Changes in mental status are a major reason for neurologic consultation and hospital admission. Despite the frequent need for mental status assessment, the evaluation is often abbreviated, with important aspects omitted. Such inadequate examinations cause physicians to miss crucial information that could speed the accurate diagnosis of mental status change needed for proper management. For example, a patient inappropriately evaluated for altered mental status might have an overlooked aphasia localized to the dominant temporal lobe as a result of ischemic stroke. Speedy diagnosis of such aphasia is necessary to provide proper thrombolytic treatment to the patient within the therapeutic time window.
The mental status examination is an often daunting task for medical students, residents, and many practicing physicians because of the variety of methods used to conduct this test. The Folstein Mini-Mental Status Examination (MMSE)
1 is probably the most routinely used screening method for assessing a patient's mental status. However, many of the methods are complex and time-consuming, involving inherent difficulties in recalling sequential steps; some are overly simplified, missing important neurocognitive features; and others are designed with only a narrow focus on limited domains of cognitive function.
1-9 As a result, the mental status of patients is often inconsistently and inappropriately evaluated. The optimal test would consist of easily remembered sequential steps, it would include a comprehensive screen of multiple domains of neurocognitive function, and it would be adaptable to focus on specific areas of cognitive testing as desired.
To reduce these complicating factors in performing a mental status examination and evaluating cognitive function, I would like to propose a new method, which I developed while serving a residency in neurology at the Cleveland Clinic in Ohio, as a way of teaching other residents and medical students. The technique provides an easy-to-remember and efficient, yet comprehensive, evaluation of a patient's mental status and cognitive function, including the six crucial components of language testing that are important in screening for acute stroke. The proposed method can be easily used by all healthcare professionals in any stage of training to proficiently describe a patient's mental status and cognitive examination. An additional benefit of the technique is that it includes all aspects of the Folstein MMSE,
1 so the gathered information can be easily extrapolated to generate a standard MMSE score if desired.
Remembering a simple mnemonic—LOCAM-LT—is required to perform the technique. When each of these letters is thought through sequentially, all information needed to comprehensively evaluate and comment on the patient's mental and cognitive status is obtained:
L: Level of Consciousness
Determine if the patient is hyperalert, alert, drowsy, obtunded, or comatose.
O: Orientation
Evaluate the patient's orientation to person (eg, self); place (eg, state, city, hospital, floor, room); and time (eg, year, month, date, day, time of day).
C: Concentration/Calculation
Ask the patient to spell WORLD backwards, or to subtract 7 from 100, and then 7 from that sum—continuing in that pattern for 5 total subtractions (ie, “serial 7s”).
A: Attention
Information on the patient's level of attentiveness should be obtained by observation of whether the patient appears attentive or distracted during the preceding step. The patient can also be asked a question such as, “If the lion chased the bear and the bear killed the tiger, which one died?”
M: Memory
Various aspects of the patient's memory should be evaluated. Immediate memory can be tested with 3-item recall or 7-digit recall. For example, ask the patient to repeat the following numbers in the given sequence: 1-9-7-6-4-2-9.
Working memory can be tested with mathematical manipulation of the 7-digit recall. For example, the patient can be asked to “add the first and last digit of the number sequence you just repeated.” Then, ask the patient to “multiply that number by 2” and “subtract that number by 7.”
Recent memory can be evaluated with a repeated recall of the same 3 items used in immediate memory testing. However, consider testing for recent memory after remote memory testing in order to obtain a longer time interval between the immediate and recent memory tests.
To evaluate remote memory, ask the patient for such personal information as date of birth, place of birth, and questions about family members or well-known historical events.
L: Language
This item is especially useful for localizing potential acute stroke. Comprehension of language can be tested with a 3-step complex command. For example, direct the patient to “hold up your right thumb, touch your left ear with it, and then stick out your tongue.” In addition, patients can be asked to demonstrate how they would perform certain purposeful movements, such as combing their hair and holding a nail while hitting it with a hammer. Difficulty with these movements could reveal signs of dementia (eg, apraxia).
Ask the patient to perform language repetition by repeating such phrases as “no ifs, ands, or buts” and “it's a sunny day outside today.”
Evaluate
naming ability by asking the patient to name common objects, such as a pen and a watch. You may also ask the patient to name as many “S” words as possible in 1 minute to screen for frontal subcortical dysfunction, as in frontotemporal dementia (about 12 words are normal), followed by the names of as many animals as possible in 1 minute to screen for temporoparietal dysfunction, as in Alzheimer's disease (about 15 names are normal).
10 It is important to remember that these normal values vary by education and age, and they can provide only a general screening.
Reading ability can be evaluated by asking the patient to read a written sentence out loud and to perform the task indicated by the sentence. For example, ask the patient to read the sentence, “close your eyes,” and to follow the instructions of the sentence. Showing a picture involving two or more people performing separate actions and asking the patient to describe what they see happening in the picture can also be done at this time.
Writing/drawing skills should be evaluated. Direct the patient to perform a task with a pen or pencil, including writing a random sentence, copying a diagram of intersecting pentagons (as per the Folstein MMSE1), bisecting a horizontal line, or inserting the missing numbers in a picture of a clock. These exercises have abnormal results in many dementia and hemineglect syndromes.
Fluency should be evaluated by listening for dysarthria when you interview the patient. Listen for abnormal vowel pronunciation by asking the patient to repeat, “Me-tho-dist, E-pis-co-pa-lian.”
T: Thought Process
Abstraction in thought should be evaluated in patients. Ask for similarities and differences between various objects or settings—such as a tent vs a cabin or a river vs a lake. In addition, during your general conversation with the patient, listen for symptoms of psychosis, delusions, and tangential or pressured speech.
By remembering the sequence and components of the LOCAM-LT mnemonic, physicians will be able to simplify the seemingly complex and time-consuming, yet important, task of evaluating patients' mental status and cognitive function. The sequence of steps in this method can be adjusted based on the particular clinical scenario, or the steps can be performed in the sequence described in the present letter for a comprehensive evaluation of neurocognitive function. Either way, the LOCAM-LT method allows for a complete assessment of a patient's mental status and cognitive function.
It is important to note that the LOCAM-LT method should be accompanied by a thorough neurologic examination of the patient to avoid missing a potential neurologic emergency—such as acute stroke, which may reveal hemiplegia or other focal findings—and to provide further evidence for diagnosis. I believe that the easy-to-remember LOCAM-LT technique, together with a neurologic examination, can provide the physician with complete confidence that an accurate evaluation of a patient's mental status and cognitive function is obtained.
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