintain a
train of thought as they answer you? If the answer to these questions is “yes” your patient’s
attention is intact.

Immediate Memory: Registration – the capacity for immediate recall, ask to repeat 4 items – dog/hat/green/
Peach. Score out of 4

Short Term Memory: Ask to repeat dog/hat/green/peach after 3 mins, may prompt eg animal (dog), colour (green).
Score out of 4

Long Term Memory:

Episodic Memory Test eg Date of Wedding YES  NO 

Semantic Memory Test eg Date of WWII: YES  NO 
Insight: refers to the individual’s awareness of his or her situation and illness. There are varying degrees of insight eg.
An individual may be aware of his or her problem but may believe that someone else is to blame for the problem;
alternatively the individual may deny that a problem exists at all. The assessment of insight has clinical significance since
lack of insight generally means that it will be difficult to encourage the individual to accept treatment.
 Judgement: involves weighing and comparing the relative values of different aspects of an issue. Determining whether
a particular judgement is sound is situation dependant

The Mini Mental State Examination

(MMSE)
By: Lenore Kurlowicz, PhD, RN, CS and Meredith Wallace, PhD, RN, MSN

WHY: Cognitive impairment is no longer considered a normal and inevitable change of aging. Although older adults
are at higher risk than the rest of the population, changes in cognitive function often call for prompt and aggressive
action. In older patients, cognitive functioning is especially likely to decline during illness or injury. The nurses’
assessment of an older adult’s cognitive status is instrumental in identifying early changes in physiological status,
ability to learn, and evaluating responses to treatment.

BEST TOOL: The Mini Mental State Examination (MMSE) is a tool that can be used to systematically and
thoroughly assess mental status. It is an 11-question measure that tests five areas of cognitive function: orientation,
registration, attention and calculation, recall, and language. The maximum score is 30. A score of 23 or lower is
indicative of cognitive impairment. The MMSE takes only 5-10 minutes to administer and is therefore practical to use
repeatedly and routinely.

TARGET POPULATION: The MMSE is effective as a screening tool for cognitive impairment with older,
community dwelling, hospitalized and institutionalized adults. Assessment of an older adult’s cognitive function is
best achieved when it is done routinely, systematically and thoroughly.

VALIDITY/RELIABILITY: Since its creation in 1975, the MMSE has been validated and extensively used in both
clinical practice and research.

STRENGTHS AND LIMITATIONS: The MMSE is effective as a screening instrument to separate patients with
cognitive impairment from those without it. In addition, when used repeatedly the instrument is able to measure
changes in cognitive status that may benefit from intervention. However, the tool is not able to diagnose the case for
changes in cognitive function and should not replace a complete clinical assessment of mental status. In addition, the
instrument relies heavily on verbal response and reading and writing. Therefore, patients that are hearing and visually
impaired, intubated, have low English literacy, or those with other communication disorders may perform poorly even
when cognitively intact.

The Mini-Mental State Exam

Patient Examiner Date

Maximum Score
Orientation
5 ( ) What is the (year) (season) (date) (day) (month)?
5 ( ) Where are we (state) (country) (town) (hospital) (floor)?

Registration
3 ( ) Name 3 objects: 1 second to say each. Then ask the patient
all 3 after you have said them. Give 1 point for each correct answer.
Then repeat them until he/she learns all 3. Count trials and record.
Trials

Attention and Calculation

5 ( ) Serial 7’s. 1 point for each correct answer. Stop after 5 answers.
Alternatively spell “world” backward.

Recall
 3 ( ) Ask for the 3 objects repeated above. Give 1 point for each correct answer.

Language
2 ( ) Name a pencil and watch.
1 ( ) Repeat the following “No ifs, ands, or buts”
3 ( ) Follow a 3-stage command:
“Take a paper in your hand, fold it in half, and put it on the floor.”
1 ( ) Read and obey the following: CLOSE YOUR EYES
1 ( ) Write a sentence.
1 ( ) Copy the design shown.

Total Score
ASSESS level of consciousness along a continuum
Alert Drowsy Stupor Coma

ADDENBROOKE’S COGNITIVE EXAMINATION – ACE-III

English Version A (2012)
Name: Date of testing: / /
Date of Birth: Tester’s name:
Hospital No. or Address: Age at leaving full-time education:
Occupation:
Handedness:
ATTENTION
➢ Ask: What is the Day Date Month Year Season Attention
[Score 0-5]

➢ Ask: Which No./Floor Street/Hospital Town County Country

Attention
[Score 0-5]

ATTENTION

➢ Tell: “I’m going to give you three words and I’d like you to repeat them after me: lemon, key and ball.” After Attention
subject repeats, say “Try to remember them because I’m going to ask you later”. [Score 0-3]
➢ Score only the first trial (repeat 3 times if necessary).
➢ Register number of trials:

ATTENTION

➢ Ask the subject: “Could you take 7 away from 100? I’d like you to keep taking 7 away from each new number Attention
until I tell you to stop.” [Score 0-5]
➢ If subject makes a mistake, do not stop them. Let the subject carry on and check subsequent answers (e.g., 93,
84, 77, 70, 63 – score 4).
➢ Stop after five subtractions (93, 86, 79, 72, 65):

MEMORY

➢ Ask: ‘Which 3 words did I ask you to repeat and remember?’ Memory
[Score 0-3]

FLUENCY
➢ Letters
Say: “I’m going to give you a letter of the alphabet and I’d like you to generate as many words as you can beginning Fluency
with that letter, but not names of people or places. For example, if I give you the letter “C”, you could give me words [Score 0 – 7]
like “cat, cry, clock” and so on. But, you can’t give me words like Catherine or Canada. Do you understand? Are you
ready? You have one minute. The letter I want you to use is the letter “P”.
≥ 18 7
14-17 6
11-13 5
8-10 4
6-7 3
4-5 2
2-3 1
0-1 0
total correct

Fluency
➢ Animals [Score 0 – 7]
Say: “Now can you name as many animals as possible. It can begin with any letter.”
≥ 22 7
17-21 6
14-16 5
11-13 4
9-10 3
7-8 2
5-6 1
5 0
total correct
MEMORY
Memory
➢ Tell: “I’m going to give you a name and address and I’d like you to repeat the name and address after me. So you [Score 0 – 7]
have a chance to learn, we’ll be doing that 3 times. I’ll ask you the name and address later.”

Score only the third trial.

1st Trial 2nd Trial 3rd Trial

Harry Barnes
73 Orchard Close
Kingsbridge Devon

MEMORY
Memory
➢ Name of the current Prime Minister...…………………………………………………………………………….. [Score 0 – 4 ]
➢ Name of the woman who was Prime Minister ............…..………………………………………………………
➢ Name of the USA president.......………………………...………………………………………………………...
➢ Name of the USA president who was assassinated in the 1960s..……………………………………………

LANGUAGE

Language
➢ Place a pencil and a piece of paper in front of the subject. As a practice trial, ask the subject to “Pick up the [Score 0-3]
pencil and then the paper.” If incorrect, score 0 and do not continue further.

➢ If the subject is correct on the practice trial, continue with the following three commands below.
• Ask the subject to “Place the paper on top of the pencil”
• Ask the subject to “Pick up the pencil but not the paper”
• Ask the subject to “Pass me the pencil after touching the paper”
Note: Place the pencil and paper in front of the subject before each command.

LANGUAGE
Language
➢ Ask the subject to write two (or more) complete sentences about his/her last [Score 0-2]
holiday/weekend/Christmas. Write in complete sentences and do not use abbreviations.
Give 1 point if there are two (or more) complete sentences about the one topic; and give another 1 point if grammar
and spelling are correct.

LANGUAGE
Language
➢ Ask the subject to repeat: ‘caterpillar’; ‘eccentricity; ‘unintelligible’; ‘statistician’ [Score 0-2]
Score 2 if all are correct; score 1 if 3 are correct; and score 0 if 2 or less are correct.

LANGUAGE
Language
➢ Ask the subject to repeat: ‘All that glitters is not gold’ [Score 0-1]

Language
➢ Ask the subject to repeat: ‘A stitch in time saves nine’ [Score 0-1]

LANGUAGE
 Language
➢ Ask the subject to name the following pictures: [Score 0-12]

LANGUAGE

Language
➢ Using the pictures above, ask the subject to: [Score 0-4]

• Point to the one which is associated with the monarchy ……………………………………………..

• Point to the one which is a marsupial ……………………………………………..
• Point to the one which is found in the Antarctic …………………………………………….
• Point to the one which has a nautical connection …………………………………………….
LANGUAGE
Language
➢ Ask the subject to read the following words: (Score 1 only if all correct) [Score 0-1]

sew
pint
soot
dough
height
VISUOSPATIAL ABILITIES
Visuospatial
➢ Infinity Diagram: Ask the subject to copy this diagram [Score 0-1]

Visuospatial
➢ Wire cube: Ask the subject to copy this drawing (for scoring, see instructions guide). [Score 0-2]

Visuospatial
➢ Clock: Ask the subject to draw a clock face with numbers and the hands at ten past five. (For scoring see instruction [Score 0-5]
guide: circle = 1, numbers = 2, hands = 2 if all correct).

Updated
20/11/2012
VISUOSPATIAL ABILITIES
Visuospatial
➢ Ask the subject to count the dots without pointing to them [Score 0-4]
 VISUOSPATIAL ABILITIES
Visuospatial
➢ Ask the subject to identify the letters [Score 0-4]

MEMORY

➢ Ask “Now tell me what you remember about that name and address we were repeating at the beginning”

Harry Barnes …………………. …………………………………… Memory

73 Orchard Close …… ………………………. ………………………. [Score 0-7]
Kingsbridge …………………………………………………………
Devon …………………………………………………………
MEMORY
Memory
➢ This test should be done if the subject failed to recall one or more items above. It all items were recalled, skip the test [Score 0-5]
and score 5. If only part was recalled start by ticking items recalled in the shadowed column on the right hand side;
and then test not recalled items by telling the subject “ok, I’ll give you some hints: was the name X, Y or Z?” and so
on. Each recognised item scores one point, which is added to the point gained by recalling.

Jerry Barnes Harry Barnes Harry Bradford recalled

37 73 76 recalled
Orchard Place Oak Close Orchard Close recalled
Oakhampton Kingsbridge Dartington recalled
Devon Dorset Somerset recalled
SCORES
TOTAL ACE-III SCORE /100
Attention /18
Memory /26
Fluency /14
Language /26
Visuospatial /16

Updated
20/11/2012