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History and Mental State Examination
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History:
An informant may be needed to allow a full and clear history to be elicited.
Mental State Examination:
Appearance and Behaviour: Look for evidence of deterioration in self care or dressing dyspraxia, repetitive or perseverative behaviour.
Speech: Look out for perseveration, impaired fluency, evidence of receptive or expressive dysphasia.
Thought: Content may be impoverished with loss of abstract reasoning. Delusions if present are likely to be simpler, less systematised and less well maintained than in a functional disorder such as schizophrenia.
Perception: Look for evidence of misinterpretation, illusions and hallucinations in any modality. Visual hallucinations may be vivid, colourful and detailed, size distortions may occur and frequently they are more troublesome in poorly lit environments.
Cognitive testing: This is central to the examination.
- Concentration. The capacity for sustained attention and affects performance of all other tests. Look for evidence of distractibility, fluctuating alertness, difficulty grasping elements of conversion. Formal tests include, counting backwards from 20 or the months of the year backwards.
- Orientation is assessed in time, place and person. Time: Test for orientation for time of day, day of week, month, year, an estimate of the length of time of the interview up to that point and the sequence of recent events. Place: Inquire about the name and location of the place where you are, but more importantly type of place e.g. home, hospital, day centre. Person: Can the patient identify surrounding persons and indicate their status e.g. doctor, spouse, friend.
- Memory
- Immediate Memory: This includes registration of new information and can be tested by digit span and registration of a word list or name and address.
- New Learning: The learning of new information (retention and recall). To test formally 5 minute recall of name and address or a word list. Impairment of new learning is often the first deficit noted in a dementing process.
- Remote Memory: This should be assessed for personal and impersonal information. It covers anything that has been learned separate from the time of testing. Ask about recent history/events, personal history, general knowledge. In dementia memories are lost in the order of most recent to most distant (Ribots law), consequently demented individuals often seem to be living in the past. Where a discrete neurological event has occurred the concepts of anterograde and retrograde memory are important.
- Formal tests for parietal and frontal lobe function should also be performed but are not described here.
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