Cognitive state examination

Cognition is the processing of information gathered by the body's sensory organs, including the processing of knowledge. There are variety of manners in which cognition needs to be tested: orientation, short-term memory, attention, language and in other areas of cognition.

Simple Orientation

A test often done in geriatrics and psychiatry to determine whether somebody is cognitively deficient is to find out if the patient is oriented to time, place and person.

Ask the person:

• Where are you?
• What's the date/time to the nearest hour?
• Who am I?

This is often used in patients to show they are clearly confused but from a medical cause (e.g. infection, delirium). It is worth doing in all psychiatric and geriatric patients on admission with a MMSE to follow.

Mini-Mental State Examintion

The 'mini-mental' (or MMSE) is a short and simple test used to assess cognitive impairment. It is split into orientation, registration, attention, calculation, recall and language. It is scored out of thirty with anything less than 24 suggesting cognitive impairment.

It should be done on initial contact with the healthcare profession where appropriate in order to monitor a patients progress whether better or worse.

Orientation

• Time: "What is the year/season/date/day/month?" /5
  
• Place: "Which country/county/city/hospital/ward are we in? /5

Ask each seperately with a point for each. When asking which season, give allowances for the fact that many months are between seasons.

Registration

• Name 3 objects and take 1 second to say each (so that the patient definitely understands you) e.g. "apple, table, ball". *Get the patient to repeat the three objects and then tell the patient to remember them as you will ask them later in the test. So you might say:
  

"I'm going to say three objects. After I have said them all, I want you to repeat them back to me."

After they have repeated them say:
"I want you to remember those three items as I will ask you what they were later on."

Each object successfully repeated gets a mark, three being the maximum - eg: Apple /1, Table /1, Ball /1

Attention and Calculation

There are two tests for attention and calculation, which are each out of 5. Do both and but only use the best score.

Serial 7s /5

Get the patient to take 7 away from 100 and then take 7 away from the resulting number (e.g. 100, 93, 86...). They should repeat this 5 times with a mark for each correct calculation. If they make a mistake continue to give them marks for subsequent correct calculations i.e. if they get "100-7=4000" and then get "4000-7=3993", they will not get the mark for getting 4000 but will get the mark for 3993.

"I want you to take 7 away from 100. Then from the number you get, take away another 7. Keep going until I tell you to stop"

This often requires repeated explanation, especially to demented patients who are likely to be the subject of this test. Feel free to explain it to them again.

WORLD backwards

This test is simpler to explaing ask the patient to spell the word "WORLD" backwards. So say:
"Spell WORLD backwards." (OK - I probably didn't need to type that out for you.)

For each letter they get in the right place, they get a mark: D /1, L /1, R /1, O /1, W /1.

Recall

Ask for the 3 objects from the registration section with one point for each object correctly remembered. /3

Language

Name two familiar objects

Show the patient two familiar objects (one at a time), usually a pen and wristwatch and ask him to name them.
So: Show them the pen and say, "what is this?"
Show them the wristwatch and say, "what is this?"

Make sure you don't pick anything that the patient might not recognise like a pistol shrimp or the Organ of Zückerhandl from a short Eastern European. You get one mark for each.

Pen /1 Watch /1

Repeat a sentence

Ask the patient to repeat a simple sentence. Traditionally this sentence is "no ifs, ands or buts". They are only allowed one attempt.

So say, "I want you to repeat the following sentence. 'No ifs, ands or buts.'"

It's one mark for the entire sentence /1.

Three-stage command

This tests the ability of a patient to follow complex instructions so make sure you give all the instructions at once. The traditional way of doing this is to tell them to take a piece of paper in their right hand, fold it and put it on the floor.

So say: "I want you take this piece of paper, fold it in half and put it on the floor."

There's one mark for each command:

• Take it in their right hand /1
• Fold it in half /1
• Put it on the floor /1

Reading

• Read the words "CLOSE YOUR EYES"

Write CLOSE YOUR EYES in large letters on a piece of paper and then ask the patient to do what it says on the piece of paper. There are no marks for reading the words aloud. Make sure your patient does not have any sort of visual impairment (e.g. having had a bilateral enucleation) as this will only prove they have a visual impairment, not that they are cognitively impaired. So say:

"I'm going to show you a piece of paper with something written on it. I want you to do what it says on the piece of paper"

There is one mark if they close their eyes. /1.

Writing

• Ask the patient to write a full sentence

Spelling, grammar and punctuation need not be correct but the sentence needs a subject and verb to get the mark /1.

So say: "I want you to write a full sentence. It can be about anything you want but just has to be a full sentence."

Drawing

Patients must get two five sided-shapes and get the corners intersecting to get the marks

• Show the patient the intersecting pentagons on the right and ask him to copy them

The pentagons must intersect and have all ten corners in order for the patient to receive the mark /1.

Scoring

• 25-30 is normal
• 17-24 shows mild to moderate cognitive impairment
• <17 shows severe impairment