How to check higher mental status in neurological examination

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Higher Mental Status (Cognitive) Examination in Neurology

The higher mental status (HMS) examination - also called the cognitive or cortical function examination - assesses the integrity of the cerebral cortex. It should be performed at the start of the neurological examination, since deficits here may affect interpretation of everything else.

Prerequisite: The patient must have intact arousal and alertness before you can meaningfully assess higher cortical functions. If consciousness is impaired, test attention and orientation first.

1. General Behavioral Observation

Begin as soon as the patient enters. Observe:

Attentiveness and arousability - Does the patient stay on track? Does attention wander?
General appearance and grooming
Motor activity and spontaneity - Agitation, psychomotor slowing
Mood and affect
Speech quality - Rate, rhythm, prosody (pitch and accentuation)
Thought process - Loosely connected, perseverations, confabulation, irrelevancies

(Bradley and Daroff's Neurology in Clinical Practice)

2. Level of Consciousness

Ranges from fully awake to comatose. If not fully awake, describe the minimum stimulus needed to elicit a response:

Verbal commands
Tactile stimulus
Painful stimulus (e.g., trapezius squeeze)

Distinguish purposeful responses (looking at examiner, pushing away stimulus) from reflex spinal responses (triple flexion).

(Harrison's Principles of Internal Medicine, 22E)

3. Orientation (Person, Place, Time)

Ask the patient to state:

Person: name
Place: where they are, what kind of place it is
Time: day of the week, date, month, year, time of day

Time is usually the first domain affected. Being off by >3 days on date, >2 days on day of week, or >4 hours on time of day is clinically significant disorientation.

4. Attention

Attention must be assessed before testing memory or other domains. Bedside tests include:

Test	Method	Normal
Digit span (forward)	Recite digits at 1/second; patient repeats	7 ± 2 digits
Digit span (backward)	Repeat digits in reverse	5-6 digits
Serial reversal	Spell "WORLD" backwards; count by 3s or 7s from 100	No errors
A vigilance test	Tap when you hear the letter "A" among random letters read aloud	No missed A's
3-step motor sequence	Palm-side-fist (also tests frontal lobe)	Smooth repetition

(Bradley and Daroff's Neurology in Clinical Practice)

5. Memory

Analyze across three time scales:

Type	How to Test
Immediate (working) memory	Give a list of 3 items; ask the patient to repeat immediately
Short-term (recent) memory	Ask recall of those 3 items at 5 and 15 minutes
Long-term memory	Ask the patient to give a coherent chronological history of their illness or personal events

Recall of the examiner's name after 5 minutes is a simple bedside test. Failure to retain items after 5 minutes despite distraction = disturbed recent memory.

(Harrison's 22E)

6. Language

A focused language screen:

Spontaneous speech - Fluency, word-finding pauses, paraphrasic errors
Naming - Ask patient to name progressively detailed parts of an object (e.g., watch > strap > buckle > clasp)
Repetition - "No ifs, ands, or buts"
Comprehension - Follow a 3-step verbal command (e.g., "Take this paper in your right hand, fold it in half, and put it on the table")
Reading - Read and respond to a written command
Writing - Write a complete sentence

This sequence distinguishes aphasia subtypes (Broca's, Wernicke's, conduction, etc.) and differentiates primary aphasia from the language of confusion (which is typically incoherent but not aphasic).

(Harrison's 22E; Bradley and Daroff's Neurology)

7. Fund of Information & General Knowledge

Ask about major historical or current events appropriate to the patient's educational level and life experience. Deficits reflect impaired long-term semantic memory or dominant hemisphere dysfunction.

8. Insight and Judgment

Usually apparent during the interview. If needed, probe with situational questions:

"What would you do if you found a wallet on the sidewalk?"
"What would you do if you smelled smoke in a crowded theatre?"

Impaired insight (anosognosia) is a marker of frontal or non-dominant parietal lobe disease.

9. Abstract Thinking

Similarities: "How are an apple and an orange alike?" / "A desk and a chair?" / "Poetry and sculpture?"
Differences: "What is the difference between a lie and a mistake?"
Proverb interpretation: "What does 'a rolling stone gathers no moss' mean?"

Concreteness (inability to abstract) suggests frontal lobe dysfunction.

10. Calculation

Appropriate to age and education:

Serial subtraction of 7 from 100 (100, 93, 86, 79...) - at least 5 steps
Serial subtraction of 3 from 20
Simple word problems involving arithmetic

Dyscalculia with other features (finger agnosia, right-left disorientation, agraphia) = Gerstmann syndrome (dominant parietal lobe).

(Harrison's 22E)

11. Visuospatial and Constructional Ability

Copy a cube or intersecting pentagons (from MMSE)
Draw a clock face and set it to a time (e.g., "10 past 11")
Identify fingers (finger agnosia)
Ask patient to describe a familiar room or route

Impaired construction is seen with non-dominant (right) parietal lobe lesions; neglect is also tested here.

12. Executive Function (Frontal Lobe)

Word fluency: Name as many animals (or words starting with "F") as possible in 1 minute. Normal: ≥15 animals or ≥10 "F" words.
Go-no-go test: Tap once when examiner taps once, do NOT tap when examiner taps twice. Perseveration = frontal lobe sign.
Luria sequences: Copy alternating patterns (palm-side-fist; M-N sequences)
Cognitive flexibility: Trail-making test concept

Standardized Bedside Scales

Scale	Time	Best Use
MMSE (Mini-Mental State Exam)	<10 min	Screening moderate/severe dementia (~85% sensitivity/specificity)
MoCA (Montreal Cognitive Assessment)	~10 min	More sensitive for mild cognitive impairment
SLUMS	~7 min	Alternative screening tool

The MMSE is the most widely used and provides a baseline score for longitudinal comparison.

Summary: Domains and Localisation

Domain	Brain Region
Memory (episodic)	Hippocampus / medial temporal lobe
Language	Left (dominant) perisylvian cortex
Visuospatial	Right (non-dominant) parietal lobe
Executive function	Prefrontal cortex
Attention	Reticular activating system + frontal lobe
Calculation	Dominant parietal lobe (angular gyrus)

(Goldman-Cecil Medicine; Harrison's Principles of Internal Medicine, 22E; Bradley and Daroff's Neurology in Clinical Practice)

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