Mental State Examination 4 – Cognition and Insight
Author(s): Farah Rozali
By the end of this CAL you will be able to:
- Describe the general purpose and component parts of the Mental State Examination (MSE).
- Evaluate patients’ mental state and use appropriate terminology to describe abnormalities.
- Consider patients’ experience of suffering mental disorders to guide empathic, non-judgemental and knowledgeable patient care across all medical specialties.
- Screen for and identify cognitive impairment, using standardised tools such as the Montreal Cognitive Assessment (MoCA).
Thank you to Neelom Sharma, Alexandra Pittock, Meroe Grove, Maia Forrester and Mercedes Smith for their major contributions to the content of this module.
Introduction Part 1 of 12
Cognition, Insight and Putting It All Together
For the final session on the MSE we are going to focus on how to assess cognition and insight, as well as drawing upon what you have learnt in the previous three sessions to hopefully get you confident in being able to carry out a full MSE.
But before all that, let’s do some revision on what we covered in the previous session…
Cognition Part 2 of 12
Assessing Cognition Part 3 of 12
The key thing when assessing cognition is to use a standardised test. Many patients maintain a good social veneer, making it surprisingly easy to miss cognitive impairment if it is not formally assessed.
There is a wide range of tests available of varying comprehensiveness, length and generalizability across cultures. The one you choose depends on the time available and degree of concern about a patient’s cognition.
For example, if you have no concerns for a patient’s cognition then a short screening or ‘mini’-test could suffice, however, if a patient came to you with a particular concern e.g. memory problems or word-finding difficulty, then you may want to do a more comprehensive standardised test, or refer to a specialist.
Standardised Basic Cognitive Screening Tests Part 4 of 12
The 4AT Part 5 of 12
The MoCA Part 6 of 12
Executive Functioning Part 7 of 12
The term ‘executive functions’ refers to the higher-level cognitive skills you use to control and coordinate your other cognitive abilities and behaviours e.g. who we are, how we organize our lives, how we plan and how we then execute those plans, are all largely guided by our executive system.
The frontal lobes are the main control system for this.
To assess for decline in executive function, you can perform the frontal assessment battery (FAB) test. This is a brief (10-min) test of executive function, which can be done at the bedside.
All you need to know at this stage is that if you have a sense that someone’s executive functioning might be impaired, one needs to test for this specifically and that that can be done by implementing a FAB test.
Reporting Cognition Part 8 of 12
Once you have screened/formally tested a patient’s cognition and there were no concerns you might say something like, ‘cognition is grossly normal and orientated to time, person and place’.
An example of somebody who appeared confused might be reported like…
“Patient appeared confused and disorientated. They did not know where they were, nor what time of day it was, and had to ask for questions to be repeated several times. They scored 17/30 on MMSE, losing points for orientation to time, orientation to place and recall.”
Insight Part 9 of 12
Questions Part 10 of 12
Summary Part 11 of 12
Hopefully by now it will make more sense to you and you will feel more confident in being able to carry out an MSE and pick up on signs and symptoms that might be detectable upon questioning or inspection of the patient.
Part 12 of 12
If you would like to try doing a full mental state examination, click here to watch an 8 minute clip of an interview with a patient and write how you would describe their MSE.
The password is lithium18
Afterwards, compare your answer with the example below.